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Therapy Remains Critical in PDGM: Skilled Criteria, Strategic Element

Imagine a world where reimbursement isn’t based on the volume of therapy visits. Instead, therapists care for patients and drive outcomes based exclusively on clinical need. 

HealthPRO Heritage experts agree: PDGM will breathe new life into how, when, and why therapists deliver care. We are, in fact, excited for a new world where our success will be measured by the evidence-based therapy we provide and the outcomes we achieve.

In this new paradigm, therapy plays a critical role in helping HHAs manage quality, satisfaction, and revenue cycle. One key to a successful transition to PDGM is that therapy must align with nursing to appropriately case manage, plan, deliver, and accurately document care that ensures outcomes are met timely. In addition, therapy professionals will need significant training and support related to proper coding and functional scoring in support of new OASIS requirements.

HHAs that understand the strategic role therapy can play in accelerating readiness in the months ahead and in successfully navigating new PDGM requirements will be better positioned for success in the new paradigm. 

Therapy is Essential to Track, Manage & Drive Outcome Measures
In a world where reimbursement will be determined by our patient’s clinical presentation, the ability to comprehensively assess care needs, deliver targeted interventions, track, and analyze outcomes will be critical. The ability to optimize outcomes and continually refine programming is an invaluable contribution to the overall success of any home health agency and is easily driven by a well informed therapy provider.

We are There for You: Support for Our Nursing Colleagues
With the transition to PDGM, one irrefutable tenet will hold true: therapy and nursing are two complementary pieces of a puzzle that must work collaboratively to coordinate care. This will hold especially true with the OASIS-D additions of Section GG and Section J.

Patients & Families First
Patients and their families still want and need world-class therapy services. The expertise of physical, occupational, and speech therapists will always be sought after, because unique and specialized therapy is a necessary component of skilled care requirements and achieving the best possible clinical outcomes and patient satisfaction.  The HHCAHPS Patient Survey results will continue to be reported as part of Home Health Compare, and outstanding therapy services are an integral part of positive results.

Two Critical Words: Quality Measures!
Quality Measures will continue to impact HHA’s Star Ratings, and therefore affect eligibility for bundled initiatives participation, preferred provider networks, and referral admission volume. Quality PT, OT, and ST affect patient’s mobility, ADLs, safety and cognition, which directly impact these scores:

HHH Blog Graphic

Great Expectations! Partnership & Network Alliances
Preferred provider networks will still measure HHAs based on critical success drivers driven by exceptional therapy services. Specifically, consider our patients being discharged sooner from hospitals or skilled nursing facilities and the necessity to demonstrate our ability to maximize functional gains, prevent re-hospitalizations and ensure optimal patient safety. Therapy is an irreplaceable component of care that instills trust from our partners that we are the right team to take care of their patients.

Stating the Obvious: Therapy is Included!
The requirements to access skilled care under Medicare Home Health do not change under PDGM. Rather than thinking of therapy simply as a “cost center,” remember that patients must be in need of skilled services that are provided by a HHA for care to be covered. Under PDGM, the following CMS CoP’s will still hold true: 

  • 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions.
  • 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician and medical social work services as specified in §409.45 of this chapter.

Considerations for your Therapy Partner – PDGM Expertise is Critical!
To be a valuable partner in the new PDGM world, therapy partners will need to step up their game. HealthPRO Heritage recognizes that we are a strategic collaborative partner impacting your quality initiatives and revenue cycle. Our PDGM Expert Panel has a clear vision for PDGM readiness strategies and will prepare front line staff and HHA leaders to assure a successful transition to PDGM through the following strategies:

  • Analysis of projected impact and agency-specific clinical strategies to mitigate associated risks;
  • Cross continuum support to help build partnerships with PAC providers to assist with diversifying referral sources and census growth;
  • Clinically appropriate visit utilization based on diagnostic grouping and functional impairment level to help mitigate and manage LUPAs;.
  • Accurate OASIS coding and/or collaboration of the Functional M items that impact the Functional Impairment Level portion of case mix;
  • Targeted documentation on secondary diagnoses to support co-morbidity capture & adjustments; and
  • Evidenced based length of stay management that fosters supports clinical excellence and Safe Transitions to next level of care at appropriate time.

Need support getting your head in the game? HealthPRO Heritage at Home can help with PDGM readiness to include strategy, education, and execution on key clinical competencies that are crucial to PDGM success.  

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Tags: Home Health, PDGM