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5 Strategies for Successful PDGM Prep

Home health agencies are less than a calendar year away from the biggest change to reimbursement that’s been seen in decades -- Patient-Driven Groupings Model or PDGM. The new rule, which goes into effect in January 2020, has the Centers for Medicare & Medicaid Services (CMS) replacing today’s 60-day payment episode with 30-day periods. The rule is designed to reduce the number of unnecessary therapy visits from home healthcare agencies. Agencies will receive payment based on value rather than volume once the rule goes into effect.

The change has many home health agencies understandably nervous, says Maria Warren, consulting director at McBee Associates, a healthcare consulting and services firm based in Wayne, Penn.

“Fears range everywhere from how is PDGM going to impact my bottom line and cash flow to am I going to be staffed accordingly considering the increased challenges on the intake and referral processing,” she explains. “Agencies are also worried about the additional review from an OASIS and coding standpoint and on the backend from a revenue cycle standpoint making sure there is enough billing and collection staff to follow up and bill on two 30-day periods. There is not one area of the agency that won’t be impacted by PDGM. It’s a lot to think about.”

Diane Link, COO at Curaport and owner and consultant at Link Healthcare Advantage says agencies need to start planning for PDGM today if they haven’t already. “You need to know where your agency is and how it's going to impact you,” she says. “You should be analyzing the current trends in your organization  - looking at how many average nursing visits you do per episode and your average therapy visits per episode. Now is the time to start looking at your back office, too. With PDGM we will be billing every 30 days so we need to make sure that order management is in line, too.”

Looking ahead and looking back are facilitated more easily with technology. In fact, technology will be the differentiator for the most successful agencies, according to Link and Warren, who say that it just isn’t possible to make such a big transition without tools and processes in place to make it happen. So just what do they suggest? Below, find five strategies that will help you plan ahead for PDGM and make the transition as painless as possible.

#1: Automate the referral process

With the change in payment parameters, coding correctly right from the start is going to be extremely important, says Brian Harris, consulting director at BlackTree Healthcare Consulting. “The more information that you can get up front at intake on that diagnosis coding, that's your coders not guessing or trying to work off of a lack of information. They can better account for all diagnoses, all symptoms, all conditions of a patient, which are going to be so important when calculating revenue,” he says.

Plus, when you remove manual keying of referral information or hard copy paperwork it gets into the system quicker and the revenue cycle and case management can start immediately, he says. You also avoid common errors, saving you time and money in the long run. Intake and referral management software helps with all of these processes, especially if you can include both scanned copies of physical documents and electronic referrals.  

#2: Streamline documentation

PDGM will require a lot more documentation at the point of intake because patients and their cases will be categorized on a much more granular level, taking into account comorbidities, functional levels, clinical groupings, and admission sources, among other characteristics. You will need to collect as much diagnosis information at the time of referral, but you’ll also have to factor in patient history and previous treatments as well. It will be crucial for those in the field as well as your back office staff to be able to document everything from the first face-to-face visit until the patient is discharged. In order to make this manageable, agencies need to put a process in place to streamline documentation.

#3: Consider an audit

PDGM will require accuracy in OASIS coding. Experts suggest doing an external audit of your OASIS documentation every two years, but with the upcoming phase in of the new regulation it’s something everyone should consider doing during the second or third quarters of this year, says Link, who says this will give you plenty of time to provide education to your employees. She also suggests making case conferences a regular in-house practice.

“You don’t know what you don’t know,” she says. “I recommend that agencies do case conferences every two weeks so you can talk about where you are with a patient, where they are with their goals, and what you need to do to put the patient needs into the reimbursement equation.”

#4: Improve communication

Today, your agency has regular internal meetings to make sure episodes are moving along successfully, but under PDGM, communication will need to be timely and effective, says Warren. “Interdisciplinary communication is going to be key in this to make sure that everybody is collaborating on what they see going on with the patient. Making sure from the beginning of when the OASIS is completed and then throughout that patient's 60 day episode everyone is on the same page and tying care to the patient’s goals.”

You should have an automated tool in place that helps your employees communicate with each other as well as with providers securely and in real time. You’ll also want to consider options that will streamline communications with patients and caregivers, too.

#5: Check in with your EHR vendor

All of the major electronic health record providers are hard at work to bring PDGM into their offerings, but there’s no consensus as to when this will be complete or to what extent it will happen. Some vendors may do the bare minimum at first while others will completely overhaul their software to make sure every facet of PDGM is included, experts say.

Vendors want to help agencies as much as they can, so you can reach out to your EHR vendor and ask to see their product roadmap around the rule, says Harris. They’re sure to comply.

“It's very important to be in consistent communication with your EHR,” he explains. “We work with around 40 or 50 different EHRs out there in the space, and we see that the base technology that you're using for everything in the revenue cycle, billing and collections --  all that it's going to have to adapt for PDGM as well. It’s going to be key to monitor the EHR’s technology releases and understand how their changes will affect your processes.”

By following this advice, you can help your agency weather the PDGM implementation and use it to improve your bottom line, says BlackTree’s Harris. He adds, “There's not really one magical trick that we can give you. We can’t say do A, B, and C, and you'll be successful with PDGM. It's going to be different for every agency. However, by analyzing your processes now and understanding where your potential risk areas are and developing improvement plans you should be where you need to be by 1/1/20.”

At Forcura, we believe being able to adapt quickly to changing regulations using technology is the key to leading a thriving post-acute practice -- one that delivers excellence to patients and supports the bottom line. Our integrated platform is highly-configurable and designed to help organizations implement best practice processes in a scalable way. From intake and referral management to round-trip comprehensive orders management to secure clinical communication and analytics at your fingertips, we’ve got you covered as you prepare for PDGM success. Contact us to learn more about our PDGM solution or click below to browse the latest PDGM resources: 


Annie Erstling leads strategy and marketing for Forcura. She has experience launching new brands, products and companies in the healthcare, technology, hospitality and consumer products industries on both the corporate and agency side of marketing. Connect with Annie on LinkedIn. 

Topics: CMS Regulatory Guidance

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