The Hidden Perks of PDGM

Transformative. Game-Changing. Disruptive. Long-Lasting. Plus some words I can’t repeat here. I’ve heard these and many more descriptions of the Patient-Driven Groupings Model’s (PDGM) effect on the home health industry. Yes, PDGM is forcing us to alter our status quo. Some home health organizations got ahead of the game prior to January 1, by reducing therapy staff or training their administrative office on new coding procedures. Those who prepared most thoroughly will more quickly discover their “new normal.” Whether you planned it or not, it will take time, as well as ongoing analysis and tweaking, for the home health industry to achieve that balance of appropriate care delivery and financially sound operations. But I believe this change is also a blessing in disguise.

Data is Your Friend

Your own historical data is the most important contributor to your economic viability under PDGM. Knowing how you provided care to your distinctive patient population and analyzing patient outcomes against your documented operations and staffing models enables you to calibrate care delivery going forward to preserve those outcomes, meet PDGM requirements -- and secure your bottom line.

PDGM forces home health providers to collect and evaluate more current patient data too – this is not a bad thing! By gathering specific patient information up-front, instead of during the course of their care, you’re more likely to identify the patients who are the best fit for your organization. But the patient’s demographics, primary diagnosis and referral setting are no longer sufficient to make this call. Now you have to dig more deeply into your referral documentation, to:

  • Identify comorbidities,
  • Predict the type and volume of nursing/therapy visits, and
  • Recognize imperceptible health complexities.


With this expanded analysis, you’ll improve your chances of receiving the reimbursements you’re due while managing your upfront costs.

There are new back-end data needs as well. Do you know which physician signatures you’re capturing within the compressed billing cycles – and which doctors are consistently delinquent? Are you tracking the age of your outstanding orders, and which physicians are your biggest source of A/R? Collecting and evaluating this data will also help you avoid financial risk.

Patient Benefits Improve the Entire Industry

Think more about the “patient-driven” rewards of PDGM. By truly seeing your patients for all of their conditions – and with much more up-front information – you significantly improve their treatment plans. Your care teams are also happier when they deliver care that is actually needed. By aligning your staff and expertise to your patient populations, the data you share with your referral sources will contribute to better patient outcomes. Do you agree with me that these activities will build stronger relationships between the acute and post-acute sectors? These will be essential as we move towards value-based care. From automating manual steps internally to introducing technology into your patients’ homes to using AI to predict the services they might need, the insights driven by PDGM will elevate the home health industry to a whole new level.

Risks Remain – But Payment Reform is Survivable

Here’s the bottom line: until EHRs are fully interconnected, so you can transmit patient health histories and documentation as easily as financial institutions make transactions, your patients will be at risk. Clinicians will also remain susceptible to burnout, trying to create care plans and treat patients without all the necessary information.

But remember, we aren’t the first healthcare sector to face (and get through) payment reform. Our most successful colleagues in the acute sector embraced the disruption of the Affordable Care Act, completely and honestly evaluated their operations, financials and clinical outcomes, then reworked their organizations…sometimes from the top down. Our Skilled Nursing Facility colleagues are in the throws of it now and are just a few months ahead with PDPM.

You and your patients can become a PDGM success story. Look for technology partners who will help you:

I urge you to remain optimistic! I see a future where home health care is vastly improved thanks to innovative home health agencies with high-performing, satisfied teams delivering the best care outcomes. Why shouldn’t your organization be one of them?

Annie 10-Retouched


As Chief Strategy Officer, Annie Erstling is responsible for driving growth at Forcura. She oversees the company's strategic planning, product innovation, marketing and strategic partnerships. She has experience launching new brands, products and companies across the healthcare and technology sectors.

Connect with Annie on LinkedIn.

Topics: CMS Regulatory Guidance

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