Serving the home health, home care and hospice industry since 1999.

by Darcey Trescone, RN, BSN


PDGM is still a topic of conversation as both vendors and providers continue to prepare for its launch January 1, 2020. We were able to catch up with a few of the vendors recently to learn more about their perspectives and preparations for PDGM.

PDGM Impact to the Industry

"The level of impact really depends on the particular home care provider. If the home care provider reacts appropriately to PDGM, the new requirements can help them maintain and potentially improve reimbursement," Mike Kramer, SVP Home Care and Hospice at Casamba told us. "Providers need to fully understand the PDGM policy and adjust their current practices and workflows accordingly."

Kramer continues, "PDGM is certainly driven by diagnoses. Close attention needs to be paid to the coding aspect of what the providers are doing when assigning the primary diagnosis and all co-morbidities for the patient receiving services. This is going to require providers be in a position to defend the diagnosis coding and services they deliver within their clinical documentation."

"Getting all the services to the patient’s and prioritizing the needs of that patient in the first couple of weeks of care is going to be important. We need to focus on the clinical needs and getting them stable, but we forget that there are other factors, beyond nursing, that are driving this patient to have problems. It’s going to require the whole home health multidisciplinary team to decrease hospitalizations," added Melissa Cooper, Chief Clinical Officer at Thornberry Ltd.

How are you preparing your customers for PDGM?

Ms. Cooper continued with more company detail:

"Many are concerned about the financial aspect of PDGM, not really concentrating on how we are going to achieve goals in 30 days where we can. Thornberry is doing many things, one is further education on the multidisciplinary team aspect of PDGM thru emails, blogs and educational sessions. If we are really going to be successful and partner with the patient and care community to improve patient outcomes it will require nursing, therapy, social work and the home care aide. Ensuring that these disciplines are established if needed and visits planned earlier in the patient’s care is key. Additionally, we have launched a PDGM evaluator update to help our customers look at the data that is coming in now and model for them what that reimbursement will be in the PDGM world. We believe along with monitoring reimbursement, working with our customers to focus on their top diagnoses, care practices in place and the number of disciplines and visits to achieve positive outcomes for their patients they will drive success."

Casamba's Kramer added, "We have been doing webinars with our customers that review the PDGM regulations along with the existing and new features available in our product. Since the first of the year we have been working closely with the CMS technical specifications and our customers to ensure PDGM readiness. PDGM education is important and we will continue to do what we can to support the industry."

"Much work needs to be done in a relatively short period of time to ensure clinicians are up to speed on the regulatory changes going forward," said Billie Nutter, president of Casamba. "What’s encouraging is that our customers leadership believes they have a strong knowledge base to leverage and help prepare their staff. Using that understanding to educate practitioners will be critical during this transition to PDGM."

Kramer continued, "PDGM will be a featured topic at our May user group. We will be sharing what trends we have seen across our customer base with the analysis we have done. We are all trying to improve patient outcomes and decrease hospitalizations. The most cost-effective environment to provide care is in the home, and that is where our patients and families would rather be. The good news is that when an episode has reimbursement for both 30-day billing periods, our customer’s reimbursements appear to be the same or better under PDGM based on our analysis."

PDGM Innovations

Mike Kramer described more services Casamba is preparing:

"We have built our own PDGM grouper and this allowed us to provide our customers with a PDGM analytical review tool within Casamba. The tool provides a comparison of the actual PPS revenue and the projected PDGM revenue for each 30-day period from January 1, 2018 to present.

"Our goal was to show our customers in real time how their reimbursement would be affected under PDGM with the current patient population and care practices they have in place. The tool provides enough detail to help our customers identify adjustments in care practices and then monitor what projected PDGM reimbursements would be based on these modifications. This approach helps our customers gain insight into future outcomes and pinpoint specific clinical themes where behavioral process changes most impact positive patient outcomes.

"We have built in alerts to the user when a disqualified diagnosis is chosen and warnings around potential LUPA scenarios. Additionally, within our clinical documentation, there are a number of links between an order and what needs to be documented to support that order. In reverse, when documentation is completed the system provides a list of orders required for physician signature."

Thornberry's Cooper added,

"We have a couple of new tools. One that we are excited about is our Smart Goals. SMART Goals are Specific, Measurable, Attainable, Relevant and Time Based. They are goals which allow the clinician to define a time frame of achievement for the patient. The goals are assessed at each visit done by the clinician to make sure they are relevant and obtainable. The goal dates can be ended with a date of achievement, marked as ongoing or the date can be modified to allow more time for achievement. The clinician's dashboard notifies them five days before the goals due date. There is also a companion supervisor's report which allows supervisor's to monitor all patient's on census for over due goals. The road map for our goals leads us to qualifying diagnosis driven goals and interventions. With PDGM on the horizon it is important to have standardized protocols and interventions to achieve consistent goals. These goals are multi-disciplinary.”

"Our interactive dashboard in NDoc will give users a warning about patients nearing the end of the 30-day period and, based on the PDGM model, will highlight those patients that are potential LUPAs. This allows the customer to evaluate in advance if the patient is truly a LUPA case or if more services are needed. As well, we have delivered managerial oversight that shows the patient population on service, where they are in their cert period and who is not meeting goals. With built in drill downs by clinician and patient the manager can easily guide the care team."

PDGM remains a highly relevant topic for providers and vendors both. These regulatory changes are continuing to feed thought leadership and innovation in home care technology.


©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.