PDGM, CoPs Put Home Health Providers in Rough Regulatory Waters

For in-home care providers, navigating the regulatory waters can often be challenging. Being flexible and monitoring the constant waves of change are key to staying afloat.

The Patient-Driven Groupings Model (PDGM) from the Centers for Medicare & Medicaid Services (CMS) and the finalized interpretive guidelines for home health Conditions of Participation (COPs) are two recent regulatory items that are causing industry stakeholders to hold their breath — and even fear that they may drown.

But by educating nurses, maintaining a flexible attitude, and advocating to regulators and lawmakers, home health providers can make it through.


That was the message shared by leaders from ElevatingHOME, Alacare and Interim HealthCare, who spoke at the Home Health Care News Summit in Chicago on Sept. 20.

PDGM nerves

CMS released details of PDGM on July 2. In its initial announcement, CMS highlighted how PDGM is meant to better align reimbursement with patient needs and set a Jan. 1, 2020 implementation date.


Many home health leaders have been pointing to issues within the rule, including changes to the Low Utilization Payment Adjustment and how a case mix weight is determined.

“The approach we have [taken] is, [PDGM] is coming, kind of like you are standing on the tracks and you can see the train coming,” Joy Cameron, vice president of policy and innovation at ElevatingHOME, said during the panel. “[But] how much can you modify and how much can you change in the time period between now and Jan. 1, 2020?”

Alexandria, Virginia-based ElevatingHOME is a nonprofit industry organization created in 2017 to advance the home-based care industry. The organization was formed to help unify the 12,000 home health agencies and 6,000 hospices in the United States.

“Is the concept good, the idea of moving payment and the patient together? It is, but you have to look at the whole patient,” Cameron said. “It is not just the concept — it is the implementation that is important and January 2020 is sooner than we know.”

Despite concerns, from a provider prospective, PDGM does have the potential to be a positive change. That’s dependent on factors such as patient mix, therapy utilization levels and the amount of referrals coming from institutions versus the community.

Birmingham, Alabama-based Alacare has done a lot of modeling to determine PDGM’s impact. That modeling has suggested payment reform will likely be a net positive for the company, said Kaye Keel, the company’s vice president of clinical compliance. Alacare is a home health provider offering skilled nursing, rehabilitative, palliative and hospice care.

Still, nurse turnover and keeping nurses up-to-date on regulatory changes is something Alacare struggles with, Keel said, adding that PDGM is going to be a real concept change for staff.

“It’s going to change the way we provide home health care, in my opinion,” she said.

Interim HealthCare is also focused on supporting its nurses during these regulatory changes.

“Many years ago, I was a marine corps officer, and I tell my nurses [that] nurses and marines are a lot alike,” said Tracy Clark, chief operations officer at Interim. “There is no better friend, but there’s no worse enemy.”

Clark believes that more nurses need to be in the room when regulatory rules are being discussed because it is on the nurses to implement them on a daily basis and if they don’t fit into the workflow it will be a struggle to execute.

Founded in 1966 and currently part of Caring Brands International, Sunrise, Florida-based Interim oversees more than 530 franchise locations in seven different countries, which combine to provide care for nearly 200,000 patients annually.

Some other issues experts have pointed to in regards to PDGM include: the potential changes in reimbursement for treating patients with co-morbid conditions, the shakeup of how the industry treats referrals that come from institutional settings versus community-based ones and so-called “behavioral adjustments,” or measures CMS assumes agencies will take in light of the new framework.

CMS has not released the finalized rule, though it did recently conclude an open comment period on Aug. 31.

The final rule will likely come out around the end of October, Cameron said.

Finding a groove with CoPs

Since the guidelines went into effect in January, providers worked to meet the new requirements for participating in the Medicare and Medicaid programs without finalized interpretive guidelines (IGs). CMS just released those finalized guidelines in September.

While having the finalized IGs is crucial for compliance purposes, the final guidelines have raised some new questions and issues. There is a potential discrepancy between what the IGs say about providing patient rights versus what CMS said about that in another recently released proposal, meant to reduce administrative burdens. For example, patient rights, under the final guidelines, were required to be provided in writing and verbally in the patients’ language of choice, however the new proposal suggests that they be provided only in writing.

In addition, questions remain as to how practical some of the CoP requirements are, and how far agencies will need to go in order to be considered compliant.

“That’s good for the side of the patient — I absolutely am not critiquing that it is important [that a patient] understands their rights and responsibilities — but I’m thinking about the space in the trunk of the nurse’s car,” Cameron said. “How many languages is she going to have to have sheets [for]? My son will go to a high school where 118 languages are spoken in Alexandria, Virginia — that’s a lot of sheets that I would need to have in the trunk of my car.”

For providers, getting the new CoPs up and running has been difficult.

“There is much retraining that we have had to do to try and get our nurses where they need to be,” Keel said. “Providing care in the home is a real challenge anyway … Honestly, the patients who [regulators] think they’re protecting are the ones that are getting lost in this.”

The bottom line is that it is hard to implement a rule that you don’t know much about, according to Clark.

“[I tell my employees], if you are treating our patients like they are your own grandparents we are probably going to be alright,” Clark said.

Clark said he tries not to be too uptight about regulatory changes because, in the end, they are ultimately going to change again. Even so, the home health industry does need to be involved and get comments to their representatives in government, he added.

“We as an industry have to get better at getting our information in as to what we really do,” Clark said. “I think there is a belief that we go out and sit with people … at the end I don’t think they really know the impact.”

Looking to 2019

Next year will likely be just as difficult — if not more — for the industry in regard to staying up to date on the rules.

“I think we are going to have to get more creative, flexible and try to be agile — you just got to be willing to adjust all the time and that’s tough,” Keel said.

While providers have to keep on an eye towards federal changes, they must also look at state rules as well.

However, there may not be as many changes coming down the pike in home health for awhile, Cameron said.

“I think there is more attention and focus on [hospice],” Cameron said. “Hospice is going to be up at bat next. So, for those of you who have hospices, my sympathies.”

Written by Kaitlyn Mattson

Companies featured in this article:

, ,