Home Health Clinicians Face PDGM Knowledge Gap

The vast majority of home health clinicians currently face a steep uphill climb when it comes to operationalizing the Patient-Driven Groupings Model (PDGM), with slightly less than eight months to go before the payment overhaul goes live, a new survey suggests.

Among its changes, PDGM uses 30-day periods as a basis for payment, with each period categorized into 432 case-mix groups for the purposes of adjusting payment. Those groups are determined by a patient’s admission source, timing, clinical grouping, functional impairment and co-morbidities, making a clinician’s coding knowhow critical to an agency’s bottom lines.

“PDGM relies more heavily on clinical characteristics and other patient information to really place the home health periods of care into meaningful payment categories,” Billie Nutter, president of EMR software and solutions firm Casamba, told Home Health Care News. “What the means to clinicians — to those who work day-to-day in home health care — is that they have to get much better at coding.”


Founded in 1997, California-based Casamba and its roughly 170 employees provide services to more than 275,000 providers across the post-acute care space.

To help gauge clinician PDGM readiness, Casamba polled roughly 500 senior-level home health executives between April 30 and May 3. Less than 33% of those executives said their clinical staff members are adequately prepared for PDGM, according to the survey.

Along those same lines, only 29% of execs who participated in the survey said they agreed with the statement that their staff fully understands the elements of PDGM to be implemented on Jan. 1, 2020, with only 3% strongly agreeing with the point.


When asked about their own understanding, more than 80% of executives said they themselves understand the elements of PDGM, suggesting there’s a disconnect between the very top of home health agencies and the people actually working in patients’ homes.

“Most high-level executives feel fairly comfortable of confident that they understand what’s going to happen, but this highlights how there’s difficulty in executing on the clinician level,” Nutter said. “It’s knowing how to take all this information and break it down into tangible bites that clinicians can understand.”

In many ways, that idea also holds true for execs in the skilled nursing facility (SNF) space, which is currently navigating the upcoming Patient-Driven Payment Model (PDPM), she added.

With relatively little time remaining, it’s especially important for home health clinicians to get up to speed on primary diagnoses coding under PDGM. About 40% of the diagnoses allowed for under the current Prospective Payment System (PPS) will not be accepted as primary diagnoses under PDGM.

In addition to clinician preparation, Casamba’s PDGM survey also looked into industry thoughts surrounding legislative efforts targeting the overhaul’s widely opposed behavioral adjustments.

More than 75% of survey respondents said they’d like to see the elimination of PDGM’s behavioral adjustments, which could pose a 6.42% rate cut to the home health industry.

Senate lawmakers introduced a bill targeting those behavioral adjustments in February. Members of the House — led by Rep. Terri Sewell, an Alabama democrat — followed suit last Wednesday.

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