Where PDGM’s Therapy Changes Will Hit Hardest

By eliminating visit-volume thresholds and tying reimbursement more closely to need, the Patient-Driven Groupings Model (PDGM) will likely steer the home health care industry away from therapy and toward nursing.

Although PDGM officially starts on Jan. 1, home health providers have already begun to shift their therapy utilization strategies to better line up with the looming payment overhaul.

A June survey of 685 providers from across the U.S., for instance, found that nearly half plan on decreasing therapy utilization in 2020.


A recently released report from Atlanta-based analytics and metrics firm Trella Health, formerly known as Excel Health, now suggests which geographic markets might be most affected by the therapy changes.

“Since therapy volume will no longer be a reimbursement determinant, agencies that have focused on therapy almost exclusively could see material revenue declines, unless they increase nursing utilization,” the Trella report reads.

Nationally, average therapy visits per home health episode ranged from a low of 6.6 in Oklahoma to a high of 13.2 in Idaho from Q1 2018 to Q1 2019. In addition to Idaho, other states that ranked as the therapy-heaviest included Colorado, Maryland, Hawaii and South Dakota.


During that same period, the overall national average therapy visits per home health episode was 9.3, according to Trella. Besides Oklahoma, other low-therapy states included California, Louisiana, Vermont and Mississippi.

In terms of episodes by clinical category, average therapy visits ranged from a low of 2.9 for “Complex Nursing” to a high of 15.3 for “Neuro Rehabilitation.” Meanwhile, “Medication Management, Teaching and Assessment — Respiratory” and “MS Rehab” were also clinical categories that tended to see high levels of therapy visits per episode.

“Given the conditions grouped into these categories, including Parkinson’s disease, chronic obstructive pulmonary disease (COPD), and joint replacement surgery, the higher number of average therapy visits seems logical and may not fluctuate much with PDGM,” the Trella report states.

How do those national therapy averages compare to nursing? Well, for nursing visits per episode, the national average was 11, according to Trella, with a low of 6.3 in Hawaii and a high of 13.7 in Florida.

In the skilled nursing world, a similar payment overhaul that went into effect Oct. 1 has already reportedly triggered thousands of therapy layoffs.

While some home health experts predict a similar pattern to happen post-PDGM, experts caution providers not to move too far away from therapy.

“Under PDGM, underutilization of therapy may become a bigger problem than overutilization,” Dr. Jason Falvey, a post-doctoral fellow at the Yale University School of Medicine, said during a presentation at the 2019 National Association for Home Care & Hospice (NAHC) event in Seattle. “If you short therapy on the front-end, you end up paying for it in the back-end.”

Telehealth and telemonitoring have been cited as creative tactics for surviving PDGM’s therapy revolution. Telemonitoring is a type of telehealth tool in which caregivers and doctors can use technology to monitor patients remotely.

“If the patient has gotten to the point that they can do their own home exercise program, what better way to make sure that’s happening than a therapist watching them via remote monitoring?” Melinda Gaboury, co-founder and CEO of Healthcare Provider Solutions Inc., said during a March conference. “I’m not saying you’re going to replace therapy with remote monitoring. I’m saying it is a possibility of supplementing having a registered therapist in the house.”

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