‘The Elephant in the Room’: Transparency, Training Keys to Overcoming PDGM’s Therapy Challenges

The much anticipated launch of the Patient-Driven Grouping Model (PDGM) has come and gone. Nearly two months later, one of the biggest early storylines is the way it has affected therapy visits and therapists themselves.

PDGM’s therapy impact appears to — at the very least — be manifesting itself anecdotally in the form of layoffs, visit reductions and downgrading full-time therapists to PRN status. Over 50% of home health agencies said PDGM was forcing a therapy decrease in a recent Home Health Care News survey, for instance.

There will be a more complete picture painted by April on the PDGM-therapy relationship, Laura Balcerak, a home health care veteran and therapy consultant, said during a webinar hosted by HHCN last week.


“There have been a lot of adjustments, transformation and change within a lot of the home health organizations,” Balcerak said.

One of the major shake-ups has been frontline workers being told that their patients require less visits than they see fit, which can be destabilizing across the board.

“We need to make sure that we’re training and [being] transparent with our staff. That we are giving them the tools to be able to deal with cut visits that may have occurred within your agency,” Balcerak said. “The elephant in the room is, you may have changed the number of visits, but their practice patterns may not have changed along with you.”


Some agencies have decreased visits, but haven’t necessarily made the appropriate changes to compensate for the loss of those visits. To improve patient outcomes with decreased visits, there needs to be a shift in how patients are handled.

“Unfortunately, we have to do more with less,” Balcerak said.

The “more with less” is because PDGM eliminated volume thresholds, meaning therapy is no longer as big of a reimbursement driver as it once was.

The growing negative sentiment over the changes is enough to disrupt therapist morale on its own, Virginia Bowen, another expert in therapy consulting with a focus in home care, said during the webinar.

“The frontline staff is unhappy — we’ve heard of staff that feel like the visits are being controlled, that they’re not allowing enough visits to actually meet the patient’s needs,” Bowen said. “Are these patients [now] being affected by unhappy staff and limited visits?”

Patient-facing workers being unhappy with the current climate could make them even less effective in the now limited time that they do have with the patients. Unhappy therapists potentially means unhappy patients, which means a negative reflection on the agency providing the care.

Even if an agency was an over-utilizer of visits before PDGM, the correction needs to be explained to both the therapists and the patients in a digestible way. If it’s not, all it feels like is less adequate care.

The discussion post-PDGM in therapy requires nuance, Balcerak and Bowen noted. Both are experts at Therapy Strong Consulting.

Firstly, if frontline staff members don’t have someone with a background in therapy to express their questions and concerns to, it can create a disconnect, Belcerak said. That includes questions and concerns over, for instance, analytical tools and software meant to help determine visits.

“I know that there’s been a lot of talk of analytics software talk out there,” she said. “Always remember the use of clinical judgment in episodes is definitely needed beyond what any analytical software can provide.”

Medalogix CEO Elliott Wood echoed as much in early February to HHCN.

“I would say, first of all, that it’s entirely possible some agencies are using predictive analytics tools to dictate visits,” Wood said. “And I would say that is an irresponsible use of technology, unequivocally.”

On the other side of things, if agencies were actually over-utilizing visits pre-PDGM, they need to do a better job of explaining why visits are now being cut. They need to work with therapists to overcome those cuts in creative ways.

Similar problems may continue to pop up or may dwindle as PDGM becomes the norm.

Either way, it’s wise for agencies to try to nip them in the bud while they can.

“It’s a little bit too soon to determine the outcomes, it’s a little bit too soon to get back all of your new patient surveys and responses,” Bowen said. “[But] if you wait to get those responses back, then you’re going to have a lot more to clean up … You really want to make sure that you’re addressing some of these issues now before they get out of hand.”

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