NAHC’s Dombi: Agencies Aren’t Panicking in the Streets Over PDGM

The Patient-Driven Groupings Model (PDGM) is shaking up the home health industry in a way that hasn’t been seen in years. Now with two months of the payment overhaul under their belt, providers are trying to predict the greater impact PDGM will have on the industry moving forward.

Perhaps no one understands that potential impact more than William A. Dombi, who has watched home health providers evolve since becoming an industry advocate decades ago.

As the president of the National Association for Home Care & Hospice (NAHC), Dombi is working to help providers navigate the new normal that is PDGM while also functioning as a congressional advocate for more than 33,000 in-home care and hospice organizations.


Home Health Care News recently sat down with Dombi at the Illinois HomeCare & Hospice Council’s annual conference, which took place in Lombard, Illinois. In addition to PDGM, Dombi also said NAHC is keeping a close eye on coronavirus — and its possible consequences for the home health industry.

Below are the highlights of that conversation with HHCN, edited for length and clarity.

HHCN: The home health industry just completed its second month under PDGM. What are you hearing about its impact?

Dombi: I think it’s too early to go beyond anecdotes. What we’re finding from providers is that they are digging deep into the weeds of PDGM at this point, with very specific operational- and compliance-type questions.


We’ve not heard anything about large closures of agencies or any kind of panic in the streets. And strangely enough, the one thing we’re surprised we haven’t heard so far is the cash flow impact. We did a webinar last week focused on cash flow. In 90 minutes of back-and-forth questions and answers, no one really talked about how the sky is falling. Now, that could be the audience we had. It could also be that this hasn’t yet gelled into a problem. At the end of February, providers were still getting their money from last year’s model. We may not see cash flow concerns for another month or so.

Therapy has become a hot topic. What are you hearing in terms of how providers are handling changes?

The predominant thing that we’re hearing is that providers are taking an interdisciplinary, team-planning approach. In the past, they may have simply said to the therapist, “You tell us how many visits the patient needs, then deliver them.” Now, they’re having nurses, various types of therapists and some of the directors of clinical services involved in care planning. We are hearing that some patients are getting less therapy than they might have in the past — and that some are getting more.

Another element that we’re hearing — and this isn’t exclusive to big companies — is that providers are looking at empirical evidence to demonstrate the best pathway to a positive patient outcome. For example, that might mean looking at 2018 and 2019 data for high-performing outcomes in terms of care plans. But the main thing around therapy is taking therapy-volume decisions away from the therapist and making it a team decision.

What about therapy-related layoffs?

I’ve talked with a number of companies, so it’s hard to generalize this answer. A number of larger companies indicate little change in terms of their volume of workers. The volume of visits coming from each worker may have changed. Their compensation methodologies may have changed, too, because for many years, per visit compensation was the modality of choice and incentivized productivity. You’re seeing a change in practice, and you’re seeing a change in compensation for the therapist.

How concerned are you about reports of providers telling their patients Medicare no longer covers home health therapy services?

We are very concerned about any misinformation that’s out there. We started hearing reports of this last month and dug in quickly to try and figure out the cause. We came to the conclusion that the cause is multifaceted. A CEO of an organization conveys to management where the organization is going with its new interdisciplinary care planning system. The management then discloses to the next level of management, who discloses to the field staff … and that translation loses the real message. That is one of the reasons we’ve seen, and that’s not an unusual part of life.

We also can’t ignore the fact that there are some providers who went into PDGM believing they just had to categorically cut their number of visits. The oddest ones are not even therapy related. One report, for example: an ALS patient who had a catheter and was told that Medicare doesn’t cover that as of Jan. 1. That’s categorically wrong.

When we first started hearing this, we went to the Centers for Medicare & Medicaid Services (CMS) and voiced our concern. The end result was that MLN Matters article that was posted just two weeks ago. We asked CMS to be broader and stronger than they ended up with their message. Unfortunately, other than individuals contacting advocacy groups and some anecdotal information, we’re not going to be able to figure this out for a bit. We’re also monitoring from a data perspective — working with the IT companies and data analytics companies — to try to get some real-time information as to what might be changing.

It’s obviously still early, but has NAHC noticed or learned of any shifts in referral patterns because of PDGM?

During our webinars, one of the questions we ask is, “Have [providers] seen a change in the nature of patients referred to the home health agency?” About 85% of the respondents are indicating no change.

We’re starting to catch word of home health providers gearing up for the coronavirus. Is this something on NAHC’s radar?

Coronavirus is at the center of the radar at the moment. It is a major concern. Apart from delivering care in the home, you also have to think of things like conferences, mass gatherings. We have a whole series of PDGM Summits scheduled starting March 30. But that’s secondary to the patient-level concern.

My first response has been that in-home care is actually one of the steps that people should be looking at relative to dealing with the virus. The isolation of infected people is one of the steps that has been taken in China and elsewhere. Care in the home is a way of keeping that person from infecting others.

Although, when we look at our patient population, they’re not likely carriers. They’re likely to be the ones who are infected by someone who comes into their home because they’re homebound, so they’re not transmitting. How do you care for them? There is a series of infection protocols that have been in place for years. So, we’re getting the information out to the home health agencies and the hospices in that respect.

Are there any challenges providers should start preparing themselves for? I’m thinking of supply shortages maybe or a sudden influx of patients.

I think the answer to both is “yes.”

On the second item, we have connected with the Authorization and Appropriations committees of Congress to try to get a waiver of the homebound requirement to allow individuals who are in need of some services to receive them.

How do you see home health providers fitting into the possible national response to an outbreak?

This is one of those times when the home health agencies have to figure out where the balance is to be struck between the safety of their staff and caring for the patients that they have. When you have patients who are on service already, they are absolutely the priority for care. One of the things we suggest is that agencies take a look at their ability to meet their current patient census. That’s going to be an individualized judgment to be made by each and every home health agency. We start with the premise that agencies have two responsibilities, their staff safety, and their patient’s needs. That may mean all hands on deck at some point in time, just as it might happen in flu season. This is a more serious risk because the mortality rate is much higher than the flu — and there’s no vaccine.

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