Post-Acute Care Policy Expert: PDGM May Support COVID-19 Treatment

The COVID-19 pandemic is overloading hospitals, prompting uncertainty about adequate space and supplies to deal with each patient. In order to diversify resources, the home-based care industry will need to play a crucial role.

Soon, home-based care agencies will have to care for their traditional patients and an influx of new ones. That includes those who have been directly affected by COVID-19 and those who think home-based care is now the best way to avoid it.

Faced with an unprecedented situation, there’s a whole lot for the industry to consider, David Grabowski, a health care policy professor at Harvard University, told Home Health Care News.


Grabowski’s work is concentrated on the economics of aging, with a focus on post-acute care and long-term care. In his career, Grabowski has served on a number of Centers for Medicare & Medicaid Services (CMS) technical expert panels; he is also a current member of the Medicare Payment Advisory Commission (MedPAC).

HHCN connected with the Harvard professor to discuss why more focus needs to be placed on home-based models, what CMS can do to help the home-based care industry and staffing issues that could arise, among other topics.

Below are highlights from the conversation, edited for length and clarity. This conversation was inspired by a recent thread that Grabowski posted on Twitter.


HHCN: One of the things you recently mentioned in a Twitter thread was the focus on overwhelming the supply of hospital intensive care unit beds, and how there’s a lack of attention being paid to where the patients are going to go after the hospital. Why do you think that is?

Grabowski: I think we’re taking one problem at a time. The problem right in front of us is: How do we manage those ICU beds? Very soon, we’re going to need to confront this idea that individuals will need to be discharged from the hospital to make room for new patients. If we’re going to do that in a safe way, we need to start planning today. That means increasing the capacity of the post-acute care (PAC) sector and also increasing its capabilities around treating patients with the coronavirus, but also safely treating those patients without the virus. How do we both isolate and treat patients with coronavirus, but also minimize any cross-infection with those other patients?

I think we’ve been playing catch up in a lot of ways. And I would assert that increasing our PAC capacity and capability is actually an opportunity for us to get ahead a little bit. Because you’re going to have this wave of patients hitting hospitals, and obviously they need to go somewhere after that. Let’s start thinking today about some creative ways to create different options.

In regards to managing the hospitalization and subsequent releases of these coronavirus patients, won’t that be nearly impossible without heavily relying on home-based care?

I think we’re going to have to use home-based models.

Let me start with just the facility problem — it’s a capacity problem. We don’t have excess numbers of SNFs, long-term care hospitals or other options in these markets. I think we will try to create specialized environments for COVID-19 patients, whether that’s a hospital-based skilled nursing facility or a long-term care hospital in the market.

One could imagine the creation of centers of excellence, specialized environments where individuals are receiving services.

Another idea for hospital capacity — and I think Governor Cuomo in New York advanced this — is using the Army Corps of engineers to retrofit college dormitories or unused military buildings as hospital space. One could imagine doing that with facility-based care as well.

Both of those options are challenging, whether you’re talking about retrofitting buildings or creating centers of excellence. They also, in some ways, can only go so far. So then we still turn to: How do we get individuals services following a hospital discharge? Home health is going to be a big part of this. I think the good news is that individuals are isolated in their homes in a way that [others would not be]. So whether or not you have the virus, you’re going to be isolated in your home. And I think that that prevents a lot of the spread issues. And obviously, the issues we saw out in Kirkland, Washington, really were a huge wake-up call about what happens in a facility-based environment with the spread of this virus, so I really like the home home-based model.

You [still] have the traditional home health population, and that’s going to continue to be a model that the agencies will treat. And then there may be some changes, in terms of patients who are usually discharged to a SNF, they are now going to be discharged to the home so there may be some increase in traditional patients.

But you’re also going to see this influx of COVID-19 patients, and how do you think about ramping up home health preparedness for that population? I really want to stress two points here: The first is that we really need to train staff and protect staff in terms of infection control, and give them all of the protective equipment to offer those services safely. If home health agencies are going to provide care for COVID-19 patients, they really need to protect the staff.

The second part is: Will these patients require a set of services that aren’t in the bundle of traditional services that a home health agency provides? Are there more advanced clinical services that these individuals will need? And that’s a place where home health could be a really good complement to other sets of services, like telemedicine, for example. Again, I think we will need to be creative here and think outside the box.

It’s a tall task to convince workers to go into places where they could potentially get sick. Do you think home health agencies will be able to manage that better?

I think they’re gonna face the same sets of challenges. Right now, there’s a lot of fear. And I think that the ways that we can really help staff are to explain to them what are the best practices around infection control, and then give them the equipment that allows them to provide these services safely in the home.

But if you’re going to go home to home, you’re really going to want to make certain that you’re following best practices around not spreading this to other individuals across households. All of the same issues that we’ve raised in the facility environment would be present [in home health]. So I do think staffing is still going to be a concern.

I know agencies have struggled with getting adequate numbers of staff right now with schools being out and lots of potential staff having issues trying to find coverage for their kids and being worried about the virus. I’m just concerned whether all the staffing shortages that we’ve seen are going to be magnified in the coming coming weeks.

Also, if we’re going to expect staff to provide these services right now, which are really important, we need to value that. And we need to do everything we can to both compensate them better, but also ensure that if they get sick, they’re going to have paid sick leave.

If a worker is not feeling well, they should stay home. And [paid sick leave] would provide compensation for them while they’re recovering so that they don’t feel that they need to go and support their family and potentially get patients sick.

The last part of this, if you’re asking people to do this work, we really need testing. We need testing at the hospital when patients are being discharged so we know what we’re getting into as a home health agency. But we also need to be testing staff regularly so that the minute somebody is positive, even if they’re not showing symptoms, they need to go in isolation and stay away from these older adults so that they don’t spread the virus further.

Do you think SNF-at-home or hospital-at-home models could play a critical role?

I think they can play a role. I think the hard part with all of this is still staffing — and how do you create these models out of the blue? There are some companies that do this around the country. But they’re largely not paid by traditional Medicare.

I think they can be a part of this. And to the extent we can, we should ramp up these models. People like them, too. The data to date suggests they offer really good services, very comparable to individuals receiving services in a traditional institutional hospital. The issue is just scale. I would love to see hospital-at-home or SNF-at-home models, especially for those higher-acuity individuals.

I think there’s going to be a group of patients for whom home health agency services are going to be appropriate and adequate, and then there’s going to be another group of individuals who need a lot more services. And if we don’t have the facility-based capacity, what about developing this hospital-at-home or SNF-at-home type model for those individuals? I think anything we can do to build those models in the short term here, we should start.

We should definitely consider paying for that at parity. And I think there’s other roles here for Medicare as a payer. There’s going to be increased costs for COVID-19 patients, whether it’s for a home health agency, a skilled nursing facility or a long-term care hospital, just in terms of infection control, isolation and the preventive gear — everything that’s going to go into their treatment.

Medicare should pay an enhanced rate to home health agencies and other PAC settings to encourage the treatment of those patients, but also to fairly compensate them for it so they can offer high quality care.

These agencies were already dealing with RAP phase outs and the switch to the Patient-Driven Groupings Model (PDGM). Do you think that any of these payment changes should be temporarily suspended?

For home health, we’re in the first quarter here of the new payment system. It’s really going to make it challenging to sort of figure out all these different moving parts.

But at a high level, there may be something about PDGM that’s actually supportive about it for this new type of patient who might need services in the context of this epidemic. By paying for patient characteristics, we’re encouraging home health agencies to take on higher-acuity patients with more medical complexities. It sounds like that might be the type of patient that’s emerging during this epidemic.

I think the RAP payments, that might be something that the CMS would want to revisit. I think the broader payment reform can work in the context of COVID-19. If it’s a liquidity issue for these agencies, I certainly think that getting additional dollars for the care of COVID-19 patients is going to be really important.

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