COVID-19, PDGM Hit Home Health Therapy Staff with ‘Double Whammy’

More than six months have passed since the Patient-Driven Groupings Model (PDGM) took effect. Despite the ample runway, many home health providers are seemingly still adjusting their therapy strategies, prolonging the initial layoffs, pay cuts and furloughs that took place at the beginning of the year.

The coronavirus is largely to blame for the continued therapy adjustments.

“We probably saw a lot more effects of … the COVID crisis than we did with the inception of PDGM,” Diana Kornetti, president of the American Physical Therapy Association’s (APTA) home health section, told Home Health Care News. “That was like the double whammy, like the other shoe landing. … That really had a greater impact on a lot of therapists’ ability to be gainfully employed during the pandemic.”


Alexandria, Virginia-based APTA represents 100,000 physical therapists (PTs), PT assistants and PT students. PTs generally focus on patients’ ability to move their bodies, with more than 70% of all home health therapy visits completed by PTs, according to Kornetti.

Meanwhile, occupational therapists (OTs) focus on improving patients’ ability to perform activities of daily living (ADL). They’re represented by the Bethesda, Maryland-based American Occupational Therapy Association (AOTA), which has more than 213,000 members.

Exact data on how PDGM and COVID-19 have affected the home health therapy world are difficult to come by. But anecdotal reports and some early data from trade organizations such as APTA and AOTA help paint a picture of the combined impact on PTs and OTs nationwide.


COVID-19’s therapy impact

While PDGM changed therapy reimbursement by basing payment more on patient characteristics rather than service volume, the Centers for Medicare & Medicaid Services (CMS) gave providers months to prepare for the new framework.

COVID-19, on the other hand, instantly disrupted therapy delivery in a number of unpredictable and unavoidable ways.

For one, it led to a nationwide, weeks-long pause on elective surgeries, which are often a starting point for home health therapy recipients.

On top of that, fear of contracting the virus prompted many home health patients to decline service or only accept telehealth-enabled visits, which currently aren’t reimbursable for agencies. Additionally, some states failed to designate therapists as essential workers.

All of those factors have had a “dramatic” impact on home health therapy delivery, leading in some cases to layoffs and involuntary visits reductions, according to Kornetti, a physical therapist by training.

HHCN has connected with home health providers that have seen it play out first-hand.

“Therapy is in a tough situation right now,” Brent Korte, chief home care officer at Seattle-area EvergreenHealth Home Care, told HHCN in April. “We have seen a sharp increase in nursing, but our therapy visits have probably seen the most drastic decrease.”

Interim HealthCare CEO Jennifer Sheets echoed that experience.

“We are seeing some decline in home health cases, specifically therapy-led cases,” Sheets told HHCN, also in April. “That’s mainly due to cancellation of elective orthopedic surgeries like knee or hip replacements.”

AOTA members have detailed similar stuggles, according to Jennifer Bogenrief, the organization’s assistant director of regulatory affairs.

“Practitioners have reported that COVID-19 makes it more challenging for occupational therapy practitioners to be able to see the patients who need OT services,” Bogenrief told HHCN in an email. “AOTA continues to monitor the situation and seek feedback from practitioners working with [home health agencies] to ensure that Medicare beneficiaries receive medically necessary occupational therapy services.”

Furthermore, APTA conducted a survey of members April 24 through May 11. It found that 44% of PTs and 54% of PT assistants saw income decrease during the COVID-19 crisis.

Meanwhile, 17% of PTs and 27% of PT assistants were furloughed; Another 5% of PTs and 13% of PT assistants lost their jobs.

PDGM before the coronavirus

Comparatively, Kornetti believes COVID-19 has had a bigger impact on home health therapy delivery than PDGM. Yet it’s worth noting that many industry leaders overestimated the impact PDGM would have on therapy delivery.

Before the coronavirus, only 24% of home health workers said their organizations had let go of therapy staff due to PDGM, according to an online survey conducted by HHCN. Most of those who reported reductions said the cuts were minor, representing 20% or less of their overall therapy staff.

One reason for PDGM’s better-than-expected therapy impact could be CMS’s guidance warning home health agencies against making drastic changes to therapy delivery.

“The need for therapy services under PDGM remains unchanged,” CMS wrote. “Therapy provision should be determined by the individual needs of the patient without restriction or limitation on the types of disciplines provided or the frequency or duration of visits.”

Data suggests providers have largely opted to readjust their therapy staff and strategies in different ways, such as modifying job positions and altering case loads, among other tweaks.

More than half of HHCN’s 480 Medicare-certified home health survey respondents reported a substantial drop in overall therapy utilization as a result of PDGM.

The various changes have drawn both praise and criticism from industry leaders.

Bogenrief sits in the latter camp. She told HHCN that AOTA continues to hear from OTs who have been negatively impacted by PDGM.

The organization’s latest survey on that impact wrapped April 1. It yielded 693 responses from therapy practitioners nationwide.

About 82% of respondents said that their home health agency had implemented new requirements to reduce the number of OT visits to patients as a result of PDGM.

“One frequently reported change that concerned many respondents was the use of predictive analytics tools that use algorithms to determine how many therapy visits (if any) should be provided based on diagnosis, even before therapy evaluations are completed,” Bogenrief said. “Respondents also voiced concerns in their comments that their clinical judgment was being overridden or ignored. We also heard that physician orders for OT were ignored or shifted to other disciplines.”

Meanwhile, Kornetti and APTA were less critical of PDGM, noting that therapy reimbursement was too volume-driven pre-PDGM.

“We … are in strong support that there needed to be a readjustment of this volume-based mentality because more was not … producing better outcomes necessarily,” Kornetti said. “We think this adjustment was warranted and was indicated in the industry.”

APTA co-conducted a survey of more 1,700 therapists pre-COVID-19. It showed a preponderance of caseload and position changes.

“A little over 40% had changes in their caseload to the negative,” Kornetti said. “In other words, they weren’t getting as many visits or seeing as many people as they did prior to PDGM — so there was an impact, … I just don’t think it was a massive layoff and reduction of service delivery in the home health setting.”

As the coronavirus continues, therapy’s importance will only continue to grow, with studies showing therapy a valuable asset in COVID-19 recovery.

“Folks are coming out [of the hospital] with the inability to walk, poor strength [and] fall risks,” Paul VerHoeve, CEO for San Diego-based home health and hospice services provider Mission Healthcare, told HHCN. “Therapy has become something that we weren’t originally anticipating being a big part of COVID [but] has been a much, much larger-used service line with many of these COVID patients within home health. … With all … the impacts on therapy in PDGM for home health, this has been a way to continue to have really active therapists involved in care plans.”

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