by Karen Vance, BSOT, Senior Managing Consultant | Clinical Operations Specialist, BKD Health Care Group
The Patient-Driven Groupings Model (PDGM) portends significant changes to the way Medicare currently pays home health agencies (HHA) under Prospective Payment System (PPS). PDGM is an effort to transition from volume- to value-based payment. Occupational therapy (OT) can provide assistance to home health agencies (HHAs) in several ways to improve the accuracy of those payments received as well as the effectiveness of the clinical outcomes achieved.
The Centers for Medicare and Medicaid Services (CMS) summarizes the Patient-Driven Groupings Model (PDGM) as 30-day payment periods placed into different subgroups for each of the following categories:
- Admission source (two subgroups): community or institutional admission source
- Timing of the 30-day period (two subgroups): early or late
- Clinical grouping (twelve subgroups): musculoskeletal rehabilitation; neuro/stroke rehabilitation; wounds; medication management, teaching, and assessment (MMTA)
- Functional impairment level (three subgroups): low, medium, or high
- Comorbidity adjustment (three subgroups): none, low, or high based on secondary diagnoses.
The overview can be found here.
The biggest change from PDGM affecting therapy is the removal of therapy thresholds triggering additional payment based on combined visit utilization. PDGM accounts for therapy provision on the plan of care based on patient characteristics, namely diagnoses and functional scoring.
OT can and should assist in identifying the diagnoses or conditions that best explain the reason for the home health episode. Providing such input improves the accuracy of the clinical grouping into which the patient is categorized. In many cases, a nurse is performing the comprehensive assessment and selecting the diagnoses meant to drive the plan of care, even when the original referral may be more focused on therapy need. The nurse’s selection may also drive a less accurate clinical or comorbidity subgroup without input from OT regarding the focus and intensity of OT services.
OT involvement is most critical to ensure data accuracy when painting the picture of the patient’s functional status. The patient’s Outcome and Assessment Information Set (OASIS) scoring on grooming, dressing, bathing, transferring and mobility, as well as the risk for hospitalization, make up the PDGM functional impairment level portion of the payment. Once again, OT collaboration with other members of the home health team can greatly improve the accuracy of the data collection, and hence the accuracy of the resources available for therapy utilization on the plan of care.
The opportunities for collaboration on diagnosis and functional scoring depend, of course, on each HHA. Regardless of an agency’s current processes, OTs should make opportunities to communicate and collaborate with other disciplines about the results of their assessments. Optimizing communication technology is the most obvious, and easy, method for immediate dissemination of assessment results, particularly regarding specific areas relating to key OASIS items. Case conferences are also a wonderful venue for sharing specifics of an individual patient while simultaneously revealing assessment ideas for gathering more accurate data on all patients. For example:
- A patient’s ability to put on and take off clothing may be easily observed during a nurse’s head-to-toe assessment to answer M1810 and M1820, but environmental issues identified during the OT Activities of Daily Living (ADL) assessment may impact the patient’s ability to safely obtain clothing out of dressers or closets. A patient who has to let go of the walker to pull on a drawer that sticks, or reach too high in the closet may have compromised balance.
- A patient with chronic obstructive pulmonary disease (COPD) may be able to demonstrate getting in and out of a shower during a ‘dry run’, however standing in a warm, moist environment for twenty minutes may compromise breathing capacity.
Diagnosis coding has always been an important function of the PPS payment, however ‘muscle weakness’ has been overused to explain the need for OT services. Even though OT may be on many plans of care for patients with musculoskeletal or neuromuscular diagnoses, the most common diagnoses in home health are chronic conditions such as COPD, congestive heart failure (CHF), hypertension and diabetes. OT has much to contribute to these types of patients such as energy conservation, pursed lip breathing and environmental modifications to improve their safety and daily function. As important as it is to assist in identifying the most appropriate diagnosis, it is as important to develop a plan of care that is most appropriate to the patient.
OT contribution is indeed critical to the accuracy of data collection and coding in preparation for PDGM as well as now. However, in addition to the accuracy of payment, it is also important to remember that accurate data collection also improves the accuracy of the clinical outcomes of an agency. If OASIS items are not properly captured at the beginning of an episode, then the improvements made by the end will not be truly represented.
As mentioned earlier, agencies may not currently have processes in place for good collaboration on OASIS data collection, however OTs can make opportunities to do so and model best practice for their agencies. The American Occupational Therapy Association is developing resources and education to help with this transition. See more information at www.aota.org/value.
Watch the American Occupational Therapy Association’s (AOTA) video, Payment Shift from Volume to Value: Maximizing the Opportunity for OT 2018. This is for Post-Acute Providers including home health and the role of OTs.