How to Improve Patient Outcomes Under PDGM

The Patient-Driven Groupings Model (PDGM) is a new reimbursement model implemented by the Centers for Medicare & Medicaid Services (CMS) for home health agencies. It replaced the Prospective Payment System (PPS) on January 1, 2020, with the aim of improving patient outcomes and ensuring that home health agencies deliver high-quality, cost-effective care. Under PDGM, patient outcomes are largely tied to clinical severity, comorbidities, functional impairment, and care needs. While the transition to PDGM has been challenging for many agencies, it also presents an opportunity to enhance patient outcomes by focusing on patient satisfaction, clinical quality, and efficient care delivery.

In this blog, we will discuss practical tips for home health agencies to improve patient outcomes under the PDGM structure. These strategies will focus on optimizing patient care, fostering patient engagement, improving operational efficiencies, and navigating the unique elements of the PDGM model.

Understanding PDGM: A Quick Overview

Before diving into strategies for improving patient outcomes, it’s essential to understand how PDGM works. Under PDGM, the payment for home health services is determined based on two primary factors:

1. Clinical grouping: This refers to the patient’s primary diagnosis, comorbidities, and the clinical severity of their condition.
2. Functional impairment: Based on the patient’s ability to perform Activities of Daily Living (ADLs), such as bathing, dressing, and eating.

The PDGM structure also categorizes patients by their timing of care, either early or late in the episode, as well as by the presence of certain comorbidities. As a result, PDGM is more patient-centered and emphasizes personalized care plans. The focus on outcome-based reimbursement incentivizes home health agencies to improve clinical quality and patient satisfaction.

Now, let’s explore practical tips to help home health agencies improve patient outcomes under PDGM.

1. Optimize Patient Assessment and Documentation

Accurate patient assessment is crucial in PDGM because the clinical grouping and functional impairment codes directly impact reimbursement. Ensuring that the patient’s health status is thoroughly assessed at the start of care and that all comorbidities and severity levels are properly documented is key to improving outcomes.

Practical Tips:

• Comprehensive Initial Assessment: Perform a detailed and thorough initial assessment, including a review of the patient’s medical history, medications, comorbidities, and functional status. This will help ensure that you are categorizing the patient correctly under the PDGM system.
• Regular Re-assessment: PDGM reimbursement takes into account the patient’s condition over the full 30-day period. Regular assessments should be made to track any changes in the patient’s condition and adjust the care plan as necessary.
• Ensure Accurate Documentation: Documentation is critical under PDGM. Ensure that your clinical notes, OASIS assessments, and other relevant documents reflect the patient’s current status, comorbidities, and functional limitations accurately. Incorrect documentation could lead to improper coding and potential reimbursement issues.

2. Enhance Care Coordination and Communication

Effective communication among the care team members (nurses, therapists, social workers, etc.) and between the agency and the patient’s physician is essential under PDGM. PDGM incentivizes high-quality care, and care coordination plays a significant role in improving outcomes, reducing unnecessary hospital readmissions, and enhancing patient satisfaction.

Practical Tips:

• Multidisciplinary Team Approach: Form a multidisciplinary care team that includes not just the primary care providers but also physical therapists, occupational therapists, and social workers. This ensures that the patient receives well-rounded care addressing all of their needs, including clinical, functional, and psychosocial aspects.
• Clear Communication Channels: Establish clear channels of communication between the home health agency and external providers, such as the patient’s physician, hospitals, and specialists. This improves information flow, enabling timely adjustments to the care plan when necessary.
• Care Plan Updates: Continuously monitor the patient’s progress and update care plans regularly to reflect any changes in their clinical or functional status. This is particularly important under PDGM, where patient conditions can vary, and reimbursement depends on timely and accurate assessments.

3. Implement Patient-Centered Care Practices

PDGM is designed to be more patient-centric, and improving patient outcomes requires a focus on personalized care. The more individualized the care, the better the potential for improved outcomes and higher patient satisfaction scores.

Practical Tips:

• Tailored Care Plans: Design care plans that are specifically tailored to the patient’s unique needs, rather than offering a one-size-fits-all approach. Take into account the patient’s functional abilities, preferences, and goals for recovery when developing a care plan.
• Patient and Family Engagement: Involve patients and their families in the care planning process. Understand their concerns, preferences, and goals for care. This promotes a sense of ownership and can lead to higher patient satisfaction and better adherence to the care plan.
• Patient Education: Provide patients with clear education about their condition, treatment plan, and what they can do to improve their outcomes. Educating patients about self-management and health promotion can help reduce hospital readmissions and improve overall health.

4. Focus on Functional Improvement

Under PDGM, patient outcomes are closely tied to functional improvement, as agencies are incentivized to improve a patient’s ability to perform Activities of Daily Living (ADLs). Focusing on functional improvement is critical to maximizing both patient satisfaction and clinical quality.

Practical Tips:

• Comprehensive Rehabilitation: Ensure that physical and occupational therapy is an integral part of the care plan for patients with functional impairments. A customized rehabilitation program designed to enhance mobility, strength, and independence can significantly improve outcomes.
• Monitor Functional Progress: Regularly track functional improvement through standardized assessment tools, such as the Outcome and Assessment Information Set (OASIS). This will provide insight into the patient’s progress and help adjust the care plan as needed.
• Promote Independence: Whenever possible, encourage and assist patients in regaining independence in performing ADLs. This not only improves the patient’s quality of life but also reduces long-term care costs.

5. Reduce Readmissions Through Proactive Care

One of the goals of PDGM is to prevent unnecessary hospital readmissions. Home health agencies can improve patient outcomes by focusing on preventive care, early intervention, and close monitoring to reduce avoidable hospital visits.

Practical Tips:

• Timely Intervention: Monitor patients closely for any signs of deterioration in their condition, such as sudden weight changes, worsening of chronic conditions, or infections. By identifying these issues early, you can intervene before they require hospitalization.
• Care Transitions: Ensure a smooth transition of care when patients are discharged from the hospital to home health services. This includes a clear and detailed discharge plan from the hospital, proper medication reconciliation, and education for both patients and caregivers.
• Post-Care Follow-Up: Implement a structured post-discharge follow-up system to check in on patients after they have transitioned from the hospital to home health care. This can include regular phone calls or in-person visits to ensure that the patient is adhering to the care plan and recovering well.

6. Leverage Technology to Streamline Care Delivery

Technology can significantly improve care coordination, patient monitoring, and communication within a home health agency. By leveraging technology, agencies can optimize their operations and improve patient outcomes.

Practical Tips:

• Electronic Health Records (EHR): Use EHR systems to track patient data, including assessments, interventions, and outcomes. EHRs provide a centralized platform for clinicians to access up-to-date information, which can improve the timeliness and quality of care.
• Telehealth: Integrate telehealth services into your home health model to improve access to care. This is especially beneficial for patients who may have difficulty traveling to appointments or those living in rural areas. Telehealth can be used for follow-up visits, medication management, and chronic disease monitoring.
• Remote Monitoring: Consider implementing remote patient monitoring tools to track patients’ vital signs, such as blood pressure, blood glucose, and oxygen levels, in real-time. Early detection of any abnormalities can help prevent complications and readmissions.

7. Foster a Culture of Continuous Improvement

Improving patient outcomes under PDGM requires a commitment to quality improvement and a culture of ongoing evaluation. Home health agencies must continuously assess their practices and outcomes to identify areas for improvement.

Practical Tips:

• Regular Audits: Conduct regular audits of patient records, care plans, and clinical outcomes to ensure compliance with PDGM guidelines and identify areas for improvement.
• Staff Training and Development: Provide ongoing training for staff on PDGM regulations, best practices, and clinical guidelines. This ensures that everyone is aligned with the agency’s goals and stays up-to-date with the latest developments in home health care.
• Patient Feedback: Collect patient feedback through surveys or direct communication to identify areas where patient satisfaction could be improved. Use this feedback to make adjustments in care delivery and enhance the overall patient experience.

Conclusion

PDGM has changed the way home health agencies operate, emphasizing the need for quality care, patient satisfaction, and efficient delivery of services. By focusing on comprehensive patient assessments, care coordination, patient-centered practices, functional improvement, and technology integration, home health agencies can improve patient outcomes within the confines of the PDGM structure. With a commitment to continuous improvement, home health agencies can meet the challenges of PDGM while delivering exceptional care and improving the health and well-being of their patients.