PDGM: What Does It Mean for Rehospitalization Rates in Home Health?

PDGM: What Does It Mean for Rehospitalization Rates in Home Health?

The Patient-Driven Groupings Model (PDGM) has introduced significant changes to the way home health agencies (HHAs) are reimbursed for services provided to patients. Implemented by the Centers for Medicare & Medicaid Services (CMS) in January 2020, PDGM replaced the previous Prospective Payment System (PPS) with a more patient-centric approach. This shift has far-reaching implications, not just for reimbursement but also for patient care, particularly in managing rehospitalization rates, which have long been a concern in home health.

In this blog post, we will explore the potential impact of PDGM on rehospitalization rates in home health, how it changes the way agencies provide care, and what strategies home health agencies can adopt to manage care effectively in order to reduce the risk of hospital readmissions.

Understanding PDGM and Its Core Changes

Before delving into the specifics of how PDGM affects rehospitalization rates, it’s important to understand the core elements of this new payment model.

PDGM was introduced as a way to incentivize better patient care outcomes rather than simply paying based on the volume of services provided. The previous PPS model reimbursed home health agencies based on 60-day episodes of care, regardless of the patient’s acuity level. Under PDGM, this has been replaced with 30-day episodes, and reimbursement is based on a number of factors, including:

• Primary Diagnosis: The patient’s primary diagnosis for which they are receiving home health services.
• Comorbidity Adjustment: The presence of additional health conditions that could complicate the care process.
• Functional Impairment Level: The degree of physical and cognitive limitations the patient has, influencing the amount of care required.
• Admission Source: Whether the patient is admitted to home health from an inpatient facility (hospital or skilled nursing facility) or another source (e.g., physician’s office).
• Timing of Admission: Whether the admission is during an early or late period in a patient’s care cycle.

Under PDGM, there is an emphasis on more accurate diagnosis coding, which helps to determine the level of care needed and the corresponding reimbursement. With these changes, home health agencies must be more precise and diligent in assessing and managing patients to optimize outcomes.

The Relationship Between Home Health and Rehospitalization Rates

Rehospitalization rates, or readmission rates, are a critical quality measure in home health care. When patients are discharged from the hospital and then readmitted within a short period, it is an indicator that their initial care plan may not have fully addressed their needs or that follow-up care post-discharge was insufficient. Readmissions can also be costly for both patients and healthcare systems, contributing to longer recovery times, financial strain, and a decreased quality of life for patients.

Home health agencies play an important role in preventing rehospitalizations by providing timely, in-home care to manage patients’ conditions after they leave the hospital. However, the relationship between home health and rehospitalization rates is complex. Rehospitalization rates may be influenced by several factors, including:

• Patient Characteristics: Severity of illness, age, and multiple comorbidities are all risk factors for rehospitalization.
• Quality of Home Health Care: Proper monitoring, medication management, and patient education during home health visits can prevent unnecessary hospital readmissions.
• Coordination of Care: Effective communication between hospitals, home health agencies, and other providers ensures that patients receive appropriate follow-up care, reducing the chances of rehospitalization.

Given these dynamics, PDGM’s focus on patient characteristics and clinical complexity offers a nuanced approach to rehospitalization prevention. In the context of PDGM, understanding how patient diagnosis and comorbidity are factored into reimbursement can offer insights into how home health agencies might manage their care processes to prevent readmissions.

How PDGM Can Impact Rehospitalization Rates

1. Incentivizing Better Patient Care Outcomes

One of the key goals of PDGM is to improve patient outcomes, which includes reducing rehospitalization rates. In the past, home health agencies were incentivized to provide more services without necessarily focusing on the quality of care. PDGM shifts this incentive by paying based on the patient’s individual health needs and expected clinical complexity, rather than the volume of care provided.

Because the reimbursement under PDGM is closely tied to patient characteristics (such as functional impairments and comorbidities), home health agencies are motivated to offer more targeted, tailored care. This shift can result in more effective treatment and better patient management, potentially reducing the likelihood of rehospitalization.

For example, patients with multiple comorbidities and functional impairments may require more intensive and frequent monitoring and care. By accounting for these complexities in the reimbursement structure, PDGM encourages agencies to provide the necessary services to manage these patients and avoid unnecessary hospital readmissions.

2. Shorter Care Episodes and More Frequent Monitoring

Under PDGM, home health services are now delivered in 30-day periods, as opposed to the previous 60-day episodes under PPS. This shorter period allows home health agencies to reevaluate patient needs more frequently and make adjustments to care plans as necessary. Regular reassessment can improve the management of patients’ conditions, making it easier to catch early signs of deterioration or potential complications before they lead to rehospitalization.

More frequent care periods mean that patients are monitored closely, which allows home health providers to intervene sooner if a patient’s health starts to decline. This could involve coordinating with physicians, adjusting medications, or changing the care approach to address specific issues before they require hospitalization.

3. Impact of Diagnosis Coding and Clinical Complexity

A critical element of PDGM is the emphasis on accurate diagnosis coding and the adjustment for clinical complexity. By ensuring that diagnosis codes accurately reflect the patient’s condition and the level of care required, PDGM helps establish a more detailed picture of the patient’s health. This information can guide care teams in addressing the right areas to prevent rehospitalizations.

For instance, if a patient has a complex condition, such as heart failure or chronic obstructive pulmonary disease (COPD), the care team will be more attuned to managing those conditions through better monitoring and treatment plans. Proper coding allows agencies to receive appropriate reimbursement for the level of care needed, ensuring that resources are allocated effectively to prevent readmissions.

4. Risk Adjustment for Readmissions

A direct consequence of PDGM’s focus on patient complexity is the ability to account for patients at higher risk of rehospitalization. The model’s risk-adjusted approach ensures that patients who require more intensive care are identified early and given the appropriate interventions. Home health agencies can leverage this information to put in place more aggressive or proactive strategies to reduce readmission risk.

With this in mind, HHAs can focus on enhancing care for higher-risk patients, such as those with chronic conditions or those recently discharged from the hospital. This could include additional home visits, telehealth consultations, or more frequent coordination with the patient’s medical providers.

Strategies for Reducing Rehospitalization Rates Under PDGM

Home health agencies are under increasing pressure to not only improve patient outcomes but also manage their reimbursement under PDGM effectively. To prevent hospital readmissions, HHAs can adopt the following strategies:

1. Early Identification of High-Risk Patients

Using risk assessment tools, home health agencies can identify patients at higher risk for rehospitalization right from the start of the care episode. Patients with certain comorbidities, functional impairments, or those with a recent hospital discharge should be flagged for more intensive monitoring and follow-up care. By recognizing these high-risk patients early, agencies can implement preventive measures to reduce the chances of rehospitalization.

2. Care Coordination and Communication

Effective communication and coordination between home health agencies, hospitals, and other care providers is crucial to preventing rehospitalization. This includes sharing information about the patient’s condition, medication regimen, and any changes in their health status. Strong care coordination ensures that all providers involved in the patient’s care are aligned and can respond quickly to any emerging concerns.

3. Telehealth Integration

Telehealth services can be an effective tool for reducing rehospitalization rates, especially under the more frequent 30-day care periods under PDGM. With telehealth, clinicians can remotely monitor patients’ vital signs and other health indicators, which helps in identifying problems early. Remote consultations can allow providers to make real-time adjustments to care plans without waiting for the next in-person visit, potentially preventing an escalation of symptoms that could lead to rehospitalization.

4. Patient and Family Education

Providing patients and their families with proper education about managing their conditions at home is essential in reducing the risk of rehospitalization. By teaching patients how to recognize warning signs and follow their prescribed care regimens, HHAs can empower patients to take an active role in their recovery. This can include education on medication adherence, diet, exercise, and proper self-care techniques.

5. Post-Discharge Follow-Up

Ensuring that home health services begin promptly after hospital discharge is key to preventing rehospitalization. Patients discharged from the hospital are often at higher risk of complications, so having home health visits scheduled early can help monitor their recovery and address issues before they escalate. Additionally, ensuring that patients have access to follow-up care from their physicians and specialists can reduce the need for readmission.

Conclusion

PDGM represents a shift towards more patient-centered care in home health, with a greater emphasis on managing patient complexity and ensuring that home health services are tailored to meet individual needs. While this shift holds promise for improving patient outcomes, including reducing rehospitalization rates, it also presents new challenges for home health agencies. By adopting strategies like early risk identification, enhanced care coordination, and utilizing telehealth tools, agencies can improve their ability to prevent unnecessary hospital readmissions, ultimately benefiting both patients and the healthcare system at large.

As home health agencies continue to adapt to the changes brought by PDGM, it will be important for them to remain focused on the ultimate goal: providing high-quality, patient-centered care that keeps individuals in their homes and out of the hospital.