Background 

Patient Driven Grouping Models (PDGM) went into effect January 1, 2020, and was the single most significant change to home health care (HHC) in the past 20 years. The ultimate end goal of PDGM was to reduce the cost of HHC delivery and better align HHC services with patient needs.  The intent was to encourage value over volume to allow patient acuity and characteristics to determine and drive payment. In addition, PDGM initiated a 30-day billing period as compared to the previous 60-day period although kept the physician driven plan of care at 60 days. It eliminated the Request for Anticipated Payment (RAP) at the start of care and eliminated volume of therapy visits as a determinate of reimbursement. 

How does the PDGM work? 

Under PDGM, the national, standardized 30-day payment rate is based on and adjusted for case mix with the potential for 432 case-mix payment groups as compared to 153 in the previous model. While this appears to be a more complex, complicated process, it ultimately is more accurate.

The case mix is determined by several subgroups including the following:

• Admission source (community verses institutional)
• Timing of the referral (early or late)
• 12 clinical groupings (including surgical aftercare/wounds)
• Functional impairment (low, medium, high)
• Co-morbidity adjustment based on secondary diagnoses (none, low, high)

What is LUPA? 

When the 30-day period involves an unusually large number or costly mix of visits based on disciplines, the HHC may be eligible for an additional outlier payment.  Each case mix group is assigned a low utilization payment adjustment (LUPA) visit threshold.  If a HHC provides fewer visits than the threshold, it will receive a standardized per-visit payment rate rather than the case-mix 30-day rate. 

Key aspects for getting wound care patients in the right case-mix  

Accurate diagnoses, billing, coding, documentation and a good understanding of the Outcome and Assessment Information Set (OASIS) are imperative to success under PDGM in getting the patient in the right case-mix especially when it comes to wound care patients.  The wound clinical grouping is potentially one of the higher reimbursements.  If wound patients are managed correctly, effectively and efficiently, they can increase revenue.  When they are not, things may look a bit different from a patient outcome perspective and fiscal accountability may be challenged. 

Years into PDGM, where do you stand?  

How do you know?  What should you look at and how do you start the analysis?

An internal analysis is a given and a good place to begin is to take stock of where you are today as an organization as compared to the initiation of PDGM. There are many tools that can be utilized to facilitate a data driven, fact based, realistic look into an organization. Tools like SWOT (Strengths, Weaknesses, Opportunities and Threats) can provide a framework to start your journey and strategically determine and develop next steps.  

Develop a standardized approach 

• Consider putting together a diverse group of people within the organization and understand the role each of these may play in affecting success.
• Encourage everyone to speak freely, share thoughts and insights and provide honest feedback. 
• Remember, not all factors are always of equal importance and distinguishing between where the biggest impact can be made to improve performance can easily become misguided. 
• Regardless of the model you choose to work under, keep in mind this isn’t a one-time exercise, it should be repeated at regular intervals to stay on task and continuously evaluate if your approach is working. 

Success under PDGM specifically with your wound population requires vigilance and focused analysis. When drilling down your analysis on wound patients, think about the following:

• Identify the goal(s)
• What exactly are you trying to achieve with your wound population now? 
• Do you want to increase referrals for wound patients?
• Are you looking to build a “best in class” wound program internally with subject matter experts (SMEs), a telehealth program, consultation services with the ability to remote in with clinicians and patients during visits and assist with case management?  Or are you looking to outsource consultation services from SMEs who can fill this need?  Maybe you are just trying to get an SME in place to provide guidance on policy, competency, and wound education.  There isn’t only one way or one right answer.
• Analyze your wound population
• How many, what etiologies, average days to healing or discharge, average length of stay overall and by etiology, visit utilization, identification of high risk wound patients. 
• Do you have data insight into your wound patient population? 
• How often can you get this information?  Is it available daily via a dashboard or do you have to “run a report” or ask someone else to retrieve the data?
• Is it available in real time or is the data retrospective?  If so, is this enough?
• Analyze your referral sources 
• Do you need to adjust how and to whom you market to?
• What is the right mix of wound patients your staffing model can safely care for and continue to be fiscally responsible?
• Analyze CMS publicly reported outcomes related to wounds
• Where do you stand regarding your competitors? For example, Outcomes trends (Improvement in status of surgical wound) and Potentially Avoidable Events (increase in number or severity of pressure injuries, discharge to the community with an unhealed stage 2 pressure injury)
• Acute Care Hospitalization (ACH) rate overall and specifically for wounds.
• Analyze risk mitigation
• Do you have policies and procedures in place, a competency program, education for clinicians and patients.
• Do you have a formulary for advanced wound care products?
• How do you ensure you are providing evidence-based care?
• Do you have clinical algorithms, pathways, goals, interventions and details?
• Do you understand state discipline specific practice acts? 
• Are you prepared for surveys?
• Do you have a wound program internally? Outsourced? Do you have any wound SMEs and how are they functioning?
• Analyze electronic medical record (EMR) function
• Is your EMR working for you? 
• Is it customizable?
• Does it help mitigate risk with wound patients?  If not, what can be done?
• Does it provide a place for standardized assessment and documentation for wounds?
• Does it provide a standardized approach for wound tracking (progression, regression, stagnation) for early intervention.
• Analyze accurate documentation, coding and billing 
• An in-depth understanding of OASIS integumentary section.
• How do you ensure accuracy with coding? 
• Who codes?  Everyone or a specific group with advanced draining? Do you outsource this?

Conclusion

In conclusion, when we think back to 2020 and the implementation of PDGM, we frequently heard conversations and discussions that ended with “time will tell” as far as our ability to successfully adapt to PDGM and care for wound patients successfully.  Years later, CMS continues to incentivize value. 

What we have learned is improved quality care and best outcomes with lower costs for wound patients is achievable under PDGM even for those that are of a higher acuity and complexity level. 

Continuing to learn and evolve with PDGM and developing a clear roadmap to follow is paramount to future successes. Where are you with your wound patients now?