Planning for PDGM: Important Now

PDGM will have an impact on every single function in the agency and planning for PDGM must begin now. Agencies that fail to plan for PDGM, can plan to fail. The new Patient-Driven Groupings Model for home care begins on January 1, 2020. Is your agency ready?

PDGM will impact your agency processes from generating referrals to discharging a patient and billing the Medicare claim. The 30-day period of care collapses the timeline for every task from securing complete documentation from the referral source at intake to ensuring timely OASIS completion, submitting the RAP and the final claim.

  • Current industry average days to RAP = 12 days
  • Under PDGM, the best practice = 3 to 5 days to RAP.

Begin Planning and Preparing Now

How? Above all, to achieve this, every single person that participates in the patient-care journey must know the part they play in efficiently managing each episode.

The focus must become a patient-centered, data-driven, outcome-oriented workflow process that promotes high-quality patient care, in real-time, for all patients and for agency compliance. Consequently, this will result in a compliant and timely billing of claims. Take the first step:

Create a PDGM Steering Committee

An agency would be well served to have staff who are very familiar with each step of the patient’s journey to be part of the agency’s steering committee. This includes members of senior leadership. Through the collaboration of a PDGM steering committee, staff in departments will become much more familiar with and have a greater understanding of what their colleagues are responsible for under PDGM. Additionally, they will understand how important care coordination and the managing of episodes will become.

Small Agencies

In smaller agencies, the management/leadership likely will have a hands-on role, directing activities, providing analysis, updating staff, identifying risk points, and working closely with clinical staff to close knowledge/skills gaps.

Larger Agencies

Larger agencies may take a different approach and make use of a multi-disciplinary team. For example, they could identify champions in each functional area who will make up the steering committee or task force. Champions will be those workers with natural leadership skills, comfortable in the role of change agent, and able to give clear direction, even to agency management.

Therefore, ideally, you will want leadership, intake manager, clinical managers, a case manager (or two), coders, and billing and collections staff on this committee. It is the workflow process of each of these areas that will need to be analyzed and modified to gather as much information as is necessary to have accurate coding, co-morbidity adjustments, OASIS assessments, days to RAP, billing and claims management.

Leverage technology

Make use of the technology updates that track data and trends. You can often find these reports on your electronic medical records system. If you and your staff do not know how to gain access to these reports, contact your EMR representative. Train all staff on how to access reports and why the reporting is important.

If your EMR is recommending a workflow process it is most likely because they have tried and have been successful with other agencies and that workflow. Don’t create workarounds.

Create dashboards for real-time performance data that have meaning to the end-user. For clinicians, this means days to OASIS completion. For coders? No more than a one day turnaround time.

Stop the cutting and pasting now. You can’t expect accuracy if you allow clinicians to cut and paste patient information. Each patient is an individual with individual needs and must be inputted as such.

Telehealth has been proven to reduce rehospitalizations because of the high level of patient oversight. Telehealth also can reduce the number of visits made to a patient in a given period.

Read more QIRT Tech Tips here.


Arguably, PDGM is the biggest change to home health agency operations since the implementation of the Interim Prospective Payment System in 1998, which did result in many agencies closing their doors. Learning from history, QIRT is strongly advising agencies to plan by assessing your financial readiness as well. As we stated earlier, under PDGM the revenue cycle is greatly accelerated. You can make changes now that will improve productivity and profitability in the short term while positioning your agency for a smoother transition.

Just as the clinical care teams need to work in coordination across disciplines, the operations/administrative teams need to work collaboratively and in coordination with one another and with the clinical team. In PDGM, there is more billing activity required. There are two times the posting and two times the reconciliation, all in accelerated cycle times. Consequently, there is a higher risk of error and penalties at every step in the process.

Prepare with QIRT

Expert Hands-On Help

To help you prepare for PDGM, QIRT will review your agency’s coding and OASIS and provide an assessment of what reimbursement will look like when PDGM begins in January 2020. QIRT will offer guidance and recommend changes to ensure your agency is ready. 

Contact our PDGM expert team today.

Or Do-It-Yourself:

  • PDGM Readiness Tool Kitan agency’s step-by-step guide to successful implementation through proper planning, preparation, communication, and training.
    • INCLUDES: PDGM Agency Guide to Success, PDGM Questionnaire, Intake Tool, Functional Impairment Chart Tool, PDGM Primary Diagnosis QIRT Tool, Top 75 Home Health Non-Valid Diagnoses Tool, PDGM CoMorbidity Adjustment, PPS/PDGM Crosswalk and the Function Impairment Chart tool 

PDGM Tools

Our QIRT experts have created these tools to assist with your home care agency’s preparations. Be sure to make good use of this QIRT advantage…on us!

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