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How to Succeed in the Patient Driven Groupings Model Era

If you are a nurse, therapist, clinical manager, or other home care professional, you might be asking: how will the Patient Driven Groupings Model (PDGM) impact me in 2020 and beyond? How can home health agencies make certain that the clinicians charged with determining diagnoses that are reported on the claim comply with regulations and policies?

ICD-10 requires that diagnoses “are only to be reported if they are conditions that affect patient care in terms of requiring clinical evaluation; or therapeutic treatment; or diagnostic procedures … ; or increased nursing care and/or monitoring.”

The Medicare Conditions of Participation require that patients have comprehensive assessments and receive care to meet the identified needs throughout. The challenges presented by PDGM requirements will be most effectively managed by home health agencies that avail themselves of resources that offer detailed guidance for patient assessment and care planning since these are overarching requirements for diagnosis identification.

Aligning Your Patient Assessment Strategy with the PDGM System

One well-known and best-selling resource is the Handbook of Home Health Standards: Quality, Documentation, and Reimbursement. The Handbook, like the PDGM system, is separated by systems and diseases to “help resonate with how clinicians think,” according to CMS.

The Handbook offers detailed guidance for system-based patient assessments and a compendium of appropriate interventions to incorporate into individualized, all-inclusive plans of care to address identified patient problems.

Commonly referred to as the “Red Book,” use of the Handbook in the care planning process will help ensure that the primary diagnosis and comorbidities reported on the home health claim are supported. The fundamentals of home health care remain, complying with the physician-directed model of care, supporting medical necessity, understanding homebound, and other tenets of the best care, are presented in a practical and conversational manner.

In addition to PDGM insight, also included in the Handbook are:

  • Sections on “Comfort Considerations,” “Queries for Quality,” and “Caregiver Considerations"
  • A strong focus on assessment, care planning, patient/caregiver engagement and supporting quality, and improved patient outcomes
  • Tips and strategies for success in areas of common deficiencies