JUNE 2019
GET FAMILIAR WITH PDGM
June 2 - 8
PDGM OVERVIEW – Understand concept for conversion from current Home Health Prospective Payment System (HH PPS) to PDGM
- Schedule training sessions, attend webinars/courses, attend state/national conferences
- Review resources on CMS’s HH Agency (HHA) Spotlight Page
June 9 - 15
HOME HEALTH COVERAGE REQUIREMENTS – Review regulations that are not changing with PDGM
- Medicare Benefit Policy Manual, Chapter 7 – Conditions of coverage, need for intermittent skilled services
- OASIS-D Guidance Manual – Functional status, assessment schedule and submission timelines
June 16 - 22
DISCUSS PDGM KEY CONCEPTS – Payment based on patient characteristics, therapy service delivery to be outcome-driven, change to 30-day payment periods
- Five (5) categories affecting payment: Timing, Admission Source, Clinical Group, Comorbidities, Functional Status
- Continuation of current OASIS assessment schedule: SOC, ROC, Follow-up (Recertification), Transfer, Discharge
- Variable LUPA thresholds
- Partial Episode Payment and Outliers
- Review the post "What Occupational Therapists Need to Know about PDGM in Home Health"
- Download the PDGM Summary Document
June 23 - 29
EVALUATE WHAT YOU HAVE LEARNED – Identify areas of opportunity, focus areas for education and staff training
JULY 2019
LOOK AT YOUR DATA
June 30 - July 6
OBTAIN PDGM vs. HH PPS COMPARISON DATA – Determine if current patient population and current practices project better or worse financial performance with PDGM
- Run current, completed OASIS assessments and claims from closed episodes through PDGM analytics software, if available, to compare performance under current HH PPS to PDGM
- Review CMS’s HH PDGM Agency Level Impacts File – Results listed by CCN (CMS Certification Number)
- Use CMS’s PDGM Grouper Tool – Provides individual patient-level information regarding classification under PDGM
July 7 - 13
ANALYZE DATA FROM A FINANCIAL PERSPECTIVE – Does current practice (coding, utilization) translate to PDGM?
- If PDGM analytics software is available for current data, start with an overall picture
- Financial results of current 60-day episodes under HH PPS and PDGM
- Percentage of LUPAs during 60-day episode vs. 30-day payment period
- Percentage of outliers
- If using CMS’s Agency Level Impacts File, review overall financial performance under HH PPS and PDGM
- Drill down into patient-specific financial impact using CMS’s Grouper Tool
July 14 - 20
ANALYZE DATA FROM A CLINICAL PERSPECTIVE – Does current OASIS clinical data (e.g., diagnosis codes, functional status) accurately reflect the clinical needs of your patients under PDGM?
- ICD-10 coding – Review current ICD-10 coding practices on both the OASIS and the claim
- Look for unspecified and symptom-based ICD-10 codes as these will likely not map to a PDGM Clinical Group
- Review comorbidity (secondary) diagnosis coding
- Do you know your return to provider or non-qualifying diagnosis rate?
- Do key personnel need ICD-10 coding training?
July 21 - 27
DRILL DOWN INTO THE OASIS AND THE CLAIM – Are the items that impact payment under PDGM completed accurately?
- Review key items on the OASIS: M1021, M1023, M1033, M1800, M1810, M1820, M1830, M1840, M1850, M1860
- Review Principal and Secondary diagnoses on the claim
- Do you have the information you need to accurately code all relevant diagnoses upon admission?
- Does the information on the claim match the OASIS?
- Does medical record documentation support the OASIS and the claim?
July 28 – August 3
EVALUATE WHAT YOU HAVE LEARNED – Identify areas of opportunity, focus areas for education and staff training
AUGUST 2019
LOOK AT YOURSELVES
August 4 - 10
ASSESS YOUR PEOPLE – Do you have the right people in the right places? Are your people informed? Access the Role-Based Assessment tool.
- Who is involved in the admissions process? Are they effective?
- Are your nurses and therapists strong, clinical evaluators?
- Does your staff understand PDGM and the shift in reimbursement?
- Do your doctors and referring providers understand PDGM and their role?
- Are your therapists involved in a collaborative team effort to ensure accurate diagnosis and OASIS coding?
August 11 - 17
ASSESS YOUR PROCESSES – Admissions, OASIS coding and completion, patient care conferences, visit scheduling, etc.
- Are your processes clearly defined? Are they consistently followed?
- Do your processes need to be improved or is it a “person problem”?
- Do you have the right person in the right role?
August 18 - 24
DEFINE NEW ROLES AND PROCESSES – Identify your desired state with respect to workflow, task/process ownership, communication, timeliness and output
- What and/or who needs to change?
- What skills and characteristics are needed for each role?
- Clearly communicate expectations
August 25 - 31
INITIATE ROLE AND PROCESS CHANGES – Continue education and training with a role-based focus, document processes
- Socialize changes in roles and processes
- Support staff who are changing roles – consider assigning staff mentor
- Establish expectations of collaboration and accountability
SEPTEMBER 2019
LOOK AT YOUR CONTRACTS
Sept 1 - 7
REVIEW CUSTOMER CONTRACTS – Assess current contract structure with HHA providers from volume and performance perspective
- What types of contracts do you currently have in place?
- How do you perform under each contract?
- Assess customer/partner relationship – strong (true partner) vs. weak (vendor only)
Sept 8 - 14
CONSIDER ALTERNATIVE CONTRACTING ARRANGEMENTS – PDGM and other value-based care payers
- Percentage of HHRG
- Per visit
- Risk-sharing, performance adjustments
- Management
Sept 15 - 21
SCHEDULE CONTRACT NEGOTIATION MEETINGS – Jointly define the metrics that communicate success with PDGM
- Readmission rates
- Other metrics?
Sept 22 - 28
EVALUATE WHAT YOU HAVE LEARNED – Identify areas of opportunity, focus areas for education and staff training
OCTOBER 2019
LOOK AT YOUR REFERRAL SOURCE DATA
Sept 29 - Oct 5
ANALYZE YOUR MARKET SEGMENTATION VARIABLES
- Record averages from trailing 12-month period to show percentage of referrals by:
- Payer mix (Managed Care, Medicare, Medicaid)
- Percentage of readmissions – focus on strategies to reduce avoidable readmissions
- Percentage from each hospital referral source
Oct 6 - 12
FORM JOINT OPERATING MEETINGS WITH HOSPITALS AND PROVIDER NETWORKS
- Aligning behaviors with mutual goals and objectives
- Discuss strategies to standardized care
- Discuss readmissions and how to improve outcomes with complex patients
- Define new processes and expectations
Oct 13 - 19
EVALUATE CURRENT PAYER CONTRACTS – Must know all payer contract requirements on admission or could be a financial liability
- How are we performing? Are we ready?
- Are current contracts financially positive for the agency?
- If not, which areas are causing loss?
- How can we improve performance?
- Can contracts be renegotiated?
Oct 20 - 26
ASSESS MARKET DEFINITION – Determine where you fit in the market and where you want to be
- Analyze strength of clinical programs offered
- Identify opportunities to strengthen your position in the market and/or services offered
- Develop a clinical grid to assist admission coordinators to more readily accept referrals
- Create messaging / branding campaigns
- Identify collateral and equipment needs
- Identify training and educational initiatives
- Consider specialties / competencies to assist in reducing variation in clinical care (e.g., Memory Care, Disease Management, Behavioral Health, Post-acute Rehab, etc.)
Oct 27 - Nov 2
EVALUATE WHAT YOU HAVE LEARNED – Take time to review changes made thus far and assess overall progress
- Are employees gaining competence and confidence in new roles?
- Is additional staff training on PDGM necessary? ICD-10 coding, Function coding (also consider adding training for staff on Section GG to ensure accuracy)
- Have you completed contract negotiations?
NOVEMBER 2019
OPTIMIZE YOUR SYSTEMS AND PROCESSES
Nov 3 - 9
OPTIMIZE THERAPY PROCESSES – Discharge readiness, clinical pathways
- Ensure readiness for discharge, assess for additional skilled needs (e.g., outpatient therapy, community resources)
- If transitioning to OP or community program, ensure hand off is successful
- Assure efficacy of caregiver training
Nov 10 - 16
OPTIMIZE NURSING PROCESSES – Interdisciplinary meetings, OASIS coding, clinical competency (with respect to decreasing visits to ED and readmissions to hospital)
- Evaluate effectiveness of interdisciplinary meetings – Is IDT collaboration evident?
- Assure new admissions are being viewed as a PDGM case?
- Does the team use PDGM terminology (e.g., principal diagnosis, comorbidities, functional impairment)?
- Are ICD-10 codes being determined and utilized efficiently?
Nov 17 - 23
OPTIMIZE DISCHARGE PLANNING – Downstream communication, caregiver training, manage readmission risk
- Referrals to next level of care (OP, community resources/programs)
- Ensure caregiver training is comprehensive and complete – from a therapy (function) and nursing (medical management) perspective
- Be able to accept calls/questions from patient and/or caregiver after discharge
- Consider follow-up contact/communication after patient has transitioned off caseload at 72 hours, 1 week and 4 weeks
- Review CMS’s Care Coordination Toolkit
Nov 24 - 30
EVALUATE WHAT YOU HAVE LEARNED
