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Patient-Driven Groupings Model

The Patient-Driven Groupings Model (PDGM) changes how home healthcare fits into payment categories, eliminates the use of therapy service thresholds and changes home health payment from a 60- day episode to a 30-day episode. This new model goes into effect beginning January 1, 2020.

What’s happening?

CMS has passed a new Patient-Driven Groupings Model (PDGM) that goes into effect beginning January 1, 2020.
Under PDGM, an episode of care is now 30 days, versus the previous 60-day episode. Additionally, the number of therapy visits no longer counts toward home health payment.
PDGM categorizes each episode of care based on five factors:1


  • Early or late: Only the first 30-day episode counts as early
  • Institutional or community: If a patient is admitted to the HHA within 14 days of an acute stay, the care will be classified as institutional
  • Clinical grouping: Patients would be assigned to one of twelve major clinical groups, based on principle diagnosis (musculoskeletal rehabilitation; neuro/stroke rehabilitation; wounds; medication management, teaching, and assessment (MMTA) – surgical aftercare; MMTA – cardiac and circulatory; MMTA – endocrine; MMTA – gastrointestinal tract and genitourinary system; MMTA – infectious disease, neoplasms, and blood-forming diseases; MMTA – respiratory; MMTA – other; behavioral health; or complex nursing interventions)
  • Functional level: This will use the Outcomes and Assessment Information Set (OASIS) questions to group patients into low, medium or high impairment
  • Comorbidity adjustment: This breaks down into no adjustment, low adjustment or high adjustment
These changes lead to several new payment categories, each with its own Low Utilization Payment Adjustment (LUPA) and a minimum threshold of two visits per category.1
PDGM also incentivizes innovation via remote patient monitoring (RPM). With RPM, the patient and/or caregiver digitally stores and/or transmits physiological data (i.e., blood pressure, glucose monitoring) to the HHA.1
This is the biggest change to Medicare Home Health in 20 years.2

Who does PDGM affect?

Home health agencies and home healthcare providers

Key Dates for PDGM

January 1, 2020
PDGM goes into effect

Why is PDGM happening?

The Patient-Driven Groupings Model is part of the continued effort to move from volume-based payment models to value-based payment models, and to help ultimately reduce the cost of healthcare.

How should you prepare for PDGM?

  • Consider technology solutions to help address RPM
  • Focus on saving staff time on administrative duties
  • Allow more time for patient care
  • Consider industry partners in telehealth
  • Educate your staff on conducting thorough assessments