Patient-Driven Groupings Model

February 22, 2021

Val DuVernet

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.