Patient-Driven Groupings Model: An Opportunity for Physical Therapists (part 2)
Part 2: Making the Case for Physical Therapy in the PDGM
By Mahmood Iqbal, PT
In part 1 of this 2-part series on the home health Patient-Driven Groupings Model (PDGM) payment system set to go into effect on January 1, 2020, I wrote about the reasons behind the change, and why home health agencies should understand that therapy will still play an important role in care.
In this installment, I want to share thoughts on how physical therapists (PTs) can function effectively within the PDGM.
To make the most of PDGM, it's important that PTs understand the answers to 2 crucial questions: Who assesses the functional impairments? And who collects the data for the functional score? Those 2 questions determine the need for physical therapy services in the 10 PDGM clinical groups that are not primarily focused on rehabilitation.
Most PTs who have home care experience know that the functional score comes from the data collection of the Outcome and Assessment Information Set (OASIS). In most home care agencies across the country, a registered nurse (RN) completes the initial visit by conducting initial and comprehensive assessments and admitting the patient under the home care episode. At present, if physical therapy has been ordered or the RN believes there is a need for physical therapy services, the RN will request a PT evaluation by obtaining physician's orders. The PT then performs an evaluation andprovides the functional impairment details. The case manager compares the PT's findings with the RN data, and the clinicians collaborate to determine the patient's appropriate functional score.
Will that happen under PDGM? I'm not sure, especially for those 10 clinical groups that are nursing centered, and for which therapy may not be the primary focus.
Here lies our greatest opportunity.
If the determination of physical therapy needs and services depends on functional score, don't we have an obligation to train those who will collect that information for functional impairments? Yes, we do. If the functional score is appropriately collected and the patient has a moderate-to-high functional deficit score, the need for physical therapy is determined and creates higher payment of the 30-day payment period for the providers. They'll be able to pay for therapy visits for their patients, because good providers understand that CMS assumes that home care providers will furnish appropriate therapy services to improve functional outcomes to make patients independent and safe, and reduce their unnecessary falls and rehospitalization.
Many studies have demonstrated a link between an individual's mobility, functional status, physical activity, and the risk for patient hospitalization. Physical therapy can improve a patient's medical condition, which in turn enhances the disease management process, medications management, nutrition, and safety. This in turn leads to a low risk of hospital readmission. As a CEO of a home health care agency, I highly recommend that PTs in home care agencies start working closely with their nursing peers and take time to train them on what an accurate functional assessment is all about. This is the PT's opportunity to be part of a single collaborative clinical team and tear down the clinical and rehab silos.
Under PDGM, collaboration is king. Fortunately, PTs are good collaborators, so we need to leverage those skills in the new system. Here are a few tips that might help.
Create the appropriate plan of care for therapy services based on the patient's actual clinical diagnosis, functional impairments, and ADL needs—not on visit numbers. The care plan should be based on patient-centered outcomes developed with the involvement of the patient and, when applicable, caregiver. The therapy plan should be part of the collaborative plan developed by a health care team providing services to the patient.
Provide a compressive home exercise program and ensure the patient's understanding of those exercises. This includes having the patient demonstrate the exercise to you early and often. In the beginning your visit frequency may be higher so that you can make sure the patient and caregiver, if there is one, understand what needs to be done at home, but that frequency may well decrease as the patient achieves better understanding.
Share your functional outcomes with other disciplines on the case, and encourage them to remind patients about the home exercises and safety instructions for fall prevention that you have provided. Emphasize the risk of patient falls and the prevention methods with everyone on the case, including the caregiver if there is one.
Manage the case in collaboration with the RN case manager, and spread out your visits to provide time for the patient to follow your home exercises and see the impact of your treatment and training. Don't make standard therapy visit schedules for every patient. It should be based on the patient's characteristics, including the patient's functional score, and individualized to meet the patient's needs and functional outcomes.
Make your therapy plan of care as part of the team plan for the overall patient outcomes, not just therapy outcomes. Ask other clinical team members how you can assist in their outcomes during your visits. For example, could you get vital signs or provide medication reminders? Your goals of therapy should be addressing overall functional outcomes and not focused solely on gains in strength or walking distance.
Link all improvement goals to specific functional outcomes. Make short- and long-term goals and share your goals with the patients and caregivers. Discuss them during each therapy visit.
Document your visit appropriately. Just documenting exercise repetitions and the distance you made the patient walk during gait training is not enough. Exercises, transfer training, gait training, or stair management training should demonstrate the connection you're making in addressing the patient's functional ability. Every visit note should demonstrate the functional limitations you addressed, ways you addressed them, and the outcomes you were able to achieve during each visit. And make sure it's not the same note every visit. Finally, make an appropriate goal to justify your next visit.
Stay in constant communication with the RN case manager, including your discharge plan and the progress of the patient toward goals. There is no such thing as overcommunication. Work with the case manager and patient to find the appropriate time to see the patient when patient participation is at the highest. If pain is causing limitation of activity, find out about medication schedules, and ask the patient to take prescribed pain medication an hour or so before your visit to optimize participation in your therapy. Help the case manager understand your work, your expertise, and your value on the clinical team as an integral and collaborative partner for the patient.
Here's an interesting fact: Under the current episodic payment system, a 60-day episode includes, on average, 7 physical therapy visits. If you look at the PDGM model, the average may range between 3-8 therapy visits in 30-day period, depending upon multiple factors including clinical grouping, institution or community referral, early or late payment period, functional scores, and comorbidities. That's worth remembering, because it shows that number of therapy visits may range from a minimum of 5-6 to as high as 12-16 over 2 30-day payment periods (60 days). If therapy visit numbers still matter to you, then you may find some encouragement in those numbers.
Home health care is the future of our ever-changing health care industry, if for no other reason than that it's a less expensive way to deliver skilled services, performed in the comfort of the home. It's a vital link to the continuum of care, and a bulwark against readmission to expensive health care institutions. And physical therapy is a critical part of home health.
I believe physical therapy will remain a critical part of home health care under PDGM, but it will require employers and providers to not hit the panic button and take the time to truly understand what the new system is all about. Yes, PDGM is a shift in how we think about home health care—but it's a shift that opens up an opportunity for PTs to take the lead and become an integrated part of the home care clinical team, increasing understanding and use of therapy services, and their values in patient outcomes and well-being.
I will leave you with this example. If one of the goals of home health is to make a patient independent in medication management, the patient must possess the independent functional ability to get up and walk safely to get the water to take the medication. Do you see the therapy need there? If you don't, home health in general—and the PDGM in particular—isn't for you.
Mahmood Iqbal, PT, is president and CEO of Home Health Care Solutions, located in Avon, Indiana. Read part 1 in this series.
Patient-Driven Groupings Model: An Opportunity for Physical Therapists (part 1)
Part 1: What's Changed, What Hasn't—and What Shouldn't
By Mahmood Iqbal, PT
When it comes to Centers for Medicare and Medicaid Services (CMS) changes, I have come to believe that there are 3 sides of the story: the CMS version, the providers' version, and the truth, which is usually somewhere in the middle. The Patient-Driven Groupings Model (PDGM) that will govern home health payment beginning January 2020 is a good example of what I'm talking about.
PDGM shook the therapy world when it was announced that the number of therapy visits will not be considered or weighed into each 30-day period pricing for home care within a 60-day episode. As usual, providers, fearful of losing money, started to lay off therapy staff without really understanding what CMS intended.
Most of us understand that therapy visit thresholds were used to determine the additional pricing to the base rate for a home care 60-day episode. Home health providers have paid particular attention to this fact, realizing that the number of therapy visits at certain thresholds adds value to the base amount of the home care episodic rate. Back when the therapy threshold was 10 visits, home care agencies tried to have a minimum of 10 visits to capture that dollar amount. When the threshold increased to 13 visits, that number soon became the norm of therapy visits for every patient. Later, the therapy threshold moved to 19 visits. Home care agencies started to add multiple therapy services to attain that number and discharged every patient after 19 visits.
So what did CMS do? CMS collected all of that information and analyzed the trends of home care agencies working to maximize their revenues unrelated to patients' needs or outcomes. Unfortunately, many therapists didn't push back against the providers' greed, as they were getting per-visit payments. Right or wrong, the data and studies have shown trends of such behaviors. From this perspective, it's no surprise that therapy thresholds were removed from the payment model.
I am not saying that every provider and every therapist was part of this trend. I'm saying that data have proven that therapy thresholds and their weight in episodic rate pricing resulted in a trend, and CMS responded to that trend. So now it's time to move forward. We can't change the past, but we can learn from it.
To understand the impact of the new home care rules on therapy we need to dig deeper into the details. I'm the CEO of a home care agency, but I'm also a PT, so I feel that I have a unique vantage point from which to see things: from the perspective of a provider as well as a physical therapist. And from my vantage point I see this to be tremendous opportunity for PTs to become an integral part of home health care and its future.
You might think that I'm out of my mind. But there's another side to the PDGM. Let me explain.
These things are continuing under PDGM for home care:
- Start of care, recertification or follow up (OASIS)
- Recertification visit within the 5 days prior to the beginning of the new episode
- Plan of care for 60 days with patient-focused outcomes based on patient diagnosis, and clinical and rehabilitation needs
- Face-to-face document requirement by the referring physician
These things are changing under PDGM:
- Patient will be placed into 1 of 12 clinical groupings, 6 main and 6 sub-clinical groups. under the clinical group of Medication Management, Teaching, and Assessment (MMTA)
- Payment changed from a 60-day episode to 2 30-day payment periods in an episode of care.
- Therapy thresholds are eliminated as a determinant of payment.
- The split percentage payment approach (Request for Anticipated Payment) will be phased out. In 2022, the RAP will be replaced with a Notice of Admission (NOA), with a late submission penalty for failure to submit the NOA within 5 calendar days of the start of care.
- The payment calculation will depend on the following 5 items:
1. The admission sources; institution or community
2. Early (first 30 days) or late (second 30 days) period of care
3. Clinical grouping model
4. Functional impairment level (low, medium, or high)
5. Comorbidities (none, low, or high)
It's inaccurate to think that the exclusion of therapy visit thresholds from the payment calculation means there are no anticipated patient therapy needs. Nursing visits, social worker visits, and home health aide visits were never part of the home care payment calculation--did that stop home care agencies from using nurses, social workers, and home health aides? No, it did not. The bottom line is this: Under the PDGM payment model, home health agencies are expected to provide the necessary services based on patient illness, patient clinical needs, functional limitations, and safety and hospital readmission risks; to make patients stable, better, and independent in their homes to prevent them from frequent readmissions to a hospital or an emergency room. This reality means that PTs still have an important role to play in any responsible home health agency.
If providers are under the impression that they will not provide therapy services when a patient's assessment suggests—and functional impairment would require—the services, then providers will create another trend for CMS to evaluate, and that evaluation could result in further cuts to Medicare payment under the homecare payment period. CMS will already be implementing a -4.36% behavior adjustment in the new payment model.
Here's what you will not find in the 2020 home health rule: any mention by CMS that therapy services will not be needed or provided for a home care payment period. Instead, here are a few statements that we have received from CMS on the question of the impact of PDGM on therapy:
"We disagree that the PDGM diminishes or devalues the clinical importance of therapy. The musculoskeletal and neurological rehabilitation groups under the PDGM recognize the unique needs of patients with musculoskeletal or neurological conditions who require therapy as the primary reason for home health services."
"For the other clinical groups, we note that the 30-day base payment amount includes therapy services, even if the primary reason for home health is not for provision of therapy. The functional impairment level adjustment, in conjunction with the other case-mix adjuster under PDGM, aligns payment with the cost of providing services, including therapy."
If you read these statements you will come to realize that while 2 clinical grouping models, musculoskeletal and neurological rehabilitation groups, will have higher therapy service needs, the other 10 clinical groupings (the more nursing-centered ones) will still require therapy services if there are functional impairments and/or other comorbidities that warrant therapy services to achieve optimal patient functional outcomes.
So is the PDGM the end of therapy in home health? CMS doesn't think so. And if home health companies are smart—and if they've learned anything from the visit threshold creep that contributed to the payment system we're about to begin in January—they would come to understand the 1 thing the PDGM can never change: the true needs of the patients in the agency's care.
Stay tuned for part 2 in this blog series, where I'll take a look at what PTs can do to demonstrate their value in PDGM.
Mahmood Iqbal, PT, is president and CEO of Home Health Care Solutions, located in Avon, Indiana.
5 Ways the US Military Has Shaped the Physical Therapy Profession
This Veteran's Day, we pause to recognize the unique role and contributions of the military in advancing the physical therapy profession. Following are a few accomplishments of our women and men in uniform.
The military introduced the country to physical therapy.
The first physical therapists (PTs) were reconstruction aides ("re-aides"), civilian employees of the Medical Department of the US Army during World War I who rehabilitated injured soldiers and taught them how to adapt to everyday life after injuries and amputations.
After WWI's end, as the military cut back on the number of aides, the first physical therapists took their knowledge to the civilian population, working for the US Public Health Service, industrial accident clinics, orthopedic surgeons' offices, hospitals, and schools for children with physical limitations.
On April 16, 1947, President Harry S. Truman, posing here with Major (later Col.)
Emma Vogel, far right, and other senior officers, signed Public Law 80-36,
establishing the Women’s Medical Specialist Corps (WMSC) in the U.S. Army.
Credit: U.S. Army Photograph.
The US Army was key to the process of standardizing procedures.
According to Col. Emma Vogel, one of the first re-aides, prior to WWI very few physicians performed physical therapy procedures, which looked upon with suspicion by many of their colleagues. It was not a defined discipline with clear standards or guidelines, and there was no research being conducted. Vogel, who later became the first chief of the Women’s Medical Specialist Corps in 1947, wrote that as a result of the success of the re-aides, "civilian practice in this field was given a tremendous impetus" and the Army played a key role in "stabilizing and standardizing physical therapy procedures."
After WWII, thousands of soldiers were treated for amputations, spinal cord injuries, and other injuries. As a result, some hospitals began to specialize in treating specific populations, allowing for study of effectiveness of patient care, including wound healing, prosthesis fitting, gait analysis, progressive resistance exercise, and constant current stimulation. Severe injuries that would have resulted in immobility during WWI now had a much better prognosis.
Military therapists served with honor, even behind enemy lines.
Like their WWI predecessors, WWII therapists served stateside as well as overseas. Metta Baxter, stationed in Italy, was a prisoner of war (POW) and received the Legion of Merit. Helen Filbert and Bella Abramowitz Fisher received Bronze Stars for their work in the Dutch East Indies and Okinawa, respectively. Brunetta Kuehlthau and Mary McMillan were captured and held at an internment camp in Manila, Philippines—where Kuehlthau continued to treat patients. These heroes and their colleagues did not gain full commissioned status until 1944.
During the Vietnam War, Army PTs treated soldiers, civilians, and POWs in 3 of the 4 combat zones.
The military was the first to train physical therapist assistants.
Late in WWII, the Army recognized the need for formally trained enlisted staff to assist PTs in the clinic. Previously, enlisted men were informally trained to help in the clinics but were needed in combat roles. In 1945, the Army approved the first formal program of instruction for the new classification of "physical therapy technicians."
The military leads the way in direct access and team-based care.
Since the 1970s, the military has allowed soldiers with neuromusculoskeletal disorders to see a PT without referral from a physician, expediting recovery for more minor conditions and freeing up physicians to treat patients with traumatic injuries—which is especially important during combat. Rather than relying on old models of care, the military health system evaluates what needs to be in place for successful outcomes and what resources are needed to achieve them. Military PTs treat patients within a multidisciplinary team of providers, offering a model for the private sector in the shift toward value-based care.
To all our military PTs and PTAs, their families, past and present, thank you for your service.
References and further reading:
American Physical Therapy Association. Remembering the reconstruction aides. #PTTransforms Blog. Alexandria, VA: American Physical Therapy Association. March 9, 2018.
American Physical Therapy Association. The Beginnings: Physical Therapy and the APTA. Alexandria, VA: American Physical Therapy Association; 1979.
Greathouse DG, Schreck RC, Benson CJ. The United States Army physical therapy experience: evaluation and treatment of patients with neuromusculoskeletal disorders. JOSPT. 1994;19(5):261–266.
Linker B. War's Waste: Rehabilitation in World War I America. Chicago: University of Chicago Press; 2011.
Moore JH, Goffar SL, Teyhen DS, Pendergrass TL, Childs JD, Ficke JR. The role of US Military physical therapists during recent combat campaigns. Phys Ther. 2013;93(9):1268–1275.
Silvernail J. Primary care and the physical therapist: lessons from the military. #PTTransforms Blog. Washington, DC: American Physical Therapy Association. Published September 10, 2018.
Smith CM. The Medical Department: Hospitalization and Evacuation, Zone of Interior. United States Army in World War II. The Technical Services. Washington, DC: U.S. Government Printing Office, 1956.
Vogel EE. US Army Medical Department, Office of Medical History. "Chapter III. Physical therapists before World War II (1917-40)." In: US Army Medical Specialist Corps History. Anderson RS, ed. Washington, DC: U.S. Government Printing Office, 1968.
Vogel EE, Manchester KE, Gearin HB, West WL. US Army Medical Department, Office of Medical History. "Training in World War II." In: US Army Medical Specialist Corps History. Anderson RS, ed. Washington, DC: U.S. Government Printing Office, 1968.