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.