Gaboury Delivers PDGM Strategies
In a pair of full day workshops on October 28 and 29, Healthcare Provider Solutions Chief Executive Officer Melinda Gaboury set forth a set of strategies to survive the Patient-Driven Groupings Model (PDGM) changes set to take place on January 1.
Throughout the seminar, Gaboury identified crucial areas where agencies are “leaving money on the table” due to lack of understanding of critical components of the PDGM. The first of these was admission source. It needs to be a resumption of care if the patient goes into a facility within the first thirty days. This results in an increased payment of about 15 percent.
A second area involved changes in condition. If there is a low comorbidity adjustment, payment increases 6.22 percent. If there is a high comorbidity adjustment, payment increases an additional 14.93 percent. Gaboury emphasized the importance of coding accuracy to achieve the appropriate case mix classification.
The next part of the program provided an in-depth review of the Home Health Value=Based Purchasing (HHVBP). This system involves two scores: Achievement and Improvement. It can result in a change in Medicare payments of five percent. Gaboury presented data on achievement and improvement scores nationally, in California, Florida and Texas. In general, California exceeded the national average in four of the seven achievement scores and five of seven improvement scores. However, in the HHVBP HHCAHPS achievement points, California scored lower than the national average in all five of the scores. This was also the case for the improvement scores. This means that California’s achievement was low and did not improve. Gaboury pointed out that HHCAHPS is part of the Star Ratings which Medicare Advantage plans and consumers use to choose their agencies. This is clearly an area for attention.
The program next focused on improving HHVBP results. Gaboury advised a strategic approach involving defining goals, expectations and responsibilities as well as staff education and focus on reported scores.
The next part of the program focused on best practices for medical review under PDGM. Gaboury recommended reviewing a sample of 10 to 20 percent of charts to assure that care is being properly documented. The review should increase to 100 percent for new clinicians. The most common reasons for denials were failure to meet certification requirements, face to face not met, medical necessity, medical necessity for therapy and homebound status.
The program concluded with a session on best practices for managing your agency in a PDGM environment. Gaboury recommended a gap analysis for problem areas such as HHCAHPS and Star Ratings. She recommended developing a Strategic Quality Plan. Such a plan should identify organizational priorities, use data and prioritize imperatives such as safe and effective care and financial viability.
CAHSAH thanks Melinda for presenting this valuable material for our members. It is essential that all agencies recognize they must focus on, and improve, operations to survive and thrive under the PDGM system.