Home Health Patient Driven Groupings
The Centers for Medicare and Medicaid (CMS) announced a new Patient-Driven Groupings Model for Home Health that replaces the Prospective Payment System effective January 1, 2020. The PDGM uses 30-day periods categorized into many more case mix groupings than the prior PPS system, and these are categorized into subgroups.
To elaborate, a brief comparison of the PPS and PDGM models is as follows:
PPS HHRG Model for Home Health – 153 Distinct HHRGs
Under the prior Home Health Prospective Payment System (PPS):
- The Home Health Resource Group (HHRG) has several components, including the functional and service utilization domains.
- An OASIS patient assessment is performed and scored.
- The result of the assessment groups categorizes the patient into one of 153 Home Health Resource Groups (HHRGs).
- HHRG scores are correlated to episodes of care.
- For example, a 58-day episode yields two new segments: an initial 30-day period (days 1-30) and a second 28-day period (days 31- 58)[i]
New Home Health Patient Driven Grouping (PDGM) Model for Home Health – 432 Distinct HHRGs
CMS finalized a case-mix classification model called Patient-Driven Groupings Model (PDGM), effective January 1, 2020. PDGM focuses on clinical characteristics and, secondarily other patient data to correlate home health episodes of care into payment categories. As noted, PDGM uses 30-day periods categorized into 30-day subgroups as follows:
- Admission source (two subgroups), which can be either
- (a) community admission source or
- (b) institutional admission source
- Timing of the 30-day period (two subgroups), which can be either
- (a) early or
- (b) late
- Clinical grouping into one of twelve subgroups, which can be:
- 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 impairment level (three subgroups) which can be:
- (a) low,
- (b) medium, or
- (c) high
- Comorbidity adjustment (three subgroups) based on secondary diagnoses, which can be
- (a) none,
- (b) low, or
- (c) high
Therefore, when attempting to ascertain where a patient / insured fits in the PDGM model for coverage and benefits eligibility for home health services, it is important to understand that the home health Patient Driven Groupings model results in a permutation of at least 432 possible case mix adjusted groups, calculated as
- Two (2) admission sources, times
- Two (2) timing, time
- Twelve (12) clinical groupings, times
- Three (3) functional impairment levels, times
- Three (2) comorbidity adjustments
Therefore, the math is (2*2*12*3*3) = or four-hundred-twenty-three (432) distinct case-mix adjusted payment groups.[ii]
OASIS Assessment Components
The OASIS items contributing to functional level are:
- M1033: Risk for Hospitalization
- M1800: Grooming
- M1810: Dressing Upper Body
- M1820: Dressing Lower Body
- M1830: Bathing
- M1840: Toilet Transferring
- M1850: Transferring
- M1860: Ambulation/Locomotion
CMS tracks and reports HHA Agency Level impact information for calendar year 2019 vs projected percent changes under PDGM using the CMS Certification Number (CCN). Based on a therapy visit ratio, number of 60-day episodes, 30-day periods, CMS published estimated PDGM payments and the payment change percent projection.
[i] CMS. OASIS Assessments, Case Mix Groupings, HHRGs See https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPShttps://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2017-01-18-HH-Presentation.pdf
[ii] CMS. 2020 PDGM. See https://www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/HomeHealthPPS/Downloads/Overview-of-the-Patient-Driven-Groupings-Model.pdf
See also O’Connor M, Davitt JK. The Outcome and Assessment Information Set (OASIS): a review of validity and reliability. Home Health Care Serv Q. 2012;31(4):267-301. doi: 10.1080/01621424.2012.703908. PMID: 23216513; PMCID: PMC4529994.
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