Capturing a Full View of Each Patent’s Clinical Profile

With the CMS implementation of the Patient-Driven Groupings Model (PDGM), home health agencies must put a strong emphasis on documentation and coding practices to receive most appropriate reimbursement for the care provided.

Success Starts with Documentation

Fully assessing and documenting a patient’s comprehensive clinical condition is key to establishing a strong foundation for success under PDGM. Documentation drives how major components of the model are calculated including clinical grouping, functional score and comorbidity adjustment. The more detail obtained leads to better patient care and improved overall outcomes.

By assessing and documenting the patient’s comprehensive clinical condition, the agency’s coders will have the detailed information needed to work within the PDGM rules. The new reimbursement model makes it essential for home health agencies to be precise and thorough during the intake and assessment process so that the specific type of services needed are identified, supported, and easily submitted to CMS.

5 Steps to Building a Complete Patient Profile

Providers likely are already doing some or much of the work needed to capture a comprehensive view of each patient’s clinical profile. However, those who are not doing so stand to miss out on many important components of the patient’s profile and, therefore could miss reimbursement. Fortunately, creating a complete patient profile does not have to be complicated.

These five steps can assist home health agencies in capturing and maintaining a comprehensive view for each patient they serve.

  • Step 1: Start with efficient intake and orders management processes and protocols
  • Step 2: Monitor and manage performance in the 12 Clinical Groups of PDGM
  • Step 3: Make sure clinicians have an easy way to achieve comprehensive documentation, especially in areas where there are challenges
  • Step 4: Develop the care plan so patients are being seen appropriately in a 30-day episode
  • Step 5: Work with partners who take a consultative approach to improvement and education versus a transactional approach

STEP 1: Start with efficient intake and orders management processes

The first contact the home health agency has with a referral source about a patient is also the first step in the documentation process. Obtaining enough referral documents from the physician and facility is one of the most important components of documentation.

Ensure that the intake staff, as well as the sales and liaison staff, have knowledge of PDGM, specifically with regards to the primary diagnosis for Clinical Groupings and avoidance of potential Questionable Encounters (QEs). Reflect on existing intake and orders management processes and identify areas where improvements can be made. For instance, the act of effectively capturing comorbidities within the documentation can affect the plan of care as well as reimbursements significantly.

To improve orders management, Home health agencies should ask themselves these questions about their existing systems and then adjust optimize their workflow.

  • Who is responsible for tracking orders?

This should be a single person within the home health agency or a dedicated team in a large organization who is responsible for tracking orders (with another person trained to step in during an emergency). Spreading this task to more than a single person can result in confusion, missing orders, and reduced efficiency.

  • How do clinical managers and directors access orders?

There must be a smart, intentional system in place that makes it easy for these team members to quickly access this information. Failing to have this in place will make it difficult to meet the requirements necessary to bill every 30 days.

  • What is the orders management process?

This should not be a secret and should not be left to chance. Many successful home health agencies have proven that the most effective orders management processes specifically detail the orders management timeline, including what actions should be taken and who must complete them.

  • How is technology assisting in orders management?

Technology solutions have simplified this process for many, so it’s a good idea to explore available options that work with the existing EHR and embrace those that have a proven record of success.

STEP 2: Ensuring the focus of care aligns with physician documentation

Reviewing the referral documents coupled with a detailed initial patient assessment, allows the HH clinician to document and develop a focus of care aligned with the physician. Confirming specifics following the assessment further establishes the correct clinical category and avoidance of QEs as well as helps capture all comorbidities impactful to the plan of care and the Comorbidity Adjustment.

Each 30-day period under PDGM will fit into one of 12 clinical groups based on a patient’s principal diagnosis. The rate of reimbursement will vary among these groups, so it is critical to know how the home health agency is performing in each of these common types of care.

STEP 3:Make sure clinicians have an easy way to achieve comprehensive documentation, especially in areas where there are challenges

To say that clinicians need an easy way to achieve comprehensive documentation is an understatement. Start by reviewing existing processes and speaking with clinicians performing documentation to learn what is working and what needs improvement. When clinicians are involved in this process, they are more invested in its success.

Documentation processes should easily integrate with the home health agency’s EMR and be available both on-site and in the field. Technology solutions again can enhance this process and streamline the steps needed to complete a comprehensive clinical record.

Clinical workflows should be updated to follow standard patient care processes and provide clinicians with guidance to reinforce their care decisions.

Finally, clinicians must have access to reliable, updated equipment as they perform their documentation duties, as well as adequate time to perform accurate documentation.

STEP 4: Develop the care plan so patients are being seen appropriately in a 30-day period

With payment periods dropping from 60 to 30 days, many Home health agencies will face significant challenges in seeing patients appropriately within the care windows. Now that Home health agencies are planning, delivering, documenting, and billing for care twice as often, care plans must be more precise in order to maintain quality and optimize reimbursement.

Fortunately, not everything is being trimmed down to 30-day periods. The 60-day certification period will remain the same, and the OASIS period also will remain at 60 days.

That said, it’s important to ensure plan of care procedures are prepared for the new PDGM landscape. When reviewing existing policies, consider the following:

  • When is the plan of care typically completed and submitted? How does this compare with requirements in place?
  • How are supplemental orders integrated into the plan of care? How is this aligned with the PDGM 30-day payment periods?
  • Do plan of care and orders timeframes align with PDGM requirements?

STEP 5: Work with partners who take a consultative approach to improvement and education versus a transactional approach

Success under PDGM will involve partnerships with different solutions providers or home health care. When selecting those to take along on the PDGM journey, pay special attention to their philosophy and approach to improvement and education. The two primary approaches that will be found are consultative and transactional.

A consultative approach will work together with a home health agency to ensure their specific needs are being met. Partners need to adjust the provision of services to help the organization achieve its goals. In contrast, partners that are transactional in nature will be more likely to be rigid within their provision of service and not supportive of the home health agency in meeting its goals.

Commitment to a consultative approach and partnership will ensure a home health agency remains at the center of the relationship, with valued input and an open line of communication. The result will be high-quality documentation fueled by technology to facilitate optimized operation under PDGM.

Putting it All Together

When complete and comprehensive documentation and coding work in harmony within a home health agency, the result is better patient care and better reimbursement for the provider. In short, it’s a true case of the best of both worlds.

The complete patient picture is clarified for the organization and an appropriate plan of care can be developed to maximize positive outcomes. Billing can then take place smoothly and correctly within the new reimbursement framework.

Moving forward with systems that have worked sufficiently in the past will create unnecessary hurdles during an already tenuous time in the industry, and that’s something that won’t work for anyone. Only when solid coding and documentation systems are in place will a home health provider be in a strong position to face PDGM in 2020 and beyond.