Acute care under PDGM


Not all hospital stays will be the same under Medicare’s new payment model

Home care providers can expect to make more money under the Patient-Driven Groupings Model (PDGM) when they treat sicker patients who are admitted directly from institutional sources -- but not every hospital stay will be considered an institutional admission source under the PDGM.

Emergency room visits and observation stays are two examples of acute care for which the admission source will be considered community rather than institutional under the new Medicare payment model taking effect in January 2020.

Patients who are admitted to home health after having undergone procedures in outpatient facilities are a third example of the model's institutional admission source exclusion. If a patient has joint replacement surgery performed at an ambulatory surgery center instead of a hospital and is referred to home care afterward, the admission source will be considered community rather than institutional.

“An in-patient stay is required for the admission source to be institutional,” said J’non Griffin, owner and president of Home Health Solutions. “Observation stays and emergency room visits are not in-patient stays, so they will be considered community admission.”

Patients admitted to home care from outpatient ambulatory surgery centers will also be considered community rather than institutional admission sources because those facilities do not meet the CMS criteria for institutional admission source.

Some types of post-acute facilities will meet institutional admission requirements – at least for the first 30-day period of home care. After the initial 30-day period, CMS will use a narrower standard to determine admission source for all subsequent 30-day periods of home care. Confused? The criteria for determining admission source under PDGM is no less complex than any other aspect of the new PDGM model. Here is a breakdown of how admission source will work under the new payment model.

First 30-day period

For the first 30-day period of home care, a patient’s admission source will be determined by records already in the Medicare system showing whether an acute or post-acute care stay occurred during the previous 14 days.


If the admission source will be considered institutional, the patient must have been admitted to home care immediately following an in-patient stay in one of these acute or post-acute care facilities:


· In-patient acute care hospital

· In-patient psychiatric facility (IPF)

· Skilled nursing facility (SNF)

· In-patient rehabilitation facility (IRF)

· Long-term care hospital (LTCH)


If the patient did not have an in-patient stay in one of those facilities during the past 14 days, the admission source will be considered community rather than institutional.

Subsequent 30-day periods The number of admissions which can be considered institutional drops sharply for subsequent 30-day periods of home care.

“Only acute care hospitalizations which occurred within the 14 days immediately prior to the contiguous, subsequent 30-day period of home care will allow the admission source for subsequent 30-day periods to be institutional," J'non said. "After the first 30-day period of home care, a stay in a post-acute care facility will no longer be considered an institutional admission source. All post-acute care stays will be community admission sources for subsequent 30-day periods."

This means post-acute care stays in a SNF, IRF or LTH will be considered community admissions even when they occur within 14 days of a subsequent, contiguous 30-day period of care..

For the admission source to be considered institutional during subsequent 30-day periods, an acute care hospital stay must have occurred within the last 14 days prior to the contiguous 30-day period, and it must have been an in-patient stay rather than an observation stay or a visit to the emergency room.

Industry concerns Some home care providers are questioning whether excluding emergency room visits and observation stays from qualifying as institutional admission will hinder the new payment model in its stated goal to match reimbursement to higher resource use.

Patients admitted to home care directly after emergency care and/or observation stays often experience complications or exacerbations which can create an increased need for skilled nursing care, J’non said. The reimbursement difference between community and institutional admission source could amount to as much as $600 to $800 per patient, National Association for Home Care & Hospice (NAHC) President William Dombi has estimated.

Based on industry concern and the volume of questions it has received about admission sources, CMS has said it will provide future training and guidance sessions on community vs. institutional sources.


Need help? Feeling overwhelmed by the complexity of the new PDGM? Home Health Solutions can help! Contact us today and we'll provide the operational analysis and training your agency needs to survive and thrive under PDGM.

710 Langston Rd. 

Carbon Hill, AL 35549 

888-418-6970

services@homehealthsolutionsllc.com

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