PDGM: The SOC/ROC question

Should your agency discharge and readmit or place the patient on hold for a Resumption of Care? PDGM poses some important considerations for home care providers.

When a patient’s home care episode is interrupted by an in-patient stay at either an acute care or post-acute care facility, and the home care provider expects to resume care of the patient later, is it preferable to discharge and readmit the patient when home care resumes?

Home care providers are weighing this question carefully under Medicare’s new payment model, the Patient-Driven Groupings Model (PDGM) which took effect Jan. 1.

The answer could impact reimbursement for the home heath agency when it bills for the following 30-day period of home care.

PDGM requires each home care patient to be classified into one of two admission source categories for each 30-day billing period: institutional or community. An institutional admission pays a higher reimbursement rate as the Centers for Medicare and Medicaid Services generally expects these patients to be sicker and require a higher use of agency resources.

But it’s not quite as easy as saying any patient coming to or returning to home health from any facility is an institutional admission. To be considered an institutional admission, the patient must have met certain criteria, including whether the discharge occurred within the past 14 days.

Was the in-patient stay less than 24 hours in duration? Was it for observation or diagnostic testing only, such as emergency room visit? If the answer to either of those questions is yes, the admission source will not be considered institutional. Instead, it will be a community admission.

Additional factors playing a role in determining the admission source include whether the home care period is the admission period or a continuing period, and whether the in-patient stay occurred at an acute care facility or at a post-acute facility. “Some agencies have been struggling this month to fully understand the admission source and the impact of SOC (Start of Care) or ROC (Resumption of Care), as it can be confusing,” said J’non Griffin, owner and president of Home Health Solutions.

“It’s important to have a good grasp on how all these factors can impact the admission source for home care patients, and make the right decision when determining whether to discharge and readmit the patient with an SOC, or hold with an ROC after the in-patient stay.”

WHY IT MATTERS In addition to the generally higher reimbursement PDGM offers for institutional admission sources, there are other considerations for agencies in making the decision to discharge and readmit or ROC.

An ROC is generally less labor intensive for the home care provider. A new face-to-face encounter most likely will not be required for the ROC. An exception would be circumstances in which the home health agency’s focus of care changes as a result of the medical condition, complication or exacerbation which required the in-patient stay. The F2F must address the primary reason for home health care. If the F2F in the medical record no longer addresses the changing focus of care, a new F2F may be required. Note, too, that if the agency’s focus of care has changed, new physician orders will be required to make all necessary changes to the Plan of Care. But, generally speaking, a discharge and readmit requires more documentation on the part of the home care provider than an SOC. If the agency chooses to discharge and then readmit the patient, all the usual SOC requirements will apply. The agency will have to have in its documentation a valid F2F and a new Plan of Care. If the agency chooses the SOC option, it will receive a Partial Episode Payment (PEP) for the previous period which was cut short.

“There are numerous considerations such as these which must go into the decision-making,” J’non said.


Need a refresher on the determining factors? Here’s a look at the three factors CMS uses to determine admission source under PDGM:

1. A 14-Day Window. The first determining factor is timeframe – specifically, the 14 days prior to the home care admission. Was the patient discharged from any in-patient facility during that 14-day timeframe?

If not, the admission source for the next 30 days is always going to be community.

But, if the discharge did occur during the past 14 days, the admission source could be either institutional or community and the additional factors described below must be considered.

2. SOC or ROC? The second factor is whether the agency performs an SOC or ROC. For SOC, a discharge from a facility (either acute OR post-acute) within the 14 preceding days will always be an institutional admission source.

This is different for ROC. For a continuing period of home care, the admission source may be either institutional or community. It depends upon the type of facility where the in-patient stay occurred. See the third factor below for an explanation.

3. Acute or Post-Acute Facility? The third determining factor for admission source at ROC is whether the in-patient stay occurred in an acute care or post-acute care facility.

If the in-patient stay occurred at an acute care facility, the admission source at ROC will be institutional.

But, if the in-patient stay occurred at a post-acute care facility such as an in-patient rehabilitation facility or a skilled nursing facility, the admission source at ROC will be community.

WE CAN HELP! Need some help making the decision? How about a Decision Tree to walk you through the process?

Home Health Solutions sells a PDGM Decision Tree in its online store to help agencies with the decision-making process. Our tool captures the decision-making process in a simple, easy-to-follow format which you can easily share with your staff members. This product is a two-page PDF in chart format, set out in traditional decision tree (if yes, do this; if no, do that) style. It is instantly available as a digital download after purchase.

Click here to visit the store now.