Home Health Articles and Information


Dec 16, 2019 3:10:00 PM / by Kristi Bajer, BSN, RN, COS-C

PDGM and Care Planning

Home Health is changing rapidly and the most successful HHA 's have been making changes to all aspects of their businesses. Care planning can be no exception. The Patient Driven Groupings Model or PDGM is a diagnosis-based payment and patient care model. This means care plans can no longer be based solely on the clinician’s assessment. Assessment based care plans are often lengthy, with multiple pages of interventions and goals. Because clinicians are often given the responsibility to write care plans alone, one agency may have vastly different care plans for patients with essentially the same admitting diagnosis and clinical assessment. Although many would defend this as "patient specific" care planning, the truth is, the fundamentals of evidence- based care are often ignored and home health outcomes suffer.


OperaCare teaches agencies to always start care plans with evidence-based practice regarding the patient's primary reason for home health. We call this the "backbone" of your care plan. Next, adaptations can be made to address your patient's individual needs. Are they forgetful? Break the teaching into more visits or make a point to teach the care giver. Do they have an exacerbated co-morbidity? Add interventions and goals specific to the co- morbidity while leaving your "back bone care plan" in place.

Below are questions to consider about your agencies care planning for PDGM:


  • Who is generating your Plan of Care?

QA and management staff with knowledge of evidence-based practice should be producing care plans. These clinicians typically have a much better understanding of value- based metrics than your field staff. HHAs must provide concise interventions with fewer visits while meeting goals.

  • What Interventions and goals is your agency using?

What is put in the plan of care must be consistent to produce consistent outcomes. Providing evidenced-based diagnosis specific care planning will ensure HHA's remain focused on the reason for the referral, meet outcomes, and prevent re-admissions.

  • When is the Plan of Care created?

Care plans must be produced more quickly for 30-day care periods to ensure cash flow stays intact. Creating care plans the same day of the OASIS visit is preferable, but agencies should complete care plans in 48-72 hours for both PDGM and RCD.

  • How do you know your interventions and goals are effective?

QIO/QIN networks along with HHQI have provided an enormous amount of evidence-based, disease specific information for us. Taking advantage of this information to produce care plans will ensure you are providing effective patient care.



Tags: PDGM, Home Health, Quality assurance, OASIS

Kristi Bajer, BSN, RN, COS-C

Written by Kristi Bajer, BSN, RN, COS-C

Kristi Bajer BSN, RN, COS-C, brings over 10 years of real world experience as a clinician, director, and administrator in home health. She is a firm believer in diagnosis driven evidence-based care in home health. Currently, she assists agencies with external chart audits and Medicare appeals, as well as providing training and coaching on OperaCare implementation and building QAPI programs using data to drive success and protect agencies from government audits.