The CoMorbidity Question
Has your HHA been wondering about care planning and comorbidities in PDGM? Some HHAs have equated a qualifying comorbidity under the PDGM payment model as a comorbidity that must be addressed in the patient’s care plan. However, this may not be true. Below are guidelines to help your HHA determine what to address for the most effective and compliant care plan in PDGM.
- Comorbidities which combine to increase reimbursement under PDGM may or may not be appropriate for the patient’s care plan
- The clinician’s comprehensive assessment of the patient’s health and functional status along with the patient’s knowledge of their medical condition must be considered
- Goals must be individualized to the patient based on the patient’s medical diagnosis, physician’s orders, comprehensive assessment and patient input
It’s the combination of the primary diagnosis prompting the home health referral, and making the clinical grouping in PDGM, along with the comprehensive assessment that determines what the HHA needs to include in the plan of care. Below are two examples;
is referred for home health after an exacerbation of CHF. He also has diabetes. The clinician determines at the comprehensive assessment, the diabetes is long standing and stable with a normal HA1C. The patient is also able to demonstrate how to check his blood sugar and follows his prescribed diet and medication regimen. The HHA lists CHF as the primary DX and diabetes is listed as a comorbidity. The HHA does not include any interventions and goals for diabetes (other than those required by the COPs).
is referred for home health after an exacerbation of CHF. He also has diabetes. The clinician determines at the comprehensive assessment, the diabetes is not well controlled, the patient is not able to demonstrate use of his glucometer and is not adhering to his diet. The HHA lists CHF as the primary DX and diabetes is listed as a comorbidity. The HHA addresses the knowledge deficit for diabetes with interventions and goals in addition to those for CHF on the patient’s care plan.484.60(a) Standard: Plan of care
484.60(a)(1) Each patient must receive the home health services that are written in an
individualized plan of care that identifies patient-specific measurable outcomes and goals, and
which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or
podiatry acting within the scope of his or her state license, certification, or registration. If a
physician refers a patient under a plan of care that cannot be completed until after an evaluation
visit, the physician is consulted to approve additions or modifications to the original plan.
Interpretive Guidelines §484.60(a)(1)
“Patient-specific measurable outcome” is a change in health status, functional status, or knowledge, which occurs over time in response to a health care intervention that provides end-result functional and physical health improvement/stabilization. Patient-specific goals must be individualized to the patient based on the patient’s medical diagnosis, physician’s orders, comprehensive assessment and patient input. Progress/non-progress toward achieving the goals is evaluated through measurable outcomes.