Patient-Driven Groupings Model

Patient-Driven Groupings Model

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Home health care is need-based and low-cost service where patients are treated within the periphery of their homes. Home health care (HHC) offers low-cost care that is efficient and comparable to clinical care.

Without increasing hospital infrastructure and related costs, patients can be looked after and healed back to health in home health care. A couple of examples of home health services include:

  • Patient and family education 
  • Caring for wounds 
  • Monitoring biometrics
  • Geriatric services for aged seniors

Home health services are provided by home health agencies (HHA), which provide skilled nursing, therapy, and other home-based patient care. HHAs follow professional guidelines and engage registered nurses who specialize in disciplines where home-based cases are commonly preferred, for instance, palliative nursing and physiotherapy. Clinical records are maintained and supervised by providers regularly to monitor the home care recipients under their home care plan in OASIS, which is designed to collect patient data. 

The Patient-Driven Groupings Model or PDGM is a change that was effective from January 2020 to classify care provided by home health agencies based on the clinical characteristics of the patients. It replaces the Prospective Payment System, implemented two decades ago and based on diagnosis coding, data, and therapy utilization.

With the new changes, home health organizations are streamlining the clinical and non-clinical activities related to care to meet compliance requirements. Earlier, under the PPS model, evaluation of internal processes was not efficiently carried out. Few home health organizations are expanding their services to accommodate complex patient care.

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Positives of PDGM in home health care


Every structural change needs skilled clinical staff to steer the workflow process without compromising the deliverable quality of patient care. Every home care provider enabler or agency needs to plan strategies that can sustain the new changes for future operations. 

Eliminates questionable items

PDGM uses diagnosis coding and patient data to reimburse the treatment services bill. It will reject therapy utilization as a part of the reimbursement. However, it does not mean that patients who need physical therapy will not get the care they need. It is just an attempt to eliminate excessive service billing and determine reimbursement based on the initial diagnosis. The ICD-10 diagnosis coding is an important part of PDGM as wrong coding can result in rejections. The codes are divided into six clinical groups and six sub-groups. There are questionable encounters where the diagnosis is stressing symptoms and not underlying causes. All questionable encounters are automatically rejected. 


Based on the patient’s main diagnosis, each 30-day care period is grouped into 12 clinical groups under the border classification of community and institutional care providers. The first 30 days are defined as early, and the rest will be classified as late periods. 

As per the diagnosis report, information related to the reasons patients are getting home health services is determined. 

Steps for Home Health Agencies to be PDGM compliant

  • Improve documentation 

The home health agency needs to improve its documentation process. 

 In simple terms improperly documented diagnosis cannot be coded right. If a physician lacks the time or feels a diagnosis is irrelevant, the patient outcome will be affected. 

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ICD-10 is the only way to read the patient history by automated administrative processes and use AI-driven algorithms to read numerous OASIS in a day. Wrong coding or wrong documentation will affect the reimbursement of plans. 

  • Patient-centric care

Many home care agencies have failed to understand the ambit of PDGM. It does eliminate therapy or set limits of therapy per patient. The focus of reimbursements is more on the structure of primary diagnosis.

If the diagnosis warrants physical therapy, it will be awarded per every bill. However, over-therapy is discouraged under the new provisions. Based on the documentation, the focus has shifted to the merits of the diagnosis coding. 

Home care agencies should not develop a practice of eliminating therapy even for patients who genuinely require a better patient outcome. 

Conclusion: Patient-Driven Groupings Model

Patient-centric provisions are needed to help with cost containment and offer better patient outcomes. Home health agencies play a significant role in the healthcare industry by taking care of patients in the comfort of their homes and averting extra pressure on hospital infrastructure.  

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