What Is PDGM?
What Is PDGM?
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DOI：
10.1097/nhh.0000000000000768
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发表时间：
2019-03-01
影响因子：
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通讯作者：
Pierotti, Danielle
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文献类型：
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作者：
Pierotti, Danielle
医疗补助服务（CMS）发布了2019日历年医疗保险家庭医疗支付更新的最终规则。今年，它包括了家庭护理费用计算方式的重大转变。患者驱动分组模型（PDGM），最初称为家庭健康分组模型，将于2020年实施，并将患者护理和资源需求直接与支付水平联系起来。该模型是为了满足2018年两党预算法案（BBA）的要求而设计的。除其他事项外，BBA要求在2020年1月之前实施支付方式的变化，对医疗保险保持预算中立，禁止使用治疗量作为支付门槛，并以30天为支付单位。对于家庭护理来说，这些都是非常重要的变化——强制检查每个机构的运作方式，并将护理图表置于更大的压力之下。与当前结构相比，最明显的变化是计费周期。目前，患者入院接受为期60天的护理，其结果和评估信息集（OASIS）评估要求与60天日历相匹配，这与该事件的付款一致。PDGM模型维持60天的护理和OASIS要求，但将账单分成30天的增量。之后，根据四类患者标准计算费用：入院来源和时间、临床分组、功能水平和合并症调整。入院来源和时间——每30天将被分为两种入院来源类别之一——社区或机构——取决于在家庭护理前14天使用的医疗保健环境。如果在30天护理期开始前14天内发生急性或急性后护理住院，则30天期间将被归类为机构。如果在30天护理期开始前的14天内没有急性或急性后护理住院，则30天期间将被归类为社区。CMS将根据PDGM将30天的护理期分类为“早”或“晚”，具体取决于它们在30天内发生的时间。第一个30天期间将被列为早期，随后的所有30天期间将被列为晚期。新的30天护理期不能被视为提前，除非在一个护理期结束和另一个护理期开始之间有60天以上的间隔。临床分组——规则包括12个临床分组
Medicaid Services (CMS) released the final rule for calendar year 2019 Medicare Home Healthcare payment updates. This year it includes a major shift in how payment for home care is calculated. The Patient Driven Groupings Model (PDGM), originally called the Home Health Grouping Model, is set for implementation in 2020, and will link patient care and resources needs directly to payment level. The model is designed to meet the requirements of the Bipartisan Budget Act of 2018 (BBA). Among other things, the BBA required changes in payment be implemented by January of 2020, be budget neutral for Medicare, prohibited the use of therapy volume as a threshold for payment, and be based on 30-day payment units. These are very significant changes for home care—forcing an examination of how every agency operates and place nursing charting under more pressure. The most obvious change from the current structure is the billing cycle. Currently, patients are admitted for 60-day episodes of care with requirements for the Outcome and Assessment Information Set (OASIS) assessments matched to the 60-day calendar, which is aligned with payment for the episode. The PDGM model maintains the 60-day episode of care and OASIS requirements, but splits the bill into 30-day increments. After that, payments are calculated from four categories of patient criteria: admission source and timing, clinical grouping, functional level, and comorbidity adjustment.Admission source and timing—Each 30-day period will be classified into one of two admission source categories—community or institutional—depending on what healthcare setting was utilized in the 14 days prior to home care. The 30-day period would be categorized as institutional if an acute or postacute care stay occurred within the prior 14 days to the start of the 30-day period of care. The 30-day period would be categorized as community if there was no acute or postacute care stay in the 14 days prior to the start of the 30-day period of care. CMS will classify 30-day periods of care under the PDGM as “early” or “late” depending on when they occur within a sequence of 30-day periods. The first 30-day period would be classified as early and all subsequent 30-day periods will be classified as late. New 30-day periods of care cannot be considered early unless there is a gap of more than 60 days between the end of one period and the start of another. Clinical grouping—The rule includes 12 clinical groups