Post-Acute Care and Home Health Care

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Patient-Driven Grouping Model (PDGM)-Effective January 1, 2020 CMS Home Health Payment Methodology. Picture

Patient-Driven Grouping Model (PDGM)-Effective January 1, 2020 CMS Home Health Payment Methodology.

Have you downloaded the CMS PDGM Excel file from the CMS Home Health Agency Center?

OASIS Tip - M1600 Patients discharged with an UTI on discharge and PAEs Report

Are your Potentially Avoidable Events (PAEs) Report showing an increase in patients being discharged while having an UTI?


Patients falls are a marker of frailty, immobility...

Ready for CMS QAPI Program?

According to CMS in 2011 several nursing homes providers begun testing CMS QAPI Program, Quality Assurance (QA) and Performance Improvement (PI), Program which includes Five Elements...

Post-Acute Care and Home Health Care

What happen to the Acute-Care organization's Discharge Planners and the Post-Acure Care Home Health Care Community Liaison? These roles have disappeared to be replace ....

Acute care facilities in the community are investing in community education, relations ships with physicians and home health agencies that can assist them to decrease the acute care organization's patient readmission.

Some organizations are contracting with organizations that will become the go in between "Case Manager" on behalf of the patient between the Acute-Care and Post-Acute organization. These "Case Management" organization's provide the Acute Care facilities with a potential discharge plan based on the patient's medical record that has a lower risk for re-hospitalization in the next 30, 60 or 90 days. It is the physician and patient/caregiver who has the final decision for the final discharge plan.

Other acute-care organizations are implementing "Discharge Phone Calls (DPC)" that targets problems that arise during the care transition period. Some of the problems are not new as Medication Management, able to reach a clinician to ask a question and follow-up appointments.

Reviewed 7/2018