Home Health Notify

Effect of PDGM on HHAs – Home Health Notify to Your Rescue

The Patient-Driven Groupings Model (PDGM) is the biggest change for home health agencies in over two decades. The shift to the new model requires agencies to examine patient needs, comorbidities, and referral sources to determine if their case-mix optimizes reimbursement. CMS describes PDGM as an alternative case-mix adjustment methodology that will further the shift to a value-based payment system and ultimately reduce the cost of home healthcare delivery. “The redesign of the home health payment system encourages value over volume and removes incentives to provide unnecessary care,” says Seema Verma, SMC administrator and consultant for Medicare & Medicaid Services. “This home health rule focuses on patient needs and not on the volume of care.”

CMS estimates LUPA rates will drop from 8% to 7.1% with PDGM implementation. The policy has dramatically changed home health reimbursement since January 2020. Most crucial area that is important for HHA is cost control while managing care plan of each patient. The change has initiated a shift in CMS’s; hence, care leaders are keen to evolve their organizations into value-driven and client / patient-centred providers.

What it means for HHAs:

The change from 60-day episodes to 30-day periods means that agencies must plan, deliver, document, and bill for care twice as often. The first 24-48 hours from start of care (SOC) will be critical to optimize reimbursement: a HHA clinician must assess the patient’s needs and document a plan of care (POC) as soon as possible.

Today, successfully implementing PDGM requires agency leaders to flex their projecting, planning, and execution muscles. In essence, it’s all about your HHAs ability to manage and execute change effectively. Since the Patient-Driven Groupings Model has taken effect, home health agencies across the country are trying to keep up and maintain compliance. The largest change facing home health agencies in over two decades has many organizations evaluating and updating internal processes. Others are expanding their service lines to serve more clinically complex patients.

PDGM is affecting each agency differently, providers should prepare by adjusting their practices and rebalancing their patient populations. To maximize reimbursements and stay compliant with the model; your organization must have a plan for how to provide effective and efficient care.

Do you have the tools you need to thrive as regulations continue to evolve?


There are many documented toolkits and programs to train your agency to become PDGM ready. Added pressures from COVID-19 have exacerbated intake challenges. Common issues include missing information in referrals, hard-to-reach referral sources, and gaps in staff knowledge about clinical groupings. You can make your HHAs PDGM ready, but turning them PDGM effective is more vital. It is critical and need of the hour to implement accurate systems to optimise the results of the toolkits and strategies.

The most pertinent option to adopt in these times, when effective change is required, is HOME HEALTH NOTIFY. This e-platform works as a game changer in implementing a much-needed transformation. It is the most organic solution for all HHAs for a revolutionary turn around in efficiency and accountability of staff. This tailor build App will contribute not only in changing the work ethos but also prove an excellent solution for PDGM standards. The Home Health Notify App progressively shifts your agency towards process-oriented systems and efficient staff. Transparent work ethics and real-time results are most favourable to all the levied parties, the patients, the agency and the PDGM policy.


Home Health Notify

Clinicians Play a Vital Role with Patients at their Home

Millions of older Americans have HHAs, providing teams of clinicians into their homes on a daily basis to assist with essential medical services and help them stay out of hospitals along with staying connected in their communities. We believe that expanding the skill sets of our nation’s HHAs is one of the keys to helping America’s growing population of seniors, age in place successfully. Since HHAs are in their clients’ homes for multiple hours each day, they can play a critical role in protecting clients’ health. It is essential that the clinicians are provided with right platforms and tools.

As patient care has evolved into a system with multiple providers, the role of a clinician has evolved with it too. It now encourages a more bird’s eye, strategic involvement. How effective these services will be, if clinicians used pre-programmed e-platforms that automatically notifies a clinical manager, office staff and patients on each and every change and development that occurs with the patient, and records their detailed medical reports and personal information. “I know most things going on in all my patients’ homes, before visiting them. I can communicate with everyone related to patients’ side as well as the medical and office staff members at the same time, while I am with patients at their home via phone.” Says Tonya Gaston, Licensed Practitioner Nurse.

Ms. Gaston’s HHA, Home Care Wellness, Lincoln Park, IL, has been using Home Health Notify, the e-platform for HHAs, since past few months Ms. Gaston also added, “HHN gives me peace of mind because I now know all the medical staff visiting the patient’s home. I can go back and read the messages which have not been attended to by me, while I was busy, or was unable to attend while caring for our patients.”

A recently concluded pilot program trained HHAs to do effective care for the patients – and it found that additional training facility and platforms improved client’s health outcomes. The 18-month study, funded by a $1.9 million grant from New York State’s Department of Health, was implemented by the Bronx-based Paraprofessional Healthcare Institute (PHI). The study tracked 1,100 home care clients who were cared for by HHAs with advanced training, and found that this group had 24% fewer visits to the emergency room compared to those clients whose HHAs did not receive advanced training. The program sheds light on critical need of effective alternatives for escalated performance of the team of clinicians. Home Health Notify has been designed keeping in mind the challenges of HHAs, the platform acts as a catalyst to improvise strategies and processes that will help medical staff, better understand, analyse and communicate your Home Healthcare efforts.

Mr. Mukesh Sutar, Physical Therapist’s, work day was divided into three parts, firstly connecting with the office for new referrals, getting their addresses then logging into Kinnser for referral document and information. Secondly, back and forth communication with clinicians regarding clinical, confidential information. Thirdly, visiting patients, taking their pictures, completing essential paperwork and dropping them to office bi-weekly.

Since his company, TONE Home Healthcare Services, started using Home Health Notify, Mukesh says, “All the information regarding the patient (Personal / Medical) is on the record, I don’t need to log into any other portals (Kinnser). This saves me a lot of time and leaves no room for errors. Several phone calls during work are now a thing of the past, since all the communication can be handled through the HHN. The mapping of route has helped us clinicians avoid driving back and forth throughout the day.”

Besides direct impact on the health of home care customers, these advanced HHA platforms and their training initiatives have another important potential benefit; by offering an enhanced career path for our nation’s one million HHAs, they help reduce employee turnover, enable home care agencies to retain our most experienced HHAs as a vital resource. That, together with increasing embrace of advanced training for the nation’s home health workforce, adds up to a major win for the well-being of older Americans.


Home Health Notify

Home Health Notify – Achieving Ultimate Goals of HHAs

The most important objective all HHAs strive for, is Increased Patient Outcome and Fewer Hospitalizations. We at Home Health Notify, believe patients are “HERO” of the routine. They should be well researched and his \ her information should be at the back of each clinician’s hand.

Patient Information

All-important patient information and details are documented meticulously in the App:

  • Patient’s phone number – Just tap the number & make a call.
  • Date of Birth – First and most essential thing the doctor’s office requires.
  • Address – Just tap the address – it will start navigating you. If it’s plugged into your car, it will route via CarPlay. Eliminates the process of entering the address in your car’s GPS.
  • Episode date – Clearly denotes the SOC and 60 days period of care.
  • Patient’s Insurance – The office shares insurance details (Medicare or Humana), in case you need to take a care decision
  • Document Storage Section – All important documents of the patient are uploaded and are available to all members anytime. Existing members as well as ones added to the group later.
  • About Section – Discipline can learn some extra information about the patient. If a patient has pets, if patient is accompanied other family members, or the patient is hard of hearing or he / she cannot walk, etc.
  • Physician and care giver details are also available here.

Patient Guidelines

Patients are as important as we make them feel. Home Health Notify assures that you are armed with ample information and options, which not only put you at ease, but also assure patients that they are in good hands

  • Referrals – They often get buried in the EMR and it can be challenging to find referrals at the right time. Now you can -access them at your fingertips. We suggest, always scan them before visiting the patient.
  • Patient Records- When any new member in the team is added, he / she has access to all patient’s important information in one place. So, soak it all up and act as a thorough professional at the patients’ home to earn their trust. Your care routine will become much more coordinated.
  • The Care Team – You will be a part of the care team in members section and can see everyone on the same page. This will enable you to call or message your team by tapping the corresponding icon.

Often-used contacts – You have access to relevant contact information of physicians, clinicians, caregivers, and patient’s pharmacy at the bottom of the page. Need not be added separately to your phone directory.

Home Health Notify

4 Pillars of Home Health Notify Platform

Home Health Notify highlights the four most important work philosophies of HHAs. We are here to pour the secret sauce, which will help your agency take complete advantage of our versatile platform. These key features are quintessential in improving staff efficiency & accountability. Following our guidelines will help you witness dramatic improvement in patient care.

1. Communicate in real-time: Time is of great essence in the medical field. As soon as you learn something about a patient that your colleagues should know, share it immediately. Instant action is of utmost importance. More so essential during the times of COVID-19. At TONE, one of the OTs received a phone call from a patient’s daughter, she said, “Mom’s not feeling well. She is coughing, has fever and suspecting COVID.” The OT didn’t share the information until much later in the day. Luckily, nobody visited the patient that day, else it would be disastrous. Such potential exposure could have been avoided with a quick text message.

2. Red is dangerous: Colour RED, in the App is always highlighted as potential risk to the patient. All alerts on the platform, flash in RED colour. It is a persistent reminder that someone is waiting on a pressing requirement, which if delayed, may have serious repercussions. Your quick and efficient response, will decrease hospitalization rates and keep patients safe. If you see RED – take action! If SOC is pending, i.e., the patient has been discharged from the hospital, but care hasn’t yet started, assistance is required immediately. For example, if bathroom transfer procedures have not been put in place and explained to an aging couple at the earliest, we put patient and their caregiver at risk for a fall and re-hospitalization.

3. Templates are a lifeline: Templates drive the platform. A huge amount of research and thought process, has been put towards developing the templates. SOC Template changes the House colour, EVAL Template changes the Discipline colour, Revisit Template updates the LUPA calendar & Map Routing, Revisit Template also updates patient’s & clinicians’ calendar. We have tried to keep them simple and self-explanatory. All patient interactions need to be recorded and shared with office staff as soon as possible. It may seem as an added chore, on the contrary, templates are just enough information to keep the team updated and aid smooth patient-care.

4. Ask for Acknowledgement: In a clinician’s busy schedule, it is challenging to read and reply all messages on time. This feature is key to seek immediate attention of a particular professional immediately. Very handy while taking crucial decisions along with the physicians, can be done virtually via HHN when there isn’t enough time to reach office staff for approvals on paper. Saves a whole lot of effort, time and paper trail. It is a very convenient feature, when clinicians are handling critically ill patients. The feature works both ways – if the patient needs you, they will ask you for acknowledgement and vice versa. When requests get routed quickly to the right person, you will witness escalation in efficiency and accountability in your team.

Home Health Notify

Top 5 Advanced Communication Features for Home Health Industry

#1 Ask for Acknowledgment:

Extremely useful in formal CONFIRMATION of messages. It comes very handy while taking crucial decisions along with the physicians virtually, when there isn’t enough time to reach office staff for approvals on paper. Saves a whole lot of effort and time, which is extremely important for Clinicians handling critically ill patients.

#2 Visible to Physicians:

A custom-built option to aid in reaching critically important messages to physicians in REAL-TIME, while filtering out regular communication between the other clinicians, office staff. This surely is a boon for Patients who need to reach out in time of direct medical advice from physicians.

#3 Visible to Patients:

The patients do not need to be involved in the regular conversation within the team full of medical jargon. This would rather make them anxious. This feature helps declutter their inbox and only read the messages directed to them. Important instructions and guidelines to the patients can be followed without any confusion.

#4 Priority Messages:

This alerts the team to handle a situation when patients’ requirement is to be met or key decisions have to be made at the earliest during a noticeable medical event. Messages marked as “PRIORITY” are open to be addressed by the entire team in case the person it is addressed to is unable to answer in time.

#5 Star Messages:

Wouldn’t you love to be able to mark a message as an important task with a ‘STAR’ option. It is a personal ‘Things to do list’ for the Clinicians. The flag works as a reminder to staff for completing various tasks like wound dressings, massage, therapy on certain patients, etc. Convenient and useful for not just Clinicians but for patients too.