COVID-19 Has Affected Home Health Therapy Utilization in Multiple Ways

Heading into 2020, therapists working in the home health world were concerned over the effects that the Patient-Driven Groupings Model (PDGM) might have on their profession.

Then COVID-19 hit, forcing them to rush into action. A year later, the true impact of the new payment model on therapy utilization is still not clear.

“I’m not really sure we’re ever going to have clean data to be able to figure out what the direct effect of PDGM on therapy utilization was,” Cindy Krafft, the owner and founder of Kornetti & Krafft Health Care Solutions, said on a recent Home Health Care News webinar.


Krafft is a licensed physical therapist and has been in the home health space for 27 years. Her company advises agencies on both operational and clinical issues.

There were some inklings of what the impact of PDGM may be heading into 2020 and during the first couple months of last year. But that was mostly from agencies struggling with how to manage the concept of therapy visits not being tied directly to reimbursement anymore, Krafft said.

Nearly half of home health agencies planned to decrease therapy utilization in 2020, according to a mid-2019 survey conducted by the National Association for Home Care & Hospice (NAHC).


“I know, as a therapist, my brothers and sisters in the therapy universe get a little antsy … thinking that [PDGM] is going to be the death knell for therapy and that therapists are all going to lose their jobs,” Krafft told HHCN in 2019.

But COVID-19 threw a wrench in every agency’s plans. Experts warned that decreasing therapy recklessly would be potentially dangerous for patient outcomes.

It’s likely true that PDGM did have some influence on therapy utilization, but finding out how much could be an unrealistic task.

“We got through a couple months and then the pandemic began, and utilization took a completely different hit with respect to trying to determine how to manage the initial crisis mode of saving lives and minimizing risk,” Krafft said. “I think PDGM did have some influence, but I don’t think we’re going to ever really be able to say it was the sole thing that impacted utilization in 2020.”

Before the public health emergency, there was a wariness attached to scheduling therapy visits because of the onset of PDGM.

But after it, there was a shift in thinking, Dr. Monique Caruth, the CEO of Fyzio4u Rehab Staffing Group, said on the webinar.

“At the beginning of the year with PDGM, we were being questioned when we put visits at twice per week for four weeks, for instance, or three times per week for four weeks,” Caruth said. “We had clinical managers sending back messages saying, ‘We have to be careful because of PDGM.’ And then COVID hit. Then it went back to giving the therapist control of determining frequency.”

Caruth has been a licensed physical therapist in Maryland since 2008. She also serves as the southern district chair of the state’s American Physical Therapy Association (APTA) organization.

She was recently elected to lead the home health section of APTA. Her term begins in February.

The post-public health emergency shift in thinking didn’t last forever, however. Utilization patterns changed again once COVID-19 infection became a larger concern around therapy usage.

“[Agencies] were very careful and trying to limit the spread of COVID to clinicians, so if a patient was COVID positive, they wanted you to do one visit in person and one telehealth visit,” Caruth said. “I didn’t find that very accommodating for patients who were highly deconditioned. So I would base my frequency or recommend that all clinicians based their frequency on how the patient presented at the time of the evaluation.”

Caruth and her team have not yet seen any pushback from that practice, which is to diagnose the amount of appropriate visits strictly based on how the patient’s condition is.

It’s a positive example of how therapy should be utilized in a post-PDGM world, Krafft said.

“I think it becomes a crisis mode [reaction], and then a standard is set that we’re going to do one visit in person and then one telehealth visit,” Krafft said. “And we know that patient care does not work well as a one-size-fits-all. I think sometimes as therapists we dig in our heels about what we think our frequency should be, just because it’s what we’ve always done, too.”

Instead, the entire industry should be flexible to setting visits strictly based on what the patient’s condition and level of acuity is, she suggested.

It could be true that, after PDGM, some agencies began to undervalue therapy. But COVID-19 may have re-emphasized the importance of it, particularly in home health care.

In the recent $1.4 trillion spending bill passed by the U.S. government, occupational therapists (OTs) — for instance — were given the right to open home health cases.

The American Occupational Therapy Association sees that as an opportunity to change the perception around OTs generally — and now prove their worth further moving forward.