A simulation using 2019 Medicare home health data applied the Patient-Driven Groupings Model, which assigns episodes to clinical groups based on the primary diagnosis code. Because Alzheimer's disease and related dementias are seldom recorded as the primary diagnosis, affected beneficiaries are routed into clinical groups defined by coexisting conditions, raising questions about how well payment categories reflect their actual care requirements.
Key Points
- PDGM assigns home health episodes by primary diagnosis code alone
- Dementia is rarely coded primary, obscuring cognitive care needs
- 2019 pre-PDGM simulation tested clinical group assignment for ADRD beneficiaries
Longevity Analysis
Cognitive decline is the condition that most often determines whether an older adult can remain functional at home, yet it disappears from the administrative record when a fracture, wound, or cardiac event takes the primary code. The consequence is a mismatch between documented need and delivered support at exactly the stage where consistent, well-matched care preserves independence. Accurate classification is a prerequisite for interventions that protect cognition, mobility, and the daily routines that sustain them.
Original published by SAGE Research on Aging, by Maxwell Cutty, Lizmarie Maldonado, Jada Johnson, Carmen Pfeil, Kit N. Simpson, Sara Knox1Department of Health Sciences and Research, 2345Medical University of South Carolina, Charleston, SC, USA2Department of Healthcare Leadership and Management, 2345Medical University of South Carolina, Charleston, SC, USA3Department of Otolaryngology - Head & Neck Surgery, 2345Medical University of South Carolina, Charleston, SC, USA.