LUPA Management in the Medicare Patient-Driven Groupings Model (PDGM) Environment

In the Medicare Patient-Driven Groupings Model (PDGM) environment, LUPA episodes are becoming more common. In this context, a LUPA episode is when a patient does not meet the CMS goals of positive care outcomes, a positive experience of care and a low per capita cost of care.

LUPA visit thresholds under PDGM vary from two to six visits and are determined by clinical grouping and episode timing. Typically, a LUPA episode occurs when a patient has an unexpected genitourinary problem that requires multiple Foley catheter changes in a short period of time.

As a result, many agencies experience a disproportionate number of LUPA visits in a given period. In the PDGM world, that may be an expensive situation for an agency.

To help avoid this problem, agencies need to start thinking about LUPA management early on. This is done by monitoring LUPA trends on a regular basis, and assigning one person to track these metrics.

Keep a close eye on visit counts in 30-day periods of care. For example, if a patient has only two or fewer billable visits in a second 30-day period of care, determine if it is impacting clinical outcomes and if the agency could potentially move that into the first 30 days.

Then, work with a healthcare IT consultant to implement processes for tracking LUPA visit trends and to ensure that LUPA thresholds are met before they occur. HCHB Analytics provides tools to help you create an efficient LUPA management process, including the ability to set alerts when a LUPA threshold is exceeded.