How Triage and Patient Engagement Can Help Under the 2026 Final Rule

On November 28, 2025, CMS released the 2026 Home Health Prospective Payment System Final Rule (CMS-1828-F), making payment cuts official. While this reduction is smaller than originally proposed, agencies will enter another year of tighter reimbursement, updated PDGM dynamics, and rising pressure to deliver high-quality care with fewer resources.

Payment Changes & Operational Updates for 2026

CMS recalculates payment rates each year. For 2026, the base payment update would have increased payments by 2.4%, but several downward adjustments offset that gain:

• A -0.9% permanent payment adjustment to account for differences between assumed and actual behavior changes under PDGM from 2020-2022

• A -2.7% temporary adjustment to reconcile estimated overpayments due to behavior changes under PDGM from 2020-2022

• A -0.1% reduction due to the updated Fixed-Dollar Loss (FDL) ratio for outlier payments

The net result is a 1.3% payment decrease compared to 2025.

CMS also finalized operational changes that will influence how agencies manage utilization, documentation, and compliance. Scrutiny of patient complexity will increase, but there is added flexibility with updated face-to-face rules allowing physicians, nurse practitioners, clinical nurse specialists, and physician assistants to conduct encounters regardless of whether they are the certifying practitioner.

Refer to CMS’s Fact Sheet here for the full operational summary.

Where Triage and Patient Engagement Can Help

The pressure points this rule creates around efficiency, documentation, accuracy, and outcomes are exactly where triage and patient engagement strategies can provide support. Here’s how.

Strengthening Outcomes in a Tighter HHVBP Environment

With updates to HHVBP, performance and payment will hinge less on subjective patient-experience measures and more on clinical and spending-based indicators. Missed or delayed triage remains one of the biggest drivers of preventable decline and avoidable readmissions. Getting patients to an RN quickly helps catch emerging issues early and reduces functional regression. As clinical performance and cost control carry more weight, real-time response and escalation pathways matter more. Speed to reach an RN, triage data, and proactive patient engagement help agencies:

• Identify decline earlier and intervene

• Reduce unnecessary hospitalizations

• Support patients between visits and strengthen care transitions

Improving Cost Efficiency Across Patient Episodes

CMS added a Medicare Spending per Beneficiary (MSPB) measure that ties HHVBP performance directly to cost efficiency across the patient episode. MSPB rises quickly when avoidable ED visits, preventable readmissions, and unnecessary in-person visits occur.

Strong triage processes help agencies:

• Resolve a high percentage of issues via telephone or video visits
• Identify changes in condition early
• Guide patients to the right level of care without defaulting to higher-cost settings like the ED or hospital

Centralizing or outsourcing triage also prevents after-hours calls from falling on visit nurses. This increases their capacity for in-person care, improves the quality of those visits, and can positively affect performance on the three new OASIS-based clinical measures.

Supporting PDGM Accuracy

New case-mix weights and comorbidity adjustments heighten the importance of timely insight and accurate documentation. Triage and engagement strategies improve PDGM performance by:

• Increasing visibility into patient needs and complexity

• Creating more early-episode touchpoints

• Strengthening documentation that supports medical necessity and appropriate visit planning

Reducing LUPA Exposure Through Smarter Utilization

Better decision support is a must with shifting PDGM-based LUPA thresholds tied to 30-day episodes and case-mix groups. Triage data gives clinicians real-time clarity on symptom severity and appropriate next steps. Paired with tools like the CareXM Insight Platform, agencies can see:

• How often triage indicates a visit

• Visit completion rates

• Visit status distribution

• Patterns driving unnecessary visits

Aligning triage insights with proactive patient engagement tools protects utilization, keeps care aligned with patient needs, and reduces avoidable LUPAs.

Protecting Revenue in a Reimbursement-Restricted Year

With cuts in place, efficiency becomes your most strategic lever. More than two-thirds of patient care occurs after-hours, making it one of the highest-impact areas for improvement.

Greater visibility into after-hours activity helps you:

• Track workload peaks and align staffing
• Monitor response times and outcomes
• Reduce unnecessary visit volume
• Understand how after-hours issues influence daytime workloads
• Identify recurring needs to inform care planning

This level of visibility will help you reduce operational drag that drains capacity and erodes margins.

Strengthen Documentation in a More Rigorous Compliance Climate

CMS is tightening program integrity requirements. Clean, consistent documentation won’t eliminate compliance risk, but it reduces exposure tied to incomplete or inconsistent clinical records.

Structured triage documentation should capture:

• Symptoms
• Escalation criteria
• Clinical reasoning
• Timelines and details of actions and decisions

The Bottom Line

The 2026 final rule raises expectations for efficiency, accuracy, and outcomes. Agencies that rely on visit-heavy models or inconsistent after-hours processes will feel the most pressure.

Triage and patient engagement strategies don’t reverse reimbursement cuts, but they do give agencies the clinical insight, operational clarity, and documentation support needed to navigate a tighter system. As the industry shifts deeper into outcome-based care, the ability to coordinate patient needs between visits will matter more than ever.

Supporting more than 10% of all Medicare daily active episodes, CareXM is the #1 provider of nurse triage solutions for home-based care. Our scale, data, and technology help agencies expand clinician capacity, reduce coordination complexity, and build the operating leverage needed to grow sustainably.

If you’d like help navigating the changes in the 2026 final rule, request time with our team here.