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Terms in this set (47)
Overview of home health:
Professional and para-professional services post-acute and long term care provided in non-medical residential settings including (social and supportive services & post-acute skilled services).
Children and working age adults comprise ___% of home care patients, commonly through what insurer?
People over the age of 85 comprise ___% of home care patients, but use higher amount of services.
Describe home health services:
Services provided in the home is a unique form of intermittent long-term care.
May be skilled services
May be unskilled services
May receive both skilled and unskilled
Medicare defines home health services as:
Provision of medically necessary services in the home for persons who are home bound due to illness or injury.
The intent of congress in crafting the benefit was to provide skilled services to treat a person's illness or injury for a finite and predictable period of time.
What is skilled care?
Medically reasonable and necessary care performed by a skilled nurse or therapist.
If a home health aide (someone who provides help daily living activities, such as bathing and eating) or other person can perform the service, it is not considered "skilled care".
Skilled nursing includes registered nurses (RNs) and licensed practical nurses (LPNs).
Skilled therapy includes licensed physical (PT), occupational (OT) and speech therapists (SP).
What is the purpose of home health?
To enable recipients to remain in the least restrictive environment as long as possible and to prevent unnecessary use of more costly inpatient health services.
What are the 3 types of home care?
1. Home health agencies: provide skilled intermittent care, including PT and OT. Includes disease state management. Typically certified as Medicare agency.
2. Hospice: provides medical and social services for those at the end of life. Certified as Medicare agency. Therapy services may range from a consultative role focusing on assisting caregivers to an active interdisciplinary role in palliative care at end of life.
3. Home care aide agencies: personal care services to assist with ADLs. No certification as it is not a covered service.
Home health agencies must be certified by:
CMS to provide services under Medicare and Medicaid.
Accreditation is a _______ process.
The community health accreditation program(CHAP) and the joint commission of accreditation of health care organizations (JCAHO) accredits home health agencies.
JCAHO currently uses data generated through OASIS (outcome and assessment information set) which is the system required by Medicare to assess outcomes in home health organizations.
Who is NAHC?
National association for home care and hospice.
A nonprofit organization that represents the nation's 33,000 home care and hospice organizations. NAHC also advocated for the more than 2 million nurses, therapists, aides and other caregivers employed by such organizations to provide in-home services to some 12 million Americans each year who are infirm, chronically ill, and disabled. along with its advocacy, NAHC provides information to help its members maintain the highest quality of care and is committed to excellence in every respect.
There are many models of home health services, including from:
Outpatient therapy practices
Pediatric private practice that provides services in the clinic or in the home
Therapists in a skilled nursing unit who provide home health services to other residents in the retirement community of which the SNF is a part.
Home care agency that contracts with a retirement community to provide services to any residents who need them.
Contract therapist company who provide per diem staff to several home health agencies.
Nationwide home health agencies with many locations.
What is covered with home health?
Part-time/intermittent skilled nursing care
Physical, occupational and speech language therapy
Medical social services
Some home health aide services
Durable medical equipment, supplies
An individual is considered to be confined to his home if:
The individual has a condition due to an illness or injury that restricts the ability to leave his home except with the assistance of another individual or if the individual has a condition due to an illness or injury such that leaving his home is medically contraindicated.
The condition should be such that there exists a normal inability to leave the home, that leaving the home requires a considerable and taxing effort.
Acceptable reasons for leaving the home include:
The need to receive "health care treatment" (includes attending an adult day care program, to attend a religious service)
Key words for home health therapy services:
In the home
Home bound due to specific reason
Before establishing a plan of care for a home health patient, ask 2 questions:
1. Is this patient homebound?
Is my service medically necessary?
Responsibility: if a home health agency sends you out to see a patient, doesn't that mean the patient qualifies?
NO! Mistakes are made. You must check to avoid fraudulently billing for these services.
Medical necessity: what does that mean?
Can these groups disagree on whether something is medically necessary?
Services that if not provided now, would result in a negative impact on the patient.
Referral source, provider, and ultimately Medicare
What does homebound mean?
Confined to home (not bedridden but leaving house would require exhaustive effort; only leaves home rarely and for medical reasons). Confined to home due to illness or injury.
Medicare defined the term and therapists examines client to find functional info that supports this homebound definition.
What is a current issue with home health?
Chemotherapy, respiratory therapy, telemonitoring, dialysis care, IV nutrition, fetal monitoring and other services have moved into the home health setting...
Thus the clients are more frail with more medical challenges.
Discharge planning from inpatient must include:
Safety of home
Willingness of caregiver/family to assist in ADLs/IADLs
Additional resources to supplement family caregiving
Therapy services in home health:
Historically home health case managers are nurses. Therapists have been dependent on nursing for recommending referrals to therapy.
Recent changes in Medicare reimbursement with a shift to a rehabilitation model in home care has helped increase utilization of PT/OT
there are opportunities for PT/OT to educate nursing about the role of the therapist vs the therapist assistant in home health care.
What is OASIS?
The outcome and assessment information set:
CMS instituted OASIS to gather the same type of data, using the same timeframes, for a huge number of patients in different diagnostic groups.
Designed to provide the necessary data items to measure both outcomes and patient risk factors.
This information is used to examine the outcomes and trends in home health nationwide.
OASIS includes the following patient characteristics:
Health service utilization
What else does OASIS do?
Represents core items, to be integrated into a comprehensive assessment for an adult home care patient.
Forms the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI).
Provides quality data for consumer's use on Home Health Compare.
Provides information on the patients conditions and needs to formulate the proper reimbursement.
Medicare's compare program is based on OASIS data--can compare different home health agencies in each state.
OASIS reporting requirements provide managers opportunities to analyze effectiveness of therapy. Looks at:
Change in patient status from admission to discharge.
We're therapy services utilized appropriately, overutilized or underutilized.
How do therapists compare to each other in patient outcomes for similar patients.
What was the value of therapy services for an individual patient.
How can patient outcomes be improved overall.
What are the requirements for Medicare?
Initial assessment visit
The comprehensive assessment
The drug regimen review
The requirement for updating the comprehensive assessment
Incorporation of OASIS data items.
All of this info must be gathered by the therapist if nursing services are not needed for the patient.
Other requirements for Medicare:
First, each initial claim submitted for the initial payment must be based on the current OASIS based case mix and include detailed statement about proposed therapy for the next 60-day period.
Then if the patients case mix category remains the same, the final payment will equal 40% of the actual case-mix adjusted episode payment.
But if the patients original projected therapy minutes change within the episode, the case-mix will be adjusted accordingly. (This will either increase or decrease the payment to the HHA, depending on the number of therapy minutes actually received).
Payment for atypical patients: what about patients who need several months of home health treatment?
The final rule states that continuous episode recertification for Medicare eligible beneficiaries are allowed. There is no limit on the. Number of 60 day episode recertifications permitted in a fiscal year.
Payments for atypical patients: what about those patients who will only need a week or two of home therapy?
Low utilization payment adjustment (LUPA). For therapy episodes that entail 4 or fewer visits, CMS will pay the HHA a per-visit, per discipline amount called the low utilization payment adjustment.
CMS was concerned about the financial incentive for an HHA to provide minimal services within an episode of care. CMS worried about the possible motivation for an HHA to delay discharge, request an additional full 60 day episode payment beyond a current episode and then just provide the absolute minimum of additional services.
Discharge issues: the LUPA exception is that if a patient is discharged because he:
....the HHA will still receive a full 60 day episode payment.
Is no longer homebound
Becomes a documented safety, abuse or noncompliance discharge during the 60 day episode payment.
Result: it benefits HHA's to discharge these patients as soon as appropriate.
What is the care instrument?
A communication tool initiated by CMS to provide longitudinal patient information when totally completed.
Four major domains (medical, functional, cognitive impairments and social/environmental factors) are tracked.
CARE measures outcomes in treatments while controlling for factors that affect outcomes such as cognitive impairments and social and environmental factors.
What does CARE instrument stand for?
Continuity assessment record & evaluation instrument.
The deficit reduction act of 2005 directed CMS to: develop and standardize patient assessment information from acute and post acute care (PAC) settings.
How is it different?
Intended to be comprehensive picture of patient as he goes from IP to IPR to SNF to HHA to OP...
Many items on CARE are already collected in hospitals, SNFs and HHA, but different wording of questions leads to different analysis.
CARE intends to eventually replace similar items on the existing Medicare forms, including OASIS, MDS and IRF-PAI, so there is a core of important data in a central place that any therapist can access.
Planned use for CARE:
Gather standardized information on status at DC from acute care hospitals.
At IP admission, DC, and other set times during post-acute care, it will document medical severity, functional status, and other issues related to outcomes and resource utilization to allow ongoing status information.
Analyze relationship between severity of illness, functional status, social supports and utilization of resources.
Analyzing info from CARE:
Help to gather the quality of care transitions, leading to a reduction in inappropriate hospital re-admissions.
CMS plans to use data to develop a post-acute care PAC) payment model that will be fair to all.
CMS issued a final rule to update the home health prospective payment system (HH PPS) rates for calendar year 2011.
The final rule also included face-to-face requirements for physicians and patients as well as specific reassessment guidelines by therapists at specific visits.
If a patients course of therapy treatment reaches 13 therapy visits, for each therapy discipline for which services are provided, a qualified therapists must provide the ordered 13th therapy service, functionally reassess the patient, and compare the resultant measurement to prior measurements. The therapist must document in the clinical record the measurement results along with the therapists determination of the effectiveness of therapy, or lack thereof. (Similar at the 19th visit)
In the final rule CMS places the 13th and 19th visit in an episode proposal with a more flexible approach. CMS states that a professional therapist reassessment in rural areas and non-rural areas under extenuating circumstances must take place anytime after the 10th visit but no later than the 13th visit; and after the 16th visit but no later than the 19th visit specific to each discipline of therapy. The assessments required relate only to each therapy discipline individually and not to the combination of therapist services.
If a patient receives skilled nursing, then who must be the case manager?
If only skilled therapy is provided, then who is the case manager and who can perform the initial assessment and comprehensive assessment?
Either a therapist or nurse.
Note: contract therapists are usually not permitted to act as case managers. OTs usually do not complete OASIS but just contribute to it (although allowed to do so by state law).
Issues unique to home health:
Home health services are a field operation and may encompass several counties.
Face-to-face contact with staff in a central setting is it practical on a daily basis due to travel requirements and productivity goals.
There is some scheduling flexibility for clinicians.
OASIS reporting requirements provide managers opportunities to analyze effectiveness of therapy.
Therapists have more responsibilities for teaching patients how to handle medical devices, communication technology and durable medical equipment than in other settings.
Issues unique to home health continued....
Complexity of environmental conditions, family dynamics, cultural issues can present safety issues or other challenges and increase the complexity of providing services.
Managers have a responsibility to supervise employees (call patients, random on-site visits)
Potential for fraud (providing services not needed, billing for services not provided, incomplete or inaccurate documentation)
Issues unique to home health continued:
Important to hire and retain experienced therapists.
Comprehensive orientation and staff training.
Educating therapists on communication technology and medical devices available to monitor or improve functional ability of patients at home.
Analysis of OASIS data to answer questions (patient improvement from admission to discharge. We're therapy services appropriate, over- or under-utilized. How do therapists compare to each other in their care if similar patients within their respective disciplines. What can therapists do to improve patient outcomes)
Understanding medicare/ Medicaid payment system and detailed regulations and educating staff.
Holding regular monthly staff meetings is important as communication with staff is commonly 1:1 since staff are usually not in the same building at the same time.
Management skills in another healthcare organization do not necessarily transfer to home health services (unique aspects of field operations. Special needs of pts with serious medical issues being cared for at home. Greater influence of social and cultural factors.)
-supervision of PTAs (state statutes that control licensure may determine if PTAs can work in home health settings. The supervising PT should make individual decisions about delegation to a PTA.
-continuity of care (maintaining regular staff for continuity of care with patients)
Opportunities in home health:
There are three major hallmarks of the 21st century: caring for people, cooperating with people, and empowering people.
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Skilled nursing facilities
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