Thursday, January 1, 2009
60-day certification period order-----Part 1 of 2


          The practice in homecare of writing post evaluation programming orders that span the full certification period will be examined in this series of articles. While many agencies have programming philosophies that require all clinicians involved in the episode to produce 60 day orders, they may fail to address the practical and financial effects of this practice. Historical Home Health delivery mandates had been the basis of these extended orders; are those programming issues relevant in today’s care environment? Will this sort of programming hinder our ability as caregivers to adapt our practices to fit impending reforms? As we review how this routine became habit for many agencies, we will discuss relevance and alternate programming models that may provide the same level, or even an improved level, of care.

            The previous fee-for-service era, established over 30 years ago, promoted the use of homecare as a less restrictive, and less expensive, alternative for patients that needed clinical services in order to remain safe and independent in their homes. In an attempt to de-emphasize the role of acute-care hospital admissions as the sole and primary care provider, CMS (then HFCA) developed the Home Health program as an aspect of the Medicare benefit. The cost-reimbursement plan was intended to prompt healthcare providers to focus on care-delivery needs that could be resolved without an acute care admission. Many homecare episodes were prolonged as a result of the combination of programming that addressed both cost reimbursement and admission reductions (either in total volume or length of stay). Home Health agencies routinely wrote orders that addressed the extended level of care prompted by these industry factors.

            Since the introduction of PPS and its capitated form of acuity-based payment, the 60-day certification period has been utilized to sub-divide the episode length of a homecare intervention. Many agencies still instruct their clinicians to write Start of Care or post-evaluation orders that span the entire cert period. This practice is at odds with the programming philosophies of PPS itself; an intermittent, short-term delivery model emphasizing education, training, and caregiver involvement as a means of restoring independence and function in the home. However, when discussing this practice with agencies and clinicians who employ full cert period orders on the care plans they create for their patients, they cite a number of reasons for the approach.

            Most prominent is the desire to avoid Partial Episode Payments (PEP). PEPs are triggered when a patient either elects to transfer to another HHA or is discharged and readmitted to the same HHA during the 60-day episode. The payment for the original 60-day episode is adjusted (or decreased) to reflect the amount of time the patient was initially under the agency’s care. Agencies participating in the Medicare Home Health industry seem to internalize that the rate of patients (discharged too early) that require re-admission during the same 60 days are often controllable via correct programming. Our concern is when agencies use full cert period orders to avoid PEPs that occur when a second agency recruits the discharged patient for admission to their agency. In an attempt to increase census (and billing), the second agency often approaches the beneficiary with information about the benefit that can generally be labeled misleading. They often offer to continue either skilled services at a level that doesn’t meet qualification requirements (B12 injections, vitals, ad infinitum care plan management, maintenance therapy, etc), or they offer the skilled involvement only as a template for the application of unskilled, aide care. Medicare beneficiaries reflect upon the length of care involvement that occurred prior to the year 2000 (before PPS), or they cite anecdotal evidence of acquaintances that received Home Health programs than may or may not have been based on an over-utilization approach.

            The hidden trap of the above approach is specific for each of the agencies involved. The first agency, when choosing to employ full cert period duration orders, wastes much of what would comprise their episode profit margin via the continuation of un-necessary services. Is the level of services that the first agency provides worth the financial resources expended, considering that the entire effort is designed to avoid financial losses? In the case of second agency, they enroll a client and submit a bill that may not survive audit scrutiny or the analysis of Recovery Audit Contractors in the not too distant future.

A more insightful approach for the first agency is likely to yield acceptable results. Start of Care and ongoing education of the Home Health benefit is crucial for patient understanding. Initial, and prolonged, emphasis of the PPS model is another important factor. The specific clinical goals, and consistent insistence that the client and caregivers must share in the care progression via education and participation, should be emphasized throughout the length of the homecare program. If the client understands that outcome success in terms of goals is the basic premise for homecare, they would be less likely to accept the enrollment opportunity offered by the second provider.

The next article on this subject will address the concept of limited staffing as a premise for full certification period orders. In addition, we will examine the modification of clinical delivery that results from this practice and propose progressive strategies for real-time program production and delivery.





Arnie Cisneros is a physical therapist with nearly 25 years of home care experience.  He is the owner of Home Health Strategic Management in East Lansing, MI,  providers of clinical service management and home care consulting expertise.  He is a nationally renowned speaker regarding the PPS refinements of 2008 and therapy utilization under the New Rule.