In the ongoing work that we at Home Health Strategic Management do with many agencies across the country, we have the opportunity to audit rehab charts of Medicare Home Health patients from a great many therapists. Numerous types of patients and clinical approaches are evident throughout the chart reviews and many of the various programming pathways yield successful results. In fact, it is rare that we don’t find some evidence of appropriate, deficit based program planning in the rehab aspect of Home Health charts. However, as we delve further into the treatment documentation, we are struck by a specific trend that affects many homecare rehab programs; the lack of focus on obvious, attainable clinical goals, especially in the areas of functional improvement as identified by OBQI indicators. How should we, as rehab providers in the Home Health world, re-wire our approach to homecare service delivery in a manner that will have value under upcoming reforms?

In this column, we certainly have established a well-documented stance that clinical rehab programming should be objective and consistent for all homecare patients in order to achieve success. A primary factor in the discussion of this topic is the primary clinician’s definition of and approach to the concept of “success”. As front-line providers, both nurses and therapists are susceptible to the practitioner-patient interface and the realities of patient satisfaction. The ability to produce an improved and satisfied patient is a basic element of both personal and professional achievement. Most clinicians, whether nursing or rehab, are confident that they provide “good” or “quality” care in their professional practice. Many of these opinions, or self-assessments, are based on subjective levels of patient response or improvement. As Home Health progresses and evolves in the near future, homecare clinicians will need to be willing to parse their performance levels in terms that are recognizable by the non-clinician. Specifically, the rehab professional, given their prominent position in the reimbursement mechanism of the Home Health benefit, should welcome discussions that help standardize the value of therapy in homecare.

Many rehab professionals cling to the concept that their services are only truly understood and recognizable by other rehab providers. A quick review of some of the realities of healthcare can help to correct this outlook. First, the backgrounds of rehab clinicians are extremely diverse in terms of social and educational experiences. Many have work resumes that span different types of care environments, work experience levels, employers and reimbursement mechanisms. When all these different types of backgrounds (all possessing PT licenses) are gathered under the Home Health umbrella, the approaches to care, and the subsequent clinical outcomes, vary widely.

Secondly, funding and programming decisions that will be the basis of rehab-related reforms installed in Home Health over the upcoming decade will be made by healthcare experts and analysts (in addition to congressional members of MedPac) that have little, if any, direct connection to the therapy community. Claims auditors and adjustors for all levels of Medicare funded programs will most certainly not be therapists, or therapy-related practitioners of any sort. In fact, it is unlikely that even nursing personnel would perform this function. Is it beyond expectation that rehab professionals should be willing to demonstrate their professional value to any and all parties? 

When addressing homecare reforms, rehab-based care nuances will need to be addressed. Clinical outcomes will need to be defined in terms that have common value throughout the industry. OBQI defined goals will be cast in an entirely different light under the Pay for Performance model; mis-guided rehab clinicians would be well served to embrace, rather than belittle, these obvious attempts at care reforms. Progressive rehab providers (and agencies that employ them) should solicit opportunities to participate in discussions regarding their services that are entirely un-connected to the time-worn, traditional responses to care inquiries. Claims from rehab professionals that repeat contrived responses such as “I give good care”, or “My patients get better; they like me”, do little to progress the industry, the profession, or the standard of care that will be necessary under the eminent healthcare reforms we face.

Hospitals, physicians, SNFs, and all healthcare providers have internalized sweeping reforms to their care delivery, reimbursement, peer review, and quality care mechanisms. All have adapted successfully to continue as quality providers carrying out the professional mandates that led them to healthcare. All rehab professionals should seek to distinguish themselves in their particular embrace of reforms as a means of improving quality outcomes for their patients.

 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.