I'm the administrator of a Home Health agency and I read your columns monthly. My question addresses our concern over the appropriate utilization of therapy in our client episodes. We have a rehab staff comprised of salary, per diem, and contract therapists. Some work for multiple agencies, some have varying homecare experience levels, and many have extensive work histories that include outpatient and SNF rehab. The concern lies in the debate between rehab and supervisory staff regarding the determination of rehab visit totals proposed at the Start of Care. Each therapist has their own ideas, views and experiences. I would like to propose some sort of standardized approach to this question that we, as an agency, can rely upon to assure correct programming? How would you approach this?
Your question is most timely and reaches to the very heart of the type of therapy programming issues the homecare industry struggles with today. Most of the confusion lies in the lack of understanding as to how to use OASIS findings to guide programming levels. Currently, most agencies allow the rehab staff to dictate utilization levels. However, many agencies have supervisory or QA staff that fail to grasp the intricacies of the PPS and the methods used to determine therapy visit totals. The answer lies in the functional section of the OASIS document itself; specifically MO650 – MO700.
Each of these questions addresses functional levels of activities of daily living; the areas primarily affected by rehab. MO 640, grooming, is also included in the ADL/IADL section but we don’t use this item as a basis for skilled therapy programming. The current OASIS has both prior and current functional levels to identify decline over the 14 days before the SOC visit. The New OASIS, to be implemented in 2009, eliminates the prior component of the ADL/IADL section and only requires a current functional level to be recorded. In order to discuss rehab programming philosophies, we must agree upon the appropriate discipline response to deficits identified in this section:
MO 650 UPPER BODY DRESSING OT
MO 660 LOWER BODY DRESSING OT
MO 670 BATHING OT
MO 680 TOILETING OT/PT
MO 690 TRANSFERRING OT/PT
MO 700 AMBULATION OT/PT
When reviewing the SOC OASIS to determine therapy levels, it must be noted that Home Health quantifies rehab need in terms of their ability to restore previous or safe levels of function. It is also relevant if the current level of function is depressed enough to address deficits without evidence of a recent (last 14 days) decline. When the New OASIS is implemented, the decline identified by the current question structure will become irrelevant in the context of the individual questions. There will only be a general question that asks if the patients’ abilities have declined prior to the SOC visit.
The common mistakes often seen when reviewing groups of SOC OASIS documents most likely reflect some of the concerns you cite and the debate between rehab and supervisory staff. Most prevalent is the under-utilization of OT in response to dressing, bathing, or toileting deficits; over-utilization of HHAs is often present in these cases. In addition, either the assignment of PT only or the blanket coupled order of PT/OT combined for all cases involving rehab is the standard operating procedure for many agencies. In order to: 1) achieve desired clinical outcomes and 2) receive appropriate reimbursement for this case, OT must be included and managed to provide services that address and restore these specific skill items. The Pay for Performance implications of this management style are obvious.
Another utilization concern often seen is the inclusion of PT on the POC without any functional deficits in the PT questions listed above. SOC clinicians seeking improvements in areas not reflected in their MO650-700 answers will have a hard time justifying their programming under audit review. If no functional deficits are evident in the SOC OASIS findings, it would be a natural conclusion that rehab may have been added solely for financial reasons. I t is also important to note that deficit levels are addressable by rehab without any specific decline identified in the prior-current answers. A patient with level 3 responses in MO650-670 may be programmed with rehab, the most prudent course would be a two-week trial of OT to determine whether timely and functional progress was possible. If so, an extension order could be obtained to complete the program with successful outcomes. If not, the OT could be limited to the two-week trial.
In conclusion, common sense and a level of programming that matches the depth of deficit is the order of the day. Try to remain mindful that rehab over-utilization, without obvious deficits (and skilled, focused delivery), gives the appearance of a financially based programming model. Try to get all rehab staff and their supervisory counterparts to limit the debate to obvious functional and clinical concerns with the common goal of successful outcomes.
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