I’m a homecare therapist for a large suburban Medicare agency with a current patient situation that seems troubling. The client is a 78 y/o female with recent hip fracture and subsequent internal fixation. Prior to onset, she lived independently and alone in a senior apartment building. A post-discharge SNF referral was planned for sub-acute rehab services with the goal of return to home. Instead, however, her daughter’s family made the decision to take the patient into their home for rehab in lieu of a nursing home admission. Hospital discharge orders called for home health (SN, PT, OT, HHA, & MSW) and DME to provide a care level that would hopefully substitute for a SNF rehab stay. Post SOC frequencies per discipline are: SN – 2Xwk, PT – 3Xwk, OT – 2Xwk, HHA – 3Xwk, and MSW – 1Xwk. Now, nearly two weeks into the home health program, the daughter states that too many visits from homecare staff are fatiguing for both the patient and the family. She wants to reduce both PT and OT to a combined 3 visits/week. My concern is that this patient needs PT and OT more than any other discipline at this time. I am also troubled that the aide will continue 3Xwk while skilled rehab services are decreased. Our supervisor says that we have to respect the family’s opinion and decrease frequencies; when I voice my concerns, she states “do the best you can”.  Any suggestions?

     Your question describes the type of programming issues that home health agencies and their clinicians face regularly. In many instances, these situations go un-addressed and the only response tends to be to follow family requests. Quite often, agencies state that the family and the client have the right to refuse services and any response other than to follow the client’s wishes would be un-ethical and even illegal. To the author, this response seems inadequate and not recognizant of the realities of the continuum of care that dictate Medicare Part A coverage. In today’s healthcare environment, patients and families need education in order to make informed and appropriate decisions about their care. Your example highlights the importance of managing Home Health programming decisions in real-time, something many agencies struggle to perform. In most cases, clinical goals are dependent on appropriate programming and agencies seeking to achieve better outcomes should adopt the mantra: ASSERTIVE PROGRAMMING = BETTER OUTCOMES. 

     In order to address your question, it is imperative that we examine what service delivery the client’s diagnosis would prompt at other points of the continuum of care. Specifically, what services (and at what intensity) would the patient receive if the SNF rehab admission had occurred as initially planned? Any sub-acute rehab SNF admission would qualify for Medicare Part A coverage based primarily on two factors: 1) the therapy disciplines involved, and 2) the intensity of those disciplines that is based on patient tolerance. In addition, it is important to note that the SNF admission would provide all the disciplines that were included in the homecare program at the frequency of 5-7 days per week. This level of programming is covered by Medicare because it is imperative for optimal clinical results. In the situation you describe, the family and client need to become educated about these realities so they can move forward with an informed decision. This is precisely where many agencies and clinicians drop the ball. If the client were your aunt and the daughter your cousin, would you be compelled to share the realities of the scenario with them so they could choose appropriately? If the answer to this rhetorical question is yes, you should move forward in this manner with your homecare patient.

      I would recommend a case management meeting with your supervisor so these questions can be addressed by the agency before sharing these concepts with the patient and family. The reality of the SNF scenario, specifically the combined PT/OT frequency of 10 visits per week, must be shared with the client. It should also be determined if the family is responding to the admittedly difficult rigors of a post hip fracture rehab program. The MSW could possibly manage a team/family meeting to discuss these topics in a supportive and educational manner. If any discipline frequencies would be decreased, the HHA could be reduced to 1-2Xwk. This would allow both the patient and family to embrace the services that will lead to desired clinical outcomes. It is the responsibility of the Medicare Home Health agency to help the client make informed decisions. Once this has occurred, the family’s requests must be honored.

      Often, agencies and clinicians alike find themselves taking the easy way out by simply responding to the request to decrease services, already over-stressed providers can lighten their workload. For these specific reasons, we advocate a pre-rap utilization review (to assure correct programming) and weekly OBQI case conferences (with individual clinicians) to maintain appropriate skilled progression and assure acceptable clinical results.

 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.