Tuesday, January 27, 2009
60-day certification period order-----Part 2 of 2

            In the first part of this series on full-period certification orders, we addressed the effects that historical and financial factors have played in the blanket use of 60-day Start of Care programming orders. Having discussed the role of Partial Episode Payments (PEPs) and the near certain fiscal losses experienced when using 60 day orders to eliminate PEP occurrences, we now turn our attention to the topic of limited staffing as a alternative justification for these extended orders.
            In the current era, limited staffing levels of licensed healthcare personnel exist across the continuum of care. For a multitude of reasons, the Home Health industry often bears the brunt of these current shortages. Challenging working conditions, a steep learning curve, agencies under clinical and financial flux as they strive to keep up with industry changes; all of these combine with other factors to limit the attractiveness of the homecare environment for nursing and rehab clinicians seeking employment. As a result, therapists and nurses that are working in Home Health often find themselves confronting overloaded clinical caseloads. At the same time, agencies find themselves seeking patients to increase census and, hopefully, earnings that would equate to success in the marketplace.
            The clinical staff shortages in the rehab profession can have a profound effect on the actual care delivery of the PPS-based Home Health program. The standard response of the under-staffed homecare provider is to propose therapy care plans that include a decreased frequency and extended duration. When compared to the service order that the client would receive if the rehab staffing level could adequately service the agency’s census, this altered version of rehab programming provides clinical interventions that are significantly different in form and function. Not only are the intended gains of these orders often unrealized, but the resultant “watering down” of the clinical program has both short and log-term ramifications. In addition, many Home Health agencies that utilize contract therapy staff feel they are unable to manage these contractors in order to gain control of the clinical treatment of the patients.
            The practical application of the above scenario usually results in 2Xwk frequencies for all rehab patients. Therapists find themselves falling into this routine in order to maximize the number of patients that they can see (on their caseload) at any given time. But despite this method, the basic caseload remains constant in volume: i.e. a PT with a 30 visit schedule maximum is still able to perform only 30 visits. In all other aspects of healthcare, intensity of clinical treatment is the cornerstone of programming and reimbursement. The value of weekly treatment frequency, particularly for rehab, is well established in the SNF Part A environment, where RUGs (the SNF version of HHRGs) specifically denote rehab frequencies required for reimbursement levels. In the author’s eyes, a 2Xwk treatment frequency for a Home Health patient that needs 3wk treatment shorts the beneficiary of this pre-paid federal entitlement program of a third of their benefit.
            Clinicians compensate for this frequency reduction by extending the duration of the program, often to complete the 60-day certification period. Further examination of this duration extension reveals two primary concerns. First, the Medicare client whose health status has reduced their mobility to the level where they are unable to routinely leave the home has a window of opportunity to regain these skills. This window of opportunity is un-affected by the therapists’ schedule. Our experience is that approximately 75% of functional rehab progress occurs in the first 30 days (our feelings are based on 25+ years in this care environment). Certainly there are exceptions to this statement (Speech, unusual circumstances, etc), but we are firm in our beliefs here. Secondly, the basic PPS mandate of education, patient and caregiver participation, and intermittent, short-term programs is often absent from the episode due to the reduced presence of the clinician in the home. The entire intervention is often seen as potentially on-going in the eyes of the patient. The Start of Care clinician and the therapist in the case often fail to emphasize how Home Health works, and how they plan to get the patient better. The extended duration often results in the episode approaching the end of the certification period, prompting the question of whether to recertify the patient. As a result, the financial billing for the episode would increase by the recertification billing total, when the entire clinical concern may have been resolvable by appropriate rehab staffing from day one.
          It is easy to see how inadequate rehab coverage can change the very complexion of this important clinical service in homecare. Unfortunately, many, if not most, agencies nationwide have found themselves participants in this practice. Pay for Performance reforms will obviously address this concern by rewarding outcomes prompted by appropriate rehab coverage. In our practice, we take steps to assure the frequency/duration question is managed through utilization review before post-eval services are initiated. We also remember that “all homecare patients are not created equal” and determine what patients have had recent declines that would rise to the level of an acute admission prior to the Home Health referral. We use this information as a sort of guidance as to what patients unequivocally require appropriate rehab intensity to meet their goals. Certainly a patient who has had a hospital admission theoretically represents a needier patient than one whose decline was slight enough for them to remain in their residence while waiting for Home Health to begin. If a therapist or agency cannot provide the appropriate staffing level to service the clinical need, the patient should be referred to another therapist or another agency so they can be treated satisfactorily.
            In closing, the practice of writing full certification period Plan of Care orders affects agencies negatively in a number of ways. For nursing, it wastes personnel on visits designed to burn up the rest of the cert period in order to avoid PEPs, spending more in doing so than PEPS themselves would cost the agency. For rehab, it penalizes the needier clients, compromises skilled claims, and dulls the rehab clinical delivery in general, leading to decreased outcomes. Home Health providers must accept responsibility for managing and delivering Plans of Care that address clinical needs instead of pre-packaged, 60-day episodes.

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.