Continuing with our emphasis on OBQI-based outcomes, we will examine the relationship between programming, care delivery, and actual goal achievement. 
          While auditing hundreds of Medicare Home Health charts in order to identify areas where service improvements could occur, the author is struck by the consistent lack of skilled propulsion in the care dynamic. All types of clinicians, whether nursing or therapy, new or experienced, find themselves behind the care curve when their programs lack emphasis in propelling the patient to success as defined by the OBQI indicators. The philosophical and operational aspects of the PPS era require that services are to be based on functional progress within a specific episode. This required progress may, in the case of nursing, relate to medication or disease teaching and management, wound care, or pain, to name a few examples. Physical therapists seek progress in areas that relate not only to ADL function and safe mobility, but, endurance, pain, and continence as well. Occupational Therapists and Speech Pathologists program for ADL function and speech/language/oral improvements respectively. But in each case, the care dynamic is common, and resultantly, the same basic techniques can be employed to elicit elevated outcome results. These techniques involve a means of pro-active service delivery based on the use of best practice-based care concepts in combination with expected rates of progress.  
          Before specifically addressing scenarios where management of the care dynamic directly affects outcomes, or level of outcomes, some discussion of this issue in the industry today is warranted. It is important to note that though many clinicians are successful Home Health providers, possess excellent skills, and deliver wonderful care, the stressful working conditions, travel, and professional demands of homecare are real for all of us. The day-to-day, visit-to-visit tedium is un-avoidable, and often affects even the most experienced clinician. Agency employers that have survived a decade of Home Health refinements strive for quality care, but they have their own specific set of management, administrative, and financial concerns and pressures to attend to. As a result, the quality and efficiency level of the actual care being delivered can become compromised. It seems likely that the success of any attempts to improve outcomes will fall squarely on the shoulders of the front-line clinicians.
          Home Health clinicians should consciously define, and then employ, an expected rate of progress for ALL their patients. After performing the evaluation and formulating the Plan of Care to include OBQI-related goals; visualize your maximal expectation for the individual patient based on factors you discovered that relate to your specific care. Are they motivated? Are there supportive and involved caregivers? What is their potential for progress based on physical findings? Remain conscious of this expectation throughout your program. As you deliver care through your individual visits, note whether your patient improves in contrast to your expectation. If not, ask yourself “why not?” Identify and then address the areas that you suspect contribute to the lack of expected progress. Continue this exercise throughout the entire episode. 
          When nursing encounters a level of med teaching improvement that fails to reach the pre-conceived expectation, they must ask themselves whether they have provided written home instructions, sought caregivers to educate, or addressed any other opportunities to improve in this area. Are the patient and their caregivers compliant and involved with your teaching? Are you teaching? This expected rate of progress can also serve as a guide for the production of skilled documentation that rises to the level of Medicare requirements. By reporting openly in your notes what you are thinking, how the patient is doing (related to your expectations), and what you are doing to promote further improvement, you’ve given potential auditors the insight required to acknowledge your skilled care. In addition, it helps clinicians remain focused on the actual care dynamic while simultaneously propelling progress. 
          Therapists looking to maximize results must emphasize the connection between the presence of, and compliance with, home programs. All discussion of these programs relates to their use as an extension of the visit by daily patient compliance, and their inclusion and performance for progression on EACH AND EVERY visit. This home program must be established on the first visit, and each subsequent visit should include an attempt to progress the intensity and functionality of the program at a level commonly seen with daily compliance. Lackluster results in this area may identify poor patient follow-thru, or maybe the intensity of the program requires modification. You won’t know this unless you perform the entire program with the client. Remember, exercises themselves are often considered un-skilled, but the progression of the exercises, as they serve to prompt function, goes to the heart of the skilled care concept. The identical technique is used for gait training: are we able to advance the level of distance or independence of mobility on each and every visit? If not, how do we alter this situation? Is this patient compliant with their home program? Have I given them one? Have I maintained emphasis on its importance by my performance and modification every visit? 
          All clinicians can improve outcomes by becoming mindful of this type of care approach. The same technique works for OT/Speech service delivery through the use of home programs to achieve results derived from repetition-based home programs and their compliance. Consistent attention to the need for skilled progress elicits similarly improved levels of results. Don’t wait for future Home Health reforms to improve the efficiency of your care delivery. An improved level of goals await if you’re not afraid to identify your expected rate of progress.