As the rehab director of a Home Health agency, I find myself confused as to whether our rehab staff should be taking vitals during their home visits. Most of our rehab clinicians are contractors and that seems to further cloud the issue since not all of the agencies they contract with require them to do so. Our therapists do not perform OASIS Start of Care visits for ‘Therapy-only” cases, so they lack the SOC experience of collecting vitals. Are there regulations that require vitals be collected by therapists?
This is a question that we are asked quite often. It seems that the inquiry highlights a larger issue that agencies struggle with on a regular basis. The question refers to how to direct and manage the content of clinical homecare visits. In order to address this larger question, we must discuss the visit concept in a global manner. Since the introduction of the Prospective Payment System model nearly ten years ago, the homecare visit itself has become a fluent, ever-evolving care delivery item. It is subject to constant refinement regarding best practices, CMS updates, and continuum of care modifications. The difficulty lies in keeping front-line clinicians current with changing expectations and requirements for contemporary visits. The question of collecting vital signs on a per visit basis outlines a specific area of the evolving visit.
It is clear that the clinical acuity of the Home Health patient has been increasing steadily since DRGs were applied to the acute hospital system in 1984. The decreases in length of stay statistics for hospital admissions means that the clinical profile of the Medicare Home Health client has become increasingly more involved; twenty-five years ago, the average homecare client was seen 18 days after hospital admission. Today, the Medicare client receives a Start of Care Home Health visit an average of 5 days after hospital admission. It is obvious to the most casual observer that the homecare clients of today are more clinically involved than those seen even ten years ago. In addition, we must also state that the homecare clinician is alone in the home, treating geriatric patients that are debilitated to the level of homebound qualifications.
It is for these reasons that we follow the standard protocol of collecting and recording vitals for ALL clients on every visit. Once this practice has been initiated, it takes little effort to provide this safety-based procedure consistently and for all patients. In all other treatment scenarios (hospital, SNF, outpatient), the rehab clinician works in close proximity with other personnel that can assist if a crisis were to arise. In addition, the increased acuity we have already identified can present a fragile patient that may require monitoring while increasing physical activity levels during treatment in the home. Most rehab clinicians understand why vital signs may be important when treating the post-CABG patient. Likewise, co-morbidities prevalent in our homecare patient population (CHF, HTN, COPD) often require additional attention during the treatment phase, and vital signs play an important role here.
Home Health Care Plans (485s) are required to contain vital sign parameters in order to identify when a physician should be notified in response to un-acceptable readings. How would this occur when some licensed clinicians perform visits without recording this data? The prevalence of battery operated devices that quickly and easily record vitals make the integration of this task a simple procedure. The permanent establishment of this procedure provides a level of safety for both the patient and clinician. Specifically, contract therapists should be eager to record this sort of information as another liability limiting activity.
As the Home Health benefit evolves under the impending reforms that the industry faces in the near future, visit content will come under increased scrutiny from a number of different directions. Pay for Performance will certainly prompt agencies to determine whether visits are efficient, skilled, and progressive. Post-acute bundling will install hospital based Utilization Review elements that will also modify rehab delivery protocols. By mandating that rehab clinicians record vital signs each and every visit, agencies will prepare their staff for the many changes that lie ahead.
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.