Last week we discussed the skilled progression requirement for all Medicare Home Health episodes. In previous articles (7/6-10/16), we identified how programs that fail to demonstrate this element of care delivery have been subject to partial claim denials. We defined obstacles that many clinicians experience when assessing their own care, and acknowledged some of the underlying philosophies that often burden our best nurses and therapists when it comes to care advancement.
Today, our study of the skilled progression concept will take a decidedly clinical turn. We will speak in specific terms regarding the establishment, and maintenance of, skilled progression in Home Health therapy clients. The case in question is an actual patient episode encountered by the author during consultative experiences with Home Health agencies over the past six months. The example described is representative of commonly seen care from all parts of the country, and is indicative of the care lapses that occur when skilled progression is not maintained on an in-episode basis. It is reflective of the scenarios seen in partial claim denials that have been experienced throughout 2009, and indicative of the scrutiny expected from Recovery Audit Contractors beginning in 2010. Though today’s example recounts a therapy episode, similar themes and claim concerns are noted in homecare nursing cases on a consistent basis.
Our case involves an 81 y/o patient who was recently discharged from a 6 day hospital admission secondary to pneumonia and CHF exacerbation. Start of Care OASIS data reveals that she lives in her daughter’s home, who provides assistance at the max level of care, several times during day and night (#1 - M0 370). Shortness of breath is noted with minimal exertion (#3 – M0 490), and she was discharged to home with an Oxygen condenser, temporarily prescribed until a return to previous level of respiratory integrity is noted. Ambulation, previously safe with a roller walker, now requires assistance for safety (#2 – M0 700). O2 sat readings were 88% when taken by the nurse during the Start of Care visit. Upon initial evaluation, the Physical Therapist noted BLE weakness (particularly hips), decreased transfers and gait safety with “poor walker control, flexed posture, shuffling and inconsistent gait pattern, mod assist for gait safety, and poor endurance X 25 feet”. Despite the fact that the PT attempted to perform a thorough evaluation (addressed throw rugs, bathroom equipment, etc), they failed to begin any skilled clinical treatment on this first visit; no initial therapeutic exercise or Home Exercise Program was provided. The PT established a frequency of 1 x 1, 2 x 3,1 x 1, and outlined a plan of care for therapeutic exercise, gait training, Home Exercise Program, and caregiver education.
The second visit occurred four days after the initial eval was performed (Tuesday after the I.E. the previous Thursday). The PT provided a therapeutic exercise program that consisted of sitting and standing exercises for 5 – 7 repetitions; the PT stated the patient and caregiver were to repeat 2-3 X day. No respiratory exercises were included. Instructions to perform diaphragmatic breathing during gait training were documented, this seems woefully inadequate for a patient sent home with 02. Gait documentation consisted of distance, device, and assistance with no obvious skilled gait description.
Subsequent visits continued in the same pattern; therapeutic exercises were “reviewed and instructed” on a visit by visit basis with no significant progression in exercises or intensity (not really sure what “reviewed and instructed” describes when exercises remain relatively static; “performed and progressed” seems a better approach). No comments were made to identify compliance by the patient or caregiver between visits or how the follow-thru of the HEP resulted in functional improvements. Gait training continued described by a documentation pattern that revealed only one gait distance/visit recorded, and increases of 5 feet/visit was a consistent pattern marked by min assist required for safety on the 6th visit. The discharge visit identified that the patient was independent with the walker x 175 feet (you do the math to reveal the gains made in this area between the 7th and 8th visit).
Cases such as these often received partial claim denials in response to Fiscal Intermediary audits in various parts of the country over the past year. The lack of skilled progression leaves the auditor with little evidence of a skilled component upon which payment could be approved. The Home Exercise Program should be “live” throughout the episode; that means performed and progressed every visit, revealing full compliance, caregiver involvement, and a direct connection to the desired functional improvements, in this case ambulation. In addition, the lack of specific exercises that address accessory respiratory musculature leaves this important (OBQI) area relatively un-addressed. The result of such an approach leaves the auditor with the functional gait results as the primary means of identifying skilled progression.
In the area of gait, the lack of a skilled description leaves us with the change in ambulatory distance as the only progressive element of our gait training program. This change in distance alone is often viewed as endurance-based, and changes in endurance are considered unskilled. No other significant gait changes were noted between visits one and six. The validity of the changes that occurred between the last two visits is questionable at best based on the rest of the episode pattern. All therapists must include “distance, device, assist and skill” in ALL gait descriptions if they hope to remain skilled in their programs. Many PTs, though educated regarding these requirements, fail to include these items in their visit notes.
In our experience, cases like these often received “partial claim denials” due to the lack of a skilled progression evident in the actual care delivery. This unskilled delivery caused the “reasonable and necessary” component of this case to come into question. Many similar cases were denied after visit 3 or 4, resulting in a LUPA. It is important and mandatory that the clinician continually craft the care to continue to deliver a level of skill throughout the entire episode, not just at the Start of Care.
In addition, many subtle nuances that may affect outcomes are evident to this author. First, the lack of a HEP established during the initial PT visit fails to signal to the patient and caregiver the importance of compliance with programming between visits (especially with the exercises that relate to compromised function). Second, the exercises initiated on that visit seem inappropriate for this patient; standing exercises would certainly require the full involvement of the caregiver to keep the patient safe in space while they perform them: the author begins with supine exercises for core, trunk, and pelvic strength when assist is required for safe mobility. Third, the time that lapsed between the first two PT visits reveals a lack of responsiveness on the part of the therapist (and agency) to the recent experience of their client and the need to assure safety in the home. Next, the frequency seems inadequate for the decline to unsafe mobility identified by the OASIS; maybe another staff PT could provide the intensity desired (3Xwk) to address unsafe mobility. And last, the absence of respiratory exercises reveals a careplan that is less than specific when addressing OASIS-identified deficits.
This case illustrates the challenge ahead for many Home Health agencies and clinicians as they prepare for the audits that RACs will bring to all providers. Requiring much more than creative documentation, audits will re-define quality care due to reliance on best practices when assessing individual cases. The reality is that we must examine the actual service delivered, and how to reinforce positive care delivery improvements, if we hope to provide the skilled progression required for success in the future.