Home Health clinicians often cite clients that are burdened by multiple diagnoses, commonly referred to as co-morbidities, when they describe the programming challenges confronted at the Start of Care or evaluation visit. Though many different and varied types of clinical factors and profiles comprise the care picture we must address in these types of patients, the resulting careplan modifications seen in homecare, particularly in the therapy realm, are nearly always identical. Almost universally, decreases in clinical frequency and intensity are seen as a response to clinically complicated patients. Ironically, this approach often serves to compromise clinical results, leaving the patients with less than desired outcomes.
Well meaning clinicians fall prey to this approach for specific reasons that are indigenous to the Home Health environment. In this column, we have documented at length the lack of Utilization Review-like controls in the history of our industry, and the scenarios discussed today describe how patient outcomes can suffer as a result. In these cases, the individual therapist must derive a plan of care, including frequency and duration parameters, for a clinically complicated client that often possess compromised rehab potential. Without the specific programming or reimbursement guidelines present at all other points on the care continuum, the therapist creates a clinical program that reflects their individual experiences, the patients’ profile, motivation, caregiver and environmental realities. Unfortunately, a number of additional factors come into play; and many of these often fail to directly serve the patients’ clinical interests.
Traditionally, therapists respond to co-morbidities by decreasing frequency (intensity) of services and extending duration (length) of services. The types of clinical justifications for these alterations are varied; dementia, weakness, age, multiple diagnoses, etc. Similar occurrences are seen in the nursing careplans of homecare clients in a less frequent manner. Upon examination and discussion with multiple therapists and agencies from various corners of the country, some of the underlying reasons for this practice tendency become evident.
Most agencies, when questioned, relate the difficulties in creating, managing, and maintaining a successful therapy staff in today’s Home Health environment. Obviously, it is difficult to attract and retain caring rehab professionals in the current healthcare landscape. In addition, the recent changes in Home Health combined with the programming, documentation, and working conditions inherent in homecare conspire to make this a daunting task for certified providers. Many agencies are unable to hire fulltime therapy staffs, and as a result, are liable to the working habits of contracted rehab professionals. All agencies in this staffing situation describe lapses in communication and manageability of their rehab personnel due to the contract nature of their roster. These realities make it difficult for agencies to modify care delivered by these professionals, particularly in the difficult types of cases we are discussing today.
As mentioned above, clients that are medically complex or burdened by co-morbidities are often seen for lesser intensity Home Health rehab programs. When questioned, the therapists will state that a decreased frequency is required because the patient is unable (too demented, frail, weak, short of breath, obese, etc.) to tolerate a traditional frequency; i.e., one regularly employed for a client with the same diagnoses. Suggestions to therapists that they utilize more traditional frequency/duration orders are often considered “unfair to the patient”.
As we often do in this column, we will turn to protocols successfully employed for identical patients at other points on the care continuum for direction in Home Health programming. In no manner are DRGs, the acuity based length of stay vehicle for acute hospital admissions, affected by any of the above concerns that may contribute to the co-morbidity of this profile. Secondly, no alterations or modifications are present in the RUG mechanism, used to determine utilization for this type of client in sub-acute Skilled Nursing Facility care. When considering that we often treat similar types of clients that differ only in the community support system that allows them to receive care in the home, why would slowing service delivery be appropriate in homecare?
It is our experience that clinically complex patients REQUIRE assertive programming to address declines or deficits in order to have any chance of achieving desired outcomes. Dementia patients need to be patterned and have repetitive activity established that maximizes their potential (in addition to achieving some familiarity with the clinician); the chances of this occurring improve with increased exposure to the clinician. Weakness in patients, whether musculoskeletal or respiratory in the origin, need rehab services to restore strength or associated function. Patients with complex clinical profiles don’t achieve goals over extended time periods; their best opportunity is to receive care in a timely manner to help them achieve their highest level of function.
In almost all cases, clinicians should move closer to complex or co-morbid patients in order to maximize outcomes in real-time. It remains to be seen how auditors will respond to lack of desired and timely progress due to decreased frequency/duration care plans in response to co-morbidity patients. In addition, audits seen to date are focused on skilled and functional progression as qualifying requirements. Lack of these in the clinical documentation will almost certainly spell denial in the future. In our practice, we try to move clinically closer to these complex patients; it is our best, and only, chance to achieve desired outcomes.