I’m a therapist working in homecare for just over 5 years. I’ve contracted with multiple agencies during this time, and each uses home health aides in a different manner. One agency provides bath aides for the entire episode of care. Another agency feels aides should be used to “give the caregiver a break”. My current employer only uses aides for short periods of time when absolutely necessary. Can you help me understand the best way to use home health aides?
The use of home health aides varies widely between agencies in just the manner you describe. This situation has evolved since the introduction of the Prospective Payment System (PPS) in response to the Balanced Budget Act (BBA) passed by Congress in the late 90’s. Prior to PPS, Medicare home health used a fee for service based payment mechanism. During that era, certified agencies were reimbursed for all visits, including those made by home health aides. The PPS structure uses a capitated reimbursement mechanism; acuity based payments are derived from OASIS information synthesized into a HHRG (Home Health Resource Group) score. Each HHRG score matches a financial payment the agency can expect to receive to provide appropriate levels of care. Today, the cost of home health aide visits made in a particular episode are absorbed by the agency and deducted from the HHRG-based net profit level.
In response to the PPS reality that aide visits were no longer reimbursable, many agencies re-examined their use of home health aides. They sought to minimize unnecessary costs for services that were not required for quality care and outcomes. These agencies explored the post-BBA Medicare regulations and discovered that PPS services were built around a skilled care model designed to maximize function and promote independence. Their resultant approach to PPS programming was to use aide visits as an adjunct to the skilled services in the home.
Today, these agencies provide aides to help promote and support the Medicare home health goal of restoring maximal function in the patient’s home. Aides are provided for short term periods in the care episode. They are paired with therapy or nursing programming and serve to assist the patient and caregivers as they strive to maximize function. They may provide bathing assistance, carry out minor housekeeping chores, or participate in therapeutic exercise, ambulation or ADL activities as defined on the aide care plan by skilled clinicians (nursing, therapy, etc.).
Less progressive agencies may continue to use aide services in the pre-PPS manner described earlier in the article. Bath aides are not only provided for the extent of the skilled care episode, but these services are often continued after the skilled element of the program is completed. Agencies often profess a desire to not “abandon” the patient by discharging the aide. Some agencies are concerned with losing the patient after the home health aide discharges because competing agencies will provide aide services in order to add a patient program to their census. These agencies certainly experience compromised financial returns by reducing the episode’s net profit margin with the costs of the non-reimbursable aide visits.
In closing, we will describe how we (and Medicare) view and use aides in the PPS homecare era. Home health aides are used to support nursing and therapy interventions in addition to ADL or bathing care. Providing aides as a mechanism of addressing care deficits does NOT help the client; in fact, it promotes patient dependence. Using an aide (for bathing) in conjunction with an Occupational Therapy program, or for exercise/ambulation when included in a Physical Therapy plan of care, allows for the support of the patient, the caregivers, and the skilled services in the homecare program. Under today’s PPS model, aides should be used only as an ancillary opportunity to promote the patient’s return to the highest level of function.
Teri N. Thompson and Arnie Cisneros are physical therapists with more than 35 years of combined home care experience. They are co-owners of Home Health Strategic Management in East Lansing, MI; providing clinical service management and home care consulting expertise. They also lecture and provide OASIS, HHRG, OBQI and P4P training at seminars nationally.