I’ve been a homecare physical therapist for approximately 5 years and have recently taken a staff position with a different home health agency. With my new employer, I will be expected to perform Start of Care visits and complete the OASIS document. The agency I’m leaving uses RN’s to do all OASIS Start of Care visits. In my previous position, I would follow the opening nurse and perform an evaluation visit and subsequent treatment. After the nurse made the SOC visit, I would often remain the only professional in the home for PT-only patients; completing the program and performing the discharge OASIS. As a result of this routine, I feel fairly knowledgeable and comfortable with the OASIS document itself. However, I do feel somewhat lost with other aspects of the SOC visit. What are my responsibilities regarding information and other Medicare required elements of the SOC? How do I assure that I’m preparing the patient for their Medicare home health program?  

Your concern is quite real and very appropriate in today’s homecare industry.

Many aspects of Medicare home health create confusion and misunderstanding for beneficiaries, particularly since the Prospective Payment System (PPS) was introduced in the late 90’s. The evolution of Medicare services has radically changed the homecare delivery system; agencies, clinicians and patients are still coming to terms with the intent and results of the reforms. To complicate matters, the 2008 PPS New Rule will further alter the home health model and set the stage for additional and far-reaching reforms over the next 5 years.

For these reasons, the Start of Care (SOC) visit is extremely important, serving as the venue where the client is educated regarding the federal benefit program that is Medicare home health. It is important to remember that Medicare health coverage is a pre-paid benefit and the home health provision (Part A) is a 100% covered program if the client meets qualifying requirements. For these reasons, the CMS corporate compliance guidelines are clear and mandatory; client education, choice and comprehension are mandatory. The SOC visit is when the requirements are most easily addressed.  Many agencies have struggled to manage this aspect of home health appropriately. Opening clinicians (whether nurses or therapists) have generally been inadequately prepared by their agencies to perform this vital SOC education correctly.

 When performing a SOC visit, it is important to instruct the client about the short term, intermittent nature of homecare. Many patients may have home health experience that pre-dates the 2000 PPS reform and therefore possess expectations of service provision that are unrealistic today. The list of policies and procedures (safety, HIPAA, emergency line, etc) required of all opening visits is quite straightforward. It is important to make sure that the patient understands the goals of their homecare program and how these goals will be achieved. Medicare seeks to address this issue by requiring that the patient and physicians be informed of frequency, duration and disciplines for the home health episode. As the opening clinician, it is imperative that you take extra time to communicate with each patient and assure yourself that they have understood and internalized your beliefs about the program that is to follow. Do they understand their responsibilities? Do they share your expectations of program goals and outcomes? Are they aware of the deficits or declines that resulted in a home health referral? Do they understand how each of the disciplines involved in the episode will seek to address these areas? Have they been adequately informed about the Advanced Beneficiary Notice and its intent before it is required? Do they understand the role of the physician and how the doctor’s order relates (or perhaps doesn’t relate) to Medicare coverage?  

As you can see, it is very important for both patient and clinician satisfaction that the home health program begins on the right foot. Agencies who covet elite OBQI scores traditionally focus on the specific content and tonality of the SOC visit so patients and clinicians start on the same page. A by-product of this approach is a well-educated clinical staff regarding the structure and delivery of a contemporary homecare program.  When a patient understands the goals of treatment and how the agency will achieve these goals, agency staff will experience an elevated level of job satisfaction and professional success.  Home health agencies and staff are well served to regularly review all aspects of patient education that occur during the Start of Care. The opening visit is about much more than the OASIS document.

Teri N. Thompson and Arnie Cisneros are physical therapists with nearly 40 years of combined home care experience. Co-owners of Home Health Strategic Management in East Lansing, MI, they provide clinical service management and home care consulting expertise. They are nationally renowned speakers regarding the PPS refinements of 2008 and therapy utilization under the New Rule.