I have served as the Chief Operating Officer (COO) of a Medicare home health agency for nearly five years. Located near a major metropolitan area, we have four offices managing a patient census averaging 1700 cases. We consider ourselves a progressive agency with extensive PPS based programs and a goal of achieving elite agency status by the end of the calendar year.

We, like many agencies, have struggled with our rehab service delivery in nearly all aspects. We have trouble keeping enough therapists on staff; currently we have a mix of salaried, contingent, and contract therapists. We constantly deal with late or incomplete documentation, excessive amounts of missed visits, and little interest from the therapists themselves to adopt the changes required by the 2008 New Rule reforms.

These concerns have been magnified as we confront the changes regarding therapy prompted by the recent reforms. We have been discussing eliminating contract relationships altogether and may explore establishing a rehab staff comprised entirely of in-house salaried therapists. What are you hearing regarding this issue?

 The role of therapy in the Medicare homecare model has increased exponentially over the last decade. The establishment of the Prospective Payment System has focused the home health industry on the functional status of the patient and specifically on the importance of rehab in achieving desired outcomes. The 2008 reform went even further by introducing a multi-level reimbursement system based primarily on therapy utilization. Today’s agencies must now directly address all aspects of therapy management and utilization in order to assure both monetary and clinical success.

The rehab therapist, meanwhile, has encountered a highly lucrative job market that has rendered them one of the most sought after professionals in today’s healthcare environment. The service needs required to address the baby boomer era’s geriatric population has created a supply/demand inequity across the rehab landscape. Many therapists have chosen to take advantage of private practice opportunities; establishing either an outpatient clinic or a service contract business. Unfortunately, many providers (SNF’s, Home Health agencies, etc) with programming requirements dependent upon rehab find themselves reluctant to utilize contract-based services in a manner similar to direct employees. They feel that the general management of a rehab employee is easier when the therapist is a direct employee. Unfortunately, this opinion ignores the realities of today’s rehab job market.

The management of rehab therapists has become a lost art in general. ALL healthcare clinicians need to be managed; it is the rehab employer who seems reluctant to directly manage the therapist for fear of losing the employee to another job offer. The latest home health reforms indirectly mandate ongoing management of physical, occupational, and speech therapists. In addition, ongoing staff turnover often causes the employer to constantly recruit and hire therapists to maintain a full staff.

For these reasons, we often find contract staff the preferred mechanism of staffing home health rehab departments. A strong rehab supervisor can educate and manage contract staff regarding the changes in home health regulations, productivity and skilled documentation. Ongoing case conferences further focus control in the area of quality clinical delivery. The fee-for-service nature of the contract relationship prompts an increased level of management and professional performance.

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.