I am a physical therapist with over five years experience in homecare. The agency I work for has just approved a policy change and now plans to have Physical Therapists perform OASIS start of care visits for PT-only patients. I am quite familiar with the OASIS document and feel comfortable regarding accuracy of my answers to specific questions. However, I feel unsure regarding my ability to craft a comprehensive plan of care that is Medicare compliant but also in the best clinical interest of the patient. Any suggestions?

           Performing a successful start of care visit requires a number of skills and more importantly, an in-depth understanding of the Medicare Prospective Payment System (PPS) and its effect on clinical patient outcomes. As home health has evolved through the many reforms of the last decade, many agencies and clinicians struggle to perform start of care visits correctly. As a result, subsequent care plans are often insufficient in their ability to provide a successful homecare program. Agencies who experience such difficulties will certainly find themselves lagging behind the pack when the Pay for Performance era arrives. As a licensed practitioner currently working in the field of home health, it is a wise move to want to assure a level of skill with any new activity you will be providing in the home.

              The correct method of performing an OASIS start of care visit requires understanding of the Medicare home health program, including its history and financial structure. The introduction of PPS marked a turning point in homecare. For the first time, Medicare home health programming and reimbursement was formulated in response to specific clinical data CMS (then HCFA) had gathered. Medicare had discovered that limited care plans had a less than desired effect on the overall health of the beneficiary (most Medicare enrollees are 65 or older). The introduction of the OASIS marked the establishment of a new philosophy for the Medicare client. CMS had found that costs of care were lower for this geriatric population when the patient received a multi-system assessment that addressed functional deficits that may not have been the focus of the original referral. That is the basis of the requirement to perform the OASIS assessment for all Medicare home health episodes regardless of the specific problem addressed by the referral.

             CMS hopes to prompt health care savings by evolving the care continuum so as to provide the appropriate level of care in the most effective (and fiscally efficient) environment. Clearly, home health has performed well in the initial trials over the past thirty years. The federal homecare benefit works well under the current model; future reforms will seek to further refine this successful program to address related factors (i.e. -increasing enrollee population, decreasing funding, higher acuity patients). The home health clinician needs to understand that when the PPS homecare guidelines are followed, the end result is a successful episode. That is, one in which patient goals are achieved and restoration of function leads to discharge. 

            Keeping this fact in mind, the start of care clinician must learn to trust the programming directives inherent in the structure of the OASIS. Most important is the functional section of the OASIS which serves to identify the correct rehab programming, a crucial component of clinical and fiscal success under the 2008 PPS New Rule. Specific OT or PT orders are appropriate for discipline related deficits noted in MOs 650-700. This is where the most commonly seen mistakes are found. Changes between the prior and current levels of function (particularly regarding OT), often go unaddressed by start of care nurses focused primarily on nursing issues. When therapists perform the OASIS during the initial visit, it is imperative that they include nursing on the plan of care when they note clinical needs beyond the scope of rehab. The same applies for all skilled services provided by Medicare home health (MSW, ST, RD, etc), regardless of which clinical license completes the start of care.

          Just as often, the patient or caregiver initially declines a needed service (again, OT is the most common example) during the start of care visit. Many patients certainly hope to get much needed rest when returning home after discharge from an inpatient stay. The patient clearly has the right to refuse any or all services, but a good start of care clinician helps them to understand the value of OASIS identified programming to achieve clinical goals. It is the job of the opening clinician to impart the importance of compliance with desired Medicare home health programming to achieve patient success. Agencies that educate, reinforce, and support this type of clinician will experience success under the home health PPS model.

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.