As the importance of rehab success becomes more relevant under Medicare Home Health reforms, it is increasingly necessary to identify and deliver a therapy program that addresses functional requirements for patient improvement. The day-to-day service delivery aspect of the homecare industry presents many challenges that must be integrated into our clinical care. Where inpatient healthcare providers have the luxury of on-site staff (hospitals, SNFs, outpatient clinics), homecare providers struggle with care modification and control due to the in-home component of our clinical delivery. OBQI requirements and the impending Pay for Performance reforms will place a premium on this actual goal achievement. The progressive agency and clinician will set themselves on a course of self-review and improvement in order to achieve clinical success, rather than just provide a homecare program.
The difference between clinical success and failure is often a matter of focus and skill in the actual crafting and delivery of a productive Home Health program. As the author works with different agencies across the country, it becomes obvious that some of the most gifted rehab clinicians often struggle to administer programs that will result in desired outcomes. Upon further study, it is noted that some of the best practices that are regularly incorporated into our care delivery are absent from many homecare rehab programs. Below, we will share random thoughts about many of the aspects of successful Home Health care delivery (as it works for us).
Eval/Start of Care education – It is extremely important to educate the client on the first visit regarding the Home Health benefit and how it works. This is where we establish that the intermittent, short-term nature of PPS requires their ongoing involvement with programming and home programs. Rehab therapists should share expectations regarding the expected duration of the program, real-time rehab potential and discharge planning. Any unrealistic beliefs on the part of the client should be dispelled at this juncture.
Frequency/Duration – Many of our previous articles addressed this item in easy to follow terms. Any and all rehab frequencies should be assertive and address concerns that don’t include the therapist’s schedule. We follow two general rules when we program: 1) Be aware of the intensity of services in other delivery areas (SNF frequencies are 5Xwk); and 2) Most (75%) of functional rehab progress occurs in the first 30 days. If the evaluating therapist is unable to provide the necessary frequency, the patient should be re-assigned to a therapist with the necessary availability.
Home program/caregiver involvement – Both are to be addressed on the first visit and re-enforced every visit. Both are essential for good outcomes. Get the patient involved in the momentum that successful progression of the home program provides and keep them involved by performing and progressing the program throughout the episode. Despite beliefs to the contrary, non-compliance is not justification to continue to provide services.
Therapeutic exercises – This aspect of care delivery often falls short of a desired level of appropriateness and skill in homecare programs. Patients should be safe and experience success in order to keep them motivated and performing the exercises as a daily home program. Problems traditionally seen are un-focused exercises, including standing activities for clients unsafe to stand on their own. Also commonly seen are exercises that fail to address underlying causes of limited function, i.e. trunk stabilization, respiratory exercises or pelvic strengthening. Make this a fun and vital care aspect by assuring compliance and success in this area.
Gait Training – Where do we start when describing concerns regarding programming in this area? Patients should receive gait training that is logical, progressive and functional. Appropriate assistive device use must be established. Safe ambulation in the home is the primary concern and should be achieved prior to theprogression to a higher level of ambulatory aid. Gait endurance is improved by ambulating rather than standing tolerance activities. Functional ambulation should be documented every visit to include device/assist/distance/skill. Higher level ambulation (uneven surfaces, out of home, car transfers) should be addressed only after in home safety and function is established.
Discharge issues – Will your client be disappointed to hear you’re discharging? Then you’ve done something wrong. The Home Health benefit as defined by PPS is a short-term event designed to maximize function and restore independence and it is the charge of the clinician to characterize their program as such throughout the entire episode. Find a way to empower your client in terms of independence and function and maintain this for the extent of your program. Don’t allow yourself to create dependence in this area.
Rehab clinicians who are able to deliver their Home Health services in the manners listed above will find a higher level of success in patient outcomes. It is important to remember that good care requires more than just a cursory modality delivery or subjective connection with a patient. Program modification in response to skillful, focused care delivery will maximize both patient outcomes and professional satisfaction.
Arnie Cisneros is a physical therapist with nearly 25 years of home care experience. He is the owner of Home Health Strategic Management in East Lansing, MI, providers of clinical service management and home care consulting expertise. He is a nationally renowned speaker regarding the PPS refinements of 2008 and therapy utilization under the New Rule.