Eli's Rehab Report

Published on Tue Oct 28, 2014 PDF

Therapists and agencies prefer a time-based schedule.

Commenters welcome the elimination of the current confusing functional assessment schedule change for home health therapy patients. But will you really find any significant progress in your patients within the newly proposed two-week period?

In its 2015 home health prospective payment system proposed rule, the Centers for Medicare & Medicaid Services (CMS) proposes “to simplify [the regulation] to require a qualified therapist (instead of an assistant) from each discipline to provide the needed therapy service and functionally reassess the patient … at least every 14 calendar days,” according to the rule published in the July 7 Federal Register. “The requirement to perform a therapy reassessment at least once every 14 calendar days would apply to all episodes regardless of the number of therapy visits provided. All other requirements related to therapy reassessments would remain unchanged.”

The 14-day schedule would be a change from the current requirement, under which home health therapists must assess the patient after the 10th therapy visit but no later than the 13th therapy visit, and after the 16th therapy visit but no later than the 19th therapy visit.

HHAs are overjoyed to see CMS make plans to dump the current byzantine visit counting requirement, according to many of the 354 comment letters received on the rule. “The current method of counting therapy reassessments has been confusing, especially in multidisciplinary therapy cases,” notes Partners in Home Care in Montana in a comment letter.

A time-based system “is certainly an improvement over the totally confusing and near impossible ‘counting visits,’” applauds physical therapist Cynthia Jarrett in Mississippi in her comment letter.

Visit Counting Headache Is A Whopper

The problem: “In multiple therapy episodes, therapists must communicate when a planned visit and/or reassessment is missed to accurately track and count visits,” explains PT assistant Brad Woodcock, regional therapy manager for NMMC Home Health in Tupelo, Miss., in his comment letter. “Our agency has spent numerous man hours manually counting, re-counting, running reports, making numerous phone calls, and scheduling changes that often cost the agency time and money related to operating in a rural area.”

The requirement isn’t just bad for agencies, Woodcock continues. The rule has led to inconsistency in scheduling and frequent schedule changes, which stress the patients. “This is especially true when 2-3 disciplines are involved,” he tells CMS.

A time-based — rather than visit-based — schedule “will be much less complicated to follow and adhere to,” applauds Linette Zuchowski in Wisconsin, a rehab director with 18 years’ experience in home care.

“I am happy that the changes proposed would separate the discipline reassessments,” cheers a rep for Pathways Home Health in California. “It has been our experience in many cases that reassessments were done unnecessarily when one discipline had just come onto a case, but another had been seeing the patient with higher frequency. This is a large waste of time,” says the commenter with 21 years’ experience in home care.

“The current Home Health therapy supervisory model across all 3 therapy disciplines has never made sense from a clinical/medical or patient outcome standpoint,” agrees Ed Schulte, executive director of Caregivers Home Health in Kansas. “Not only is the tracking across disciplines difficult, but it requires a supervisory visit schedule that was often completely unrelated to patient progress or need,” Schulte says in his letter.

Therapy Patients Need More Time

HHAs may be welcoming elimination of the 13/19 visit functional assessment change with open arms, according to the comment letters that were due earlier this month. But they are decidedly opposed to the replacement CMS floats to perform the reassessment at least every 14 days.

Most of CMS’s therapy reassessment regulations “thus far are based on reimbursement time points rather than clinical ones,” points out physical therapist Bill Anderson, manager of therapy practice for VNA Home Health and Hospice in Portland, Maine. “There is ample evidence that changes in function as a result of improvements in functional strength, balance, and other impairments typically take longer than the 14-day reassessment period that is being proposed,” Anderson says in his comment letter.

“It seems strange why a 14-day reevaluation model was desired,” says PT and consultant Arlynn Hansell from Ohio in her comment letter. “In home health, unless you are dealing with a knee or hip replacement patient, minimal progress is seen within 14 days.”

“Therapy visit frequency in home health is often less intensive than in the Part-B setting (e.g. 2-3x per week versus 4-5x per week),” Schulte tells CMS. “Requiring a home health therapy supervisory visit on an every two-week calendar basis would mean that patients receiving intermittent HH services 2x per week would need a supervisory visit every 4th visit. For most home health patients, this frequency level is unnecessary to provide good outcomes.”

Not enough: “Even the best therapist with the most compliant patient you or I have ever seen with an astounding level of rehab potential will be left at odds when reassessing a patient’s progress towards goals and the associated plan of care after two (2) routine therapy visits,” contends Brandon Douglas of Oklahoma in his comment letter.

In certain scenarios, the functional assessment visit would come with even fewer visits made first. Consider this one submitted by PT Tom Pugh with Sacred Heart Home Health in Eugene, Ore.: “Home therapy evaluations often take place on Thursday. No therapy visit is scheduled for Friday. Our agency, like many, does not provide weekend coverage. If the patient is not available the following Monday (common) but can be seen on Tuesday, 5 of the 14 days have elapsed without a therapy visit. One more therapy visit is scheduled for this week. Another weekend goes by. And the therapist is watching for a reassessment notice for that patient. 20-plus patients is a common caseload.”

In two-visit scenarios, if the patient cancels or refuses a visit, the reassessment deadline could come after only one visit, another commenter points out in his letter.

Limited: Complex cases that require visits from many other disciplines also result in less frequent therapy visits, points out a rep from Centra Health in Virginia. Patients can’t or won’t tolerate that many visits.

“Following the trends of the past decade, home health agencies are more and more frequently treating patients that previously would have been seen in Skilled Nursing Facilities that have multiple morbidities and limited tolerance to therapeutic activities, thus requiring a reduced frequency of therapy care,” agrees Douglas Farrell of Georgia in his letter. 

Note: To peruse the 354 comments on the proposed rule, go to www.regulations.gov, search for “CMS-2014-0090,” click on the rule entry, scroll down to the “Comments” section, and click on “View All.”