Introduction to Physical Therapy in the Home Care Setting Home Health Section of APTA Key points Home care industry Client populations Prospective Payment System (PPS) Physical therapy services Assessment Treatment Communication Discharge planning Resources Home care industry Historical structure Disciplines Regional structures Fee-for for-service (FFS) Home Care agency structures Certified Licensed For-profit Not-for for-profit Hospital Based Free standing 1
Client populations Early Intervention Pediatric Adult Acute Hospice Pre-Operative Health & Wellness Home care agencies: current structure Managed Care: FFS & case rates Medicare: Prospective Payment System Outcomes ASsessment Information Set Home Health Resource Groups 1 year experience in a related setting (common recommendation) Future Health & Wellness Ergonomics Medicare HIM 11 Health Insurance Manual Homebound Skilled service MD order Reasonable & necessary Intermittent Rehabilitation potential Unique and individualized care plan Prospective Payment System What is the same? Medicare Guidelines OASIS Efficient use of HHA Discharge Planning begins on Day One What is different? Reimbursement is for a 60-day episode OASIS responses now determine Medicare payment Fixed sum for the episode 2
Timeline of Home Health Medicare PPS Development Medicare Changes: BBA, PPS, etc. We are here! October 29, 2000 1997 1999 2000 2001 2002 2003 2004 2005 1997 1998 1999 2000 Balance Budget Act of 1997 Interim Payment System for Home Health October 28, 1999 HHPPS Proposed Rule published in the Federal Registry December 27, 1999 60 Day comment period on Proposed Rule for HHPPS ends July 3, 2000: Final Rule of HHPPS published in Federal Registry October1, 2000 HHPPS Effective Balanced Budget Act of 1997 SNF PPS Effective MDS Tool Home Health PPS Effective OASIS Tool Rehab Hospitals PPS Effective FIM Tool 75% IRF rule 65% IRF Home Health PPS Became effective 10/01/2000 Medicare reimbursement for home care changes from a fee-for for-service payment to a fixed sum payment The OASIS assessment now determines the amount of the payment PPS represents a significant change in Medicare reimbursement OASIS Outcomes ASsessment Information Set CMS, then HCFA originally developed OASIS as a tool to measure outcomes CMS, then HCFA then decided to also use OASIS as a means of determining payment 22 of the 76 OASIS questions are currently identified as the components of fee calculation based on a Case Mix study 3
Home Health PPS Responses to 22 specific OASIS questions are organized into 3 domains: Clinical Severity Functional Status Service Utilization Each question has a point value based on severity Scores are totaled within a domain and assigned to severity categories The combination of the three totals creates a Home Health Resource Group (HHRG) Clinical Severity Domain M0230 Primary Home Care Diagnosis: Orthopedic, Neurological, Diabetes Burns/Trauma, if M0440 is Yes M0250 Therapies: IV/Infusion, Parenteral, Enteral M0390 Vision M0420 Pain M0440 Wound/lesion with Burn/Trauma M0450 Multiple Pressure Ulcers M0460 Current Pressure Ulcer Stage M0476 Stasis Ulcer M0488 Surgical Wound M0490 Dyspnea M0530 Urinary Incontinence M0540 Bowel Incontinence M0550 Bowel Ostomy M0610 Behavioral Functional status domain M0650 - Dressing upper body M0660 - Dressing lower body M0670 - Bathing M0680 - Toileting M0690 - Transferring M0700 - Ambulation/Locomotion OASIS Item M0175-1- No hospitalization past 14 days Service domain Value Points Score No If box 1 S0 Min = 0-20 hospitalization past IS BLANK 1 S1 Low = 3 14 days S2 Mod = 4-64 M0175-2 or 3 If box 2 or 3 2 S3 High = 7 Inpatient rehab/snf discharge past 14 days M0825 - Receipt of If box 1-10 or > Therapy therapy visits 4 4
HHPPS payment variations... LUPA: Low Utilization Payment Adjustment Four (4) visits or less are paid on a per visit basis SCIC: Significant Change In Condition An adjustment in the episode payment when the patient experiences a significant change in condition not envisioned in the original plan of care PEP: Partial Episode Payment Patient is admitted to Agency A, then elects to transfer to Agency B. Agency A receives a proportional payment based on length of stay. Patient meets treatment goals, is discharged, then subsequently re-admitted during same 60-day episode Home Health PPS Episode of Care = 60 Days The OASIS assessment determines the payment for the 60 days care package Re-certification now means a new episode of care Incentives are reduced for agencies to reject patients who require more intense services Physical therapy services Assessment PMH and previous level of functioning Gait ADL & IADL Cognitive/mental status Cardiopulmonary status Integumentary Neurological PT assessment (continued) Musculoskeletal PROM AROM Strength Home & environmental assessment DME: Present, ordered, needed Living space: Functional & Quality of life Social & support systems 5
Intervention Appropriate Effective Documentation Ease of use when providing care To support clinician: Recording clinical care Support reimbursement Regulatory standards Plan of care Who are the goals derived for? Measurable Function related Achievable Patient/caregiver Agreement Participation Discharge planning Establish role and goals from day 1 Awareness of learned helplessness Patient goals Other team members Community resources Continuum of care Time management What helps clinicians maximize their time with the client? Commuting Organization of resources & supplies Scheduling 6
Communication Coordinator of Care (CoC) Physician and other services Patient, family, & caregivers Payers: managed care Durable medical equipment (DME) Technology that works for you! More is not always better... Vision 2020: six pillars Autonomy Professionalism, Direct Access, The Doctor of Physical Therapy, Evidence-Based Practice, and Practitioner of Choice Resources National Association Home Care (NAHC.org( NAHC.org) Visiting Nurse Association of America (VNAA.org( VNAA.org) Home Care Association of America (HCAA.org( HCAA.org) Center for Medicare and Medicaid (CMS.gov( CMS.gov) Home Health Section of APTA (homehealthsection.org) State chapter of APTA, state home care association Industry groups, publications, and list serves Thank you for attending! Home Health Section APTA 7