Jennifer Loehr, M.A. CCC-SLP Megan Malone, M.A. CCC-SLP Gentiva Health Services
Identify three different reimbursement sources for home health therapy. Determine appropriate frequency and duration timelines for the plan of care. Identify how many months of therapy are allowed in a certification period. Identify five general assessment areas included in the OASIS. Identify the reimbursement system for home health by medicare.
Cost-effective strategy for many families and insurance companies while maintaining the highest quality of life possible. Many older adults are remaining in their homes with assistance from family members, hired caregivers, and home health care agencies. Providing care in a patient s home can be challenging. The environment of care is one that is dynamic and patient controlled.
Home Health Agencies are organizations that provide healthcare services to patients that are home bound. Services may include: Speech Therapy Physical Therapy Occupational Therapy Nursing services Social Worker Registered Dietician Home Health Aide
Pros of working in Home Care Setting: Allows for one-on-one interaction with client Allows SLP to provide treatment in functional environment Flexibility of schedule Autonomy Interdisciplinary interaction Family interaction & education
Challenges in Home Care: According to ASHA s 2007 Health Care Survey, SLP s view the following as their top challenges: 1. Paperwork (clinical and reimbursement) 2. Insufficient reimbursement (for clinical services) 3. Keeping current with advances in clinical information 4. Unsatisfactory salary/benefits 5. High productivity requirements 6. Managing caseloads at multiple sites 7. Resources to respond to diversity within caseload 8. Not being valued by other disciplines/administration ASHA, 2007 (2)
There are a number of reasons why a patient would need home health care: Post surgery (Hip replacements) Post acute rehabilitation (Stroke) Illness (Parkinson s disease, Alzheimer s disease, cancer) Injury (Hip fractures, head injury)
According to ASHA s 2007 Health Care Survey: 51% of SLP services in home care are provided to infants & toddlers 26% to adults Top Areas of Intervention: 37% Swallowing 25% Aphasia 21% Cognitive-Communication 9% Motor Speech 14% to preschoolers 8% to school-age children ASHA, 2007 (2)
Age range of home care clients 50-59 years: 10% 60-69 years: 15% 70-79 years: 35% 80 years and older: 35% ASHA, 2007 (2)
Top 5 primary medical diagnoses of home care clients CVA: 63% CNS diseases: 8% Respiratory diseases: 5% Hemorrhage/Injury: 3% Other neoplasm: 2% Top 5 Functional Communication Measures scored by SLPs working in home care Swallowing: 54% Spoken Language Expression: 37% Motor Speech: 29% Spoken Language Comprehension: 26% Memory: 15% ASHA, 2007 (2)
Although the criteria for HH care stipulates that the patient be home bound, there are different settings that a person may call home : Home Independent Living Facility Assisted Living Facility Alzheimer s Assisted Living Facility
The overall adult population seen in home care : Is more medically acute and fragile Has a wide-range of disorders Has an emphasis on dysphagia & cognitivecommunication issues Demands prioritization of goals due related to number of visits Is more culturally diverse Requires evidence-based practice, with an emphasis on functionality of goals ASHA, 2007 (1)
Referrals: May occur upon discharge from a hospital, rehabilitation, or long-term care facility. Physicians may also refer patients directly to home health providers. Collaboration with other disciplines Registered Dietitian diet modifications Social Worker to obtain needed home medical equipment, counseling regarding role change Physical Therapist positioning for feeding, gait training Occupational Therapist assistance with feeding and writing Registered Nurse medication management and the effects of on speech, language, and swallowing performance Team MUST work together for patient outcomes. ASHA, 2008
1. Educator 2. Data Collector 3. Consultant 4. Case Manager 5. Advocate ASHA 2007
Clinician: Provided diagnostics and treatment with functional goals related to independence in the home. Assist patient with transition from home health rehabilitation to an outpatient setting. Treatment diagnosis may include dysphagia, aphasia, apraxia, symbolic dysfunction, hearing loss, agraphia and dysarthria.
Team Player: Despite being very autonomous, the HH speech pathologist is very involved in the rehabilitation team including the PT, OT, nurse, dietician, social worker, clinical case coordinator and physician. Frequent contact with other team members is very important to the success of the patients rehab. Coordinate your therapy visits to prevent overlaps or non-billable time. Some successful means of communication: case conferences, communication log, e-mail.
Patient/Family Support and Education The HH agency clinicians may be the only connection for the patient to the outside world. Education of patient/family/caregiver staff is a very important part of the plan of care. Constant assessment regarding the patient s and or family s emotional adjustment is necessary. It is very appropriate to make referrals: Clergy, social worker, psychologist etc.
Must: Remain flexible Evaluate client s and family s goals and expectations Involve family as integral part of treatment & carryover process Provide thorough documentation Assess client & initiate treatment within first hour of meeting client Set appropriate frequency and duration of treatment Have a knowledge of varying medical conditions & different cultures and their beliefs ASHA, 2007
Patient Management: Patients may be medically fragile Patients may present with a wide-range of disorders (swallowing problem, compounded with cognitive-linguistic/memory issue) Must prioritize goal areas (base on number of authorized session & client need) Currently, the emphasis in HH is on swallowing & cognitive-linguistic goals Functionality of goals is key Increased reliance on Evidence Based Practice ASHA, 2007
Patient Issues: Limited supervision for patients who are seriously ill (special precautions for dysphagia patients) Visits are not as frequent. Patient will often need to do homework. Patients with dementia need very functional therapeutic activities with reduced treatment time. Monitoring and reporting of functional changes, physical or behavioral, should happen immediately.
Client factors Non-compliance (Thobaben, 2007) Characteristics: Failure to progress Exacerbation of symptoms Development of complications as evidenced by objective tests or behavior that is indicative of failure to adhere to treatment plan Reasons: (Thobaben, 2007) Discomfort from treatment ( medication side effects) Expense of treatment Personal, religious, cultural beliefs related to treatment Personality traits, denial of illness, or mental disorders Addiction to alcohol or drugs
Client factors continued: Fatigue Client may be returning from facility or hospital stay Client being seen by a number of disciplines for care Scheduling Coordination with client s life & schedule Coordination with other discipline schedules Make effort to schedule during an optimum time for client s success Time of day (may be more effective in morning for cognition goals) Schedule swallowing treatment around meal times for functionality Client may not understand need for service Education by SLP is critical to explain scope of practice, education of diagnosis and treatment, & goals.
Factors that affect client satisfaction of home care treatment: Technical Quality of Care Communication Personal Relationships Between Client and Provider Delivery of Services Laferriere (1993)
Family Factors Family support is critical to the success of treatment in home care setting. Family dynamics differ across clients Considerations: Some family members may live with client; others involved in care decisions may live in other areas Family members are working and are unavailable to participate in the rehabilitation process and post-discharge care of the patient. Dissolution of family systems (ASHA, 2007 (1)) Family may have unrealistic expectations for treatment Family may have lower expectations of client potential Family may not fully understand their role in client progress
Family Issues: Family members may be having difficulty with transitions be careful not to let them dominate your precious time! Family/caregivers should not depend on your therapy visit for respite. Report any suspected elder abuse to your clinical care coordinator immediately.
Environmental Factors Very functional therapy environment Use the bathroom, kitchen, and bedroom! Limited structured therapy materials Home may have fewer distractions yet AL facility may have numerous distractions. AL facilities may have group or community activities you can use for therapy.
Environmental Factors Home Factors Noise/Distractions Family involvement ( To observe or not to observe?? ) Lack of privacy Role of Guest (Sines, 2005) Can lead to role conflict & confusion Distance
Regulatory Factors: Joint Commission Many home health care agencies are accredited through the Joint Commission. This regulatory agency reviews or "surveys" programs for their compliance on standards related to quality care. Medicare Other regulatory agencies State boards of speech pathology Occupational Safety and Health Administration (OSHA) regulates infection control procedures and mandates universal precautions. ASHA. 2007
ASHA members are required to follow the ASHA Code of Ethics HIPAA (Health Insurance Portability and Accountability Act of 1996)* Regulations apply to covered entities, but it is advisable that all SLPs familiarize themselves with HIPAA rules Administration simplification regulations focus on three areas: Privacy of protected health information Electronic transfer of health data Security of health information Impacts all forms of communication of health information (electronic, written, oral), as well as billing and information storage Violations may result in fines and penalties ASHA, 2007
Medicare Payment from Medicare is called the prospective payment system (PPS) Medicare (Center of Medicare Services) reimburses the HH agency according to the level of care needed by the patient. This level is determined by the initial evaluation performed either by a nurse or therapist. The HH agency is given payment for a 60 day period of care. If care is terminated early, either because the patient met his/her goals, was discharged due to lack of progress, etc. the agency must pay back a percentage of funds to the CMS agency.
Private Pay There are patients who may chose to pay out of pocket for any services not funded by Medicare or insurance: Maintenance therapy Home health aid Private duty nursing
Insurance The documentation criteria doesn t change. Reimbursement is generally a percentage with a co pay required by the beneficiary. Pre-authorization is generally required.
OASIS: The first clinician or nurse that is sent to admit a patient completes the OASIS form. Each home health agency uses the same format with only slight variations per agency policy. There is a designated OASIS form for use of nursing, physical and speech therapy (as of this date, occupational therapists do not have the authority to perform the initial assessment for a home health agency)
Outcome Assessment and Information Set (OASIS) The OASIS helps home health agencies determine what patients need, develop the right plan for their care, assess that care over the course of treatment, and learn how to improve that quality of care. The OASIS form is comprised of a set of fill-in and multiple choice questions that include, but are not limited to: Patient demographics Diagnosis Pain assessment Change in condition and treatment Medication assessment ADL function (Including, communication, mobility, feeding, toileting, dressing, grooming, hygiene) Multi-system status (GI, Respiratory, skin integrity, cardiovascular, urinary status and nutrition) Cognition and behavior Psychological status Social support Community resource involvement
OASIS: The speech pathology assessment section of the OASIS generally includes the following sections: Motor speech production Augmentative communication Dysphagia Cognition Language processing Language expression Reading comprehension Written formulation
If the SLP is not designated to complete the OASIS, a general speech-language assessment is done. This assessment contains all of the evaluation information included in the OASIS form pertaining specifically to the speech pathology evaluation. The SLP may use any battery or subtest that will lend the proper results and information. (i.e. Western Aphasia Battery, Ross Information Processing Assessment) All assessments must include a summary of current level of performance. As long as a patient is on services, a re-assessment is required by the SLP every 60 days. (The re-assessment guideline is mandated by the state licensing board and may vary from state to state.) This re-assessment must include a summary of current level of performance and changes since the start of care.
The plan of care is comprised of treatment modalities and long term goals. Long term goals are included in the assessment and re-assessment documentation. Short term goals may be included on daily documentation. Documentation of functional progress must be included in order to continue providing skilled therapy. Frequent documentation of progress toward goals should be included on notes.
Long Term Goals: Based on assessment results and geared toward functional independence. Long term goal time frame can be any length up to 60 days (length of certification period). After 60 days a recertification (ROC) is completed for another 60 day period with new LTG s. Goal examples: Patient will verbally communicate basic wants and needs. Patient will use augmentative communication device to communicate basic wants and needs in home setting. Patient will tolerate all oral intake of liquids, solids, and medication without risk for aspiration. Patient will follow all compensation/cues independently for safe ADL function in the home. Caregiver/family member will demonstrate knowledge of safe swallow guidelines by return demonstration.
Part of your goal setting will be determining the frequency of your visits and the duration that you will provide therapy. There are a total of nine weeks in a certification period. Frequency: How many visits per week? Duration: How many weeks? Example: ST 1-2w1, 2w2, 1w1 (Speech therapy one to two visits the first week. Two visits the second week and one visit the last week.) ST 3w3, 2w2, 1w1 (Speech therapy three visits the first three weeks, two visits for two weeks, and one visit the final week.) ST 2w9 (Speech therapy two visits for nine weeks)
Guidelines for documentation will vary for different home health agencies. Start of care OASIS (SOC) Recertification OASIS (ROC) Transfer OASIS Discharge OASIS Speech therapy assessment (non-cert) Speech therapy discharge (non-cert) Daily documentation Time sheet Travel log Vital signs Progress notes Education Patient/family/staff signature
Treatment, like goals, must be guided by patient & family input Must be functional & meaningful Must allow for optimum practice of goal in time allotted to increase likelihood of carryover. Should align nicely with other discipline s goals.
Case Study 85 year-old man; living at home post left hemisphere stroke; demonstrates difficulty in communicating wants & needs clearly due to motor speech impairment. Also shows signs/symptoms of aspiration when eating a regular consistency diet, as confirmed my MBS study in hospital. Responds well to cueing & able to imitate strength exercises & compensatory strategies for safer swallow. Memory deficits evident (possible dementia); low vision Former auto worker; wife is deceased; living with son & daughter-in-law who both work during day; nursing assistants manage patient care during day; looking for interesting & motivating activities for patient to engage in.
Step One: Prioritize Goals Safe swallowing primary goal Improved motor speech production secondary goal. Goal One: Improved Swallowing Patient will successfully complete 80% of pharyngeal strengthening exercises modeled by therapist to improve safety of swallow for regular diet. May include tongue base retraction (pulling tongue straight back, gargling, yawning), effortful swallow, effortful breath hold, maneuvers Patient must also practice exercises on own (example 10 times/day for 5 minutes)
Goal One: Improved Swallowing Patient will recall and demonstrate the compensatory strategy of a chin tuck 80% of trials during meals to increase safety during eating & reduce signs/symptoms of aspiration. Use of spaced retrieval technique & written cue to recall compensatory strategy. Patient will remain on mechanical soft & nectar thick liquids until course of treatment indicates patient has strengthened muscles of swallowing mechanism, consistently utilize compensatory swallowing technique, & shows no s/s of aspiration on regular diet/thin liquids during bedside evaluation & MBS study.
Spaced Retrieval (SR) Technique used to help persons with cognitive impairments recall important information over progressively longer intervals of time. Has been used successfully with patients with Alzheimer s Disease, Traumatic Brain Injury, Parkinson s Disease, and Dementia related to HIV (Bourgeois et. al, 2001; Camp, et. al, 2008; Neundorfer, et. al, 2004; Malone et. al, 2007) Is an effective tool that therapists can use to help clients reach their goals in rehab therapy and is billable and reimbursable. Takes advantage of the procedural memory system and is success-based.
Spaced Retrieval: Begin with a prompt question for the target behavior and train the client to recall the correct answer When retrieval is successful, the interval preceding the next recall test is increased. If a recall failure occurs, the participant is told the correct response and asked to repeat it The following interval length returns to the last one at which recall was successful. SR Example: Goal: Client will correctly recall and demonstrate use of chin tuck during meals to decrease risk of aspiration 80% of trials. Prompt Question: What should you do when you swallow? Answer: Tuck (one word response, plus demonstration of strategy due to motor speech deficits).
Engagement activities Base around interests & hobbies, may also include opportunities for practice of goal areas. May include looking at pictures/books of different types of cars; practice saying color of item and other details; fine motor practice of taking items apart and putting back together (flashlight, etc.); choosing meal/grocery items from a list; assisting in setting table, sorting silverware; folding items; sanding wood, etc. picture puzzles of cars, grandchildren, etc. Picture Puzzle Example
Goal 2: Improved motor speech production Patient stimulable at word level production Treatment may include word imitation of common items in home, names, action words ( Help, Eat, More, Yes, No, Stop, etc.) & gestures, moving toward short phrases & use of augmentative means (writing, use of picture/word cards) Treatment will also include homework practice of targeted treatment words. Patient will accurately communicate wants and needs to improve safety & interaction with family/staff at word & short phrase level 80% of trials.
Word/Communication cards Bathroom Hungry
Possible duration of treatment/number of sessions ST 2w5, 1w2 (Speech therapy two visits for five weeks; once a week for 2 weeks) 1 hour sessions; 20-25 minutes on swallowing; 20-25 minutes on speech production, with rest periods; 10 minute review of homework and instructions for family & staff. Communicate with other disciplines for carryover practice of target goals during other treatment sessions (example ask nursing to encourage production of words during care)
Case Study 66 year old gentleman diagnosed with progressive frontaltemporal dementia with severe expressive aphasia. He was living at home with his wife for several years with this diagnosis until his impulsivity and poor judgement necessitated the need for placement in an locked facility for his safety. This patient is a retired computer programmer and his wife is a retired school teacher. They have children and young grand children that come to the facility frequently to visit. This patient has a great deal of difficulty communicating to family and staff members creating increased emotional lability, frustration, and social isolation. His wife is very concerned for his well being and adjustment to his new living environment and hopes that speech therapy can help him with communication, orientation to his new surroundings and assist him in finding leisure activities that are appropriate to his language and cognitive levels.
Goals: Resident will be able to utilize verbal and non-verbal communication to express his very basic wants and needs 100%. Use of augmentative communication device with icons and/or photographs with labels. This is called his speech book Training of facility staff to ask basic, direct questions (i.e. Are you in pain? Are you hungry? Where is your speech book? Resident will be able to locate major facility landmarks with visual cues 100%. Use visual cues such as large labels and signs. Use spaced retrieval cues Resident will participate in appropriate facility and personal leisure activities with supervision 100%. Develop personal leisure list of appropriate activities for resident to participate in with family and staff. Have list available to activities director and care staff
Case Study 70 year old gentleman with a diagnosis of severe pharyngeal dysphagia following intubation during his stay in the hospital for complications following an attack of infuenza. Patient has had a PEG tube placement in the hospital. Prior to discharge, the modified barium swallow study indicated some improvement in his swallow functions with a recommendation for trial oral feeding (puree) with speech therapy. Patient has a very weak, non-productive cough and a weak, hoarse vocal quality. Patient was discharged to home with home health speech therapy to improved swallow functions and resume oral feedings.
Goals: Patient will tolerate oral intake of all food, liquid, and medication without aspiration. Pushing/pulling exercises hard swallow supraglottal swallow safe swallow compensation (cough and clear)
Goals Patient will demonstrate improved vocal quality with reduced vocal hoarseness 50% Work on respiratory support/strength through exercises and improved postural support (physical therapy referral) Increase sustained phonation Teach soft cough/throat clearing Teach vocal hygiene
Client s motivation is the driving force behind carryover of treatment Desire to eat certain foods, communicate effectively, etc. Many clients approach therapy passively Get them involved & motivated from the initial session Therapy should be described as a procedure to help change the client s behavior, with the clinician s assistance Responsibility for treatment lies with the client; Let them own their own treatment
Provide several opportunities for client to practice skills with others in environment Provide feedback to client (recordings, use of mirror, etc.) Provide several opportunities for reinforcement of skills Graphic representations (charts of progress, working toward personal goal) Involve persons who patient admires to act as motiviators
Make clients aware of the purpose of homework assignments (have client participate in creating them with you). Practice under emotional conditions (answering telephone, etc.) Practice in distracting conditions (during activity, over environmental noise) Provide family with instructions on how to respond to client responses (ask for clarification, model correct posture, etc.) Post reminders of goals Make sure that treatment always ends in successful responses (promotes intrinsic reinforcement of new behavior) Engel, et. al (1966).
ASHA (2007). Health care issues brief: Home Care. Available at http://www.asha.org/members/slp/healthcare/home_care.htm ASHA (2007). ASHA SLP Health Care Survey: Caseload characteristics. Rockville, MD: Author. ASHA (2008). Getting started in home care. Available at http://www.asha.org/members/slp/healthcare/start_home.htm Thobaben, M. (2007). Noncompliance: A challenge for home health nurses. Home Health Care Management & Practice, Vol. 19, No. 5, 404-406. Laferriere, R. (1993). Client satisfaction with home health care nursing. Journal of Community Health Nursing, Vol. 10. Sines, D., Appleby, F., & Frost, M. (2005). Community Health Care Nursing. Wiley- Blackwell. Bourgeois, M., Camp, C., Rose, M., White, B., Malone, M., Carr, J., & Rovine, M. (2003) A comparison of training strategies to enhance use of external aids by persons with dementia. Journal of Communication Disorders, 36, 361-379.
Neundorfer, M., Camp, C., Lee, M., Skrajner, M., Malone, M., & Carr, J. (2004). Compensating for cognitive deficits in persons aged 50 and over with HIV/AIDS: A Pilot Study of Cognitive Intervention. Midllife and Older Adults and HIV, 79-97. Malone, ML, Skrajner, MJ, Camp, CJ, Neundorfer M, Gorzelle, GJ: Research In Practice II: Spaced- Retrieval, A Memory Intervention. Alzheimer s Care Quarterly. (2007); 8(1): 65-74. Camp, C. J., & Malone, M. L. (2008) Mise en œuvre d'interventions de récupération espacée auprès de personnes atteintes de la maladie d Alzheimer. Cahiers de la Fondation Médéric Alzheimer, number 3. Social Services (2004), 3, 1, 79-97 Camp, C., Cohen-Mansfield, J, Capezuti, E. (2002). Use of nonpharmacologic interventions in nursing home residents with dementia. Psychiatric Services, 53 (11), 1397-401. Skrajner, MJ, Malone, ML, Camp, CJ, McGowan, A, Gorzelle, GJ: Research in practice I: Montessori-Based Dementia Programming (MBDP). Alzheimer s Care Quarterly. (2007); 8 (1): 53-64. Squire, LR. Declarative and nondeclarative memory: multiple brain systems supporting learning and memory. In: Schacter, DL, Tulving, E, eds. Memory Systems. Cambridge, MA: MIT Press; 1994: 203-232. Engel, D., Brandriet, S., Erickson, K., Gronhovd, K., & Gunderson, G. (1966). Carryover. Journal of Speech and Hearing Disorders. 31(3) 227-233.