The many changes that have redefined Home Health over the past decade have conspired to create many levels of understanding regarding exactly what the benefit provides and how it works under the Prospective Payment System (PPS). These areas of confusion extend to many of the participants involved in a standard homecare program; MDs, patients, providers, and clinicians. As further changes, in the form of audits, denied care, outcomes, and qualified care are seen, it is imperative that Start of care clinicians help define how the Home Health benefit works for each individual patient. This helps patients and their families understand exactly what Home Health provides for their care, why those elements are important, and how the patient can best utilize them to achieve their goals.
These scripts are relevant for all Start of Care visits, regardless of the discipline involved. The statements included are explanations of the system that the patients have contributed to financially for most or all of their working life. This exemplifies how we address misunderstandings before they occur. The verbiage is not required to be replicated exactly, but the points contained are important and must be understood by both clinicians and patients. They are important and must be addressed during ALL Start of Care visits. Breakdowns of the specific ideas that must be conveyed to the patient are summarized below.
START OF CARE
As you know, your physician has ordered a homecare program to help you return
to your previous level of function in the home. In helping you with this type of care, it is important that we be on the same page as to how we will make this happen. I’m sure you are aware of the many changes that Medicare has been going through that keeps changing how Medicare can help patients like yourself. Some of the changes are financially based, but many are changes in how we help people like you return to their previous level of independence and safety Just as people stay in hospitals for shorter periods as a result of medical advances, Home Health keeps changing in what it provides for clients in the home. We all pay for Medicare coverage, myself included, and its important to know how it works and what is expected of you.
First, your doctor ordered homecare for you with specific services in mind. Medicare doesn’t allow me to just put those services in your home; I have to perform an OASIS assessment first. This admission evaluation determines whether what your doctor ordered is what you need in terms of Medicare Home Health. It also determines whether you also require some form of care your doctor failed to order in this case. If it does, we can provide that to you at no cost.
COMPLIANCE
Second, Home Health requires participation on your part; you must work with the homecare clinician, or clinicians, to help achieve your goals using the benefit you have paid into during your working life. You must participate in the program as we instruct in order for us to continue to work with you; this is a Medicare requirement and we can’t continue with the program if we are lacking in this area. I will give you homework so that, working together, we can make sure you continue to improve during the entire program, not just the days I come for a visit. Unless we can demonstrate to Medicare that this is occurring, I won’t be able to keep coming to help you.
NON-COVERED SERVICE
In the same way that al Medicare works, there are qualification requirements for this type of service. You must be homebound, and have clinical needs and declines that are addressable through homecare. If these are not present, the order from your doctor doesn’t change this. If you or your doctor would like services provided that are not covered by the Medicare Home Health program, there is a Home Health Advance Beneficiary Notice (HHABN) that allows you to receive these services if you are willing to pay privately. Home Health has changed drastically over the last ten years in these areas; just ask me to help you understand these things if you are confused.
PROGRAMMING
When I complete the OASIS evaluation, we will discuss in what areas Medicare says you need care coverage. Medicare expects we will install these services in your home program so you can get better as fast as possible. If you decline those services, some of the other clinicians on your program may not be able to help you get better as fast as you can. Likewise, when I tell Medicare what intensity of services are required that they have to fund in order to get you better, their opinion of how necessary this is will change if, for any reason, we are not able to deliver that level of services.
PROGRAMMING EXAMPLE
The referral from your doctor ordered nursing and physical therapy for your Home Health program. When I complete the OASIS, it is clear that Medicare would agree that we have some nursing needs regarding medication and wound management. The fact that you walk safely throughout your home makes the physical therapy your doctor ordered an uncovered service. However, the OASIS reveals that you need Occupational Therapy (OT) services to help you get back to independence in bathing and dressing. Your request for a bath aide also confirms these deficits are limiting you previous level of independent function in these areas. Therefore, PT will not be on your careplan; OT will be there instead. They are quite similar to PTs, but they work on the areas in which you need help. Even though Medicare no longer pays us to provide bath aides (they haven’t since 1999), we will send one out to you 2x wk until the OT helps you perform these type of tasks on your own.
IMPORTANT THOUGHTS ADDRESSED ABOVE
1) Here’s how the benefit works; its important you understand it.
2) Let’s get on the same page right from the start
3) We don’t just come out and get you better; this is a team effort and you and your caregivers are on that team.
4) Your doctor ordered homecare for you; Medicare has certain things they will and won’t provide regardless of what your doctor ordered.
5) Those things have changed significantly over the last 10 years; this is common in all areas of healthcare.
6) Therapy helps with dressing, bathing, toileting, safety, and ambulation; they will not be here for long, please take advantage of them and their expertise.
7) Make sure visits and compliance are not taken for granted.
8) Your system (Medicare) has addressed how to provide things you want or need that aren’t coverable by the benefit today; private pay via HHABN.
SUMMARY
The above scripting helps assure patient insight into the Home Health benefit that we, as participating providers and clinicians, are compelled to provide for informed care and optimal outcomes. These Medicare parameters are well defined and finite; we can help our patients by helping them understand how to access the benefit in the most efficient manner. It saves both patients and providers the unnecessary levels of confusion and conflict that distract from patient care, outcomes, and satisfaction.
Special thanks to Arnie Cisneros, PT for supplying this article from the Home Health Strategic Management newsletter.
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