Assessing Prior Level of Function to Shape Effective Home Health Care

How do you know the patient is at their “prior level of function” or “baseline”? 

At the Home Health start of care, a comprehensive assessment is completed to determine what health and function–related deficits the patient currently has.  The OASIS is part of this comprehensive assessment and asks the assessing clinician to respond to questions regarding the patient’s prior ability to perform self-care tasks (dressing and bathing) and functional tasks (ambulation and transfers). So, how exactly do we develop a plan of care, keeping this in mind? 

Perhaps the patient has been seen by your agency in the past or the physician has documented the patient’s previous ability in the referral paperwork. If this documentation is not available, the guidance states that we can ask the patient and/or the caregivers about prior ability. However, we need to determine if the information received from these sources is accurate. Was the patient performing these tasks safely prior to illness or injury? Who made this determination and how long ago was the timeframe? 

If the patient has had a stroke, typically the change in the patient’s ability is clear. An onset of a disease process is much more easily spotted. But for patients with chronic conditions, this is more difficult. In this case we must look for an exacerbation. Remember an exacerbation is defined as an acute increase in the severity of a condition, i.e., a worsening. What changed from their baseline state even with that disease? If they have CHF, did they develop chest pain, increased fatigue, or SOB? How were they prior to that change? It’s not a timeframe but a change that we are looking for.

What about a situation where a patient just fell in the bathroom? How were they before that fall? How has the fall changed that patient’s life? Are they in pain, walking with a walker, unable to walk and temporarily chairbound. How did this event change them physically, functionally, emotionally?

Per CMS, during this (evaluation) visit, the therapist must assess the patient using a method that allows for objective measurement of function and successive comparison of measurements. Next, the therapist develops an individualized plan of care to address the barriers and deficits identified during their comprehensive assessments.  

Is the therapist a barrier?  

• We must keep in mind that our care must be wholistic. We cannot limit our assessment to just the physical or cognitive deficits of the patient, we need to consider their environment, and other social determinants of health which could limit their ability to remain safely at home.  

• Many of our patients are geriatric. We need to be sensitive to the learning capabilities of our patients versus the complexity of the skilled instructions that we provide. Simply visiting and instructing a patient and/or caregiver at an evaluation–only visit may not be sufficient to ensure success.  We may be providing too much information at once. Remember to “chunk” and “check” your information and stop when your patient is still successful. Teaching itself may be a clue to your therapists indicating of the need  for additional visits because the patient may not be able to retain all the information that is needed in 1 visit to keep them safely at home. 

Documentation is key:  

• If goals exceed the prior level of function or baseline, strong documentation to support clinical reasoning of how/why the patient can achieve a higher, safer level of independence. (Was the patient’s prior level of functioning safe?) 
• Words like “prior level of function” and “baseline” can limit optimal rehabilitation potential.  Ensure documentation includes the time frame/circumstances of the patient’s prior level of function and/or baseline functional abilities: did home health see them 3 three months ago? Do we have a therapy assessment from a facility? Do we have notes from a physician? 
• At the time of discharge from home healthcare, can the patient safely exit the home? Perform safe car transfers? 

• At the time of discharge from home healthcare, can the patient do “normal” things? For example, get a drink, open/close a door, open a jar, pour their own coffee, heat a meal and move that meal to a table safely to consume it?  Can they safely walk around the house?  

We want to discharge the patient with better, safer functional ability, demonstrating improved outcomes and likely positive patient satisfaction feedback.