When the introduction of PDGM in 2020 eliminated therapy as a primary reimbursement driver, many home health agencies questioned the value that these services provided. However, eliminating therapy thresholds was never intended to replace clinician judgement or promote underutilization of therapy. PDGM relies on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories.

With Home Health Value-Based Purchasing (HHVBP) scheduled for implementation January 1, 2023, there is no time like the present to discuss the positive impact appropriate utilization management, including therapy utilization, can have in helping your agency achieve clinical excellence and optimize reimbursement.

Keeping the bigger picture top of mind

Connecting the dots between OASIS scoring, plan of care, and patient goals to guide appropriate therapy utilization

In preparation for HHVBP, agencies are increasing staff education on scoring the items that make up the OASIS-based Quality Measures in VBP, specifically the Total Normalized Composite Change in Mobility (TNC Mobility) and Total Normalized Composite Change in Self-Care (TNC Self-care), which are both crucial. Both the TNC Mobility score and TNC Self-care score make up 50% of the total OASIS scoring impact on the Total Performance Score (TPS).While the importance of OASIS accuracy should not be underestimated, there is more to navigating value management than scoring the OASIS assessment.

Keep full picture top of mind—how is your agency ensuring a patient focused plan of care that serves individual patient goals? Are they identifying how to decrease their rehospitalization rate or emergency department use? Additionally, where does the agency stand regarding patient satisfaction?

Clinicians responsible for OASIS completion should have a working knowledge of how to score all OASIS items, but should also be knowledgeable in what to do with this information. Oftentimes, agencies are hyper focused on the data, the “score”, that they forget that “the score” represents a patient under their care who has needs. Let’s look at Patient Z to see what the OASIS scores for a few OASIS-based Measures are really telling us, aside from contributing to the HHVBP Quality Outcome Measures.

The patient’s goal is to be able to safely walk to and get into the car independently by their birthday.  Patient was referred from an acute inpatient facility for home health skilled nursing.

Regardless of which disciplines are on the hospital referral, an agency should be looking not only at what the skilled nursing needs are, but also identify what other needs the patient may have as they develop the plan of care. Based on assessment findings, Patient Z exhibits a high risk for falls with functional limitations while completing basic tasks. If you consider the patient’s birthday goal, a referral to physical therapy should be prioritized. If you take away the patient’s goal, the assessment findings alone should raise a red flag for high risk falls at home, which could potentially lead to a hospital visit. In addition to physical therapy, additional disciplines like occupational therapy should be considered. If the patient exhibits cognitive decline of any sort, speech and language pathology should be considered.

Based on a study published in the Gerontological Society of America “home health patients are at greatest risk of hospitalizations within the first weeks of home health. Over 25% of hospitalization occurred in the first 6 days and over 50% occurred in the first 2 weeks.”  A first-of-its-kind study based off 1.4 million Medicare cases from CMS, Therapy Outcomes Post-Acute Care Settings (TOPS) shows that physical therapy and occupational therapy have a positive effect on patients in post-acute care settings. Most importantly, they are finding reduced readmissions to acute-care hospitals after therapy.

Under HHVBP, the Claims-based Measures comprised of Acute Care Hospitalization (ACH) and Emergency Department Use (ED Use) account for 35% of the Quality Measure Weighting. There is no doubt that the addition of multidisciplinary care, early in the episode of care, could make a difference in re-hospitalization and ED Use.

Physical, occupational, and speech therapy assess the patient’s physical limitations, environmental, and behavioral/cognitive challenges in order to provide suggestions to help patients overcome challenges. The goal is to improve safety and allow them to stay in their home after discharge from home health.

Looking back to Patient Z, therapy disciplines play a vital role in a patient’s ability to safely remain in the community (OASIS M242O D/C Community) and out of the hospital. Therapists work not only with the patient but the patient’s family and caregivers by providing valuable education and support to keep the patient safe at home for as long as possible. Showing improvement in any of the OASIS-Based Measures is a “win-win”. The patient “wins” because they can remain in their home, will be satisfied with the care provided, and more likely to recommend the agency to others. The agency “wins” because their scores at discharge compared to start of care will show improvement.

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McBee Episode Management Services

McBee Episode Management Services help home health organizations optimize visit and discipline utilization to achieve clinical excellence and ensure financial viability. With a patient-centric approach, our clinical consultants provide your organization with insights into your utilization management to identify trends, optimize areas of improvement, and recommend next best steps to integrate new care patterns into your culture.
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