Home care is next frontier in rehab: Are you ready?
Managed care, shorter stays call for home services
To compete in the 1990s, rehab providers are going home the patient’s home that is.
In fact, 70% of your fellow readers who replied to the 1996 Hospital Rehab Reader Survey report they are either providing home health services or considering getting involved in home health.
They’re taking advantage of a new source of patients those who are being discharged from inpatient rehab as soon as they are medically stable but before they are functional enough to come into the hospital for day treatment or outpatient rehab.
The typical home health agency has little to offer in the way of rehabilitation services, says James C. Summerfelt, MS, PT, director of home health and rehabilitation planning operations for the Rehabilitation Institute of Chicago (RIC), who has 20 years experience in home health management.
But the need for such services is on the rise because of demand from payers, physicians, and the patients themselves, he adds. This creates a prime opportunity for rehab service providers to step in and fill the gap.
If your facility is considering venturing into the home health market, several options are open to you.
Some rehab providers have contracted with existing home health agencies to provide physical therapy, occupational therapy, speech therapy, and rehabilitation nursing. Some have found it more feasible to form their own independent home rehab agency. Others have joined forces with a home health agency within their hospital system.
If you choose to contract with an existing home health agency, they will reimburse you on a per-visit basis at a rate you negotiate. If you decide to provide rehab as an independent agency, you will negotiate directly with payers.
Some contract with therapists to provide care on a per-visit basis. Others have their therapy staff on salary and assigned only to home care. Generally, home health therapists receive slightly higher pay than therapists who work in a clinical setting. Some hospitals reimburse them for mileage. (For details on some of the varied options for operating a home health service, see related article, p. 32.)
A typical home health rehab patient is being discharged from acute care, inpatient rehab, or a skilled nursing facility but is unable to function safely at home.
"If patients aren’t medically acute, in many instances, their rehab needs can be dealt with within the home. Patients want to be home, and that is the best place to get service so they can function in the home," says Susan Saya, PT, MBA, contract therapy service director for Braintree (MA) Hospital Rehabilitation Network.
Interim treatment
After receiving home therapy services, patients may go to a day treatment center or outpatient therapy clinic to complete their rehab.
"Home care isn’t where they end up. It’s to make sure they are safe at home and functioning as well as they can so they can proceed to day care or outpatient and continue their rehab," Summerfelt says.
Home health therapists at St. Vincent’s Home Care in Erie, PA, see a lot of patients who have no specific rehab diagnosis but need help with mobility and conditioning, says Jeanne Downey, MS, team leader of rehabilitation for St. Vincent’s Health Center.
For instance, an elderly patient who has had abdominal surgery might be scheduled for home health physical therapy and occupational visits to help him learn to walk safely and rebuild his strength.
Many of these patients would end up in a nursing home if it weren’t for home health, Downey says.
If you enter the home care market, you can expect about 60% of your patients to be covered by Medicare. The vast majority of the rest are likely to be covered under a managed care plan, Summerfelt says.
Whether you opt to set up your own home health agency and deal directly with payers or contract your services to a home health agency, your facility will be reimbursed on a per-visit basis, regardless of the diagnosis.
Under current rules from the Health Care Financing Administration (HCFA), home health is reimbursed on a cost system, but that is likely to change to a prospective payment system in the next few years as Congress considers Medicare reform.
Home rehab providers report that they negotiate per-visit rates with other payers, or with the home health agencies, depending on whether they operate their own home rehab services or contract with existing services.
Reimbursement rates are typically higher than for outpatient treatment but, under Medicare rules, a visit includes patient care, charting, conferencing, and travel. This means a typical home health visit lasts an hour and a half or more, compared to 45 minutes to an hour for a typical inpatient or outpatient visit.
While the cost for space and equipment is less than treatment in a clinical setting, personnel costs are likely to be higher since home health therapists can treat only a few patients a day.
30 visits on average
The typical rehab patient receives about 30 home health visits, including nursing, Summerfelt says, adding that the average number of visits varies greatly by geographical area.
Frequency depends on payers and patients’ conditions with the typical patients receiving a therapy visit two or three times a week, he adds.
In an eight-hour work day, the average home health therapist working in an urban area can treat five to seven patients, Summerfelt says. The figure includes travel time, documentation, and communication between disciplines.
"A lot goes into that eight hour day and they have to be pretty good in time management to get all that in," he warns.
Rehabilitation Hospital of Indiana (RHI) in Indianapolis expects each of its full-time home care therapists to perform five hour-long treatments a day. At St. Vincent’s, the benchmark is for therapists to treat six patients a day.
In an eight hour day, Houston-based Legend Rehabilitation Services therapists see five to six patients. Some opt to work longer hours and see more patients, says Prem Gogia, PhD, PT, president of the company.
Because home health therapists work alone, the team approach to treatment isn’t as easy to accomplish as when the entire staff is in the hospital at the same time.
Legend regularly sets up conference calls if a therapist in one discipline needs to consult with others who are treating a patient. The Legend staff is expected to attend case conferences at the home health agencies.
At RHI, the home based rehab treatment team sits down within 10 days of admission and every 30 days thereafter to discuss patient goals and functions.
"This team approach requires careful coordination of schedules to allow staff time to come for the case conference, but we think a team approach is important," says Melissa Dill, MS, OT, outpatient program manager.
Scheduling therapists to see patients in a wide geographic area and keeping up with documentation from people in the field are challenges faced by home health providers.
At Braintree, an administrative assistant maintains a database of clinicians, the areas they cover, cases being treated, and the anticipated discharge date. She coordinates the schedules of the therapists and makes sure all patients are covered.
Braintree’s home health therapists must take their paper documentation at least weekly to one of the hospital’s satellite locations where it is picked up by the hospital’s courier system. The staff at Braintree Rehabilitation Venture compile the documentation and send it off to the referring home health agencies who use the information to bill the payers.
If patients have received home health therapy from St. Vincent in the past, Downey tries to schedule the same therapists to treat them.
Downey tries to match patients according to the therapists’ preferences and the geographic area in which their other patients live. For instance, one prefers to treat more severe diagnoses, such as spinal cord injury and strokes; another prefers to work with orthopedic patients.
Last fall, St. Vincent began using a computer software system designed for home care which will eventually eliminate the need for home care employees to come into the office except for supplies, says Sister Cindy Brown, office manager for St. Vincent Home Care.
Nurses and therapists in home care use laptop computers to record assessments, care plans, and progress notes. The laptops interface with the home care’s computer system and transfer the patient information by modem. The home care system has 30 laptops and plans to purchase more in 1997 to expand the capabilities.
Eventually, therapists will use the computers to e-mail each other and set up conferences, track authorized visits and patients needing recertification, and keep track of documentation needed by the billing office, Downey says.
The computer system software is produced by Delta Health Systems in Altoona, PA.
[Editor’s note: For more information on Delta Health Systems software, call (814) 944-1651 and ask for marketing, or visit their Web site at http://www.deltahealth.com.]
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