Home Health & Hospice Week

Don't wait until the last minute to comply with the therapy changes hitting April 1, or the joke will be on you.

In the Nov. 17, 2010 Federal Register, the Centers for Medicare & Medicaid Services finalizes home health agencies' requirement to have therapists -- not therapy assistants -- conduct functional reassessment visits on the 13th and 19th visits or every 30 days. In certain cases, therapists may make the visits in the 11 to 13 and 17 to 19 ranges. CMS also will require more specifics in therapists' documentation (see Eli's HCW, Vol. XX, No. 6, p. 42).

"Practice, practice, practice being compliant with the reassessment timeframes before the April 1 implementation deadline," urges physical therapist Cindy Krafft with Fazzi Associates. "That way agencies can find where the process breaks down and correct it before it is 'official.'"

The bottom line:Waiting until the last minute can lead to mistakes when it will count, Krafft tells Eli.

Heed this additional expert advice to smooth your transition into the new therapy requirements:

• Assess yourself. If you haven't already done so, start your transition process by assessing where you stand currently on therapy issues. "HHAs should be looking at their current processes, tools, job descriptions, etc. related to therapy to identify what is missing and how things will need to change by April 1st," advises Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C.
• Plan new scheduling. The biggest challenge for most agencies will be timing the reassessment visits by the therapists correctly, experts agree. Sometimes the visits must occur on the 13th and 19th visits, sometimes in the 11 to 13 and 17 to 19 visit ranges, and sometimes before the 30-day deadline. And the visits are timed based on the total number of therapy visits, combining disciplines for the visit count.

"Project the combined [therapy visit] frequencies and plot the anticipated re-assessment visit on the calendar," recommends occupational therapist Karen Vance with BKD in Springfield, Mo.

If the visit range applies to you, you should likely plan on doing the reassessment at the beginning of the range, Adams suggests. That way, you've got some leeway so you can "avoid being caught without getting it done by the time limit."

• Communicate and coordinate. Therapy reassessment visit timing won't be accurate if you stop at the planning and scheduling stage. Therapy and scheduling team members must stay in contact to make sure the reassessment visits occur when required, based on shifting visit numbers.

"Count the [therapy] visits as they come into the office for a safety net measure," Vance recommends. That means you'll have to enforce timely submission of documentation by your therapists.

Don't rely on that counting to do it all, however. "Communicate among one another ... particularly if the projections didn't come out as expected," Vance stresses.

Many providers "will need to determine new ways to coordinate to be sure the reassessment visits are done timely," Adams expects.

• Strengthen therapy documentation. The new requirements are merely "clarifications" of existing policy and agencies and therapists should have been doing this all along, CMS maintains in its rule. However, "many agencies have not been in compliance with the documentation practices and qualified therapist oversight we would expect," the agency acknowledges in the rule.

With the new requirements in place, CMS will expect much stronger therapy documentation. The agency will "require that measurable treatment goals be described in the plan of care and that the patient's clinical record would demonstrate that the method used to assess a patient's function would include objective measurement and successive comparison of measurements," CMS says in the rule. That, in turn, will enable "objective measurement of progress toward goals and/or therapy effectiveness."

Therapists should consider three important points when documenting, Vance tells Eli.

1. The functional part: "Goals have to satisfy the question, 'so what?'" she says. You can't just list measurements, you have to say how the patient is using them.
2. The objective part: Make sure "the same words used by different people paint the same picture of the patient," Vance says.
3. And the measurable part: Ask yourself, "Can we count the progress toward the goals?"

"Therapists will need to integrate more evidence-based tools in evaluating their patients for specific conditions such as balance, perceived exertion, endurance, etc.," Adams counsels. They should use evidence-based tools "both at the time of the initial assessment and periodically through care to show improvements."

• Hold therapists accountable. Often home care providers have let therapists slide with poor documentation, late paperwork, and overuse of therapy assistants, experts say, particularly in areas with therapist shortages. Now is the time for that to stop.

"Supervisors and quality improvement staff will have to pay more attention to the therapy documentation," Adams says. And they'll have to "hold the therapists accountable for documenting specific evidence-based testings."

Plus: Therapists will have to justify the services and the need for continuing therapy, especially at the higher thresholds, Adams adds.

 "Medicare is asking us to prove our worth," Vance says. "It shouldn't take any longer to document this if we were doing it all along as originally asked."

• Launch major education effort. "There will need to be a lot of education for the therapists about evidence-based tools and tests, and revised standards for documentation," Adams points out.

But your education shouldn't be limited to therapists. "Agencies will also have to educate their QI or supervisory staff in what to look for in the therapy records and what type of follow up when the home health clinical record does not meet the new requirements," Adams notes.