OASIS Alert

Clinicians often forget to ask one key question.

If your therapists are making clinical decisions as if one size fits all, expect denials when medical reviewers start looking at your therapy visits.

The HHS Office of Inspector General put reviewing episodes with a M0825 high-therapy use as a central home health agency focus in its 2007 Work Plan (see Eli's OASIS Alert, Vol. 7, No. 10, p. 98). But that doesn't mean you should cut your therapy visits, said Cindy Krafft, physical therapist and director of rehabilitation for Peoria, IL-based OSF Home Care, in her Aug. 10 teleconference on clinical decision making, sponsored by Eli Research. Instead, focus on what is clinically appropriate for each patient, she instructed.

Hidden trap: Many therapists base decisions about visit frequency and duration on their experiences before coming to the home care setting, Krafft says. So a therapist used to working in a hospital or rehab facility may now be working with patients much further along in their recovery.

But these patients still need therapy, Krafft stresses. To individualize patient care plans, encourage therapists to picture home care patients in a different way. When choosing goals with patients, remember to compare them to people of the same age in the community or to what they were doing before this illness. Then decide what goals might be attainable, she says.

Bulletproof Your Plan of Care

Problem: One of the most common problems with therapy plans of care is therapists' tendency to base the frequency and duration of visits on habitual patterns of care or non-clinical constraints -- such as geography or their relationships with other team members, Krafft reports.

But for your plan of care to stand up to medical review, you must base it on the individual patient's needs and goal. Use these four steps to individualize your plan of care:

1. Start with a high-quality assessment. To support your decisions, you need to know what the patient could do before, what he can do now, and what he needs to be able to do going forward, Krafft says. Be sure to document what you assess.

2. Decide how far the patient can go. You must have specific and attainable goals, Krafft says, but you also must ask the key question: "How much therapy is the patient willing to have?" The answer may be little to none. This is a crucial factor in determining the results of your efforts.

3. Look at the 60-day episode. Don't be in a hurry to discharge a patient. In home health, you don't necessarily need to be in and out in a week or two. Instead, you can plan the therapy to work with the patient's recovery rate. You can even plan a visit after a break to evaluate the patient's success in following the exercises or to move to the next level when the patient is ready, Krafft suggests.

4. Understand homebound status. A patient must be homebound to qualify for the home health benefit, but that doesn't mean he never leaves the house. Just because he can get to a doctor's appointment doesn't require you to transfer him to outpatient therapy, for example. If it takes a great deal of preparation and assistance to get him to an appointment, he can still qualify as homebound. Therapy provided at home is "real therapy" and often can address real-life issues better in the setting the patient contends with every day, Krafft says. 

Note: For much more on clinical decision making order a tape, CD or transcript of Krafft's teleconference "One Size Does Not Fit All -- Clinical Decision Making" at http://nginstitute.com/conference/tapes.cgi or call (800) 508-2583.