meeting criteria for home health
03/02/21 16:16 Filed in: Frequency of home health care
One of the more perplexing aspects of skilled home health care is how to set the frequency for your start of care patient today. There are multiple factors to consider and implement. But the fact is there is not simple formula for figuring it out. The most important point is to ensure the patient meets all of the criteria for home health care including a skilled need (or medical necessity), a physician (or NP or PA) willing to oversee the plan of care and sign all necessary orders, and the patient must be homebound for the duration of the care. The patient has to show continued measurable gains throughout the duration of care in order to continue to qualify for home health care.
Clinical Pathways for major Illness
Many agencies have developed their own or use standardized clinical pathways for major illnesses such as heart disease, respiratory illnesses, diabetes or kidney disease. Check with your agency for information. These will include specific guidelines for teaching and frequencies designed to align with the PDGM reimbursement rules.
Task-oriented skilled need
If the patient meets all of the criteria, then you have to consider the skilled need. What is the primary reason for the home health care? If it’s not a clear-cut task-oriented skill then it’s a little more challenging to figure out a frequency. The things we do know is that there must be a skilled need for a second visit for the first one to be reimbursed.
With experience, it will become obvious that patients usually put on their best impression of themselves at the first visit. You’re an invited guest in their home and they want to be a great host. Sometimes they’ll try to postpone the start of care if they’re not up to it. You’ll need to assure them that your purpose is the assess their situation and help them and you don’t need to be entertained. The second visit usually reveals more because the patient is more receptive and less inclined to feel the need to be the good host. So, a second visit is recommended to be 1-2 days after the SOC. This allows the nurse to make a more realistic frequency and adjust what was ordered after the first visit.
Adding on PRN visits
If the care is being task driven such as by wound care, new diabetic teaching, or IV infusion and/or line care, then the frequency of the visits will need to meet with the standards of care practices. The object of skilled home health care is to teach and then discharge (teach and get out). In these cases, you’ll front load the visits with a frequency of daily visits for up to a week and then decrease to three times in one week and then 2 visits and then 1. If your agency allows, you can include 1-2 PRN visits which need to be specific such as for soiled dressings or the dressing falling off; troubleshooting IV lines or pumps; unexpected hypo or hyperglycemia requiring interventions. You can always get an order for more visits. (And you’ll need one for any missed visits.)
If the care isn’t strongly task oriented such as patient education about a disease process including medication teaching or teaching a family member to fill a med box, teaching symptoms of CHF and how to manage a low sodium diet, understanding the role of the medications and monitoring weight this likely wouldn’t support daily visits but 3 times for one week and then 2 times and then reevaluate. You can always work with the PCP and adjust the frequency with strong documentation.
Thursday or Friday SOC exceptions
The difficult situation is when the SOC is on a Thurs or Friday. It’s important to get the first 2 visit in as close together as possible. Medicare frowns on a frequency of 1 wk 1, 3 wk 1, 2 wk 1. Why was only 1 visit needed in the first week and then 3 the next? It needs to be obvious and well documented why this happened and should be avoided if at all possible. Weekend visits should be reserved for daily care needs and new SOCs. Thursday SOC is better because you can see again Friday and then Monday the following week.
Continuity of staff also helps create a better plan and flow whenever possible. True case management helps provide for continuity and reduces the need to reinvent the wheel each visit. You will also need to allow for other disciplines such as therapies, home health aides, and social workers to slide into place after your SOC and the patient can become overwhelmed with too many visitors. Communication with the other disciplines is important and building a schedule that works for the patient is important. A calendar in the home helps keep things on track.
If the patient has insurance that requires prior authorization this can be even trickier. Another thing you’ll have to work around is MD visits. The nurse cannot go on the same day the patient sees the PCP. This is considered a duplication of services. The aide, therapist or MSW can however go that day if the patient allows it. (If there is an aide going, the RN has to supervise the HHA every 14 calendar days, so that has to be factored in to scheduling the visits and decreases the flexibility.)
Let’s review the main points:
- • There is no set rules or formula – the frequency should meet the unique needs of the individual patient
- • Make SOC visit and schedule the second visit within 1-3 days then…
- • Front-load visits and taper off as patient or caregiver learn the care
- • Pad with 1-2 specific PRN visits – or get an additional order to cover unexpected needs
- • Task- oriented care usually dictates the frequency, or do you use clinical pathways?
- • Patient education-oriented visits will be less frequent and end sooner
- • If insurance authorization is needed, the frequency will be leaner and shorter
- • Documentation must support the frequency with skilled need performed, homebound status, and measurable gains
For further reading refer to the HIM 11 for specific rules.