Krista: Thank you for the introduction. There is a lot of information in this course so sometimes it might feel like we are going a little bit fast, but feel free to always refer back to these handouts. We just wanted to get as much information out there as we could to help people navigate in the home health setting. There are also great tips if you have never worked in home care, if you have worked in home care for a long time, or if you need some clarity around some information.
What is Home Health?
To begin, what is home health?
According to Wikipedia:
Home care is supportive care in the home. Care may be provided by licensed professionals who provide medical treatment needs or by professional caregivers who provide daily assistance to ensure the activities of daily living (ADLs) are met. In-home medical care is often and more accurately referred to as home health care or formal care. Often, the term home health care is used to distinguish it from non-medical care, custodial care, or private-duty care which refers to assistance and services provided by persons who are not nurses, doctors, or other licensed medical personnel.
According to Medicare.gov, home health care is a wide range of health care services that can be given in the home for a person experiencing an illness or injury. Home health care is usually less expensive, more convenient, and just as effective as care in a hospital or skilled nursing facility (SNF).
There are a lot of things that can fall under the home health umbrella. The definition, according to Wikipedia, is as simple as you can get. As it says here, the term home health care is often used to distinguish it from non-medical care, and that is exactly what we will be talking about today. Jumping down to that second paragraph, according to Medicare.gov, home health care is a wide range of health care services that can be given in the home for a person experiencing an illness or injury. It is important to understand that Medicare, who is a large payer for home health care services, is releasing this as a great alternative to some of the inpatient options for patients.
What is a stakeholder?
- A person with an interest or concern in something, especially a business.
- Denoting a type of organization or system in which all the members or participants are seen as having an interest in its success.
- Who are the stakeholders in home health?
- The Public and Regulators
A stakeholder is a person that has an interest or concern in something, especially a business. We will be talking about stakeholders in relation to home health. The stakeholders in home health will include the clients and caregivers, the agency, the public and the regulators, and the payers. It is important that, as an occupational therapist working in the home health world, you understand who has what role as different stakeholders. Sometimes I think we get really caught up in thinking about just the client and caregiver, the agency stake, or even our own. And, it is important to understand that there are many players sitting at the table, and we have to work with each one. I will now run through these stakeholders to give you a good understanding of who is all at the table.
Clients and Caregivers
- Clients and caregivers have a stake in the home health process because their health and well-being is affected. They expect care and services that will enhance their quality of life.
- Because Medicare is the largest provider for HH services in the US, beneficiaries are typically over 65 or permanently disabled and unable to work.
- In 2013, 30% of clients receiving HH were 85 and older, 32% were between 75-84, 24% were between 65-74 and only 14% were under 65.
- OT’s working in HH can expect a majority of their clients to be older adults.
- Data compilation allows us to know what the majority of HH clients may be dealing with medically. OT’s will receive information on the client’s primary diagnosis before the evaluation. The primary diagnosis best describes why home health services are medically required and are typically the most acute issue for a client at the time of referral.
This is a really obvious one to most of us. I want to talk a little bit about the clients that you probably will see in home health care, especially for those of you that might be new to home health and need a good background to understand who the clients are that you might be seeing. Medicare is the largest provider of home health services in the United States. Thus, beneficiaries are typically going to be over 65 or permanently disabled and unable to work. In 2013, 30% of clients, receiving home health, were 85 years old or older, 32% were between 75 and 84, 24% were between 65 and 74, and only 14% were under 65. There are going to be some home care OTs working with folks under 65 or in a pediatric setting. But for this purpose, we will be referring to older adults and their caregivers, but I feel like a lot of these skills can be transferred over to the pediatric population as well. So if you are thinking, "This does not fit the clients that I see," do not worry as I think you will find some useful tools here.
As an occupational therapist, you should always get, from your agency, a primary diagnosis before you go out and do the evaluation. It will describe why your home health services are medically required, which is a key part of home care. It is typically related to the most acute issue for the client. However, they may have lots of other things going on as seasoned OTs will definitely understand. Figure 1 some pictures of different folks in different settings that will help you understand the clientele for home health clients.
Figure 1. Examples of home health clients.
In the top left, we have this client who is 100 years old living in an assisted living facility. Home care OTs can go to assisted living and independent living facilities. The middle picture shows a gentleman that is in a secured care unit because of dementia and risks for wandering. And then in the far right, this client lives in a home with his wife. The one setting that OTs are not going to be going to for home health care is skilled nursing.
In 2013, the primary diagnoses of Medicare beneficiaries that were the most prevalent were diabetes, heart failure, hypertension, chronic ulcer of the skin, osteoarthrosis and allied disorders, and cardiac dysrhythmias. These 6 diagnoses totaled 34.9% of the primary diagnoses in HH.
- However, HH clients typically experience more than one health diagnosis.
- Approximately 50% of clients enrolled in home health care were in an acute setting prior
- 1 in 4 clients receiving home health care services is hospitalized during their care.
We do have to understand that while they have that primary diagnosis, they are likely going to have lots of other health diagnoses. Half of the clients enrolled in home care have been in an acute setting before whether it is a hospital, skilled nursing facility, or rehab. And 1 in 4 clients receiving home health care services is hospitalized during their care. That is 25% of clients going back to the hospital. We are all privy to the new movement where we want to avoid rehospitalizations as much as possible, and home health care is really being looked at as an avenue to help people stay out of the hospital.
How Does OT Relate to This Stakeholder?
When we talk about the stakeholders, we want to relate that right back to occupational therapy to keep it relevant to everybody that is listening. This is obvious, but when we are working with clients to improve their quality of life, we need to facilitate engagement in meaningful occupations, improve safety, not only for the clients but also the caregivers, and provide support and guidance to the caregivers and to the clients. If you have a spouse, a daughter, or a paid caregiver, it is important that you are working with them so that they can help the clients manage their chronic issues. We will talk more about that as we go along.
The second stakeholder we will talk about are the agencies. They have a stake in home health because they are in business and need to follow the rules and regulations and provide interventions that are acceptable and beneficial to the clients. Agencies will hire occupational therapists to work full time, part-time, or on a per-diem basis. You can also be a contract occupational therapist. I have done that for many years with home health agencies.
How Does OT Relate to This Stakeholder?
Agencies do expect that OTs and other members of the health care team follow regulations and the policies and procedures that they have in place. Occupational therapists should always advocate for their role in the home health team to protect the hiring of occupational therapists. The reason I brought that up is that the regulations actually do not require that agencies have an occupational therapist on staff, but they do have regulations that require nursing, physical therapy, and speech therapy. Thus, OTs can get left out. We have to continue to advocate for our important role in home care.
Some of the bullet points that are listed here are great talking points for your management team if they do not have a value for occupational therapy or understand all of the different things an OT can provide.
OT’s can provide:
- Occupational profiles and performance assessments
- Activity analysis
- Can improve data accuracy
- Can improve outcome measures
- Specialists in occupations like ADL’s, IADL’s, rest and sleep, leisure, work, play, socialization, etc.
We are obviously the experts in the occupational profile development and performance assessments that are very key in a home health setting. We are also the activity analysis gurus. We can look at things when people are in their natural context and pick it apart to make things better. We can help our agencies improve data accuracy and improve their outcome measures. Your supervisors and managers will probably be very interested at those two bullets. We also specialize in occupations like ADLs, IADLs, rest and sleep, leisure, work, play, socialization, et cetera. If you are ever feeling like occupational therapy is not being valued the way that it should in your setting, make sure that you talk to your managers and supervisors about these points.
Coming back to how we relate to this as a stakeholder, we have a similar stake that the agencies do. They expect the clients to understand the regulations. And if you are having a hard time understanding the regulations or you are not clear, make sure that your agencies have policies and procedures in place that you know how to follow. And if they are not there, make sure that you ask the questions so those policies and procedures can be developed. It is hard when we are talking about a home health webinar because the rules and regulations we can talk about in one regard on a more national scale, but it is very important that your agency is giving you information based on your state. Sometimes, I will be a little bit vague when it comes to rules and regulations, but it should give you talking points to be able to take back to your supervisors.
Public and Regulators
The third stakeholder is the public and the regulators. The reason that this is a stake is that public monies are used for Medicare and Medicaid that are being spent on home health practices. They have a stake in understanding where the monies are going. They have regulators that work to oversee those funds, and regulators will also come in and not only see that the public money is being spent correctly but also to ensure that quality and appropriate services are being provided and that those things are in place to protect the public at large. When you have somebody like a surveyor come out and need to shadow you while you are doing home care, remember that they are looking at rules and regulations that are there to protect your clients.
How Does OT Relate to This Stakeholder?
We are expected to understand and adhere to the rules and regulations as a minimum requirement for reimbursement and for the good of the public. All professionals are expected to participate in a survey which is a process provided by those regulators again ensure that we are following the rules and regulations and that we have a good understanding of them.
The last stakeholder we will talk about are the payers. This is a little bit different. We have our regulators that are looking at the quality provisions of what we are doing. Then, there are additional regulators or different people that are coming out making sure that we are spending the money correctly. The payers are writing the check for our services, and they want to make sure that we are providing the most cost-effective options with expected good clinical outcomes. If you are doing things that are not going to maximize the patient's potential, then your third-party payers are going to look at that and say, "What can you be doing differently?" We need to make sure that we are considering that when we are providing care. The way that we relate to this stakeholder can be in a positive or a negative way. If an agency does not follow the regulations of a payer, that agency can be in jeopardy for payment from the payer and that can impact our employment and the sustainability of the agency. I have worked with a handful of agencies that have ended up not being able to stay open because they did not follow the rules and regulations correctly.
How Does OT Relate to This Stakeholder?
OT professionals must be accountable for the knowledge of the rules and regulations of the payers. I keep saying this, but it is on us. We cannot always just defer to the agencies, we have to make sure that we have a good understanding of those rules and regulations and that the agencies that we work for are spending the money correctly and taking good care of our clients. There is not a lot out there in regards to occupational therapy in the home setting so it is important that your documentation provides a good rationale for your treatment interventions. I encourage all of you to consider doing some research within your agency based on your clinical outcomes and what OTs can do. You can always get in touch on a bigger scale too and talk to different universities or study groups about how to gather information about the importance of OT's involvement in home health care. Enhancing that research development will also support third-party payment.