Hello,
My name is Angela and I am a student at Concordia who is entered into a debate with my fellow OT classmates. The topic is "should OT's be allowed to open cases in home health under Medicare part A"?
Do you think this should have been included in the new health reform bill?? ...or are you happy this doesn't pass for a certain reason?
Please let us know your opinion! It will greatly enhance our debate :) Include reasoning why you are for or against.
Thank you very much!
Hi Angela!
The real statement behind your question is that OT should indeed be considered a QUALIFYING service in home health. This would enable us to not only "open" but also be a stand-alone service (meaning that the person could get OT -only under their home health benefit).
You can look through the SIS forurm archives to find more support for this argument but in short, we have been working towards this goal for over a decade. The reason we cannot get it passed and supported is because the government "sees" this as a cost increase for Medicare (because now you open the door to pay for "OT only cases" under the home health benefit). Check out some of the wonderful archived stuff our legislative affairs dept has put out on this topic in the past but, basically, congress operates on a "zero net increase" system (meaning if you approve something that costs money in one place, you better figure out a way to cut that same amount of anticipated cost out somewhere else).
Because we have failed repeatedly due to the above reason, AOTA and OT has taken a different tactic...a baby step towards this goal with the bill to allow us to "open" in those rehab only circumstances where OT along with PT and/or ST is already ordered prior tot he case opening. ( I may be off on the bill a bit...check Carol Siebert's stuff...its the most accurate and brilliant :)
As for can/should we open? I think we are possibly the BEST suited to open a case in home health, given our natural knowledge of so many things critical to the OASIS and the areas of outcome being examined.
Hope this helps some. I can't see you losing the argument if you do your homework!
Pam Toto, MS, OTR/L, BCG, FAOTA
I work in HH and I say "no". I don't think most OT's are well enough trained, especially in medications, to be responsible for often complex HH cases. I am quite happy NOT being able to open HH case.
Also, OT currently is able to stand alone. I have personally done several d/c oasis'.
Ron Carson MHS, OT
Hi Angela,
Great question. As a director of an outpatient and home health agency, my answer is yes. Occupational Therapy being a initiaitng service would have improved access to clients in need, decreased delays in service for therapy, and made the system more efficient. We are a natural fit into the home health setting and can often capture a more accurate picture of a clients needs in completion of the OASIS and better demonstrate outcomes in the D/C OASIS due to our big picture thinking.
As Pam already indicated, the challenge in the past has been with the Congressional Budget Office's score of us becoming a qualifying service and the estimation this would lead to an increased cost for the system. I believe AOTA's efforts to pursue the initiating service option was a brilliant way to address this issue and hope we continue to advocate for it. Home health is a growing service line and holds alot of growth potential for occupational therapy as we work to help people age in place.
Amy
Angela
I also agree with Pam & Amy for the same reasons they have stated. There have been many instances when the admitting nurse has asked me questions regarding the patient's safety and ADL status, especially on recert. I too have completed a few DC OASIS forms, they are time consuming but I believe that I am able to complete them and use my available resources if needed to clarify questions.
Good luck on your debate.
Nancy
Pam pointed out the distinction between the need for OT qualifying a person for the Medicare part A home health benefit and the role of OT to conduct the start of care assessment for a Medicare part A patient. Prior to 1999, OTs could conduct the start of care assessment (admission), even for a Medicare part A patient.. However, when the rules for Medicare certified home health agencies were updated in 1999 to mandate inclusion of OASIS and a drug regimen review, there were provisions included about who could conduct start of care assessments. That rule says that if nursing is ordered, nursing MUST conduct the start of care assessment, including OASIS. But if only therapy services are ordered (no nursing), then a therapist MAY conduct the assessment if that therapy service establishes eligibility for home health according to the payer.
So OTs can already conduct the start of care assessment for many non-Medicare part A patients, and HR1094 would partilally restore the situation that existed prior to 1999, allowing the agency to determine which therapy discipline (including OT) is most appropriate to conduct the start of care asssessment for patients who do not have nursing ordered.
Obviously, I support the proposed change. It was included in the House healthcare reform bill, but unfortunately the final version was based on the Senate language. What is proposed has no cost, has the support of both the National Home Care Association and the APTA, and it gives agencies more control of how to use their resources. The AOTA Board of Directors has made this issue a strategic priority. What's missing? You hinted about this in your post--what's missing is willingness of OTs--especially OTs in home health--to step forward, support the legislation and step up in their agencies and deliver as equal partners with our PT and SLP colleagues. We seem to be more willing to cast ourselves as "victims" of the qualifying service rule. We need to be change agents who can help agencies conduct more accurate patient assessments to inform more appropriate and effective care plans to produce outcomes that matter to patients, to agencies and to payers. If we're willing to be second class citizens, we're going to wake up one day and discover there is no longer a place for us in the home health industry. We need to get the legislation passed, but it's just as important for home health OTs to be willing and ready to deliver as an initiating service.
Carol Siebert, MS, OTR/L, FAOTAPrincipal, The Home Remedy, Chapel Hill, NCChairperson, AOTA Affilated State Association Presidents
Honestly, I do NOT think that OT should open HH episodes of care, at least based on my limited experiences. Personally, I do not have the training, expertise or professional name recognition to be an effective "case manager" for a HH episode of care.
Contrary to your implications, I do NOT think OT is less valued because we are not a qualifying discipline. We are less valued because our practice pattern of focusing treatment on the UE. Thus, even if congress does authorize OT to become a qualifying discipline, there will be little positive impact on HH therapists.
I think that HH occupational therapy helps break that pattern of focus on the upper extremity. The context of home allows opportunity for true occupation based practice in many ways. A therapist can select interventions that are meaningful and appropriate for the patient and its up to us to break away from the focus on the upper extremity. If we as a profession want to do that, we can and we can document the functional benefits from completing more functional activity.
I actually think that occupational therapists are well suited to be case managers because of the perspective we bring to the table. Some home health settings, such as mine, has RN case managers for all cases including therapy only.
Amy, HH should break the pattern of focused UE OT, but in my experience, it doesn't. Read some of my stories and it's painfully clear that in my "neck of the woods", UE OT remains as the predominate and PREFERRED practice pattern. Unfortunately, it seems that ALL disciplines (RN, PT, MSW, etc) also see OT as primarily focused on treating the UE.
HI Ron,
I am not sure if you understand the ramifications of the information gathered on the Oasis and it's impact on not only the provision of OT for the patient, but the reimbursement of the services provided. In order to advance my training in the understanding of the use of and purpose of the Oasis, I have just completed training through the Oasis Certificate and Competency Board, which I suggest to any therapist working in HH. Here is a link: http://www.oasiscertificate.org/main/
Do you want to rely on a PT/SLP/RN answering the questions related to I/ADL/pain that can impact your ability as a therapist to provide services to the patient. The more we rely on other disciplines to determine our service provision, the more OT will be left out of the services provided for that patient. Especially PT which continues to encroach on OT.
You are right, OT can stand alone ONCE they have been providing services AFTER PT, SN or SLP have opened and been providing services then OT can finish out the services and do the Oasis DC. However, even if a pt needs OT and the PT/SLP/RN attempt to open the case but the pt does not qualify for their service, the pt cannot receive OT.
I am not "quite happy" to stand on the sidelines, I would rather increase my education and stand next to PT/SLP/SN instead of behind them waiting for them to allow my services.
I fully understand the ramifications of not opening an episode of care. But, I don't think it's the most significant problem facing OT's in home health. The problem I see is that OT is NOT recognized as being the EXPERTS in improving patient's ability to care for themselves. Almost every single home health patient has some degree of self-care difficulty, Yet, why is it that only a small percentage of patient's receive OT? Right now, my agency has 3x the number of PT's as OT's. Why is that?
The problem is not that we don't open episodes of care, it's that we spend entirely too much time, energy and effort in working on people's UE! Until this changes, OT's will never be a dominant force in home health. PT's encroach on OT BECAUSE WE INSIST ON BEING UE THERAPISTS! You make an interesting point about other services needing to be provided before OT. I can't imagine a PT opening a case without seeing a patient and in 2.5 years, there's never been an SLP open a case, that I'm aware of. So, I think your point may be accurate but not very realistic. As you say, you had to attend a course to advance your training. The average OT is not well trained in the various issues of the complex process of opening home health. I agree with you about not standing behind other professions and readily admit this is a significant problem for OT. But, I just don't see opening episodes of care as being a significant advancement in resolving this issue. If Medicare suddenly said OT could do a SOC's, there wouldn't be a significant change in OT utilization nor recognition of our value and worth. Rather than advocating for OT doing SOC's., I choose to advocate for OT to stop focusing treatment on patient's UE and to start focusing treatment on improving occupation, (i.e. self-care and productivity). When and if this occurs, then I see great value in opening home health episodes. Out of curiosity, do you know why OT's are the only disciple not able to do SOC's? Thanks, Ron Carson MHS, OT
There are some significant changes down the pike for home health services and the implementation as noted in the federal register have been delayed until April to help agencies make changes. Specifically in the area of payment, documentation, and that an OT, PT, not an assistant need to make a visit with the client at certain milestone visits. Thanks to AOTA and others, a PT will not be assessing an OT client for these visits. These are important issues to be aware of in your agency. If OT do not remain competent and step up to the plate to do any type of OASIS assessment, we are not as versatile, and instead of becoming a necessity we become a profession easy to not refer to or to cut in order to decrease expenses and increase profit margins for HHA. HHA and their Rehab services are still on the radar as MedPac reports that HHA are still beefing up visits to feed the cash cow and not necessarily basing decisions on clinical needs of the clients. Because of these reasons, it would be in the best interest of our profession to be recognized as an authorized clinician to perform OASIS initial assessments. I think your point Ron on OTs doing UE therex is way outdated. Even suggesting that OT need to help folks improve occupation is almost outdated. Activating clients and motivating clients to take charge of their healthcare/chronic conditions is where it is at now. If you and other OTs don’t communicate your treatment approaches and the outcomes you have with your clients to your agency, and do not remain competent to do all types of OASIS, then the change in utilization of OT will decrease because HHA are a business and all business have to keep budgets. The trends in healthcare are moving more toward how we activate clients and their caregivers to take charge of their own chronic conditions and ADL as a method to reduce hospital readmissions. There is much that can be done on behalf of HHA to reduce their role in being the “senders” of their clients back to the hospital. OT can step up to the plate and advocate for their role in working with clients and completing OASIS documentation properly and accurately. OT in their HHA can help clients ID their daily habits/routines and those of their caregivers to help them manage medication routines more safely, assess and change environmental factors that may influence falls or keep clients from following best practice for monitoring weights/BP to better manage CHF for example. OT can help clients personalize tools specific to their learning style on how to monitor signs and symptoms to better manage chronic conditions and call their primary MD ahead of time, and look at their clients community participation or in home activities to eliminate barriers risk factors associated with falls and social isolation. OT can also help clients set up emergency self-management plans for living at home independently and safely. This is a perfect time for OT – helping clients ID what is meaningful in their ADL, grading the ADL so the clients’ goal is achievable, and teaching clients how to measure their own progress and take charge are what OTs need to work on with clients and document properly. Helping clients increase their independence through environmental adaptations and technology, training caregivers to “coach their loved ones to do as much as possible”, and connecting clients with community resources to make larger home remodeling changes that promote safety and independence for the long term are some of the things OTs can offer their clients in the home or in private practice for those who do not qualify for in home services. Jennifer DeRosa, BS, OTR/L, CAPS 1425 Broadway #461 Seattle, WA 98122-3854 P-206-403-0190 F-206-420-4462 www.adaptableforlife.com
These are important issues to be aware of in your agency. If OT do not remain competent and step up to the plate to do any type of OASIS assessment, we are not as versatile, and instead of becoming a necessity we become a profession easy to not refer to or to cut in order to decrease expenses and increase profit margins for HHA.
HHA and their Rehab services are still on the radar as MedPac reports that HHA are still beefing up visits to feed the cash cow and not necessarily basing decisions on clinical needs of the clients.
Because of these reasons, it would be in the best interest of our profession to be recognized as an authorized clinician to perform OASIS initial assessments.
I think your point Ron on OTs doing UE therex is way outdated. Even suggesting that OT need to help folks improve occupation is almost outdated. Activating clients and motivating clients to take charge of their healthcare/chronic conditions is where it is at now. If you and other OTs don’t communicate your treatment approaches and the outcomes you have with your clients to your agency, and do not remain competent to do all types of OASIS, then the change in utilization of OT will decrease because HHA are a business and all business have to keep budgets.
The trends in healthcare are moving more toward how we activate clients and their caregivers to take charge of their own chronic conditions and ADL as a method to reduce hospital readmissions.
There is much that can be done on behalf of HHA to reduce their role in being the “senders” of their clients back to the hospital.
OT can step up to the plate and advocate for their role in working with clients and completing OASIS documentation properly and accurately. OT in their HHA can help clients ID their daily habits/routines and those of their caregivers to help them manage medication routines more safely, assess and change environmental factors that may influence falls or keep clients from following best practice for monitoring weights/BP to better manage CHF for example. OT can help clients personalize tools specific to their learning style on how to monitor signs and symptoms to better manage chronic conditions and call their primary MD ahead of time, and look at their clients community participation or in home activities to eliminate barriers risk factors associated with falls and social isolation. OT can also help clients set up emergency self-management plans for living at home independently and safely.
This is a perfect time for OT – helping clients ID what is meaningful in their ADL, grading the ADL so the clients’ goal is achievable, and teaching clients how to measure their own progress and take charge are what OTs need to work on with clients and document properly. Helping clients increase their independence through environmental adaptations and technology, training caregivers to “coach their loved ones to do as much as possible”, and connecting clients with community resources to make larger home remodeling changes that promote safety and independence for the long term are some of the things OTs can offer their clients in the home or in private practice for those who do not qualify for in home services.
Jennifer DeRosa, BS, OTR/L, CAPS
1425 Broadway #461 Seattle, WA 98122-3854 P-206-403-0190 F-206-420-4462 www.adaptableforlife.com
Jennifer,
Thank you for your post and sharing your comments. I am ramping up on my knowledge on the implications of health care reform implementation to lead an ad hoc committee for AOTA.
Earlier this week I attended a 2 day conference put on by "America's Health Insurance Plans." I think your comments about focusing on chronic care management, symptom management and putting OT in the picture as part of the primary care team in the home is right on target.
The health arena is going to change very, very quickly in the next couple of years. We need to keep our eye on these trends and respond and I believe that we are very well positioned to take advantage of what I see coming down the path.
Students being educated today (larger groups than ever before) are looking forward.......and we need to set our sights there as well.
Brent Braveman
Brent Braveman, PhD., OTR/L, FAOTA
Opening OASIS will not significantly change our perceived value. SLP's can open cases and how often are they utilized? The problem with OT in home health is that we have very little perceived expertise and that expertise revolves around the UE. I've read on this forum where on d/c planner said "PT can do it all". And I believe that's a very common belief in the health care system. Again, OT being an opening service will not change that perception. I fail to see how improving occupation is outdated. Occupation is about empowering people to take care of themselves. I'm not sure what you consider occupation. I'm a big believer in patient-directed care. Patient's tell me their "problems" and I help solve them. But, that approach doesn't always go over well in home health, which is driven by nurses who generally tell people what wrong with them.
On the contrary, the fact that OT has not been a qualifying discipline for the last 45 years has indeed affected our perceived value. We can sit around and argue our internal issues of occupation, but until we are ready to step up and loudly connect ourselves to what is important to our agencies, our employers, it is a moot point to salvaging an incredibly wonderful setting in which we practice.
I have the honor of working with home health agencies across the nation as a home care consultant, and I can tell you, directors are prepared to replace an open OT position with a PT simply because they can "open" cases more that OT. Are you prepared to sacrifice your job so you can practice in isolation, or will you engage with your agency to frame your practice in a way that is meaningful to your emplyer as a stakeholder?
That was the whole reason for going with the "initiating service" rather than pushing for a qualifying service as we have done for well more than 10 years. AOTA has the wisdom on the Hill for knowing politics as well as practice. If we have been unsuccessful for all of these years (all of which I have been present for), then taking a different tack to get a "toe-hold" for altering perceptions is a wise approach.
BTW, the reason OT was not a qualifying discipline in the first place has everything to do with the fact that when Medicare was writing the Conditions of Participation in 1965, they were looking for existing accrediting bodies. At that time, we were not licensed. We have been fighting that battle ever since. We were not organized enough at the time to meet the criteria. Are we going to continue debate this issue utnil we no longer have jobs in this wonderful arena, or get organized (finally) and get this passed?
I say the survival of the profession in an existing practice arena far surpasses any one person's opinion of whether or not he personally wants to step to the plate and do what he needs to do to become competent in a skill required of the setting.
Karen Vance