By Robert Hall, MD, Chief Medical Officer, Optum Workers’ Comp and Auto No-fault Solutions
Home health services are an important bridge between an acute injury (or medical condition) requiring continued medical treatment and/or functional assistance and the time when the patient’s care needs can be met either independently or by family members in the home environment. In order for home health services to provide focused and medically necessary care, a treatment plan that is periodically reviewed and revised by the treating prescriber must be in place and followed. The treatment plan should list the medical problems and functional barriers limiting the patient from receiving care on an outpatient basis, such as physical therapy or wound care management. Barrier-specific goals and interventions directed toward reaching those goals should also be noted. Progress notes should reflect either the advancement toward achieving the stated goals or explain why the goals are not being reached with proposed changes to the treatment plan. Using treatment guidelines, the level and duration of service should be commensurate with the current medical needs and functional limitations of the patient. Regarding the current level and types of services being provided in the home, the following questions should be considered:
1. Is the patient confined to the home or does leaving the home require considerable and taxing effort?
Home health care services are typically considered reasonable and medically necessary only if the patient’s medical condition or functional deficits limit the safe entry into and exit out of the home and transportation to/from a health care provider’s place of service. For instance, a tetraplegic patient who is ventilator-dependent may not have the ability to be safely and routinely transported to their physical therapy appointments. Similarly, a patient with severe cardiopulmonary disease may have shortness of breath with ambulating even the smallest of distances outside their home.
2. Is there a detailed treatment plan in place with stated goals?
A signed medical treatment plan is essential in communicating the patient’s medical condition, expected treatment course, and precautions. This treatment plan should also be routinely reviewed and updated by the prescriber to reflect the patient’s progress or potential setbacks. For example, a patient who has had a total knee replacement may be instructed to have limited weight-bearing on the affected limb for a matter of days and gradually progress to weight-bearing, as tolerated. In the meantime, knee range of motion exercises would be noted in the treatment plan with instructions on how and when to advance the range of motion toward the expected goals. Wound care instructions for the surgical site would also be included.
3. Is the service provider reputable and responsive to complaints and concerns?
Services being provided to the patient within his/her home should be provided by health care professionals with high moral and ethical standards. Within the home health setting, patients should be able to rest comfortably in knowing the providers entering their home each day have been carefully vetted, well-managed and are accountable to high standards of quality.
4. Are the services provided related to the compensable condition?
As with the delivery of any managed medical care, whether a workers’ compensation or auto injury, the compensability determination should be a part of the initial evaluation. For instance, a patient with chronic rotator cuff injuries sustaining a fractured ankle may require physical therapy in the home to help regain ankle stability and leg strength. However, occupational therapy for the chronic shoulder condition would most likely be unrelated to the compensable ankle injury.
5. Is the level of service appropriate?
This question is one of the most common and important questions of all when looking at home health services being requested or provided. In general, the right amount of home health service in the home is dependent upon the medical complexity and physical limitations of the patient. In other words, the need for more than one health care provider in the home at the same time should be justified by a concurrent need of assistance from both of them. For instance, a morbidly obese patient who is unable to reposition in bed may need assistance from two providers to help the patient get in/out of bed or to get dressed. However, the use of medical devices such as lift systems and hospital beds can significantly reduce the need to have two health care providers in the home at the same time.
6. Is a registered nurse (RN) providing in-home nursing services when a licensed practical nurse (LPN) would be able to administer the same level of care?
The scope of practice, which is usually determined at the state level, varies between RNs and LPNs. While RNs usually have expanded job duties when compared to LPNs, such as the ability to take phone or verbal orders from the treating prescriber and starting intravenous catheters, they may share many of the same roles when it comes to checking vital signs, assisting with patient care needs, wound dressing changes and medication administration. However, the cost associated with an LPN providing care is usually significantly less when compared to the cost associated with care delivered by an RN.
7. Are RN or LPN services being provided when a home health aide would be appropriate?
Measuring patient vital signs, changing uncomplicated wound dressings, performing range of motion exercises, as well as providing assistance with activities of daily living, such as eating, bathing, and/or dressing are services states may allow home health aide to perform. When the complexity of the medical care required by the patient is minimal, a home health aide may be able to provide the necessary patient care services in the home at a much lower cost than that of an RN or LPN, without detriment to the quality of care given to the patient.
8. Are home health aide services being provided when attendant or companion care would be appropriate?
In some cases where patients’ care needs are limited to supervision or assistance with housekeeping or food preparation, an attendant or companion (also known as a homemaker) may be able to provide the level of service necessary to keep the patient safe and comfortable. Without the additional need for medical training, homemakers and companions can provide the necessary level of assistance at a lower cost than nurses or home health aides.
9. Are any services being duplicated, that is, are there more than one health care professionals in the home at the same time?
Multiple types of home health services are often ordered when the patient is discharged from the hospital. For instance, a multiple trauma patient may have an initial order for home health nursing, physical therapy, occupational therapy and a home health aide. Over time and as the patient’s injuries heal, the number of health care providers in the home should decrease. This is because the patient’s functional level and independence should be improving. Even if the function levels do not immediately improve, the physical and occupational therapist may instruct the nurse or home health aide on how to perform range of motion exercises, safe transfers in and out of bed, and how to safely maintain weight-bearing restrictions. Furthermore, the continuous requirement of two nurses in the home at the same time would be highly unlikely as this level of medical care is rarely needed in the hospital setting, even on an intermittent basis.
10. Are community programs, such as adult day care, national associations (spinal cord injury, traumatic brain injury, etc.) available to provide opportunities for improved socialization?
Socialization can be recreational and therapeutic. Being a part of a community, especially among other people who share similar medical diagnoses or functional impairments, provides the opportunity to interact with others who have experienced comparable struggles. Learning from one another about how to cope with, adjust to, and overcome disability through specific strategies and modifications to personal surroundings, whether home or outside environment, offers a level of dialogue and support that may not otherwise be obtainable through care providers. These programs can also be valuable to family members and caregivers who may benefit from speaking with others going through similar situations.
11. Can durable medical equipment (DME) or home modifications be utilized to reduce dependence on home health care providers?
The opportunities to use DME or to make meaningful modifications to the home (for improved safety and convenience of injured and disabled people) continue to grow alongside technological advances. In many cases, the use of DME and/or home modifications can significantly reduce the amount of home health care services required. For example, the use of lift systems to help immobile patients transfer from the bed to their wheelchair can reduce the need for assistance from two caregivers to one. Slide boards, commonly used by patients with spinal cord injuries, can also help with getting from one surface to another.
12. Are there opportunities for home monitoring systems, such as sensors, alarms and reminders for the cognitively impaired?
Cognitively impaired patients, caused by either age-related illness or traumatic brain injury, may require supervision for safety while in the home. Specific safety concerns may include the use of medications as prescribed, remembering to turn off kitchen appliances or leaving the home without supervision. Therefore, the use of sensors and alarms to help remind patients with cognitive impairments of potentially unsafe behavior may decrease the amount of supervision required.
13. Are meal preparation services available that would reduce the number of services provided?
Assistance with meal preparation may be one of the most frequent needs for non-medical services within the home. Identifying potential meal preparation services within the community can be a more economical means of ensuring patients receive adequate nutrition if they are unable to prepare their own meals.
14. Will the current services being provided improve the patient’s condition and level of functional independence?
The ultimate goal of treatment, whether physical or psychological, is to improve health and function. In some cases, patients who are healing from their injuries or illnesses continue to receive home health services at levels that were originally prescribed after hospital discharge. When these services persist beyond their need, the patient may feel less motivated to push themselves to do more for themselves. In other words, they may be at risk for becoming more dependent upon the home health services, such as meal preparation or housework, that were originally intended to promote recovery of independence, health and function.
15. Would additional physical therapy for strengthening and transfer training (for the patient and family) improve safety during transfers and ambulation?
In addition to the weakness that may be directly caused by an injury or illness, prolonged inactivity can result in further muscle weakness and decreased endurance. Patients and family members may, therefore, feel unsafe with transferring from one surface to another, such as from the bed to a chair, or with ambulation inside the home. In these situations, several sessions of physical therapy to help instruct patients and family members on strengthening exercises and proper transfer techniques may improve the overall level of safety and confidence, resulting in more independent mobility within the home. The use of certain DME may also prove beneficial.
16. How many times has the patient been re-hospitalized due to complications occurring while at home, such as falls and infections?
It is important to continuously monitor the quality of care and environmental safety within the home as a patient progresses through the healing stages of their injury or illness. If their recovery is interrupted by preventable complications, such as recurrent infections or falls, measures should be taken to intervene and reduce the risks of further complications. Specific measures may include further improving the safety of the surroundings within the home, additional home health care staff training and/or education, or ultimately transferring care to another home health agency. Finally, the use of evidence-based and best-practice guidelines to minimize the risk of infections within the home, such as with the management of indwelling urinary catheters, should be required.
17. Are specific nursing and therapy orders being individualized to the patient or are the orders nonspecific, such as, “evaluate and treat”?
Medical care is more effective when individualized to patient-specific factors and needs. Home health care providers, such as nurses and therapists, rely on the prescriber’s knowledge of the patient’s medical diagnosis, precautions, and current medical and functional needs. The initial home health prescription, along with any ongoing treatment orders, should be specific to the patient’s current medical and functional status, reflecting the most current treatment needs.
18. Is the appropriateness and effectiveness of the prescribed medical treatments, DME and therapies being documented?
Communicating the patient’s level of progress and the effectiveness of the current treatment interventions with the prescriber are necessary to ensure continued recovery. If a particular DME item or type of therapy is not producing the desired results, further use of that modality should be reconsidered. This will help minimize unnecessary and unproductive interventions, which if continued, may increase frustration from the patient and their family members with no added treatment value.
19. Are the patient and family members and/or caregivers receiving routine education and training on falls prevention, medication management and wound care?
One of the main goals of home health care is to assist patients with moving toward a higher level of independence with their own care and safety. This requires ongoing education and training for the patient, family members and/or caregivers who will be assisting with care. Proper training with medication administration, safe transfer techniques, wound care and the use of DME can decrease the risk of complications as well as promote an increased level of independence with care needs.
20. Is the patient showing signs of clinical improvement, such as decreasing pain, healing wounds, and improving endurance?
Evidence of clinical improvement is necessary to determine if the current treatment path is effective or if it needs to be modified. For example, as injuries and wounds heal, pain should gradually decrease. An unchanged or increased utilization of pain medications in non-cancer settings may indicate either the condition is worsening, a complication (e.g., infection) is occurring, medication tolerance is developing or the medications are being used inappropriately. Skin wounds should also be continually monitored for signs of healing, such as decreasing size of the wound and decreasing drainage. Finally, improving endurance as evidenced by increasing amounts of ambulation in the home or decreased assistance required with self-care activities indicate progress in recovery.
21. Are social services or any other patient advocacy referrals being considered when necessary?
Emotional stress levels within the home can rise naturally following a major injury or illness. Compounded by uncertainty about the future, the anxiety family members and/or caregivers may have related the patient’s current medical condition and level of assistance required for their care, may (in some cases) lead to frustration, hostility or neglect toward the patient. In these sensitive situations, a social services referral may be necessary to alleviate tensions and identify potential options for counseling or an overall safer environment.
Home health care services provide an essential role in the medical recovery of patients unable to independently care for themselves and/or requiring ongoing medical treatment after being discharged from the hospital setting. Knowing the indications for home health care and the questions to consider both before and during home health treatment can significantly improve patient healing and financial outcomes.
About Dr. Robert Hall
As Corporate Medical Director, Dr. Robert Hall advises customers and employees on evidence-based clinical and rehabilitation guidelines that optimize pharmacy, home health and durable medical equipment programs, promoting better outcomes for injured workers. He also offers counsel on processes and procedures, identifying and reducing prescription medication misuse and abuse.
A practicing, board-certified physical medicine and rehabilitation physician, Dr. Hall has treated patients in private practice, private and state-run hospitals and out-patient clinics. His areas of focus include electromyography, pain management, musculoskeletal medicine and stroke rehabilitation.
After receiving his Bachelor of Science in Electrical Engineering at The Ohio State University, he continued his medical training and was chief resident in physical medicine and rehabilitation at the university’s medical center. Dr. Hall also serves as an adjunct assistant professor of Physical Medicine & Rehabilitation at The Ohio State University Wexner Medical Center. He has been awarded the distinction of “Best Doctors in America®” since 2009.
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