Providing Cost-Effective Home Evaluations Before SNF Discharge
By Ashley Opp
Photo at right: Occupational therapists, such as Wendy Welch-Gillen, are working ensure patient safety in home environments.
Occupational therapy practitioners want to know that their patients are returning to safe environments when they are discharged from rehabilitation centers, but it can be tricky to do home evaluations efficiently, and even trickier to get reimbursed for such services. However, occupational therapists at Heartland Willowbrook Health Care Center in Houston, Texas, have devised a way to ensure patient safety in an efficient way that Medicare will reimburse.
Evaluating Home Environments
Heartland Willowbrook has an interdisciplinary team made up of occupational therapy practitioners, physical therapists, and speech-language pathologists who assist patients with stroke, head injury, spinal cord injury, spina bifida, amputation, or orthopedic issues to return home. “Initially, we did not do home evaluations because they weren’t reimbursed if the patient wasn’t present, and it was very labor-intensive and geographically challenging for the therapist to go with the patient and do the home evaluation,” says Wendy Welch-Gillen, OTR/L, the director of rehabilitation at Heartland.
Skilled therapy practitioners joined forces and came up with a solution. Prior to discharge, “We have the family come and get the patient. A physical therapist and occupational therapist work on transitioning the client from the wheelchair into the car, training the family as they go. They follow the family to the home. While the occupational therapist measures things like the height of the bed or the width of doorways, doing the actual evaluation, the physical therapist navigates the barriers in the home,” explains Welch-Gillen. New graduate Lauren Robinson, OTR, “Really had the vision for what needed to happen and what program was missing,” says Welch-Gillen, and she’s worked with more seasoned therapists to generate strategies to maximize the home evaluation’s benefits for the patients, families, and the company. “It’s really a team approach,” Welch-Gillen says.
The team approach allows practitioners to identify problems in the home. When they return to the clinic, they discuss with the family what modifications and adaptations to make, recommend equipment, and further train the family members on other accommodations. Rather than simply dropping the patient off at home, “We come back to the building and brainstorm, which gives us time to create a safe environment, and that’s something that makes families grateful,” Welch-Gillen says.
The main benefit, however, is improved patient outcomes. “Through the home evaluations, we can bring weaknesses more to light and patients become more willing to work on them. When we do the home evaluation, they really understand that their [occupational therapy] is a focused effort towards a deficit that they have and that they’ve seen themselves have in a home environment,” Welch-Gillen says. “The outcomes are better, the families are happier, and we feel better about sending someone home into an environment that we’ve assessed and adapted. We know that there will be a decreased risk of falls or that they know how to call 911 or life alert from home. We know that we’ve set up a system that they can be successful in.”
How does the rehabilitation center get reimbursed? Home evaluations are considered a part of the per diem it receives for Medicare Part A patients (as opposed to an acute setting). “If we’ve established a payment level of X amount, whatever treatment we do that’s a skilled, medically necessary service, is paid with that per diem money,” explains Welch-Gillen. Services for patients with insurance are also paid through a per diem. “When we do the home evaluations, we are doing the same things that we do in the course of treatment, like tub transfers or maneuvering through doorways. We take patients out of a controlled environment in our facility into real-life, real-time situations and observe how they react,” she adds.
The Red Tape
Medicare law prohibits occupational therapists from opening up a home health case. A physical therapist, nurse, or speech-language pathologist must go in first, determine whether occupational therapy is needed, and consult with occupational therapists as appropriate. As Welch-Gillen puts it, “I’m really uncomfortable that the law says it takes another discipline to say that I’m needed; only an occupational therapist knows if occupational therapy is needed.”
AOTA agrees. “We have been lobbying to get legislation reintroduced to fix this problem and will continue to do so,” says Tim Nanof, AOTA legislative representative for Federal Affairs. Several bills addressing the inequality of skilled therapy services under Medicare have been introduced, but to date they have failed to pass.
Welch-Gillen met with her Congressional representatives in Washington, DC, for AOTA’s Capitol Hill day on September 17. When she returns next year, she’s counting on numbers to do a lot of the talking for her. “We’re trying to pilot the effectiveness of home evaluations by collecting data from them. I hope to go back to Congress next year and say, ‘I’ve done this many home evaluations, my company has done this many, and through our proactive intervention we have allowed patients to return home safely with appropriate modifications to age in place. But you have to allow us do what we do best,’” says Welch-Gillen. “Everyone needs to know—Congress, CMS [the Centers for Medicare & Medicaid Services], intermediaries—how we can actually save Medicare dollars by doing a proactive environmental assessment.”
Welch-Gillen, Robinson, and their team demonstrate that despite frustrating regulations, a little ingenuity can have a big impact on helping people to continue living where they want to live, independently and successfully. “The most rewarding things are the moments when everything comes together and you realize that a patient is leaving and they have earned their independence back,” says Welch-Gillen. “They feel like there’s nothing they can’t do, and you helped be a part of that.”
Ashley Opp is AOTA’s senior staff writer.