Capital Report

Home health opportunities improve patient access to OT services

Jennifer Bogenrief and Andy Bopp, Volume 29 • Issue 10 • October 2024, pp. 6-8

If you have worked in home health (HH) in the last 40-plus years, you are aware of policy barriers that can make it challenging for occupational therapy practitioners to deliver medically necessary skilled occupational therapy services to Medicare Part A beneficiaries. Combine that with current health care workforce shortages and an HH payment model with different incentives for HH agencies, and patient access to care can be even more difficult. Decades of AOTA advocacy have pushed Congress and the Centers for Medicare & Medicaid Services (CMS) to recognize the role of HH occupational therapy in achieving positive patient outcomes and avoiding negative events, such as rehospitalizations and falls, and helping to ensure timely access to care. CMS is now considering policy changes that would ease delays and obstacles for beneficiaries seeking Medicare Part A HH services. 

An illustration collage with a clip board, a heart, a suitcase, a home, a calculator, a car and home, and three people 

A Little History 

Occupational therapy was briefly a qualifying HH service under Medicare Part A in 1980 but lost this status in 1981 as part of a large package of general budget cuts. To avoid being cut from the benefit altogether, a compromise was made so that a Medicare Part A beneficiary can only receive occupational therapy as a part of an HH episode of care if they are also receiving nursing, physical therapy (PT), or speech-language pathology (SLP) services. In 2000, Medicare policy changed to require initial and comprehensive assessments to be completed by members of skilled disciplines that established eligibility for a patient’s Medicare Part A HH benefit, and to require that the Outcome Assessment and Information Set (OASIS) be integrated into the comprehensive assessment. CMS determined that occupational therapists were not allowed to open Medicare Part A HH cases, meaning they could not complete the initial and comprehensive assessments. This led HH agencies to use fewer resources to educate OTs on OASIS data collection, even though occupational therapy is one of several skilled disciplines responsible for performing the OASIS. Historically, PTs and SLPs could only open an HH case if the beneficiary was not receiving nursing services. Then came the COVID-19 public health emergency (PHE). 

Recent Victories for OT 

CMS issued numerous temporary PHE flexibilities to streamline delivery and allow patient access to care during a time when patients, families, caregivers, and providers were all trying to find the safest way to receive services and ease the burden on hospitals. The PHE triggered a key temporary waiver to allow OTs to perform the initial and comprehensive assessments for all HH patients receiving therapy as part of the plan of care. The waiver to allow OTs to open Medicare HH cases was important because it meant CMS acknowledged that they are qualified to do so, and that occupational therapy has a role at the start of care. 

In December 2020, AOTA advocacy led to the passage of the Medicare Home Health Flexibility Act, which allowed OTs to open Medicare HH therapy cases. On November 9, 2021, CMS published the CY 2022 final HH prospective payment system (PPS) rule and finalized provisions allowing OTs to perform the initial and comprehensive assessments required to open Medicare HH therapy cases, beginning on January 1, 2022. However, the rule did not alter Medicare’s criteria for establishing eligibility for the HH benefit.  

In September 2023, AOTA member Tracy Mroz, PhD, OTR/L, FAOTA, of the University of Washington, was invited to testify about home health access issues at a Congressional hearing, because of her ongoing research on rural health care. She reported, “In rural areas, less than 60 percent of Medicare beneficiaries who have a planned discharge from hospital to home health ultimately receive that care.” She also noted that, “Even when rural residents are admitted to home health, many face disparities in access to rehabilitation services compared to beneficiaries in urban areas.” AOTA anticipates a continuing Congressional focus on rural health issues and believes that occupational therapy can play a critical role in enhancing patient access in such areas if unnecessary statutory and regulatory barriers are eliminated. 

Why OTs Should Open HH Cases 

When OTs are not able to open HH cases, there is an even greater risk than before that occupational therapy may not be used for patients who need it. In the previous HH PPS model, because therapy visits helped increase reimbursement for the agency, there was less risk of occupational therapy being left out. Now that therapy is a cost for HH agencies, they are more careful about the amount of therapy they provide. AOTA has heard many reports of decreased utilization of occupational therapy under Medicare Part A HH, and we have told CMS our concerns that patient access to occupational therapy services should be based on individual need, determined by the therapist’s clinical judgment. Occupational therapy is an excellent discipline to start an HH case because of the way OTs assess and evaluate a patient’s home environment, how they function, possible safety issues, and other needs and strategies (e.g., medication management and daily management of conditions). OTs opening HH cases can reduce delays in patient access to care and help ensure patient access to skilled occupational therapy services. 

Medicare Home Health Accessibility Act 

The Medicare Home Health Accessibility Act (HR7148) would establish occupational therapy as a qualifying Medicare home health benefit. Rep. Lloyd Smucker (R-PA), lead sponsor of the Act along with Rep. Lloyd Doggett (D-TX), has been actively working to promote the bill, which was first introduced in January 2024. He specifically addressed the importance of OT and HR7148 during a House Ways and Means Committee hearing on health care at home, and he authored an Op-ed on the bill that appeared in McKnights Home Care. In both the hearing and Op-ed, Rep. Smucker emphasized the benefits of occupational therapy in the home for Medicare beneficiaries as well as savings to Medicare that can be generated when occupational therapy services are provided to prevent falls and other accidents that can result in ER visits, hospitalizations, and even institutionalizations. HR7148 now has 11 House co-sponsors. 

Opportunities to Improve Patient Care Access 

In its CY 2025 HH PPS proposed rule, CMS included a Request for Information (RFI) seeking input on whether CMS should shift its longstanding policy and permit all classes of rehabilitative therapists (PTs, SLPs, and OTs) to conduct the initial and comprehensive assessment for cases that have both therapy and nursing services ordered as part of the plan of care. CMS also included another RFI to better understand the HH agency referral process, the plan of care development process, and the scope of HH services patients receive. AOTA submitted comments to support a policy change to permit rehabilitation therapists to open cases when both therapy and nursing services are ordered as part of the plan of care. Such a policy change would help improve timely access to care and patient access to necessary therapy services. The OASIS is a multi-disciplinary assessment instrument, and agencies should properly train all clinicians administering it—including both nurses and therapists. 

In addition, CMS proposed a new HH CoP standard to require agencies to establish an acceptance to service policy that would include the following criteria related to the agency’s capacity to provide services: the anticipated needs of the referred prospective patient, the agency’s case load and case mix, the agency’s staffing levels, and the skills and competencies of the agency’s staff. Agencies would be required to develop, implement, and maintain an acceptance to service policy and consistently apply it to each prospective patient referred to the agency for HH services, as well as make public accurate information regarding the services offered by the agency and any limitations related to the types of specialty services, service duration, or service frequency. 

CMS will publish its CY 2025 HH PPS final rule by early November 2024. AOTA will monitor CMS’ actions and share updates. 

Promoting the Role of OT in Your Home Health Agency 

If it doesn’t already do so, encourage your HH agency to allow OTs to open cases and support them through proper agency training. Look to AOTA’s Micro Credential on Performing a Home Health Start of Care or CMS’ free training to increase your skill and comfort with performing the OASIS. 

Support the Medicare Home Health Accessibility Act. If CMS proposes changes to the CoP to allow OTs, PTs, and SLPs to conduct the initial and comprehensive assessment for cases that have both therapy and nursing services ordered as part of the plan of care, then support that as well. Watch for updates from AOTA on federal legislation and regulations and opportunities to advocate for occupational therapy in home health. 

In the meantime, use AOTA’s Quality Toolkit—including the quality checklists—to help demonstrate the objective value of occupational therapy and how it can help both the agency and patients to meet their goals. Tell your colleagues about how you engage patients in the plan of care to help them achieve their goals. Be a proactive member of the HH team to help your agency achieve quality outcomes. 

Resources 

Jennifer Bogenrief, JD, is AOTA’s Director of Regulatory Affairs. 

Andy Bopp is AOTA’s Senior Legislative Representative. 

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