Q: The agency I work for doesn't permit us to see patients on maintenance therapy. Is this correct?
As I interact with home healthcare agencies across the country, I am concerned that far too often the mention of the term "maintenance therapy" is met with "we don't do that here" or "there are no patients like that in our area." Despite a second court ruling issued in February 2017 to direct the Centers for Medicare and Medicaid Services (CMS) regarding formal education for both providers and auditors that the "improvement standard" does not exist in the post Jimmo environment (Center for Medicare Advocacy, 2017), many agencies do not even have a plan in place to assess opportunities and ensure that patients are accessing this part of the home healthcare benefit when appropriate. If your agency is currently providing minimal-to-no maintenance therapy, here are some questions to consider:
1. Do you review cases in which there was only an evaluation visit provided by therapy?
a. Very often the documentation indicates that recommendations were made-exercises, equipment or self-care strategies-and yet continues on to state some variation of "no rehabilitation potential". If there was no potential to benefit from skilled therapy interventions, why were recommendations made? Clearly the therapist saw something that triggered a need to intervene-so why is there no planned follow up? These cases are great discussion points specific to maintenance therapy. The decision to not provide additional visits is typically driven by the idea that the patient will not improve so we "can't" see him or her again. As defined in the benefit, maintenance therapy compels us to follow up and ensure the therapy recommendations are EFFECTIVE when the focus is on stabilizing function/preventing decline.
2. Have you had partial denials of therapy visits? In other words, not all the therapy visits were considered to be lacking in skill but only some of them-most often the last week or two of therapy care.
a. Despite the Jimmo decision and subsequent court ruling this year, the overwhelming majority of therapy visits are being placed on the claim as restorative in nature-meaning improvement is expected. Many patients who receive therapy have a course of care that shows steady improvements until they are deemed ready for discharge. There are others that improve initially but then reach a plateau (a word that should no longer make people flinch) and there is a concern as to whether the gains made are sustainable given the overall condition of the patient. In these situations, therapy may continue for another week or so to ensure the patient is stabilized-which actually indicates a transition to a maintenance approach to care. Yet the therapist and the agency identify all visits as restorative. In these situations, the reviewer is NOT misunderstanding the regulations and is correctly concerned about the skill level when no improvement is happening anymore. Had at least some of these patients been formally transitioned to a maintenance focus of care, the risk for a partial denial could be reduced.
3. Why aren't you providing more than the occasional maintenance therapy course of care?
a. When we advocate for our patients to payer sources, we are quick to cite the complexity of their medical conditions, their mobility and self-care challenges, and the impact of both environment and caregiver on their ability to remain safely in the home. Many of us have seen an increase in the level of issues our patients present with compared to 10 years ago-some of which it attributable to shorter hospital stays. Home healthcare is being driven by the payer source, hospitals, and postacute partners to keep people out of the hospital and emergency departments. Given the level of importance of these issues and the population we serve, how do we remain confident that there is really no need for maintenance therapy? The ability to stabilize function/prevent decline is a tremendous component of disease management programs for complex patients.
I challenge home healthcare agencies to formally take a look at how they have been implementing maintenance therapy programs. If there are questions or concerns about how to do this well, seek out credible educational resources, as this is a much bigger issue than simply read the regulations and telling therapists to "do it." Careful consideration of both clinical decision-making and documentation issues ensures that an effective, efficient, and defensible course of action is in place.
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