The Role of Therapy in Post-Acute Care Settings

Long-term and post-acute care (LTPAC) settings include inpatient rehab facilities, long-term care hospitals, skilled nursing facilities, and home health agencies (HHAs). Each LTPAC setting utilizes a different comprehensive assessment instrument for collecting and reporting patient data to the Centers for Medicare and Medicaid Services (CMS). HHAs have been using the Outcomes and Assessment Information Set (OASIS) since 1999.

In October of 2014, the bipartisan Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) was signed into law, requiring LTPAC providers to collect, report and share standardized patient data with each other. According to CMS, the Act intends for standardized post-acute care data to improve Medicare beneficiary outcomes through shared decision making, care coordination, and enhanced discharge planning.

The IMPACT Act requires reporting on standardized patient data including:

  • Functional status, including mobility, self-care, and/or a history of major falls
  • Cognitive function, including the ability to express ideas and understand, and an individual’s mental status
  • Impairments including incontinence, impaired hearing or sight, and/or the inability to swallow

The Act also requires that standardized quality measures be developed and implemented from five quality measure domains, one of which is “Functional status, cognitive function, and changes in function and cognitive function.” As CMS steadily shifts its reimbursement model from quantity-based to quality-based, these requirements emphasize the role of clinical therapies in the post-acute care arena.

Occupational therapy (OT), physical therapy (PT), and speech-language pathology (SLP) address a patient’s physical, emotional, and spiritual recovery. PT, OT, and SLP can be critical components of the PAC plan of care (POC) and can greatly influence outcome assessment. They can provide skilled rehabilitation support and education: during post-operative recovery, for chronic disease management, and/or in order to avoid hospitalization or institutionalization. They can help the patient cope with new symptoms, return to full functioning, or compensate for and live with new limitations.

In a PAC or HHA setting, therapists will assess physical, psychological, social, and environmental factors relative to the patient’s diagnoses and prognoses. They will create individualized POCs to address the specific needs, circumstances, challenges, and goals of each patient. For HHA therapists, the home environment offers unique opportunities:

  • to observe and evaluate a patient’s spontaneous activities in addition to daily routines
  • to identify real and potential functional and cognitive barriers
  • to identify existing and potential supports

PAC/HHA therapists address issues such as:

  • Mobility and positioning: patient’s need for/use of cane, walker, wheelchair, or adaptive equipment; balance; fatigue; dyspnea; or pain
  • Cognitive functioning: Patient’s understanding of diagnoses, interventions, symptoms, limitations, and restrictions
  • Environment and safety, including falls management and prevention, home safety, and emergency preparedness: physical layout and home decor (furniture, rugs, clutter); lighting and handrail/grab bar placement; pests and cleanliness issues; accessible exits
  • Medication and pain management: patient’s understanding of need for medications and importance of medication regimen; visual ability to read medication labels/instructions; cognitive and physical ability to adhere to medication regimen
  • Other ADLs/IADLs: patient’s ability to manage bathing, dressing, toileting, eating, meal preparation, etc.
  • Leisure pursuits and social interaction: patient’s ability and willingness to participate in hobbies and interests
  • Chronic disease and pain management: patient’s ability to incorporate prescribed or recommended regimens into daily routine for exercise, dietary, hygiene, health monitoring, medication, and compensatory strategies

CMS Requirements for Clinical or Skilled Therapy

For HHAs, the CMS coverage requirements for skilled therapy services are detailed and specific. According to CMS, PT, OT, or SLP services qualify as skilled if “the inherent complexity of the service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist.” Skilled therapy services are covered when they are “reasonable and necessary to the treatment of the patient’s illness or injury or to the restoration or maintenance of function affected by the patient’s illness or injury.” CMS cautions that a patient’s medical condition (diagnosis and/or prognosis) can be a valid factor in determining if therapy services qualify as skilled, but should never be the sole factor.

CMS requires that for each therapy discipline (PT, OT, or SLP) for which services are ordered and provided, a qualified therapist must complete an initial functional assessment. When more than one therapy discipline is provided, a qualified therapist from each of the disciplines must functionally assess the patient.

As finalized in the CY 2020 Home Health Prospective Payment System (HH PPS) Rule, the PT and OT POC can be carried out by a qualified therapist assistant, under the supervision of a qualified therapist. However, CMS specifies that a qualified therapist is still responsible for:

  • Initial assessment and POC
  • Reassessment every 30 days
  • Development and modification of a maintenance program
  • Supervision of services provided by therapist assistants

Physical Therapy in a PAC Setting

Physical Therapy involves the use of exercise and other interventions to help restore optimal functional mobility, reduce pain, and/or reduce the risk of injury. PT can decrease the duration and severity of functional disabilities and help patients return to their desired daily activities, whether their problems are the result of injury or disease.

According to the American Physical Therapy Association (APTA), PT services represent a significant portion of Medicare expenditures in PAC settings and “are integral to improving the quality of care provided to patients while reducing overall costs.”

Physical therapists are experts in the diagnosis and treatment of musculoskeletal and movement disorders and can help patients with balance issues, joint pain, or walking difficulties. They can help treat the decline or loss of functional mobility due to:

  • post-surgical conditions like total hip or total knee replacement
  • strokes and heart attacks
  • chronic conditions such as congestive heart failure, chronic obstructive pulmonary disease, Parkinson’s disease, multiple sclerosis, and amyotrophic lateral sclerosis
  • trauma such as fractures

The physical therapist will complete an initial comprehensive assessment and then work with the patient and caregivers to develop an individualized POC that addresses the patients’ specific needs, challenges, and goals. PTs in the home can utilize available resources to maximize the rehabilitation experience.

PTs, together with licensed physical therapist assistants (PTAs), will target those movements that can no longer be performed normally. PTs and PTAs can provide a variety of interventions to help patients return to their highest level of achievable function and to help prevent falls and major injuries. These include:

  • balance, posture, coordination, mobility, and gait training
  • strength and range of motion exercises
  • pain management modalities
  • surgical wound monitoring and assessment (within the scope of State Practice Acts)
  • cardiopulmonary rehabilitation exercises
  • neurological rehabilitation techniques

Occupational Therapy in a PAC Setting

OT involves the therapeutic use of skills or “occupations” to help patients participate in necessary and meaningful daily activities. Occupational therapists (OTs) are effective and valuable members of the PAC clinical team. For HHA therapists in particular, the goal is to maximize positive outcomes for patients by giving them the techniques and tools they need to optimally—and as independently as possible—function in their home environment. They accomplish this goal through observation, evaluation, intervention, and education.

Assessment and intervention focus on specific skills or occupations that have been directly affected by a patient’s diagnosis or condition, and on the patient’s ability to perform the broad range of everyday activities necessary to live safely and productively. OTs help promote independence by improving these skills and identifying alternative compensatory methods when necessary, including the design, fabrication and/or fitting of orthotic and self-help devices.

Occupational therapists will teach strategies to help improve or maintain current functioning, and to prevent further loss of functional abilities. They offer teaching and guidance for family members and caregivers, as well. OTs help patients improve their quality of life by offering strategies for:

  • participating in self care
  • managing limitations
  • regaining or improving skills and efficiency
  • avoiding or minimizing the risk of further decline or injury

IMPACT Act requirements have brought functional cognition to the forefront, and OTs can assess activities of daily living (ADLs) and instrumental ADLS (IADLs). IADLs are a measure of functional status that can indicate a patient’s ability to live independently. 

Washington University researcher and educator Carolyn Baum defined functional cognition as “the ability to use and integrate thinking and processing skills to accomplish complex and essential IADLs.” Baum explained that while occupational therapists have not traditionally been seen as focusing on IADLs, the IMPACT Act is changing that. She said that OTs address and treat cognitive function from the perspective of occupational performance “in which the therapist [asks patients] to use their cognitive abilities to do real world tests and tasks.”

OTs can collect OASIS data any time subsequent to Start of Care (SOC), including resumption of care, recertification, and discharge time points. They can also help other agency staff understand the most effective techniques for assessing ADLs and IADLs for the OASIS assessment, which in turn can help ensure accurate outcomes and appropriate reimbursement.

Speech-Language Pathology (SLP) in a PAC Setting

Speech-language pathology focuses on a patient’s ability to understand and use words and on helping the patient overcome limitations and impediments that can affect daily activities, interpersonal relationships, and safety. 

Speech-language assessment and diagnosis is an essential component of PAC and HHA rehabilitation. According to CMS, coverage of SLP services “is not determined solely on the presence or absence of a beneficiary’s potential for improvement from the therapy,” but rather on the assessment of demonstrated need for the “specialized judgment, knowledge, and skills of a qualified speech-language pathologist.”

Speech-language impairments may affect the vocal cords, muscles, nerves, or other structures within the throat or mouth. They can be due to muscle or respiratory weakness, vocal cord or brain damage, stroke, or other medical conditions.

Speech-language pathologists can treat or prevent breathing, speaking, cognition, and swallowing disorders by improving or restoring function. SLPs at home can also help with:

  • verbal and written expression
  • auditory processing
  • reading comprehension
  • memory, reasoning, and attention span
  • adaptive speech devices
  • non-oral communication 

Therapies under PDGM

The Bipartisan Budget Act (BBA) of 2018 included several requirements for home health payment reform. CMS addressed these requirements with the Patient-Driven Groupings Model (PDGM), which became effective on January 1, 2020. PDGM is a revamped version of the Home Health Groupings Model (HHGM) that CMS introduced-–and then discontinued–-in 2017. CMS described PDGM as an alternative case-mix adjustment methodology that will further the shift to a value-based payment system and ultimately reduce the cost of home healthcare delivery. “The redesign of the home health payment system encourages value over volume and removes incentives to provide unnecessary care,” said CMS Administrator Seema Verma.

PDGM cut payment periods in half, and eliminated therapy volume as a determinant of payment for HHAs—a change required by BBA 2018. The previous system relied on the number of therapy visits a patient received to determine payment, something the Medicare Payment Advisory Commission (MedPAC) had been concerned about for a long time. According to CMS, therapy thresholds encouraged volume over value. By eliminating their use in determining payment, PDGM would remove any financial incentive to over-provide therapy services and help to shift the focus towards a more value-based system.

Under PDGM there are only two clinical groups—musculoskeletal rehabilitation and neuro/stroke rehabilitation—that allow therapy as the primary reason for HH services, but therapy services should be provided regardless of the clinical grouping. It is important to remember that the elimination of the therapy threshold does not mean that therapy services will no longer be paid for, and CMS advises that the need for therapy services under PDGM remains unchanged: “therapy provision should be determined by the individual needs of the patient without restriction or limitation on the types of disciplines provided or the frequency or duration of visits.”

PDGM ties therapy payments to patient clinical characteristics and patient needs, particularly through the Functional Impairment group. Under PDGM, a functional impairment level of low, medium, or high is designated for each 30-day period based on the following eight OASIS assessment items:

  • Grooming
  • Current ability to dress upper body safely
  • Current ability to dress lower body safely
  • Bathing
  • Toilet Transferring
  • Transferring
  • Ambulation and locomotion
  • Risk for hospitalization

While the initial HHA reaction may be to drastically cut therapy services for patients, instead HHAs should involve therapists early, beginning at SOC. It is often nursing that performs the initial comprehensive assessment, even when the original referral is more focused on the need for therapy, but qualified therapists can be instrumental in the accurate assessment of functional impairments. Therapists can and should be involved at SOC to help identify the diagnoses and conditions that will determine the patient’s functional impairment level and drive the POC.

With PDGM’s and CMS’s increasing focus on value-based care, the need to improve clinical outcomes is more pressing than ever. Ellen Strunk, president of the PAC-focused Rehab Resources and Consulting Inc., told Home Health Care News: “Research shows that therapy can improve long-term functional outcomes and that therapy contributes to patient satisfaction.”

According to CMS, a comprehensive assessment conducted by a skilled therapist can help to ensure that patient needs are identified, an individualized therapy plan of care is established, therapy services are provided, and goals of care are met. Accurate assessment also improves an agency’s clinical outcome documentation, but improvements in OASIS functional impairment data can’t be truly or accurately documented unless the OASIS items are properly assessed and recorded in the first place. Utilizing the unique skills and expertise of their qualified clinical therapists can give HHAs and PAC providers a needed edge in an increasingly value- and quality-based system.