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Post-Acute Care andLong-Term Services: Evolution toValue-Based Care
Table 4 (continued)
Title Scope of practice Education
Dietitian Plan food and nutrition programs, supervise
Physical
therapist
Occupational
therapist
Recreational
therapist
Attending
primary care
physician
meal preparation, and oversee the serving of
meals. They prevent and treat illnesses by
promoting healthy eating habits and
recommending dietary modications. They
perform nutrition screenings for their clients
and offer advice on diet-related concerns
such as weight loss and cholesterol reduction
Physical therapists provide a variety of
medical services to help individuals who
have been injured or physically affected by
illness to recover or improve function. A
physical therapist must be able to evaluate a
patient’s condition and devise a customized
physical rehabilitation and treatment plan to
enhance strength, exibility, range of
motion, motor control, and reduce any pain,
discomfort, and swelling the patient is
experiencing
Occupational therapists help patients
improve their ability to perform tasks in
living and working environments. They work
with individuals who suffer from a mentally,
physically, developmentally, or emotionally
disabling condition. Occupational therapists
use treatments to develop, recover, or
maintain the daily living and work skills of
their patients. The therapist helps clients not
only to improve their basic motor functions
and reasoning abilities, but also to
compensate for permanent loss of function.
The goal is to help clients have independent,
productive, and satisfying lives
Recreational therapists devise programs in
art, music, dance, sports, games, and crafts
for individuals with disabilities or illnesses.
These activities help to prevent or to alleviate
physical, mental, and social problems
Responsibility for initial patient care, and
support discharges and transfers. Also make
periodic, pertinent on-site visits to patients
and insure adequate ongoing coverage (see
chapter “The Role of Practitioners and the
Medical Director”)
At least a bachelor’s degree.
Licensure, certication, or
registration requirements vary
by State
Graduate from a physical
therapist educational program
with a master’s or doctoral
degree
A master’s degree or higher in
occupational therapy is the
minimum requirement for entry
into the eld
Bachelor’s degree with some
additional training is usually
required for this eld
In addition to 4years of medical
school most nursing home
attending physicians complete a
primary residency, which is
typically 1–3years. Some go on
to complete a geriatric
fellowship as well
19
(continued)
20
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R. G. Stefanacci and M. A. Kaminski
Table 4 (continued)
Title Scope of practice Education
Medical
director
Roles and responsibilities of the medical
director in the nursing home can be divided
into four areas: physician leadership, patient
care–clinical leadership, quality of care, and
education. Nursing facilities are required to
have a medical director as outlined in OBRA
87 (see chapter “The Role of Practitioners
and the Medical Director”)
Currently Maryland is the only
State that requires Medical
Directors to be a Certied
Medical Director (CMD) in
Long-Term Care or have similar
training. CMD was established
by the American Medical
Directors Association to
professionalize the eld of
medical direction
Nurse
practitioner
(NP)
Advanced practice nurses provide
high- quality health care services similar to
those of a doctor. NPs diagnose and treat a
wide range of health problems. They have a
unique approach and stress both care and
cure. Besides clinical care, NPs focus on
health promotion, disease prevention,
health education, and counseling (see
chapter “Nurse Practitioners, Clinical
The entry-level training for NPs
is a graduate degree. At this
time, NPs complete a master’s
or doctoral degree program.
This means that NPs earn a
bachelor’s degree in nursing
(4years of education), then
their graduate NP degree
(2–4years of education)
Nurse Specialists and Physician
Assistants”)
Consultant
pharmacists
Focuses on reviewing and managing the
medication regimens of patients, particularly
those in institutional settings such as nursing
homes. Consultant pharmacists ensure their
patients’ medications are appropriate,
effective, as safe as possible and used
correctly; and identify, resolve, and prevent
medication-related problems that may
interfere with the goals of therapy
The Doctorate of Pharmacy
(Pharm.D.) is the only
professional Pharmacy degree,
and the 5-year Bachelors of
Science in Pharmacy is being
phased out as a professional
degree. Since this program
traditionally follows 2years of
pre-pharmacy education,
students typically take 6years
of post-secondary education to
obtain their Pharm.D
Nursing home
administers
Responsibility as the managing ofcer of the
facility to plan, organize, direct, and control
the day-to-day functions of a facility and to
maintain the facility’s compliance with
applicable laws, rules, and regulations
The administrator shall be vested with
adequate authority to comply with the laws,
Typically, a certicate program
of about 120h is required
before sitting for a licensing
examination. Most are required
to have completed a bachelor’s
degree program as well as
preceptor training as an NHA
rules, and regulations relating to the
management of the facility
a
Part-time position
Post-Acute Care andLong-Term Services: Evolution toValue-Based Care
21
References
1. http://www.medpac.gov/docs/default- source/reports/chapter- 6- site- neutral- payments- for-
select- conditions- treated- in- inpatient- rehabilitation- facilities.pdf.
2. https://www.managedhealthcareconnect.com/articles/admission- criteria- facility- based-
post- acute- services.
3. Brault MW.Americans with disabilities: 2010. Washington, DC: US Census Bureau; 2012.
www.census.gov/prod/2012pubs/p70- 131.pdf.
4. Feinberg L, Reinhard SC, Houser A, Choula R.Valuing the invaluable: 2011 update the growing contributions and costs of family caregiving. http://assets.aarp.org/rgcenter/ppi/ltc/i51-
caregiving.pdf.
5. O’Shaughnessy CV; National Health Policy Forum. National spending for Long-Term Services
and Supports (LTSS), 2012. Basics_LTSS_03-27-14.pdf.
6. https://www.cms.gov/Outreach- and- Education/Medicare- Learning- Network- MLN/
MLNProducts/Downloads/InpatRehabPaymtfctsht09- 508.pdf.
7. https://www.prolianceorthopedicassociates.com/dr- barrett- blog/the- results- of- the- 2020-
american- joint- replacement- registry.
8. https://www.medicare.gov/coverage/skilled- nursing- facility- snf- care.
9. https://www.managedhealthcareconnect.com/articles/direct- admissions- skilled-
nursing- facilities- are- you- ready.
10. https://www.managedhealthcareconnect.com/articles/how- reimbursement-
changes- long- term- care- will- impact- who- and- how- we- care.
11. LaPointe J. AHA nds aws with the patient-driven payment model for
SNFs. RevCycleIntelligence.com. https://revcycleintelligence.com/news/
aha-nds-aws-with-the-patient-driven-payment-model-for-snfs
12. Centers for Medicare and Medicaid Services (CMS). Skilled Nursing Facilities PatientDriven Payment Model Technical Report. cms.gov website. https://www.cms.gov/Medicare/
Medicare- Fee- for- Service- Payment/SNFPPS/Downloads/PDPM_Technical_Report_508.pdf.
Published April 2018
13. Stefanacci RG. How to Be Included in a Health System’s Preferred SNF Network. Ann
Longterm Care. 2017;25(5):24–6.
14. McHugh JP, Foster A, Mor V, etal. Reducing hospital readmissions through preferred networks of skilled nursing facilities. Health Aff. 2017;36(9):1591–8.
15. Pathway Health Services. Quality improvement tool for review of acute care transfersINTERACT version 4.0 tool. Pathway Health website. http://www.pathway- interact.com/
wp- content/uploads/2017/04/148604- QI_Tool- for- Review- Acute- Care- Transf_AL.pdf
16. https://www.managedhealthcareconnect.com/articles/special- needs- plans- are- special-
long- term- care
Home Health Care
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RobertC.Salinas
Introduction
It is estimated that by the year 2050, the number of people age 65 and over in the
USA will increase from 46 million to 90 million, representing the fastest growing
segment of our population. Although this age group makes up 16% of the current
population, it disproportionately accounts for approximately 36% of all health carerelated expenditures [1]. As older Americans have a strong desire to remain in their
homes (or in an independent or assisted living facility) and age in place, this trend
will continue to increase the need for community-based home care services. Many
are aficted with multiple chronic conditions (multi-morbidities), homebound, and
experience difculty in accessing timely and needed health care services. As a
result, many receive fragmented and inadequate medical care.
With hospital-based care shifting more to community-based care, a dramatic
paradigm shift is occurring [2]. In addition to “urgent care at home” programs, telemedicine, remote patient monitoring, palliative, and home-based primary care programs, “hospital at home” programs are being developed that enable patients to
receive acute care at home. Hospital at home programs have proven effective in
reducing complications while cutting the cost of care by 30% or more, leading to
entrepreneurial efforts to promote their use. Thus, a combination of “high tech and
high touch” programs are making home-based care a viable option for patients who
are in need of acute care or hospital post-acute care.
The elderly often require emergency room evaluation for acute illness, unintended injuries, and exacerbation of chronic conditions such as congestive heart
failure, chronic obstructive pulmonary disease, and diabetes [3]. These patients
experience shorter lengths of stay in the hospital setting [4]. Many need post-acute
R. C. Salinas (*)
OU Department of Family and Preventive Medicine, Oklahoma City, OK, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. Winn et al. (eds.), Post-Acute and Long-Term Care Medicine, Current Clinical
Practice, https://doi.org/10.1007/978-3-031-28628-5_2
23
24
care to regain their premorbid functional status and to remain safe in the community
[5]. Distant monitoring technology, changes in clinician reimbursement, and more
intersystem communication can prevent hospital admissions and readmissions.
Accordingly, home-based care has become a vital part of the health care system.
Further expansion and integration of home-based care can help meet the needs of an
overburdened health care system for persons who are homebound [6]. Home-based
care has the potential to decrease the costs of care, improve patient outcomes, and
improve patient, family, and health care workers’ satisfaction. This chapter reviews
the delivery of medical care in the home, practitioner home visits, and services provided by home health and hospice care agencies.
R. C. Salinas
Home Care
Home care is dened as the provision of health care-related services and durable medical equipment to patients at home for the purpose of restoring and maintaining his or
her maximal level of function, independence, comfort, and health [6, 7]. This entails
a clinician coordinated interdisciplinary approach and the use of therapeutic, diagnostic, and social support services. Generally, the patients’ goals of care determine the
plan of care and the level of services needed. This can include house calls by a physician, nurse practitioner, or physician assistant in collaboration with the services provided by the home health care agency. Home care services are eligible for patients
who have intermittent skilled needs subsequent to a decline in functional status due to
an exacerbation of a chronic condition, acute illness, or injury, or who transition to
home upon discharge from a hospital, rehab facility, or a skilled nursing facility (SNF).
The Physician House Call
Despite wanting to “age in place” at home, some older adults may opt to move into
an assisted living facility (ALF), a personal care home or group home, or an independent living facility (ILF). Contrary to common belief, patients are not required
to be homebound in order for a practitioner to provide a house call and to be reimbursed for the medical service they provide. However, there are homebound require-
ments for patients who require services provided by a home health agency. Situations
under which a practitioner can justify a home visit include:
• An acute care visit when the patient is unable to travel to an outpatient clinic or
emergency room.
• Ongoing management of a progressive and debilitating chronic condition.
• Need to gather more information about the environmental and social conditions
of a patient, for example, who continues to experience recurrent falls and injuries
or if there is a suspicion for abuse or neglect.
Home Health Care
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25
• Recurrent ER visits and/or hospital admissions.
• Provision of palliative care and discussion of end-of-life care preferences, includ-
ing hospice care [8].
Some physicians have established their practice exclusively in home care. Homebased primary care (HBPC) can be a viable alternative for some practices, and has
been shown to potentially reduce overall cost of care for patients diagnosed with
serious illness [9]. The Veterans Hospital Administration has had a well-established
HBPC program for over 30years.
Preparing fortheHouse Call
In preparation for a home visit, it is important to anticipate the purpose and goals
of the visit in order to better determine the patient’s care plan. This requires
advance notice of the visit to the patient, family members, and/or caregivers, as
well as the home health agency or hospice and the patient’s community-based
caseworker (if the patient has one) who is responsible for coordination of the
patient’s care. Planning ahead can ascertain what procedural instruments and
supplies may be required such as toenail clippers or supplies for injections
(Table1).
During the home visit:
• Address the patient’s medical condition.
• Review all medications including those prescribed, over-the-counter, and any
herbal supplements, and the reason for each.
• Assess the patient’s functional status, memory and cognitive ability, and level of
independence (Basic ADL’s and Instrumental ADL’s).
• For patients with physical limitations, identify the need for adaptive or dura-
ble medical equipment to maximize safety and independence. Assistive
devices and durable medical equipment such as a walker or bedside commode
can aide a person in remaining independent in the home and delay
institutionalization.
Table 1 The doctor’s bag
Stethoscope Examination gloves (latex free)
Blood pressure cuff Syringes and needles
Thermometer Sharps container
Pen light Scissors/forceps/toenail clippers
Pulse oximeter Laptop EMR
Prescription pad Guaiac Cards/developer
Pharmacopeia Hand wipes
Reex Hammer Band-aides/Ace Bandages
26
Table 2 Assessment in the home
Patient overall assessment
Functional assessment (BADLs, IADLs, falls)
Mental/cognitive assessment
Nutritional assessment/food availability
Medication use and compliance
Advance care planning
Assessment of caregiving burden
Assessment of the caregiver
Environmental assessment
Safety in the home/outside
Needs for durable medical equipment (DME)
Community assessment
Safety of neighborhood for health care providers
Availability of community resources
Table 3 Medicare part B reimbursement 2021
New patients Established patients
Code Reimbursement
99341 $51.98 99347 $52.24
99342 $73.73 99348 $79.94
99343 $121.95 99349 $122.90
99344 $172.85 99350 $170.25
a
Reimbursement will vary from state to state
a
Code Reimbursement
R. C. Salinas
a
• Identify the environmental need for home adaptation, remodeling, or retrotting
that can improve home access, safety, and mobility.
• Caregiver assessment is also important in determining if a plan of care can be
successfully implemented in the home (Table2 lists important aspects of a home
assessment).
• To recognize and address caregiver burnout.
Billing forServices
Under current Medicare rules, any licensed physician, nurse practitioner, or physician assistant can perform a house call and bill for services rendered using the
appropriate CPT code for the level of service provided [7]. Most third party payers
follow the rates and guidelines for billing set forth by Medicare and Medicaid.
Practitioners are also allowed to bill based on the amount of time directly spent with
and in counseling the patient. It is important that each component of the patient
encounter be appropriately documented for the level of service coded as to history,
examination, and medical decision-making complexity (see Table 3). Note that
Home Health Care
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Table 4 Members of the home health care team
Skilled nurse
Physical therapist
Speech therapist
Occupational therapist
Home health care aide
Social worker
Case manager
Wound care nurse
Medical Director
a
Some home health care agencies or corporate entity may have either a medical director or corpo-
rate medical director
a
27
practitioners are not allowed to bill for travel time associated with making a house
call. Numerous versions of mobile-capable electronic health records (EHR) have
the ability to document and to facilitate the exchange of patient information such as
medication reconciliation, laboratory results, and diagnostic studies.
Agency Home Health Care
Under current Medicare guidelines, beneciaries who have a documented need for
episodic care may be eligible for home health care. The purpose of home health care
is to have an interdisciplinary team of qualied health care providers (see Table4)
to provide assistance in the home for a person who requires skilled nursing care,
physical therapy, speech therapy, and other services. Often a referral is made when
a physician or an advance practice provider notes a patient’s decline in health and
level of function that places the patient at risk for falls, hospitalization, or institutionalization [6]. At other times, home health care can assist in delivery of palliative
care in seriously ill patients who are ineligible for hospice or have chosen not to
enroll in hospice [10].
Members oftheTeam
Delivering effective home health care depends on each member of the health care
team using their skill set aimed at restoring health based on the patient needs [11],
while negotiating health care goals with the patient and family and then developing
a plan of care that can sustain efforts to attain and maintain these goals. The home
health team must have regular contact with the patient and the patient’s family and
be able to ascertain whether the plan of care can be successfully implemented in the
home (or elsewhere).
28
R. C. Salinas
Skilled Nursing
A licensed practice nurse (LPN) or registered nurse (RN) can provide skilled-level
care to patients in the home that may include:
• Educating patients and caregivers on acute and chronic medical conditions.
• Instructing on how/when to administer medication.
• Obtaining laboratory specimens and reporting results.
• Coordinating home X-ray studies, home infusion of medication and IV therapy.
• Providing wound care.
• Administering vaccinations.
The nurse’s admission assessment should include functional, memory and cognitive status, and medication reconciliation of prescribed and all over-the-counter
medications [12–15]. Most home health care agencies now use a software program
to screen for potential drug–drug interactions with this report subsequently sent to
the patient’s physician for review.
Nurses usually provide services one to two times a week, but can be more frequent at the start of care (front loaded visits) in order to meet patient needs. Nurses
often identify other medical conditions that need to be brought to the attention of the
practitioner and also recognize barriers to the delivery of care, such as caregiver
stress or nancial burdens. The role of the home health nurse continues to expand
and can include the promotion, monitoring, and maintenance of health [16].
Physical Therapist
Home health physical therapists provide therapy to improve lower extremity
strength and conditioning. Patients often have a history of falls or have become
deconditioned following hospitalization. Referrals for home physical therapy frequently are for patients who have suffered a stroke or had lower extremity orthopedic surgery [17, 18]. Physical therapists assist in educating the patient’s caregivers
on how to improve patient function, safety, and independence and provide recommendations for durable medical equipment (DME) such as canes, walkers, shower
chairs, and suggestions for retrotting bathrooms.
Speech Therapist
Under the current Medicare home health care guidelines, a physician can request a
referral for home health care solely for the purpose of providing speech therapy in
the home. The speech therapist can also perform an initial screen for swallowing
that may subsequently necessitate a formal swallowing study in order to more adequately assess dysphagia and make recommendations as to diet consistency.
Home Health Care
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29
Occupational Therapist
Home health occupational therapists often work in tandem with physical therapists
to promote better function of the upper extremities and self-care of the basic ADLs.
The occupational therapist may also recommend adaptive equipment or DME that
can assist the patient. Some therapists may have acquired skills in assessing a
patient’s swallowing.
Social Worker
Most home health care agencies have medical social workers on staff, or if not, will
out contract this service. Medical social workers can play an important role in the
care of patients with complex psychosocial needs. This may include to help identify
caregivers (paid and informal), to address caregiver stress, and to make inquiries
and suggestions to alleviate nancial hardship.
Home Care Aide
Based on necessity, home health care agencies can provide nurse aides to assist
patients in their ADLs such as bathing and dressing and to provide light housework
if a patient is too weak to do so. They can supplement the personal care provided by
family members and other caregivers who may be in the home less frequently than
needed. Use of an aide to provide services is contingent upon the need for skilled
nursing for the patient.
Requirements forAgency Home Health Care
There are several requirements that must be met for a physician to order home
health care for a (Medicare) beneciary. First, as of April 2020, a physician, an
Advance Practice Nurse, Clinical Nurse Specialist, or Physician Assistant must
determine that the patient meets the requirement for “homebound” status and sec-
ondly that the patient has a need for episodic skilled nursing care, physical therapy,
or speech therapy.
The denition and interpretation of homebound status often leads to confusion.
This is reviewed in Table5.
For the initial Home Health certication, the Affordable Care Act (ACA) now
requires that the certifying physician or advance practice provider, document a face-
to- face encounter with the patient. This encounter must have addressed the medical
condition for which this episode of home health care is being ordered. The
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