COVID-19 Has Affected Home Health Therapy Utilization in Multiple Ways

Heading into 2020, therapists working in the home health world were concerned over the effects that the Patient-Driven Groupings Model (PDGM) might have on their profession.

Then COVID-19 hit, forcing them to rush into action. A year later, the true impact of the new payment model on therapy utilization is still not clear.

“I’m not really sure we’re ever going to have clean data to be able to figure out what the direct effect of PDGM on therapy utilization was,” Cindy Krafft, the owner and founder of Kornetti & Krafft Health Care Solutions, said on a recent Home Health Care News webinar.

Krafft is a licensed physical therapist and has been in the home health space for 27 years. Her company advises agencies on both operational and clinical issues.

There were some inklings of what the impact of PDGM may be heading into 2020 and during the first couple months of last year. But that was mostly from agencies struggling with how to manage the concept of therapy visits not being tied directly to reimbursement anymore, Krafft said.

Nearly half of home health agencies planned to decrease therapy utilization in 2020, according to a mid-2019 survey conducted by the National Association for Home Care & Hospice (NAHC).

“I know, as a therapist, my brothers and sisters in the therapy universe get a little antsy … thinking that [PDGM] is going to be the death knell for therapy and that therapists are all going to lose their jobs,” Krafft told HHCN in 2019.

But COVID-19 threw a wrench in every agency’s plans. Experts warned that decreasing therapy recklessly would be potentially dangerous for patient outcomes.

It’s likely true that PDGM did have some influence on therapy utilization, but finding out how much could be an unrealistic task.

“We got through a couple months and then the pandemic began, and utilization took a completely different hit with respect to trying to determine how to manage the initial crisis mode of saving lives and minimizing risk,” Krafft said. “I think PDGM did have some influence, but I don’t think we’re going to ever really be able to say it was the sole thing that impacted utilization in 2020.”

Before the public health emergency, there was a wariness attached to scheduling therapy visits because of the onset of PDGM.

But after it, there was a shift in thinking, Dr. Monique Caruth, the CEO of Fyzio4u Rehab Staffing Group, said on the webinar.

“At the beginning of the year with PDGM, we were being questioned when we put visits at twice per week for four weeks, for instance, or three times per week for four weeks,” Caruth said. “We had clinical managers sending back messages saying, ‘We have to be careful because of PDGM.’ And then COVID hit. Then it went back to giving the therapist control of determining frequency.”

Caruth has been a licensed physical therapist in Maryland since 2008. She also serves as the southern district chair of the state’s American Physical Therapy Association (APTA) organization.

She was recently elected to lead the home health section of APTA. Her term begins in February.

The post-public health emergency shift in thinking didn’t last forever, however. Utilization patterns changed again once COVID-19 infection became a larger concern around therapy usage.

“[Agencies] were very careful and trying to limit the spread of COVID to clinicians, so if a patient was COVID positive, they wanted you to do one visit in person and one telehealth visit,” Caruth said. “I didn’t find that very accommodating for patients who were highly deconditioned. So I would base my frequency or recommend that all clinicians based their frequency on how the patient presented at the time of the evaluation.”

Caruth and her team have not yet seen any pushback from that practice, which is to diagnose the amount of appropriate visits strictly based on how the patient’s condition is.

It’s a positive example of how therapy should be utilized in a post-PDGM world, Krafft said.

“I think it becomes a crisis mode [reaction], and then a standard is set that we’re going to do one visit in person and then one telehealth visit,” Krafft said. “And we know that patient care does not work well as a one-size-fits-all. I think sometimes as therapists we dig in our heels about what we think our frequency should be, just because it’s what we’ve always done, too.”

Instead, the entire industry should be flexible to setting visits strictly based on what the patient’s condition and level of acuity is, she suggested.

It could be true that, after PDGM, some agencies began to undervalue therapy. But COVID-19 may have re-emphasized the importance of it, particularly in home health care.

In the recent $1.4 trillion spending bill passed by the U.S. government, occupational therapists (OTs) — for instance — were given the right to open home health cases.

The American Occupational Therapy Association sees that as an opportunity to change the perception around OTs generally — and now prove their worth further moving forward.

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Stimulus Money, Therapy Changes and COVID-19 Strategies: Top Home Health Stories of 2020

The Patient-Driven Groupings Model (PDGM) was supposed to define home health care in 2020.

Instead, this year was almost entirely shaped by COVID-19, a point that’s reinforced by the most widely read stories on Home Health Care News. Of the top-10 stories on HHCN in 2020, eight were related to coronavirus coverage.

From the first outbreak in Kirkland, Washington, to the latest developments in government support for health care providers, HHCN was on top of it all. Reflect back on this unprecedented year in home health care by browsing through the content below.

“House Stimulus Package Sets Aside $200 Billion for Front-Line Worker Hazard Pay” (May 13)

There have been several different federal COVID-19 stimulus packages passed since spring, with the House and Senate often locked in tense political debates on the details. HHCN’s top story of 2020 was an inside look at a May House proposal — the Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act.

While nothing came of the Democrat-backed bill, it did highlight the growing recognition of front-line health care workers. Specifically, the proposed relief package included a $200 billion fund for essential-worker hazard pay.

As of Thursday, lawmakers were reportedly close to signing off on a roughly $900 billion relief deal that would include another round of stimulus checks and other much-needed financial benefits for Americans. Liability protections for businesses — something Republicans have pushed for — are likely not included in the deal.

“AOTA, APTA Sound Off on PDGM’s ‘Terrifying’ Therapy Consequences” (Feb. 3)

Going into this year, one of the main storylines of PDGM was the reimbursement overhaul’s impact on in-home therapy services.

After the Patient-Driven Payment Model (PDPM) was implemented in the skilled nursing facility (SNF) space in October 2019, many operators opted to cut or furlough therapy staff. Some industry experts expected home health agencies to do the same.

Certainly, some providers did shift their therapy strategies. But it’s almost impossible to identify whether home health therapy cuts were tied to PDGM or the ongoing public health emergency.

“Home Health Providers Likely to Face Future COVID-19 Fallout” (May 6)

Early on, home health providers had to adapt to care for a surge of COVID-19-positive patients. Quickly, though, it became clear they would have to respond to other challenges as well.

Among those challenges: the influx of non-COVID patients that were getting discharged from hospitals faster to maintain acute care capacity. By not recovering in the hospital for longer, patients discharged to home health care in 2020 have been weaker and more deconditioned than in the past.

A similar trend has emerged — higher patient acuity levels — as referral sources looked to avoid congregate care settings like SNFs.

“Loopholes in COVID-19 Unemployment Program Threaten to Deplete Home Care Workforce” (April 7)

On one hand, labor experts predicted that a depressed economy and the closure of certain businesses would lead to a larger worker pool for in-home care agencies. On the other, initially robust unemployment benefits meant some caregivers could get paid more by opting out of work.

In conversations with HHCN, most home health and home care executives have said the recruitment and retention of workers remains extremely difficult.

“Calm Before the Storm: In-Home Care Providers Brace for COVID-19 Surge” (April 16)

Although COVID-19 outbreaks started to surface in mid-March, home-based care agencies didn’t start feeling pandemic pressures until mid- to late-April. Leading up to that time, operators scrambled to secure enough personal protective equipment (PPE) and educate their patients on the safety of their services.

“‘No Strings Attached’: CMS Sending $30 Billion to Home Health Agencies, Other Medicare Providers” (April 9)

In April, CMS announced that it was sending a first tranche of $30 billion to all Medicare-reimbursed health care organizations, with funding coming from the Public Health and Social Services Emergency Fund under the CARES Act. More tranches followed, with HHS releasing another $1.1 billion in direct aid to nursing homes on Wednesday.

“CMS Announces $165M to Support Home Care, Reduce ‘America’s Over-Reliance’ on Nursing Homes” (Sept. 23)

In September, CMS announced the availability of up to $165 million in supplemental funding to states operating Money Follows the Person (MFP) demonstration programs. While that news was exciting, it was related comments from Administrator Seema Verma that really piqued home-based care agencies’ interest.

The tragic devastation wrought by the coronavirus on nursing home residents exposes America’s over-reliance on institutional long-term care facilities,” Verma said at the time. “Residential care will always be an essential part of the care continuum, but our goal must always be to give residents options that help keep our loved ones in their own homes and communities for as long as possible.”

“Home Care Careers ‘Are Suddenly on the Map,’ But Recruiting Remains a Challenge” (Nov. 4)

Staffing continues to be a challenge for home-based care providers. Even as unemployment rose to record-highs during the COVID-19 crisis and demand for home-based care skyrocketed, providers found it hard to find qualified workers.

But one undeniable tailwind was how spotlighted home care careers became during the public health emergency. President-elect Joe Biden outlined a plan to boost the caregiver workforce, politicians vied for home-based care on both sides of the aisle, and everyday Americans become more aware of what home-based care workers did on a daily basis.

“One positive thing that I think came out of COVID — and I think this is just a real positive thing for the whole industry — is home care careers are suddenly on the map,” Brandi Kurtyka, the CEO of myCNAjobs told HHCN. “Senior care just got the biggest ‘Got Milk’ campaign that we’ve ever seen.”

“[Updated] House Passes CARES Act, Fast Forwarding Home Health Care Innovation Beyond COVID-19” (March 27)

Efforts have certainly stalled since, but when the initial relief packages came out in March, home-based care providers could not get enough of the details — of which there were many.

When the record-breaking $2 trillion stimulus package known as the CARES Act passed, providers were granted monetary and regulatory relief. It was the first shoe to drop in a litany of changes ultimately made to the home-based care space.

It created the Provider Relief Fund and made temporary, beneficial changes to reimbursement. But it also created a more virtual industry, rendering face-to-face requirements and other traditionally in-person practices as relics of the past.

As Confirmed Cases Rise, Home Health Industry Turns Its Attention to Coronavirus” (March 4)

This is the story that kicked everything off — the first time that HHCN reported on the coronavirus in 2020. “People have been asking me, ‘Where are we with the coronavirus?’” National Association for Home Care & Hospice (NAHC) President William A. Dombi was quoted saying. “It’s scary.” Those fears would soon turn out to be well founded.

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