Guide to Re-Assessments in Home Health for Therapists

When to Perform a Re-Assessment

Re-assessments in home health are an essential part of ensuring that patients continue to receive appropriate care, but there must be appropriate justification and timing. 

They should be conducted based on the following guidelines:

1. Every 30 Days (Required)

   • Re-assessments must be completed every 30 days, typically within days 25-30 of your initial visit, to comply with Medicare and home health regulations. 

     1. This may be documented for compliance purposes on long frequencies such as 2w8, which would require a “30 day re-assessment.”

     2. You should not re-assess a patient simply because a frequency has ended (IE the end of a 2w2). Instead, additional visits could be ordered within a Therapy Order with justification for the add-on frequency.  

2. Change in Patient Condition (Rare Cases)

   • If there is a significant and measurable change in the patient’s condition, such as a decline in function, a new diagnosis affecting mobility, or a significant improvement warranting modification of the care plan, a re-assessment is necessary.

3. Requesting Additional Visits (Only When Justifiable)

   • Therapists often submit re-assessments to request additional visits; however, these should only be done when there is a true, justifiable need for continued skilled care. 

     1. As discussed above, these should only be input on day 25-30.  

What Does NOT Justify a Re-Assessment for Additional Visits?

Therapists should avoid requesting additional visits solely because of:  

• Lingering pain or weakness: Patients may continue to experience some pain or weakness, but this alone does not justify continued care. Many patients can manage symptoms through medication, stretching, or other modalities without additional  skilled therapy intervention.  The stretching and exercises for weakness would have been addressed during the visits.  

• Residual weakness: If the patient has been properly trained in safe transfers and home exercise programs, they should be able to continue their progress independently (with or without the assistance of caregivers).

• Inability to perform ADLs independently: Home health focuses on rehabilitation, not long-term personal care. Patients who require ongoing assistance with ADLs should have caregivers, whether family members or paid caregivers. If a caregiver is unavailable, an MSW referral for In-Home Supportive Services (IHSS) could have been initiated earlier. Additionally, OT’s can request for adaptive equipment and train patients and caregivers on its use during the initial course of treatment.

• Fall Risk Without Justification – If the patient has already been taught fall prevention strategies, home modifications, and a balance program, continued therapy is unnecessary unless there is a new risk factor.

• Slow Progress – Lack of rapid improvement does not automatically justify ongoing skilled therapy. Home health is for short-term intervention, and patients should transition to self-management or outpatient therapy if needed.

• Patient/Family Request for More Visits – Just because a patient or family wants continued therapy does not mean it is medically necessary. There must be an objective, skilled need that was previously not addressed or required further intervention .

• Lack of Motivation to Perform Exercises Independently – If the patient has been instructed and is physically capable but chooses not to follow through, this does not justify continued skilled intervention.

• “Insurance Will Cover It” Mentality – Additional visits should not be justified simply because insurance allows it. The need must be medically necessary and skilled.

• Chronic Conditions Without Skilled Need – If a condition is stable and therapy is not actively altering the patient’s progress in a meaningful way, home health therapy should end.

• Personal relationships - Just because you like the patient, doesn’t mean you should re-assess them indefinitely! 

• To maintain your caseload - There are always more patients, we’re facing an unprecedented number of patients, if you find your caseload is not what you would like please reach out so we can get you more patients! 

When is Continued Therapy Justified?

A re-assessment for additional visits may be appropriate if:

• There is a significant functional decline or new impairment requiring skilled intervention that came about After your initial evaluation.   

• Teaching on durable medical equipment (DME) needs to be expanded, but only if this was not adequately addressed during initial visits. If teaching was deferred, there must be a clear justification for why it is now necessary (such as equipment delivery). 

• Patient’s condition has changed significantly, requiring an updated care plan with measurable goals. E.g. upgraded or downgraded weight bearing status.

• New Safety Concerns or Environmental Barriers – If a patient’s home setup has changed, creating new risks that require skilled intervention to ensure safe mobility.
  New Functional Goals Emerging – If new goals have been identified that are essential for the patient’s independence and require skilled therapy.

Key Takeaways

• Re-assessments are mandatory every 30 days but should not be used to justify additional visits unless there is a significant skilled need.

• Therapists should not request extensions for routine pain, weakness, or inability to perform ADLs unless there is a skilled component requiring continued therapy.

• Home health is temporary and meant to provide short-term, justifiable skilled care.

• Proper discharge planning should be in place to ensure the patient can continue progress independently or with caregiver assistance.

“The question every therapist should ask themselves, when considering a reassessment is, what or why was this impairment not addressed during the initial care plan”

By following these guidelines, therapists can ensure that re-assessments are used appropriately and in alignment with home health regulations and patient needs.

How to Input a Re-assessment

The final visit will always be plotted as a Discharge visit on EMR.  If you visit a patient to assess them and identify that they require additional visits, you can change the visit type and hit ‘Update’ to easily transfer information over from your discharge visit note.  If you require assistance with this, please notify the office and they can support you!

Upon submitting your Re-assessment, the team will either call this in to the agency for approval or submit to the agency for insurance authorization, depending upon the patient’s payer.  

Upon approval, the visits will be plotted and you, along with any relevant parties such as PTAs or COTAs, will be notified.  

Upon denial, you will be notified and your documentation will be re-coded to a discharge.  At this point, you should let us know if you do not understand or agree with the agency’s reasoning so that this can be resolved from an ethical and documentation perspective.  Please note that the agency will always advocate for the patient, but may have a different set of standards or information.  Quality documentation will go a long way in helping the agency to understand your perspective as well. 

Reassessment Documentation Prompts

Use this checklist to help guide your reassessment notes and ensure medical necessity is clearly supported.

Functional Status

• Has the patient made progress toward current goals? Watch for plateauing, indicating max potential.  

• Are goals being met, partially met, or not met — and why? 

  • Remember: unmet goals do not mean there is continued skilled care to be provided.  

• What functional limitations remain (e.g., gait, transfers, stairs)? Why hasn't therapy already addressed this?

Example: Patient has made steady progress towards goals, improving from Mod assist to Min assist with sit-to-stand transfers, allowing for more independent ADL completion. Patient has the potential to reach Modified Independent to further reduce caregiver burden. However, progress was temporarily slowed by an upper respiratory illness during week 2 of care. Despite caregiver presence during most transfers, patient has not yet demonstrated consistent independence with use of assistive device (FWW) due to impaired motor control and poor activation of left gluteal musculature. During transitions, patient exhibits left hip drop consistent with Trendelenburg gait, resulting in compensatory trunk lean and reports of lateral hip and low back pain. Continued skilled PT is necessary to address underlying hip abductor weakness (Glute Med 3-/5), retrain safe transfer mechanics, and progress toward modified independence with transfers. Training sessions will focus on targeted strengthening, neuromuscular re-education, and repeated task-specific practice using AD. 

Changes Since Last Visit

• Any change in medical condition, such as hospitalization, new diagnosis, or decline? How will skilled therapy help with this?

• Has there been a recent fall? Why weren't fall precautions addressed previously? If they were, why will more therapy suddenly help?

Example: Patient reported a fall last night, resulting in bruising on left hip.  Patient had recently expressed eagerness to resume ambulation due to improved strength and endurance, and attempted to transfer without caregiver assistance. While caregiver support had been limited but present during the initial weeks of care, recent schedule changes have left gaps in supervision, which were not previously anticipated. Though fall precautions had been introduced (e.g., education, equipment recommendations), patient’s increased confidence may have led to overestimation of abilities. Additional therapy is indicated to reassess safety awareness, reinforce adherence to assistive device use, and train on strategies for safe unassisted transfers. PT will also coordinate with MSW to revisit need for in-home support services due to caregiver limitations.

Example: Patient experienced a recent CHF exacerbation, resulting in increased shortness of breath and fatigue with minimal exertion. While patient had previously demonstrated good carryover of home exercise program and safe use of assistive devices for ADL completion, they are now struggling to tolerate basic mobility tasks, such as ambulating to the restroom or completing grooming activities without rest breaks. Patient is currently under the care of their primary physician for medication adjustments, but due to deconditioning and fluctuating endurance, skilled PT is required to re-establish safe activity tolerance. Therapy will focus on energy conservation techniques, pacing strategies, and adjustment of the HEP to match the patient’s current cardiopulmonary status. Education will also be provided on monitoring vital signs during activity to avoid overexertion and prevent rehospitalization.

New/Updated Equipment

• Has any new DME been delivered (e.g., walker, wheelchair, hospital bed) which now requires training?

• Is the patient safe and independent with the equipment? Does the patient require further training with the equipment? Why wasn't this addressed during prior visits?

Example: A front-wheeled walker was delivered during the third week of care. While patient received initial training, they continue to demonstrate unsafe compensatory strategies, particularly during turns and when fatigued. During session, patient was observed using the walker to lean and rest, compromising balance and increasing fall risk. Skilled PT is necessary to reinforce proper gait mechanics, safe turning techniques, and teach alternative methods for energy conservation and rest breaks during ambulation. Continued training is needed to reduce fall risk and promote functional independence.

Example: A Hoyer lift was recently delivered, enabling safer and more feasible transfers for the caregiver. While the family has begun initial training, skilled therapy is required to ensure proper use of the device, including safe body mechanics, sling application, and transfer positioning. Patient’s participation in transfers will also be facilitated as tolerated. Additional sessions are necessary to prevent injury to caregiver, ensure consistent use of lift, and improve patient's comfort and safety during transport to appointments.

Example: Patient began using a bedside commode to reduce the distance required for toileting due to recent episodes of lightheadedness. However, they continue to exhibit impaired dynamic balance during transfers and require cueing for safe sequencing. PT is needed to train the patient on safe sit-to-stand techniques, appropriate use of handholds, and transfer strategies to reduce fall risk. Continued sessions will focus on strengthening and improving transitional movements to restore independence with toileting.

Caregiver Dynamics

• Are there new caregivers involved? Who are they and how will they safely care for the patient?

• Do existing caregivers need education or training on patient safety, mobility, or transfers? Why haven't they learned these things during prior visits?

• Is there caregiver concern or difficulty noted? 

Example: Patient’s daughter recently became the primary caregiver. She has received basic instruction but requires further training on safe transfer techniques, proper body mechanics, and fall prevention strategies to reduce injury risk for both patient and caregiver. At next session, caregiver will be trained on home exercise program (HEP), cueing strategies, and slide board transfers to promote safety and confidence in daily caregiving tasks.

Example: Patient’s spouse has assumed increased caregiving responsibilities due to a recent decline in patient’s mobility. However, caregiver expresses difficulty assisting with toileting and bed mobility, citing fear of injury and lack of proper technique. Skilled therapy is required to provide hands-on caregiver training, education on adaptive equipment, and strategies for safe patient handling to promote continued care at home and reduce risk of caregiver burnout.

Home Environment

• Any changes in the home (e.g., moved to a new location, added stairs, clutter)?

• Environmental barriers impacting the plan of care? Discuss these and how more visits will help with this.  

  • Remember: Refusal to make modifications is within the patient's right, but may limit progress and may cut skilled care short.  Continued lack of modifications is unlikely to be improved by further visits.  

Example: Patient recently moved from her daughter’s single-story home to her son’s residence nearby. The new environment presents several accessibility challenges, including four steps separating the patient’s living space from essential areas such as the kitchen and bathroom, and a bathtub in place of the previous walk-in shower. Training on tub transfer bench usage, stair navigation, and grab bar placement will be conducted to support patient safety and functional independence in the new environment.

Example: Patient’s home was recently modified with new flooring that has increased slickness, particularly in the bathroom and hallway. Additionally, several rugs and thresholds pose tripping hazards. Skilled therapy is required to conduct a home safety assessment, train on hazard negotiation, and provide recommendations to minimize fall risk and improve mobility within the altered environment.

Plan of Care Adjustments

• Have goals or expectations changed? Why?

• Do goals need to be updated or revised?

• Is continuation of therapy justified based on current status, potential for improvement, and objective facts surrounding the need for skilled home health therapy?

Example: Patient progressed from Max assist to CGA for transfers and was beginning ambulation in week 3, but developed a UTI in week 4 resulting in temporary functional regression. Although condition is resolving, the patient now exhibits hesitancy and reduced balance confidence. Although patient has been educated in safe ambulation techniques, they now demonstrate compensatory gait patterns and reduced reaction time with perturbations due to hesitancy post-infection. Skilled intervention is required to re-assess gait mechanics and retrain balance strategies to prevent re-injury and promote safe functional mobility 

Safety Considerations and Patient/Caregiver Goals

• Is the patient safe for current mobility level?

• Is the patient motivated to continue therapy? This isn't alone a reason to re-assess, but is an important factor. 

• Are there any risks that need to be addressed before discharge? Why haven't these been addressed during prior visits?

Example: Patient has demonstrated inconsistent adherence to HEP, citing pain and lack of understanding of the purpose of certain exercises. During session, PT observed incorrect mechanics leading to increased strain. Additional skilled sessions are required to re-train on correct techniques, address barriers to compliance, and re-educate patient on the importance of each exercise in regaining independence. Patient non-adherence is observed as resolvable through alternative teaching strategies to address modifiable factors such as poor health literacy and compensatory strategies being incorrectly utilized due to pain.