Setting Frequencies

Who sets frequencies? You do! But there are still factors to consider.  Below we will discuss some of these factors so that you can set frequencies to maximize patient progress while still keeping healthcare costs low.

Factors

Diagnoses (Exacerbated vs Onset, as well as severity)

How the patient presents is going to be one of the biggest factors.  A post-op ortho patient is going to be younger, on average, and more motivated. They are going to heal faster.  So typically you will see them for a heavy frequency and then quickly taper off.  Something like 3w1 2w1  or even 4w1 3w1 wouldn't be abnormal.  You're there to make sure they are acclimating to the environment, easing off any strong pain medications, having good recovery of the surgical wound, and learning to use their new body!  

A patient with a recent  CVA, on the other hand, may be a good candidate for PT, OT, and ST services with each going out a few times per week for a longer period of time.  We're trying to throw everything we've got at those patients to prevent long-term effects.  At the same time, the patient is likely to be exhausted with all of the appointments, so typically you will see these patients still 1-2 times per week for a period of 3-6 weeks.  With PT, OT, and potentially ST alternating - this means the patient is receiving daily or almost daily care.

An existing stroke, on the other hand, may be exacerbated but will not warrant visiting the patient for a high frequency and duration.  We aren't going to go back in time and change a chronic illness.  But we can help to set the patient up on the right path.  Visit the patient for 1-2 visits per week for several weeks and help them to learn the home exercise program, teach them or their caregivers safe transfers, and help them to move onto outpatient or community living.  

Prior Level of Function

This leads us to the discussion of Prior Level of Function. How a patient used to perform matters.  If they've had the chronic effects of a CVA set in, there is only so much we can do in home health.  We likely aren't going to restore their Prior Level of Function to before the disease onset.  However, we can help to get them to a place of renewed independence (or on the right path!) A post op patient may have previously required assistance due to degraded function, but will likely be a good candidate to get up to independent or modified independent! 

Higher PLOF: Patients who were more active and independent prior to the initiating event requiring home health may benefit from more intensive therapy initially to return to their baseline more quickly.

Lower PLOF: Patients who were less active or had pre-existing mobility issues might require a more gradual approach.

Insurance

Now let's be honest with each other here: insurance matters.  We may not like it, but there is a cost to the care that is provided.  Patients with Medi-Cal based plans like IEHP are going to be authorized fewer visits than patients with Medicare or even a private insurance.  The entire point of managed care plans is to decrease "waste".  Medicare continually changes payment methodologies (HHPPS to PDGM) and increases rates far below inflation to encourage more efficient use of home health services.  And as much as therapists want to believe that every visit is justified and fight for their patients, the job of the insurance is to ensure that there is justifiable, scientifically backed, skilled care being provided at each visit -- keeping insurance rates and taxes low while still providing what they say they will for a healthier population.  

So when setting frequencies, we definitely advise advocating for your patients and their needs, but also recommend being realistic.  Asking for 10 visits when you know 5 will get approved won't get the patient more visits.  If anything, the insurance might actually authorize 6 if you have good justification for it and appear to be asking in good faith.  

Special Programs

Intertwined with PLOF, insurance, and diagnoses are special programs.  This might be the so-called 'hospital at home' trial patients, AKA ECAH, that are receiving high frequency care at home rather than going to a SNF.  You can learn more about ECAH patients on our ECAH info page.  Hospice patients are also special cases.  You can read more about those on our hospice info page but the goal is different for hospice patients, so they will have lower frequencies and fewer visits.  Worker's Compensation patients are also special cases, with these patients often having orders  set by the worker's compensation company specific to the severity of the patient's injury.  You can read more about Worker's Compensation patients on our Worker's Compensation info page.  

Caregiver Involvement

Caregivers can truly make or break a patient's success!  Some caregivers may frequently cancel visits or refuse to schedule, while others may motivate the patient to exercise and take your wisdom into account.  At an evaluation if you have a motivated caregiver involved, you may be able to visit the patient less frequently and for a shorter period.  Patients without the support of caregivers may need to see you more frequently and for a longer period of time.  

If Caregivers are no longer available, you should explain why.  If the daughter was available because she took time off work, but is no longer available to help a patient move on to outpatient, for instance, you should note this specifically.  This helps to justify home health as opposed to outpatient. 

Patient Motivation

Patient involvement is key to setting a frequency, careplan, and justifying care.  It isn't our job to judge patients who may be struggling with frustration or depression as a result of their situation, but ultimately we cannot go out to visit patients continuously if they are not showing progress.  Often this means exercising when you aren't there and participating in therapy.  When in doubt, talk to the agency and they should be able to assist you with managing an unmotivated patient against our responsibility to ensure they are receiving comprehensive care.  

We've also had therapists tell us "the patient wanted the visits but I think they're fine" while writing an evaluation that attempts to justify care -- albeit unconvincingly! If you're running into this, be honest with the agency.  It might be harder to have this conversation with the patient, but it is far better to discuss your clinical judgement with the family honestly and to let the agency know if you are running into any problems.  Occasionally some agencies may authorize a visit or two to  keep their customer, the patient and/or physician, happy.  But the true payor, the insurance, will always want there to be a convincing argument.  

Agency

The agency is there as a middle-man to keep everyone happy. They must ensure you feel heard as the clinician, the physician feels heard as a referral source and the ultimate decision-maker for the patient, they must keep the patient happy, and they either must manage the expectations of the insurance or, in the case of Medicare, be the utilization managers.  In many instances they may also be the knowledge base on the patient, having insight into this patient's medical history, if they are a "frequent flyer" and other services they may be receiving in conjunction.  

As a contractor, it should be your job to balance your ethical duties to the patient with the customer service you aim to provide to the agency.  Setting high, unnecessary, unjustifiable frequencies will degrade trust -- especially when they are paying per visit.  Fighting with the agency, badmouthing them to the patients, or attempting to circumvent them by going straight to the physician is going to result in a degraded relationship.  Instead, try to trust that they are making decisions that are within the best interest of the patient and reach out if you are struggling to understand their thought process or struggling with how to convey your viewpoint.  

Day of the Week

This might sound odd as a factor, but it's a big one! Very frequently we have clinicians request 2x/wk on a Friday...but the week ends on Saturday! When will this 2nd visit happen? Or a 1w1 2w3 with the eval on a Monday or a Tuesday.  That means the patient won't get their first visit for a full 7 more days.  The first week we should be frontloading to ensure the patient is getting more intensive care when they are most vulnerable.  Now we all know why this happens. It has to do with availability.  

Maybe the patient doesn't want to be seen for their first followup until next week.  If that's the case, write that! "Patient is declining another visit until next week".  Just explain and know the risks this present for rehospitalizations or falls, especially if the patient was a recent discharge from the hospital or SNF.  And of course if the patient has told you they're waiting until after their surgeon appointment on X date, their MBS, an MRI, or otherwise-- always chart that.  

Now perhaps you know the PTA/COTA (or even yourself) won't be available until next week.  Reach out to us! We can't promise that we will have anyone available with short notice, but we're happy to try.  But we staff PTAs and COTAs with the assumption that an Evaluation will be performed on a set day, resulting in a set number of visits being completed that week.  If the evaluation is delayed, you can also document and we'll give them and the agency a heads up.  

Sunday-Wednesday: Recommend ordering 2 visits unless you have a 1x/wk POC.  Explain gaps due to tests, medical appointments, or other patient delays.  

Thursday-Saturday: Recommend ordering 1 visit unless this is a very high frequency case.  

Justifiable Skilled Care

What all of this really comes down to is skilled, justifiable care.  We've seen it all here at Lifespan. "I want 15 visits to work on the home exercise program" is met with "why can't the therapist teach a home exercise program in several visits?"