Getting Started in Home Care

The delivery of speech-language services in the home allows for one-on-one interaction in an environment where the patient is most comfortable. Therapy activities can be tailored to address "real life" functional needs. The home setting also provides opportunities to individualize each patient's care plan to their specific environmental and social needs.

From the standpoint of the speech-language pathologist, home care practice affords added flexibility and autonomy, interaction with patients and families on a personal level, and opportunities for true interdisciplinary service delivery.

Patient Demographics

The following information comes from the National Outcomes Measurement System (NOMS) data collected from ASHA members across the country.

Age range of home care clients

• 50-59 years: 10%
• 60-69 years: 15%
• 70-79 years: 35%
• 80 years and older: 35%

Top 5 primary medical diagnoses of home care clients

• CVA: 63%
• CNS diseases: 8%
• Respiratory diseases: 5%
• Hemorrhage/Injury: 3%
• Other neoplasm: 2%

Top 5 Functional Communication Measures scored by SLPs working in home care

• Swallowing: 54%
• Spoken Language Expression: 37%
• Motor Speech: 29%
• Spoken Language Comprehension: 26%
• Memory: 15%

Average length of stay for home care clients

37 days

Reimbursement mechanism

Home care speech-language services may be covered by Medicare, Medicaid, private insurance, other third party sources or may be private pay. Coverage often requires the recipient to be homebound. Physician orders are usually required as well as on-going physician certification of the plan of care.

Impact of reimbursement system on clinician

Formal assessments are required for all new patients. Completion of the OASIS data set is required for Medicare reimbursement. The amount of the home health agency's reimbursement for each episode of care is generated from the OASIS assessment data. Accrediting bodies, such as the Joint Commission or CHAP may define additional specific assessment criteria. Pre-authorization and regular follow-up for additional visits are often required. Documentation must accurately reflect the need for skilled, intermittent care.

Referral process

Patients may be referred for home speech language intervention upon discharge from a hospital, rehabilitation, or long-term care facility. Physicians may also refer patients directly to home health providers.

Collaboration with other disciplines

Home care is the ideal venue for team collaboration. For example, a patient from a recent CVA might have the following treatment team in addition to the services of the speech-language pathologist:

• Registered Dietitian-for diet modifications
• Medical Social Worker-to obtain needed home medical equipment, counseling regarding role change
• Physical Therapist-positioning for feeding, gait training
• Occupational Therapist-assistance with feeding and writing
• Registered Nurse-medication management and the effects of on speech, language, and swallowing performance

To achieve successful patient outcomes the home care team must work together to select and reinforce all segments of the plan of care. For example, other team members might ask simple questions and look for the use of three word responses during their sessions, while the SLP would have the patient walk from the kitchen to the living room during the speech session.

Documentation Requirements

Documentation requirements vary from agency to agency. Some agencies use point of care electronic charting while others may use agency specific forms or SOAP notes. Each patient encounter (visit, care coordination, MD contact, etc.) is documented. Visit notes describe patient status, treatment and patient response, teaching and response, assessment of the visit and plans for future visits. The OASIS data set must be completed at the start of care, recertification, transfer, resumption, or discharge time points. If speech-language pathology is the qualifying service, the SLP may be the one to complete the OASIS.

Resources

Go to the SLP Health Care area of the ASHA Web site to access:

• ASHA Speech-Language Pathology Health Care Survey
• Health care frequently asked questions (FAQs)
• ASHA member forums
• Issue Briefs

Go to the Billing and Reimbursement section of the ASHA Web site to access:

• Medicare Fee Schedule
• Billing and coding information
• Reimbursement frequently asked questions (FAQs)
• Medicare Medical Review Guidelines

Go to ASHA Practice Policy to access ASHA policy documents on preferred practice patterns, dysphagia, clinical record keeping, autonomy, etc.

Centers for Medicare & Medicaid Services

Outcome and Assessment Information Set (OASIS)