Maximize Function

Reduced functional status is correlated with increased risk of readmission. Three measures relating to functional status are included in the home health agency Star Rating calculation. Functional and cognitive status assessment and improvement will also be part of new IMPACT Act measures adopted in the next few years.  Functional status is closely linked to risk of hospital readmission - meaning that home health agencies can address multiple important priorities by closely evaluating and developing improvement interventions targeting functional status

Relevant Medicare Measures - Home Health:
Managing Daily Activities 

  • How often patients got better at walking or moving around
  • How often patients got better at getting in and out of bed
  • How often patients got better at bathing
  • IMPACT Act: Functional status, cognitive function, changes in function and cognitive function 
 Top Tip: Involve occupational therapists to develop patient-specific plans that improve functional status and ADL performance
Best Practice Interventions
Goal: Address cognitive status and non-compliance barriers to physical function

Best Practice Interventions:
  • Screen all patients for depression or cognitive impairment
  • Document cognitive changes and depression as risk factors
  • Ensure consistent caregivers and assign caregivers with expertise working with patients with cognitive changes
  • Fully engage family and other caregivers. Assess caregiver factors that may impact readmission and include caregiver in plan of care
  • Refer to social work or community-based services for transportation, respite care.
  • Establish individualized functional status plan of care and that addresses patient-identified goals
  • Offer rehabilitation services to at risk patients, coordinating both therapy and skilled nursing activity
  • Refer to Occupational Therapy (OT) for ADL assessment and patient teaching
  • Include rehab staff (PT, OT) in developing Plan of Care that promotes improved functional status
  • Manage pain that limits function
  • Consider palliative care consultations for patients with pain/dyspnea related functional limitations
  • Educate referral sources (physician groups) on need for therapy, palliative referrals
  • Implement care pathways or EMR prompts to increase OT, palliative referral initiations within the agency
Goal: Staffing patterns applied effectively to ensure staff have expertise managing ADLs
Best Practice Interventions:
  • OT referral for ADL assessment, educational training and teaching with client
  • Front load therapy
  • Hire Rehab manager to coordinate activity of all therapists
  • Ensure therapists have plan of care directed at ADL-related goal improvement
  • Ensure adequate staffing of therapists, using therapy aides where permitted by State law
  • Use contract or travelling PT or OT staff as needed (with appropriate training and oversight to ensure their practice is consistent with agency objectives
  • Work with referral sources (physician groups) to educate on value of rehabilitation, including showing agency-specific metrics on improvements in ADLs
  • Implement care pathways or EMR prompts to increase OT referral initiations within the agency, and develop template referral request for physicians and hospitals that includes specific OT objectives
  • Develop relationships with rehab staffing agencies and/or travel staffing agencies.  Ensure consistent performance of contract staff by integrating these staff into the agency’s education, training, and evaluation programs. Assign work to contract staff based on demonstrated competency in both administrative and clinical functions.
  • Use a skills checklist to screen traveling or temporary staff, and interview carefully to ensure staff have necessary skills to impact functional status
Goal: Identify patient-specific improvement goals
Best Practice Interventions:
  • Establish individualized plan of care and patient goals
  • Introduce the option of palliative services combined with current treatment
  • Use motivational interviewing to identify patient goals
  • Have patient teach back goals and / or document them and post in the patient home
  • Engage caregivers and family in activities that contribute to improvement goals
  • Personalize patient educational material by reviewing it with the patient and document
Page updated August 2019