In-Home Therapy after Knee Replacement

In-home physical therapy (PT) helps knee replacement patients recover more successfully, with six to nine PT visits being a generally optimal level of treatment.

That’s according to research findings from the University of Colorado School of Medicine, recently published in the Journal of Bone and Joint Surgery. A team of physical therapists analyzed Medicare home health claims for patients who received total knee arthroplasty in 2012 and subsequently had in-home rehabilitation.

The review involved nearly 6,000 Medicare beneficiaries.

Individuals who received fewer than five home health visits from a physical therapist had more problems in resuming activities of daily living, the researchers found.

The results of this study have implications for a bundled payment model known as Comprehensive Care for Joint Replacement (CJR). In this program — mandatory in certain markets identified by the Centers for Medicare & Medicaid Services (CMS) — hospitals are responsible for managing costs for a full 90-day care episode for orthopedic patients, including their surgery and post-acute rehab.

Because therapy is more costly to provide in inpatient settings such as skilled nursing facilities (SNFs), CJR hospitals are incentivized to route more patients directly home after surgery.

However, if these patients do not receive appropriate levels of at-home PT, they could be at higher risk of a re-hospitalization — and being readmitted to the hospital drastically drives up the episodic cost of care.

Generally, patients in rural areas and who have other complex medical conditions receive fewer home health visits, the researchers found.

“Our study may help care providers prescribe more optimal dosages of at-home physical therapy for these patients who are discharged,” said lead author Jason R. Falvey, Ph.D., in a post on the CU School of Medicine website. “ … The risks of not providing the appropriate level home health care may result in higher overall health care costs in the long term.”

Adding a further wrinkle: The proposed Patient-Driven Groupings Model (PDGM) would change the Medicare home health payment framework to dis-incentivize high volumes of therapy.

Written by Tim Mullaney

Major changes for the “Good” for Medicare-2019

Medicare Advantage is an increasingly prominent payer for home health agencies. These plans — offered by private insurers using government funds — also will be allowed to cover private duty home care services starting in 2019.

“Although there have been many strides in adopting and using virtual care and telehealth within the past year, there is considerable opportunity for the home health industry to more fully embrace the power and value of this technology,” Horner said. “Barriers include the fear of a new technology being disruptive to current workflows, lack of an IT infrastructure which can support patients’ evolving digital health habits, and reimbursement policies.”

In October, CMS proposed a rule that would give MA plans more flexibility to offer government-funded telehealth benefits to all enrollees, regardless of whether they live in rural or urban areas. In addition to eliminating the market restriction, CMS’ proposal would also allow MA enrollees to receive telehealth services from home, rather than requiring them to go to a clinic, SNF or other health care facility.

If implemented, the proposed changes would go into effect for the 2020 plan year. In part, CMS is proposing the changes, according to the agency, because the Bipartisan Budget Act of 2018 allows MA plans to offer “additional telehealth benefits” as part of government-funded “basic benefits.”

Medicare Advantage is an increasingly prominent payer for home health agencies. These plans — offered by private insurers using government funds — also will be allowed to cover private duty home care services starting in 2019.

“Expanded access and coverage for virtual care will benefit the entire health care ecosystem,” Horner said. “The use of technology to allow visiting nurses and home health providers to deliver care remotely will optimize productivity by turning ‘drive time’ to ‘patient time,’ while also helping agency owners and administrators better hire, train and retain talent.”

‘A step in the right direction’

Spun out of Stratus Video’s telehealth division at the beginning of 2018, Synzi is an example of the impact telehealth can have on home health providers’ operations. Synzi’s tech platform uses a combination of video, email and secure messaging tools to help home health providers stay in touch with patients.

Trilogy Home Healthcare, a Florida-based home health company with roughly 3,000 patients and about 700 employees, began using Synzi in June across a handful of its locations.

“The feedback we have received from referral sources has been very positive,” Trilogy CEO Dale Clift told HHCN. “The accounts that are using the Synzi platform appreciate that we are being proactive in case managing our shared patients.”

Trilogy is not yet able to quantify how telehealth has improved its operations, Clift said, but promising findings have been reported in a number of past pilot programs.

One telehealth home health pilot program in Colorado, for example, reported a 62% reduction in 30-day re-hospitalizations related to congestive heart failure, chronic obstructive pulmonary failure and diabetes. Over a 60-day episode of care, emergency department use also fell sharply, as did nurse home visits and costs of care.

“Anytime CMS approves and reimburses for additional services that will enable the patient to get better comprehensive care and engages them in their own outcomes is a step in the right direction,” Clift said. “Right now, telehealth is an incurred cost and an investment by the agency. I think with the current landscape, one needs to be a ‘big picture’ and forward-thinking type of agency in order to validate the return on investment.”