It is the equvilent of a DRG for diagnosis codes. Clinical : evals the pts medical status by assessing primary diagnosis, vision, level of pain,presence of ulcers, dyspnea, urinary, and bowel status, need for infusion, and behavior. Functional : asscess the pts ability to perform activies of daily living. Dressing , bathing , eating , toileting , transfering and ambulation. Service Utilization:determines what level of service the pt is likely to need based on location at the time of the home care referral home, hospital,skilled nursing and whether there will be a need for 10 or more therapy visits in the next 60 days.
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The purpose of this study was to present descriptive information on the characteristics of 2, Medicare home health clients, to quantify systematically their patterns of service utilization and allowed charges during a total episode of care, and to clarify the bivariate associations between client characteristics and utilization.
The model client was female, years of age, living with a spouse, and frail based on a variety of indicators. Specific subgroups of clients, defined by their morbidities and frailties, used identifiable clusters of services. Implications for case-mix models and implications for capitation payments under health care reform are discussed.
Several factors contribute to the heightened recent interest in understanding the role of home health care in the continuum of services for Medicare beneficiaries. Second, the increasing numbers of the very old among the Medicare beneficiaries are expected to contribute to more demand beyond the 2.
Third, the number of Medicare-certified providers also has been growing steadily over the past several years, increasing 43 percent from to to 6, HHAs U. General Accounting Office, and leveling off at 6, in This growth in the number of providers is expected to continue as hospitals continue to enter this market and as recent legal and administrative changes increase the Medicare services available to Medicare beneficiaries.
Last, the incentives of Medicare's hospital prospective payment system PPS have also contributed to increased use; shortened stays and more care needs at discharge have contributed to greater home care demand post-discharge Noether, All these factors have increased concerns about the growing expense of home care and, hence, interest in promoting its efficiency.
PPS and capitation systems are viewed as complimentary ways to redirect incentives from the current cost-based system, with its traditional inflationary incentives, to more cost-conscious behavior among the providers. An initial step towards promoting efficiency, either by PPS, a capitated managed care system, or any other policy redirection, is to document systematically the characteristics of current HHA clients, the actual services they receive, the charges for these services, and more importantly any significant associations between client characteristics and types, amount, and charges for services received.
Once current practices are systematically documented, the implications of redirections can be considered. A prior analysis of the present data examined the concordance between planned and approved visits during the first 60 days of home care Branch, Goldberg, and Cheh, The present analyses present descriptive information for total episodes of Medicare home health care.
These agencies had been recruited within 10 States California, Connecticut, Florida, Illinois, Massachusetts, Ohio, Pennsylvania, Tennessee, Texas, and Wisconsin from the universe of known HHAs in those States that met three inclusion criteria urban location, non-government operated, and established before January 1, A total of agencies met the criteria and were approached; expressed initial interest in participating in this data collection effort; and of these, 86 agencies actually submitted data.
From each of the participating agencies, a systematic sample of clients was selected, designed to yield approximately 80 to Medicare HHA clients per agency who were admitted for a new episode of care during calendar year The sampling fraction for each HHA varied; consequently, the individual responses were weighted by the inverse of the sampling fraction.
The sample sizes indicated in the tables are the number of respondents; the percents are based on the weighted data. For each client admitted to HHA care, HCFA Forms and are completed to establish medical necessity for home health care and to document treatment plans and other aspects of the case.
Therefore, for this analysis, the conceptual definition of a new episode was that the client had not been receiving HHA services for the preceding 60 days. The operational definition of the start of a new episode relied on the HHA percent Bill Skeleton file in the following way. The day after this day billing gap was designated as the episode start date for this analysis.
These 2, clients comprise the analytic group for this analysis, and their data were appropriately weighted. The end of an episode was defined as the last day of home health care following the start date that preceded another day gap in the HHA percent Bill Skeleton file.
The HHA percent Bill Skeleton file included all claims processed through September , which is 9 months after the start date of the last possible new episode during the study window of calendar year However, previous experience has shown that a 6-month lag in the processing of home health claims can exist, which could cause some distortions in exceedingly long episodes and some of the episodes that began in late We estimate that only a small percent may be truncated in our analysis.
Table 1 presents the weighted distribution of episode lengths of stay according to this definition. More than 40 percent of the Medicare HHA clients completed their home care within 30 days Only about 5 percent of the clients had episodes lasting 6 months or longer.
Although there were a few exceptions, the information provided on HCFA Forms and is without missing data in nearly all fields. HCFA Form provided sex and age categorized as under 65 years of age, years, years, and 85 years of age or over in this analysis information. The most common diagnosis was malignant neoplasms Type of services included skilled nursing, home health aides, physical therapy, occupational therapy, speech therapy, medical social work, and other.
Rates of service use were calculated both for the total sample and for the subset who received the specific type of service. Respondent characteristics are presented in Table 4 as cross-tabulations with allowed visits. Approximately two of every three HHA clients were female Living arrangement was unknown for nearly one-half of the clients Concerning the source of admission to the Medicare HHA, about one of every five came directly from the community Concerning their mobility restrictions, very few had none 3.
Approximately 1 of every 10 The vast majority of clients were receiving some prescription medications only 5. Two of every three were receiving four medications or more. Concerning nutritional status, nearly one-half CNS is central nervous system.
Eleven categories of functional limitations were identified for each of the HHA clients. The vast majority of the clients were reported to have endurance limitations The next most common limitations were reported for approximately one in every four clients vision limitations for Slightly less than one of every five clients were reported to have hearing limitations The remaining four limitations were reported for less than 10 percent of the clients: 7.
Simply summing across the number of limitations that any individual HHA client was reported to have, it is interesting to observe that the clients in general had multiple limitations. Only 1 in every 10 9. Nearly one of every three The last 30 percent had four limitations or more, including 4. The most prevalent diagnosis was malignant neoplasms Five to 10 percent had heart disease-other 8.
The 16th most common disease was chronic skin ulcer 2. Table 2 presents the distribution of allowed visits and charges for a total episode during for these Medicare HHA clients.
The vast majority of HHA clients received skilled nursing visits The remaining types of skilled care were provided to much smaller percents of clients, ranging from 14 percent receiving medical social work services to 2 percent receiving speech therapy. The second column of Table 2 presents the mean number of visits during the whole episode by type of visit for the total sample of clients.
The mean number of visits for all clients was Three of the services occupational therapy, speech therapy, and medical social work provided less than one visit on average to these clients.
The next column presents the mean number of visits for the subgroup that used the specific type of visit. Among users, home health aides provided the highest number of visits per regimen at Both physical therapists and occupational therapists provided about 8 to 10 visits, on average, to the subset who received them.
Medical social work was used both by a small percent Table 3 presents the distribution among these Medicare HHA clients of allowed visits and allowed charges during a whole episode by the type of visit. Inspecting the total visit column, the range varies considerably according to the type of visit the client received. The mean number of total visits among all clients was nearly 23 visits. However, those receiving speech therapy received almost 54 visits on average, with 11 to 12 visits on average from the speech therapist contributing to their increased amount.
Regimens of nearly 14 and 11 visits for skilled nursing and physical therapy also contributed to their visit average. An occupational therapy regimen of approximately 8 to 9 visits was also the norm of those receiving either speech therapy or occupational therapy, contributing to the total mean visits of 54 for the former and 47 visits on the average for the latter group.
For the 90 percent receiving skilled nursing services, their total mean visits was nearly 24, with more than one-half their visits The same patterns emerge when inspecting Table 3 from the perspective of allowed charges, suggesting that variation in charges were minimal, as implied by the homogeneity of charges per visit for skilled nursing and physical, occupational, and speech therapy as mentioned previously.
Table 4 presents the distribution of allowed visits during an episode according to the characteristics of the client. The patterns of allowed visits and charges as a function of the characteristics of the HHA client are very similar because of the homogeneity of charges among four of the professional therapies.
Therefore, the charge data are omitted from this table. Furthermore, the large sample size lends itself to observing frequent statistical significance between client characteristic and number of specific services, as indicated by a chi-square analysis. Consequently, statistical significance is not indicated in this descriptive report, and the authors' judgments concerning practical significance are.
Inspecting Table 4 for differences in total visits or types of visits associated with characteristics of the client suggests some interesting patterns. The sex of the client was associated with both the number of allowed visits and the charges for an episode, with females receiving slightly more skilled nursing visits in particular and more visits in general. An exception was observed with speech therapy, for which male clients received approximately two to three times more visits than female clients.
However, the prevalence of speech therapy is low even for males 0. The age of the client also had a moderate association with the number of allowed visits and charges. Those under 65 years of age received fewer visits in general and fewer skilled nursing and home health aide visits in particular. There were few differences in type or amount of services among the age subgroups of those 65 years of age or over.
Living arrangement had a modest association with services received. Those living alone received fewer total services Those living alone received fewer home health aide, physical therapy, occupational therapy, and speech therapy visits than the other household compositions, whereas those living with spouse received slightly more speech therapy services.
The admission source was associated with allowed visits and charges selectively. There were few differences in total services or type of individual services among those admitted from the community, from hospitals as medical patients, or from hospitals as surgical patients.
Those whose admission source was unknown 1. Those admitted from nursing homes again, a small subgroup at only 3. The relationship between the client's mobility restrictions on volume and cost of allowed services was extremely variable. Those with wheelchair restrictions received substantially more services
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