Home health care has enjoyed robust expansion in the past two decades. An historic lack of therapists working in home care gave physical therapists, occupational therapists, and speech-language pathologists the luxury of working in a high-demand environment during a period of low supply. This allowed clinicians to choose territories, schedules, and caseloads and immerse themselves in the home care realm at their own pace. Full time, part time, per diem, one patient on the way home, independent contractor, employed staff, salaried, benefited per visit...so many options and so few constraints! It was at this time that we entered home care-a golden time to begin. With minimal administrative-imposed responsibilities, we could revel in patient care rendered in a double-bookless environment that surpassed any clinic's or institution's attempts at providing a functional rehabilitation setting. Nothing could be more clinically relevant than restoring abilities in the patient's home.
Quickly, our attention turned from the uniqueness of patient care to the possibilities. Home rehabilitation was underutilized in the field and underrepresented in the office. Most agencies scrambled to provide therapy services for unsolicited referrals and did not have the rehabilitation staff to expand service provision. Willing therapists transitioned from independent field work to collaborative team roles. Attending weekly conferences and inservices provided opportunities for therapists to educate agencies on indications for rehabilitation, proper use of therapies, and the benefits of therapist input in care planning, home health aide supervision, and case management. We continued therapy provision in the home, now working in coordination with agencies rather than on distant, detached levels.
As agencies and therapists realized the potential of rehabilitation, momentum gained. Integration of rehabilitation on performance improvement teams, problem-solving committees, and task forces and expansion of roles to include inservice training, supervisory positions, and direct physician and payer marketing began. The blending of clinical and administrative roles heralded a recognition of rehabilitation as a vital, rather than ancillary home health care team member.
Now, at a crossroads, home rehabilitation adapts for continued evolution. While in the past, therapist participation in administrative home care issues was optional, the advent of managed care and prospective payment makes this participation mandatory. Home care therapists must fully integrate themselves in the workings of agencies, not only to safeguard quality patient care, but also at a more basic level, to protect the role of rehabilitation in the home. Pressures to contain costs within the changing financial framework of home care create incentives for agencies to downsize staff and step down patient care. Therapists who remain current with these changes and work with administration become valuable resources to agencies. This first of two home care issues of Topics in Geriatric Rehabilitation assists therapists with these tasks.
A primary marketing tool of agencies is proof of resource efficiency. The first article, "Cost Effectiveness of Home Rehabilitation: A Literature Review," is a necessary primer for home care therapists seeking to justify their cost efficiency. All home care articles reporting cost data that involved home rehabilitation services are summarized for easy information retrieval. Therapists can use this as a starting point in rehabilitation program design to evaluate what interventions succeeded and, more importantly, which ones failed.
Linda Treml and Carrie Carter Schulman's article shares the results of a pilot study investigating the enhanced use of support workers to provided nonskilled therapeutic programs to patients receiving rehabilitation. This article provides a template for therapist case managers working in capitated and prospective payment environments to attenuate therapy services with lower cost providers for optimum patient outcomes.
Judith Mitchell and Bryan Kemp's article enlightens home care therapists about the use of paid caregivers in the home. As incentives for early discharge from home services continue, therapist case managers will look more to the use of community resources to provide long-term custodial services to patients who do not have the potential to regain independence in those areas. This article explores issues related to patient satisfaction and problems encountered with paid attendants. Therapists use this information to realistically prepare patients and families for the scope of personal attendant services and to better coordinator these services for patients.
Finally, Linda Krulish offers a timely piece on niche program development. With the changing reimbursement climate come numerous opportunities to develop specialty areas in agencies that provide desirable market share. Whether the goal is streamlined after-care for elective arthroplasties or cutting-edge fall prevention programs, this article takes therapists step by step through the development, implementation, and evaluation of niche programs for rehabilitation.
Attention to historically administrative issues in home care such as these ensures rehabilitation practitioners a continued and rewarding role in home health care. We hope home care therapists will take the time to carefully read these selections. Keeping pace with current knowledge provides the only fitting backdrop for success in this new millennium.
-Michelle E. Moffa-Trotter, PT, GCS
Home Physical Therapist; Clearwater, Florida
-Wendy K. Anemaet, MS, PT, GCS, ATC
Home Physical Therapist; Miami, Florida