Occupational Therapy and Home Health Care

For occupational therapy practitioners (OTPs) who are looking for flexibility, autonomy, and an occupation-based practice, home health care may be an option worth investigating.

According to the Centers for Medicare and Medicaid Services (CMS, 2022), "OT is an integral component of rehabilitative services in physical, cognitive, and psychosocial impairment. OT is based on purposeful, goal-directed activity (occupation). The goal of OT is to prevent, improve, or restore physical and cognitive impairment following disease or injury."

Recommended course: Home Health Therapy: An Overview for the Occupational Therapist Using the OASIS, 2nd edition

Providing interventions in a client's natural environment is an optimal practice setting for OTPs where clients perform their activities of daily living (ADLs), instrumental activities of daily living (IADLs), home and health management, and mobility in their home turf.

Furthermore, this approach to therapy allows clients to recover in their familiar and comfortable surroundings, thereby reducing stress. Caregiver and family education are vital in optimizing outcomes for consistent follow-through with care planning.

Qualifying disciplines

OTPs comprise the home health team with nursing, physical therapists, speech therapists, social workers, and home health aides. At present, occupational therapy (OT) is not a qualifying discipline. A qualifying discipline needs a particular service in the initial order to establish client eligibility for their service covered under the Medicare Part A home health benefit.

The client must also need an order for physical therapy, speech therapy, or skilled nursing. The order can include occupational therapy, but OT alone does not qualify for home health benefits covered under the Medicare Part A benefit (Grote, 2023). OT is a qualifying discipline for other insurers, such as Medicaid programs and private insurance plans.

OT can "stand-alone" for Medicare home health clients after discharge by other disciplines. If OT is the only discipline remaining, a client is still eligible for a second recertification period under the home health Part A benefit (Grote, 2023). OT can initiate the initial and comprehensive assessments for home health therapy-only clients not receiving skilled nursing care (Sandhu, 2023).

Eligibility criteria

When a physician or allowed practitioner (nurse practitioner, physician's assistant) orders or refers a client for home health services, the client is required to meet all five of the eligibility criteria:

1. Homebound status
2. Need for skilled services (can only be performed or supervised safely and effectively by a skilled professional)
3. In the care of a physician/allowed practitioner
4. Receive services under a plan of care authorized and reviewed by a physician/allowed practitioner
5. A face-to-face encounter with a physician/allowed practitioner for their current diagnosis

Homebound status

Homebound does not imply bedbound. The client's physician determines the homebound status based on their findings from evaluating a specific condition. If a client qualifies for Medicare's home health benefit, the plan of care will certify homebound status.

After receiving home health services, the physician must evaluate and recertify the plan of care (POC) every 60 days. The client is required to have a face-to-face encounter with their physician every 60 days.

To qualify for Medicare Part A benefits, a client must meet two criteria for homebound status:

Criteria #1 (one standard must be met)

• Clients either need assistive devices (crutches, canes, wheelchairs, and walkers), special transportation, or assistance from another person to leave their home because of an illness or injury OR diagnosed with a condition that makes leaving the home medically inadvisable

Criteria #2 (both standards must be met)

• Leaving home demands a considerable and taxing effort
• The usual inability to leave the home must exist

Homebound criteria for psychiatric clients include:

• Illness is demonstrated by a refusal to leave the home due to depression, paranoia, and agoraphobia
• Due to illness, it would be unsafe for the client to leave home (hallucinations, violent behavior)

Clients can leave their homes for the following:

• The necessity for medical treatment
• Participate in religious services
• Attend a licensed adult daycare center
• Family reunions, funerals, graduations
• Occasional trips to the beauty salon or barber

Beyond traditional occupational therapy

Leaving the structure and support of the clinic can be daunting when providing skilled OT in the home. The challenges of changing regulations, scheduling, documentation, driving, and setting up a "mobile clinic" requires flexibility, creativity, organization, problem-solving, "thinking on your feet," and a non-judgmental attitude.

OTPs will encounter an array of lifestyles, values, and home conditions that may differ from ours. Clients can cancel at the last minute, and scheduling conflicts occur, especially when several disciplines provide care. OTPs are "guests" in the client's home and must respect their wishes. Nevertheless, the rewards of providing occupation-based treatment in a client's natural environment outweigh the frustrations.

Strategies and techniques

OTPs employ expansive strategies, techniques, and therapeutic interventions for clients' independence, safety, and enhanced well-being, including:

• Evaluate and instruct clients and caregivers in daily activities
• Teach therapeutic exercise programs to increase joint mobility, strength, balance, and flexibility
• Address pain management for improved participation in daily activities
• Instruct in joint protection and energy conservation techniques
• Evaluate and recommend home safety modifications such as grab bars, handrails, footwear, lighting, rearranging furniture, smoke detectors, non-slip surfaces, and removing trip hazards to reduce falls and injuries
• Recommend modifications for accessibility, such as ramps, walk-in showers, lowering countertops, closets, and widening doorways
• Evaluate and instruct in the use of adaptive devices
• Evaluate and instruct in the use of assistive devices (wheelchair positioning and mobility, walkers, canes, and crutches)
• Make recommendations and train in assistive technology
• Instruct in stress reduction techniques for enhanced well-being
• Evaluate and teach compensatory strategies for improved functional cognition
• Caregiver education and support
• Provide resources such as loan closets for durable medical equipment, local agencies, and special transportation
• Recommend compensatory strategies for deficits such as low vision, decreased fine motor skills, or coordination (for example, teaching new ways to manipulate pills and containers)
• Instruct in medication adherence and management
• Evaluate and design interventions for sleep hygiene
• Instruct in emergency preparedness
• Communicate consistently with the interdisciplinary team and family members
• Evaluate and instruct in incontinence management
• Develop a plan of care for dementia to maintain independence and safety

Occupational therapy in disease management

The management of chronic diseases involves the management of daily activities. OTPs possess expertise in translating "doctors' orders" into manageable habits and routines. The ways that OT can help manage chronic conditions include:

Diabetes: The many aspects of diabetes management that must become daily routines include monitoring blood sugar, hygiene, foot care, meal planning and preparation, healthy coping strategies, incorporating physical activity into daily routines, and compensatory strategies for vision, sensory, or motor loss that can interfere with daily activities.

Heart failure: Occupational therapy addresses energy conservation strategies to reduce the demands of daily activities while incorporating appropriate physical activity and self-monitoring, such as daily weights and modified diets, into daily routines.

Chronic Obstructive Pulmonary Disease (COPD): OTPs address energy conservation strategies and self-monitoring to prevent exacerbations such as pacing, planning, and stress management into daily routines.

Pediatric home health

Pediatric OTPs provide treatment for infants through adolescents. Occupational therapy optimizes the child and adolescent's abilities and engagement in age-appropriate occupations. OTPs collaborate with family members to prioritize their most significant needs and incorporate them into therapy. Therapy intervention focuses primarily on feeding skills, gross and fine motor skills, eye-hand coordination, and social/emotional development. 

OTPs also evaluate and recommend home safety, accessibility, and equipment needs. Medicaid covers more than 75% of home care, non-Medicaid State Children's Health Plans (SCHIP); in some cases, private insurance plans will cover therapy (Hudak & Simpser, 2017).

Referral to pediatric occupational therapy

Referrals to occupational therapy include several conditions or injuries that interfere with development, such as:

• Prematurity
• Autism
• Down syndrome
• Dyslexia, dyscalculia, and other learning or sensory processing disorders
• Congenital cardiac disease
• Oral aversion/feeding disorders
• Plagiocephaly
• Fine motor issues
• Cerebral Palsy
• Cancer
• Neurodegenerative disease
• Serious injury or recovery
• Genetic diseases
• Chronic respiratory and pulmonary conditions

Pediatric occupational therapy treatments

Treatments are individualized for each child. Therapy for infants and toddlers may focus on feeding abilities and achieving developmental milestones. Older children may focus on fine-motor skills, eye-hand coordination, balance, and daily living skills. 

All treatments utilize play, which is a child's primary occupation. Therapy for injuries focuses on helping them return to sports, preferred leisure activities, or daily living skills. 

Benefits of home care for the pediatric population

Like adult home care, the natural environment allows therapists to individualize treatment in ways impossible in a clinical setting. OTPs develop treatment plans considering the home environment, family dynamics, and a child's disposition. 

Pediatric OTPs can utilize a child's favorite toys, engage in outdoor play, and maximize parent involvement to motivate the child in goal achievement.

Importance of family education

Parent education plays a more prominent role in the home because OTPs can take the time to talk to families in-depth about their challenges and concerns and the treatment plan needed to achieve their goals. 

To maximize the benefits of skilled OT, families are encouraged to carry over the recommended therapy program outside the sessions. Daily repetition solidifies the skills needed to achieve independence and safety.

Conclusion

Home health care in a client's natural environment reaps numerous benefits for maximizing independence, safety, and well-being. The flexibility and autonomy offer OTPs a work-life balance that is not always available in clinical settings. 

Although scheduling, documentation, cancellations, and driving challenges can result in frustration, the opportunities for creativity and making a difference in our clients' lives can outweigh the disadvantages of this unique practice setting.