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Assessing Functional Ability for an Effective Plan of Care

    A patient’s functional ability is a key factor to consider in creating a home health care plan. The intent is to discharge the patient with better, safer functional ability, demonstrating improved outcomes. 

    According to the Centers for Medicare & Medicaid Services (CMS) guidelines, the therapist must use an objective method to assess the patient’s function during the evaluation visit and compare the measurements over time. Following the assessment of the patient, the home health physical therapist (PT) develops a personalized care plan with a specific treatment goal aimed at helping the patient reach their best functional level. This plan should address any barriers or deficits identified during the comprehensive assessment while considering the patient’s prior level of function as a baseline.

    Assessing the Prior Level of Function

    Here are some tips for gathering accurate information about the patient’s “prior level of function” when conducting a therapy evaluation and comprehensive assessment at the start of care:

    1. Check medical records or ask the patient or their caregiver

    The patient may have been seen by your agency in the past or the physician could have documented the patient’s previous ability in the referral paperwork. In cases where this documentation is not available, the guidance suggests that we can inquire with the patient and/or the caregivers about their prior ability. Nevertheless, it is essential to verify the accuracy of the information received from these sources. It is important to know whether the patient was performing these tasks safely before their illness or injury, who made this determination, and the timeframe in which it was made.

    1. Look for exacerbation

    For certain cases, the change in the patient’s ability is typically evident and the onset of a disease process is much more detectable. However, for patients with chronic conditions, this becomes more challenging. In such cases, we need to observe an exacerbation, which is defined as an acute increase in the severity of a condition, indicating a worsening. We need to identify what changed from their baseline state even with that disease. For example, if they have congestive heart failure, we need to determine whether they have developed chest pain, increased fatigue, or shortness of breath. What was their condition like before this change? We are not focused on a specific timeframe but rather on identifying a noticeable change.

    1. Consider other factors such as the patient’s environment and social determinants of health (SDoH)

    In the case of a patient who recently experienced a fall, we need to evaluate their condition before the fall. We should also assess how the fall has impacted the patient’s life. They might be experiencing pain, relying on a walker, unable to walk, or temporarily confined to a chair. We must analyze how this event has brought about physical, functional, and emotional changes.

    Developing the Plan of Care

    Documentation is essential in rehabilitation. If goals exceed the patient’s prior level of function, robust documentation is needed to justify how and why the patient can achieve higher, safer independence. We must also consider whether the patient’s prior level of functioning was safe and include details about the timeframe and circumstances of their baseline abilities.

    Upon discharge from home healthcare, it is crucial to assess the patient’s ability to leave their home, perform safe car transfers, and complete everyday tasks safely. The goal is to discharge the patient with improved, safer functional ability, resulting in better outcomes and positive patient satisfaction feedback.

    Consistency and Accuracy in Documentation

    The plan of care should be consistent with the OASIS and therapy evaluation. The OASIS serves as a record of the comprehensive assessment conducted at the beginning of care. It gathers information about the patient’s previous ability to perform self-care tasks (dressing and bathing) and functional tasks (ambulation and transfers).

    Developing the Plan of Care involves considering numerous factors. It is crucial for your clinicians and QA support staff to collaborate closely to ensure an accurate, compliant, and patient-centered Plan of Care. Here are key aspects to look out for:

    • Ensure precise responses to the functional M and GG items.
    • The therapy evaluation should provide a clear understanding of the patient’s functional needs, enabling the identification of appropriate goals and interventions.
    • Assess the patient’s potential for rehabilitation.
    • Ensure the provision of appropriate assistance.
    • Verify the correct parameters and frequency of treatment modalities.

    Read more about improving home health therapy documentation here>