Diagnosis Dementia: Working with Patients with Dementia in Home Care under PDGM

Editor's Note: This text is a transcript of the course, Diagnosis Dementia: Working with Patients with Dementia in Home Care under PDGM, presented by Megan Malone, MA, CCC-SLP and Jenny Loehr, MA, CCC-SLP.

Learning Outcomes

After this course participants will be able to:

• Describe the patient-driven groupings model (PDGM) for reimbursement in home health care and its effects on speech-language pathology services.
• Identify at least two strategies to implement when working with patients with dementia and their caregivers in the home health setting.
• List two impact areas in which speech-language pathologists can demonstrate to agencies the value and need for their services.

Introduction

We are excited to provide some updated information regarding dementia and PDGM.

Dementia Facts

5.8 million Americans were diagnosed with Alzheimer's or other dementias in 2019. Dementia is not going away any time soon and there will be a continued need for us to work with these individuals. $290 billion is the estimated cost for caring for individuals with Alzheimer's or other dementia types in 2020. That means there will also be an increased burden on caregivers, family members, and patients.

25 percent of Medicare beneficiaries who are 65 and older with Alzheimer's or other dementias have at least one home health care visit during the year. This is an average compared with 10 percent of Medicare beneficiaries 65 and older without dementia. That means that most individuals who have a diagnosis are going to be seen by somebody from a home health agency. Home care is going to become more prominent in the years to come. Speech-language pathologists will play a part in dealing and working with individuals who have Alzheimer's and other dementias.

Home Health Facts

This information is critical if you are going to work in home health with individuals who have Alzheimer's or dementia. Home health agencies have to adhere to the Conditions of Participation (COPs). These are a set of rules and regulations that all home health agencies must follow if they are going to participate in the Medicare Reimbursement Program. If they want to get money from Medicare for the patients that they are seeing, they have to adhere to the rules that are put forth in the COPs. You do not have to memorize them, but you should have an idea of what the rules are according to Medicare. 

Home health agencies must ensure that patients meet eligibility criteria. This includes having a patient show that there is a medical necessity. They need to have a diagnosis and a disease that requires skilled care. They will also need medical care in their home. Patients have to demonstrate that they need our skills and have to be homebound. There is a lot out there about what homebound means for our patients in COPs, specifically regarding dementia. Let's say the caregiver takes a patient out of the home. It is most likely taxing on that patient, and we would potentially have to read about what a homebound status means. Safety is an important factor when it comes to home health-related aspects. If a patient is planning to leave the home when it is not safe to do so, that means that they are still homebound. It is important for speech-language pathologists to become familiar with the homebound criteria moving forward.

The Outcome and Assessment Information Set (OASIS) is a comprehensive assessment tool that is used in home health to establish eligibility. It helps determine how much service is going to be provided to the patient. It also helps you realize what kind of equipment is going to be needed. The OASIS is key to whether or not we are going to get reimbursed for the services that we provide the patient.

Home health agencies are responsible for STAR ratings, as well as meeting patient satisfaction and other functional outcomes. This has become a challenge throughout the shifts in reimbursement. We need to be mindful and understand that each and every one of us, speech-language pathologists in particular, play a role in these factors.

PDGM Myths

PDGM came into play on January 1, but there were still a lot of questions. I want to highlight some of the most popular myths that are still circulating about PDGM. The first myth is that Medicare no longer reimburses for therapy services, particularly for speech-language pathology. This is wrong because the Centers for Medicare and Medicaid Services (CMS) put out a statement about the importance of therapy services. It listed speech-language pathology services in regard to taking care of patients who are homebound and playing a part in home health care services. Medicare still reimburses for therapy services.

The second myth is that Medicare no longer reimburses for a patient with a dementia diagnosis. That is wrong. Medicare has not changed their eligibility criteria. Prior to PDGM, Medicare paid for patients' services even though it had a diagnosis of dementia. They still continue to reimburse for patients with a diagnosis of dementia.

Another myth is that Medicare allows for a set amount of therapy visits for patients per episode. The truth is that Medicare does not care how many visits a home health agency provides. That means it is up to the home health agency to determine how many visits should be provided to the patient. We would hope that the home health agency allows the clinician to make that decision, and ultimately oversees the physician who signs the plan of care.

Medicare no longer allows speech-language pathologists to perform OASIS assessments. This is wrong as well. Speech-language pathologists are given the privilege to provide the assessments during a patient's episode of care. I would say that it is more important now that speech-language pathologists are taking part in providing OASIS assessments moving forward.

The last myth is that Medicare will no longer reimburse maintenance therapy. Maintenance programs keep patients safe and aging in place, now more than ever. This needs to happen despite having a chronic or terminal illness such as dementia. 

PDGM Facts

In case you are not aware of how PDGM works, I am going to talk about the newest method of reimbursement for Medicare in home health services. It is the most significant, major reimbursement change we have had in 20 years. Prior to PDGM, home health agencies were reimbursed depending on therapy services. The more therapy services that an agency provided, the more reimbursement that agency received. Many agencies were incentivizing clinicians to provide more services. All of a sudden Medicare put on the brakes, so that is no longer the case. Agencies are reimbursed depending on patient characteristics.

There are multiple characteristics for reimbursement. These include the patient's diagnosis, what comorbidities there are for the patient, and the admission source, which is where they came from. There is more reimbursement for somebody coming from acute care rehabilitation centers and skilled nursing facilities (SNF) than in the community.

The timing can be complicated as well. This has to do with how many episodes the patient is receiving under the care of their home health agency. Additionally, the functional score comes from the OASIS. There is a set number of factors from the OASIS that will determine the level of functioning the patient is experiencing.

Billing cycles have changed with PDGM as well. We now bill every 30 days instead of every 60 days. Medicare has retained episodes of care to be at 60 days. Patients will be on service for 60 days with two separate billing periods within that episode. Accurate coding has always been important, but even more so now because reimbursement is dependent upon diagnosis and comorbidity. We have to be accurate in regard to how we submit our claims to Medicare.

Functional Impairment Levels

Functional impairment levels show whether somebody is functioning at a low, medium, or high level, which comes from certain OASIS items:

• M1800 Grooming
• M1810 Dressing Upper Body
• M1820 Dressing Lower Body
• M1830 Bathing
• M1840 Toilet Transferring
• M1850 Transferring
• M1860 Ambulation
• M1033 Risk for Hospitalization

These are called M questions, and the admitting clinician will get a baseline of these. With the next OASIS that is performed, whether it is for a recertification, transfer, or discharge, the scores are going to be compared to the first assessment. That is how you get your determination for reimbursement.

One Last Fact

I cannot stress how important it is to code these documents accurately. We do not expect you to be an expert, so you should be getting assistance from your home health agency. We should be doing whatever we can to get the most up-to-date diagnosis coding for that patient. Dementia diagnosis can also be added as a comorbidity. However, if it is only added as a comorbidity, it will not get as much reimbursement compared to using dementia as the primary diagnosis. If a patient has both a broken hip and a comorbidity of Parkinson's dementia, that will boost reimbursement. This way, your services can be covered by Medicare. In order to fit a primary diagnosis into the neurological reimbursement category, there are only two out of the 12 categories that take therapy services into account, which are neurological and musculoskeletal.

Some of your patients who have a primary diagnosis of dementia can be included in the neurological reimbursement category, and there may be reimbursement considered for therapy services. However, primary diagnoses for dementia have to be specific. For instance, the code is G31.83 for dementia with Lewy bodies. It is important that there is specificity regarding the primary diagnosis because that is going to help you get reimbursed for your claim. It is going to prevent an additional documentation request (ADR) from Medicare, meaning you would have to dig and find whatever can be covered.

Dementia Treatment Basics

The need for skilled services with our dementia patients has not changed. It is the mechanism for the reimbursement of those services that have undergone changes with PDGM as of January 1, 2020. Patients should continue to receive services that focus on cognition and strategies to assist with compensatory strategies for the effects of dementia. It is also important to train caregivers in changing the way they communicate with their loved ones.

All of the education and skilled treatments we have been providing for these patients should still be in effect. We may have to make a few concessions based on what is going on in terms of timing, as well as how we set up our sessions and prioritize goals. How do we navigate this differently while remembering that the way we treat these patients and caregivers should remain the same?

We should continue to evaluate and treat patients as ordered. Set goals and visit patterns that match the needs of the patient. Listen to what your clinical judgment and ethics tells you to do and make decisions based on that. We may have to make a few pivots for the amount of visits. If you do your evaluation and you see reasons for this person to receive services, then you would order your visits same as always.

You also want to think about your main priorities. Talk with your agency and the physician in order to get those approved. Agencies, as well as Medicare, should not be dictating the number of visits speech-language pathologists provide. If we are using the COPs and our agencies are receiving reimbursement from Medicare, we go by their guidelines. They do not dictate the number of visits, so that applies to the agencies as well. If you are hearing about this from your agency, those are discussions that need to be had. Your agency may be telling you what to do, but you may feel differently about what your patient needs. Is there a possibility for compromise? Can we look at the situation through a different lens

Speech-language pathologists and clinicians may be asked to improve the efficiency of care. What are the most important things this person needs to work on? That emphasis on patient and caregiver training is important as well. How can we use our expertise to provide instruction and demonstration to caregivers? Based on evaluations, how can we provide that information in a shorter number of visits?

We always should be prioritizing goals in a different way. The number of goals may shrink in order to focus on the ones that are going to be the most effective in terms of the patient’s safety and communication. 

These questions focus on the tenets of evaluation in home care:

• Can the patient communicate their very basic wants and needs?
• Can the patient take nutrition, hydration, and medication safely and in adequate amounts?
• Is the patient safe in their living environment?
• What kind of education/training is needed for the patient, family, and/or caregiver?

An example regarding communication would be teaching the person to call 911 or talk to an ambulance. How we evaluate the person's ability to communicate their basic wants and needs should be a priority as well.

We always want to take a look at the patient's nutrition level, hydration, and medication safety. Are they at any risk for deterioration? Are they at risk for confusion related to their medication? These factors play into functional outcomes and can have an impact. This would also include aspects like dysphagia treatment.

We want to look at safety as well. Do we need to modify their environment, or can we teach them to be safe? For example, you can help them to remember their equipment. You may think that that is more related to physical therapy. In reality, speech-language pathologists and physical therapists work hand-in-hand. The physical therapists work on the actual use of their equipment or implementing strategies while speech-language pathologists can help the patient remember how to do certain tasks. We can also use different cognitive techniques or visual supports to help people recall that they need to push off of their chair or have their walker before they leave the room.

Look into the education needs for the patient, their family, and the caregivers. We first want to assess the patient and their living environment, such as who they are living with. Regarding caregivers, we may have some who are ready to accept any recommendations that we give, while other times we do not get that. In that case, we might have to consider if this person needs more education. This could mean observing therapy, following through with written recommendations, or just understanding the basic deficits the person might be dealing with. For family members who have never dealt with this before, it is a lot of stress and new things to learn. These basics, such as shortening commands and questions, might not be second nature to most people. These are things that we can provide education on. We have to evaluate how willing and able that caregiver is, whether they are a family member or not. We then have to decide how long that training will take.

Prioritizing Goals

Here are some questions to consider while prioritizing goals:

• What treatment areas will affect this person the most?
• What means the most to the patient to address?
• What are some abilities and strengths the patient exhibits that can help them to successfully reach their goals?
• How many therapy sessions will you need to achieve these goals and/or how many sessions has the patient’s insurance provider authorized you to have to treat this patient?
• Does the patient agree that they need therapy?
• What goals will help build patient success?
• What other disciplines are involved?
• Are the patients’ caregivers willing to participate in treatment/carryover?

Addressing what means the most to the patient is important because we should be documenting what the person-centered goal is in our evaluations. These are discussions that we need to have with the patient. I try to frame the question in a way that suggests that if we could wave a magic wand and make something easier, what would it be? That can allow the person to express what they would like to focus on during treatment. You may receive dismissive responses or a lack of understanding about why you are there in the first place. We could then explain what speech pathologists do and how we are well-equipped to work with cognition and memory.

Asking about a patient’s abilities and strengths is a huge piece because our evaluation measures seek out the weaknesses. The person is coming in with a diagnosis and needs therapy, so we want to help improve an area that is not functioning normally. The patient’s abilities are going to be our foundation to assist with their weaker areas.

If the patient’s ability to read is preserved, we can incorporate some use of visual supports. With written cues, we may have to make some variations in terms of print size or location in order for the person to see them. This can be a way that we compensate for memory deficits. We can put a visual next to their plate at the dinner table or a reminder on their walker. We want to look at strengths and abilities in order to figure out how to circumvent the deficits that the person is exhibiting. This has changed the way I work with patients because it comes from a more positive perspective. Even if the person is advanced with something like dementia, they can respond to nonverbal cues, music, or touch and we can capitalize on those. If they cannot communicate verbally, their fine motor skills might still be intact. We could then provide communication cards or other forms of adapted augmentative communication so they can still express themselves. If we go from that perspective, it is more success-oriented for both the therapist and the patient.

We then have to look at how many therapy sessions we will need to achieve these goals, which is always hard for us. We have to use our clinical judgment to decide how long we think we need to see a patient. Under this new reimbursement model, there are changes that demand your attention. Your agency may say, “Can you try to complete your patient’s goals in a less amount of visits?” In this situation we may be thinking, “What priorities can I work on?” There may need to be some discussion with your agency. Just because you are given a few initial visits does not mean that you cannot go back in and work with them. Maybe we can dig in early, get things established, and see how they are doing. As skilled needs show up again, we can talk with the physician about additional visits.

Does the patient agree that they need therapy? Sometimes, people are more than willing to take the assistance that we provide. Other times they are not so keen on it. It is important to see what the patient is saying and listen to what they believe they need. We need to paint a clear picture for them about what type of assistance, instruction, and support we can provide to them. I think that changes their minds when they see how we can assist, even if we only have a couple of visits and we open them up to trying new things. When they see that they are capable of improving, they are more open to the process.

Look at the goals that will help build patient success and think about the disciplines that are involved. It has always been tricky to schedule within home care, stagger visits, and prioritize which disciplines should be involved at which points. It is helpful to weigh that into our decisions about what we want to do for the patient and what the biggest priorities are. If there are several other disciplines involved, we may have to look at staggering our sessions.

Goal Examples: Teaching and Training

Here are some examples of teaching and training goals:

• Caregivers will demonstrate knowledge of safe liquid administration by thickening liquids to recommend consistency independently.
• Family members will demonstrate knowledge of dementia resources by locating them in the education book provided.
• Caregivers will participate in training and education on using communication strategies and demonstrate ability to teach back strategies.
• Family members will list signs and symptoms of aspiration.

We want the family to know what they can do and how they can access information. Can the caregiver participate in training? Can they then teach? This can include decreasing the length of questions or commands, demonstrating that they can communicate with their loved one, listing the signs and symptoms of aspiration, and so on. There are a lot of ways that the caregivers can be involved in seeing the patient make progress, as well as maintain safety and function.

Important Note

It is important that the caregiver or family member states that they are willing to do therapy or willing to participate in caregiver training. However, it is also important that we document if they are unwilling to do so. Medicare will not reimburse for teaching and training of somebody who has stated that they do not want to learn. They do want to see that we are educating, instructing, and training the caregivers.  Do they demonstrate understanding? Were they able to perform teach-back methods? We need to document this in order to show that we are not just doing the education, but that the caregivers are following through as well.

If you have limited visits, do not limit your creativity because there is a lot to accomplish in a visit. Thoroughly educating caregivers requires an amount of time that we may not have.

Here are some basic ideas:

• Create a resource/education toolkit:
  • Handouts explaining communication strategies
  • Resources for memory strategies
  • Lists of websites or community resources
• Use functional materials in the home that will address identified priority goal:
  • ​Teach patient how to use cell phone to contact family, emergency services or set reminders for medication times

I frequently use this toolkit with a lot of my patients. I put together handouts on whatever I typically teach, such as cognitive strategies or communication strategies. It could also make a good visual support and include different websites they can look at. Do not just hand the caregiver a book and expect them to read it and understand. Instead you can say, “I thought we would focus on this one page” or “This is what I was focusing on with your loved one.” You can then ask if they had questions or ask them to demonstrate what they learned during the following visit. If you give a smaller assignment, people will follow through when they expect you to ask about it.

Another suggestion would be using functional materials in the home that address the identified priority goals. This does not change in the advent of PDGM. We need to know that a patient can show you how to use their cellphone in order to contact family or emergency services and set medication time reminders.

Documentation

Here are some points about documentation:

• Use the International Classification of Functioning, Disability and Health (ICF) Framework
• American Speech-Language-Hearing Association (ASHA) resource on goal-writing using ICF for Dementia:
  • https://www.asha.org/uploadedFiles/ICF-Dementia.pdf
• Document honestly and ethically
  • Prioritization of goals can possibly allow for more positive outcomes sooner
  • Keep communication open between yourself and your agency about documenting a patient's need for continuing care

In terms of PDGM, documentation remains the same as well. We want to use the ICF framework and there are great resources through ASHA on goal-writing. The linked PDF is specifically for dementia and it walks you through how to use that framework for the different things you might be working on with a person who has dementia.

Being able to document honestly and ethically is important as well. With prioritizing goals, we may be able to see more positive outcomes even sooner. However, I think it is important to maintain communication with your agency about documenting patient need for continuing care. Agencies should be demonstrating the importance of therapy and the frequency of meeting based on patient need, which is established by objective and measurable testing. It should all be data-driven, so we then have to make sure that we are documenting the ongoing need for treatment in every visit note. This not only refers to how caregivers follow through with goals or how the patient is progressing, but also how they are demonstrating a need for ongoing treatment. That needs to be shown in all of our documentation.

Goal Examples: Cognition & Communication

Here are a few examples of goals that relate to cognition and communication

• Patients will recall times of medication administration using visual cues to increase medication adherence over 3 consecutive therapy sessions using the Spaced Retrieval technique (technique used to help persons recall information over progressively longer intervals of time).
• Patients will demonstrate proper self-administration of medications by taking medications at correct dosage times as evidenced by use of medication checklist and assessment of patient’s medication organizer to insure medication adherence over 3 consecutive therapy sessions.
• Patients will correctly recall facility room numbers to decrease wandering in the facility and increase overall safety over 3 consecutive therapy sessions using the spaced retrieval technique (technique used to help persons recall information over progressively longer intervals of time).

These could be anything related to medication administration. It could be something like responding to an alarm or working on the safety issues of wandering. 

Goal Examples: Cognition

Keep in mind that a lot of these goals are not only expressing what we are going to be working on, but also why it is important and how it impacts safety or communication. Make sure that those are embedded in these examples:

• Patients will recall the need to ambulate with walkers at all times to decrease fall risk using visual cues at the initial trial of three consecutive therapy sessions using the spaced retrieval technique (technique used to help persons recall information over progressively longer intervals of time).
• Patients will recall and demonstrate recommended hip precautions to reduce risk of re-injury using a visual cue for eight out of 10 trials.
• Patients will demonstrate the use of communication cards to facilitate expression of wants, needs, and pain for 80 percent of trials with minimal support.
• Patients will recall the location of their personal memory book and use it in order to recall personal information and daily routines over three consecutive sessions using the spaced retrieval technique (technique used to help persons recall information over progressively longer intervals of time).

With hip precautions, that might be something that the physical therapist is working on. However, maybe we are also helping them remember what they can and cannot do as a result of their hip replacement. Again, this has not changed based on PDGM. We can look at working on a smaller amount of goals initially and continue to work with patients as needed.

Case Study

I want to use a case study as an example of working with a patient who has dementia in a facility setting. The man in the study was 75 years old and had a diagnosis of Alzheimer's dementia. He lived in an assisted living facility with fairly high-functioning residents. He was referred to speech therapy for wandering, which placed him at risk for his own safety, as well as upsetting the other residents.

The focus of the treatment was using the space retrieval technique and using visual cues. He used to raise pigeons, so they used some visuals of pigeons around the facility as a reminder of where he was supposed to go. He was initially seen by a speech-language pathologist for 22 visits over two certification periods, which occurred pre-PDGM. However, we wanted to illustrate how the needs for these patients do not change, even though we may prioritize things differently despite the reimbursement changes. He was also being seen by occupational therapists and skilled nursing.

Some other factors include him living on a busy street with no locked exits, experiencing increased confusion for time and place, scoring a 20 out of 30 on the Saint Louis University Mental Status (SLUMS) evaluation, and having an increased cognitive need. He was also wandering into other residents' apartments.

These were some of the goals that were addressed:

• The patient will correctly recall strategy to locate room using spaced retrieval prompt (“When you need to find your way, what do you do?”) in 80 percent of trials independently.
• The patient will locate visual cues in the facility for eight out of 10 trials independently.
• The patient will locate the dining room from his room using visual cues only in three out of five trials.
• Family and caregivers will show return demonstration of compensatory strategies with 100 percent accuracy.

When it came to locating rooms, he would look for the visuals of the pigeons. This demonstrates that if you prioritize meaning for a person, that can help keep them safe. Seeing a picture of a pigeon would not help me, but it was meaningful for this gentleman. Those visual cues were then used throughout the facility and became a goal for caregivers as well.

The family and caregivers expressed that they were willing to participate. The plan of care was then discussed within the team. When we want to prioritize goals, think back to the questions we previously addressed. Is the patient safe in their living environment? The answer in this situation was no. What kind of education or training is needed for the patient, family, or caregiver? In this instance, instruction on cueing for the patient, the use of the visual cues, and being able to cue the patient appropriately was necessary.

Under PDGM, we may look at scheduling visits differently. They may have set the visit pattern based on the evaluation results and the time established to meet the goals. However, if we are limited in visits or we want to prioritize, the way we would do that in this new environment is to focus on establishing visual support for the patient. Provide written instruction to the patient's caregivers and their family. Early caregiver instruction would be helpful if visits are limited.

Work with the patient to set up the recall. You can establish the space retrieval question, their recall of the response, and teach them to look for the visual supports. Doing this will get them a jumpstart on things, then that baton could be passed to the caregivers. Document that progress using ICF and discuss with your agency if more visits are needed, if a compromise can be made, or if we can keep tabs on him with skilled nursing and occupational therapists being involved. Bring speech back in at a later date if the patient or caregivers need more support.

Ethical Considerations

What we do with our dementia patients has not changed much over the years and we need to be smarter and more efficient in what we do.

There have been a lot of ethical considerations since PDGM came into effect:

• Qualified patients are not receiving the care they need.
• Home Health Agencies are dictating the plan of care without input from the attending physician.
• Home Health Agencies are altering the care plan (i.e. changing visits) without M.D. approval.
• Clinicians are asked to see patients without proper orders.
• Speech-language pathologists are asked to perform functions that are not within the scope of practice (i.e. wound care) or provide services without skilled service.

As a clinician, you will feel in your gut if something is right or wrong. The main gist of this ethical consideration is to ask yourself if you are doing the right thing. Am I doing the right thing? Is this right for the patient? Is this right for the industry?

Do not hesitate to be vocal. If you are being asked to reduce your visits or you are being told that the patient cannot be seen, report your concerns to your immediate supervisor. You can then report your concerns to ASHA. Sarah Warren is our current healthcare regulatory advisor and Medicare expert. She wants to hear from you if any aspect of your profession is compromised by PDGM, so you can get in touch with her through ASHA. She can then report those stories to CMS. You can also report your concerns to Medicare directly. If we start seeing that dementia patients are not being seen for therapy services under the home health agency's care, we are going to reach out and there will likely be a penalty. 

Speech-Language Pathology Impact Areas

You are valuable and that has not changed with PDGM. You have unique skills and knowledge, and you impact areas that are vital to home care. You can directly affect the improvement of outcomes, especially in areas such as medication management. This area is one of the reimbursement buckets. You can also reduce falls and rehospitalizations. You can impact STAR ratings, which then affects the agency referrals and reimbursement. Continue to provide care and encourage completion of agency satisfaction surveys. You can also participate in the agency's Quality Assurance and Performance Improvement (QAPI) program meetings.

Show Your Value

You can show your value by turning your mindset into demonstrating success through data. We need data to demonstrate the effectiveness of speech-language pathology. This data comes from evidence-based assessments and tools and leaves little room for questions regarding impact. Due to this, CMS took out a lot of questions on the OASIS document pertaining to speech-language pathology, communication, swallowing, and so on. We have to use evidence-based tools and be able to report back to CMS. You can talk about how you are doing with your patients and showing your value through using data and evidence-based tools.

Role in Conditions of Participation

Our role in the COPs has not changed, but speech-language pathology needs to be involved in completing the comprehensive assessments. Get the training that you need and become involved.

Here are some other aspect to remember:

• Completing the comprehensive assessment
• Coordination of care
• Care planning
• Participation in Quality Assurance & Performance Improvement committees/meetings (QAPI)
• Ongoing interdisciplinary assessment
• Patient/Caregiver counseling and education
• Medication management

PDGM Survival Strategies

The way that we are going to survive is to become more involved than we ever were before. Think hard about your decisions and take vital signs. Work with your physical therapists, occupational therapists, and your nurses.

Here are some other points:

• Better care planning and visit utilization
• Perform at the top of your license
• Collaborate and use a team approach
• Work outside of your silo
• Consider telepractice
• Perform OASIS assessments
• Get involved in medication management

I recommend that you go to ASHA for resources and opportunities for education on telepractice. I think it is going to be prominent in home health in the coming years.

References

American Speech-Language and Hearing Association (2020a). Demonstrating Value of Speech-Language Services in the New Home Health Payment Model; Accessed at https://www.asha.org/Practice/reimbursement/medicare/Demonstrating-the-Value-of-Speech-Language-Pathology-Services-in-the-New-Home-Health-Payment-Model/ on 3/10/20.

American Speech-Language and Hearing Association (2019b) Scope of practice for Speech-Language Pathology; Accessed at https://www.asha.org/policy/SP2016-00343/ on 3/10/20.

American Speech-Language and Hearing Association (2020c) Medicare Home Health Prospective Payment System: The Patient-Driven Groupings Model; Accessed at https://www.asha.org/Practice/reimbursement/medicare/Medicare-Home-Health-Prospective-Payment-System/ on 3/10/20.

American Speech-Language and Hearing Association (2020d). International Classification of Health and Disability. Accessed at 3/13/20 at https://www.asha.org/slp/icf/

American Speech-Language and Hearing Association (2020e). Person-Centered Focus on Function: Dementia. Accessed on 3/13/20 at https://www.asha.org/uploadedFiles/ICF-Dementia.pdf.

Centers for Medicare and Medicaid Services (2020); Home Health Patient-Driven Groupings Model; Accessed at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM on 3/10/20.

Loehr, J. & Malone, M (2013). Diagnosis Dementia: Goal Planning & Documentation in Home Care. Presented for www.speechpathology.com

Loehr, J. & Malone, M. (2019). Imagine the POSITIVE: PDGM strategies for SLP’s in Home Care. Presented at the annual convention of the American Speech-Language and Hearing Association, Orlando, FL.