Occupational Therapy in Home Health and Quality Outcomes for High-Risk Rural Medicare Beneficiaries

PURPOSE AND BACKGROUND: Rural home health patients tend to be sicker and at higher risk for readmission than urban patients (Probst & Bhavsar, 2014), and home health agencies serving rural patients face several barriers to providing care (Skillman et al., 2016). Furthermore, the optimal amount and mix of services needed to achieve high-quality outcomes is unknown. This study examined the association between service provision, including occupational therapy, and quality outcomes for rural beneficiaries receiving home health for conditions that placed them at high risk for readmission and emergency department use.

METHOD: This study was a retrospective cohort analysis of rural Medicare beneficiaries who received home health after hospitalization for acute myocardial infarction, heart failure, pneumonia, or chronic obstructive pulmonary disease between 2011 and 2013. Data sources were Medicare administrative data, including home health claim, Outcomes and Assessment Information Set, and Provider of Services files, combined with Area Health Resource File and USDA Economic Research Service county typology files.

Outcomes included community discharge after the initial 60-day episode of home health and hospital readmission and emergency department use during the initial 60-day episode of home health. Service provision measures included number and type of visits received by occupational therapy, physical therapy, speech therapy, skilled nursing, medical social work, and home health aide visits. To assess relationships between service provision and outcomes of care, we used hierarchical multiple logistic regression models to account for clustering of beneficiaries within counties and controlled for sociodemographic and clinical characteristics of beneficiaries as well as characteristics of communities and home health agencies.

RESULTS: Of the 47,838 beneficiaries included in this study, 23.5% received occupational therapy. Receiving any occupational therapy was associated with 11% higher odds of community discharge (95% confidence interval [CI] [1.04, 1.19]) but 16% higher odds of hospital readmission (95% CI [1.10, 1.24]). Receiving any occupational therapy was not significantly associated with odds of emergency department use. Receiving more skilled nursing visits, any home health aide visits, and any medical social work visits was associated with significantly worse performance on one or more quality outcomes. The number of occupational therapy, physical therapy, and speech therapy visits combined was not significantly associated with quality outcomes.

CONCLUSION: More service provision and the involvement of more disciplines in home health generally did not lead to better quality outcomes for this population of high-risk rural beneficiaries. Occupational therapy did contribute to a higher likelihood of community discharge but did not decrease readmissions. These seemingly inconsistent findings reflect the potential benefit of occupational therapy in home health for helping rural beneficiaries remain in the community, but also the challenges of preventing readmissions for rural beneficiaries with higher acuity and greater service needs from multiple disciplines. Policymakers, payers, and providers need to consider how current reimbursement mechanisms and possible redesigns affect service provision and outcomes for rural Medicare beneficiaries, especially those who may need extensive services.

References

Probst, J. C., & Bhavsar, G. P. (June, 2014). Differences in case-mix between rural and urban recipients of home health care. Columbia: South Carolina Rural Health Research Center.

Skillman, S. M., Patterson, D. G., Coulthard, C., & Mroz, T. M. (2016). Access to rural home health services: Views from the field (Final Rep. No. 152). Seattle: WWAMI Rural Health Research Center, University of Washington.