The California Division of Workers’ Compensation is on the last lap toward promulgation of home health care regulations. It’s been a multi-year odyssey.
The second 15-day comment period ends on September 26,2016. I’d wager that it is unlikely that we’ll see further changes from the current version (see link to that below), though commenters can always lodge their opinions.
This is an issue of great importance to a small subset of California’s injured workers, i.e. some workers with the most life-changing injuries which severely impact the ability to get by without assistance.
The development of the home health care regs has followed the evolution of California’s MTUS (the Medical Treatment Utilization Schedule), and in particular the July 2016 adoption of the ODG-based Chronic Pain Medical Treatment Guidelines.
The prior version of MTUS had a very restrictive section on home health services.
The current version of MTUS says this about home health care services:
“Recommended on a short-term basis following major surgical procedures or in-patient hospitalization, to prevent hospitalization, or to provide longer- term nursing care and supportive services for those whose condition is such that they would otherwise require inpatient care.Home health care is the provision of medical and other health care services to the injured or ill person in their place of residence. Home health services include both medical and non-medical services deemed to be medically necessary for patients who are confined to the home (homebound) and who require one or all of the following: 1). Skilled care by a licensed medical professional for tasks including, but not limited to, administration of intravenous drugs, dressing changes, occupational therapy, physical therapy, speech-language pathology services, and/or 2) Personal care services for health-related tasks and assistance with activities of daily living that do not require skills of a medical professional, such as bowel and bladder care, feeding, bathing, dressing and transfer and assistance with administration of oral medications, and/or (3) Domestic care services such as shopping, cleaning, and laundry that the individual is no longer capable of performing due to the illness or injury that may also be medically necessary in addition to skilled and/or personal care services. Domestic and personal care services do not require specialized training and do not need to be performed by a medical professional (ACMQ, 2005) (Ellenbecker, 2008).A prescription or request for authorization for home health services must include justification for medical necessity of the services. Justification for medical necessity requires the physician’s documentation of: (1) The medical condition that necessitates home health services, including objective deficits in function and the specific activities precluded by such deficits; (2) The expected kinds of services that will be required, with an estimate of the duration and frequency of such services; and (3) The level of expertise and/or professional licensure required to provide the services.
Homebound is defined as “confined to the home”. To be homebound means:
- The individual has trouble leaving the home without help (e.g., using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of the occupational illness or injury ORLeaving the home isn’t recommended because of the occupationalillness or injury AND
- The individual is normally unable to leave home and leaving homeis a major effort (CMS, 2014).
Evaluation of the medical necessity of home health care services is made on a case-by-case basis. For home health care extending beyond a period of 60 days, the physician’s treatment plan should include referral for an in-home evaluation by a Home Health Care Agency Registered Nurse, Physical Therapist, Occupational Therapist, or other qualified professional certified by the Centers for Medicare and Medicaid in the assessment of activities of daily living to assess the appropriate scope, extent, and level of care for home health care services (CMS, 2015). The treating physician should periodically conduct re-assessments of the medical necessity of home health care services at intervals matched to the individual patient condition and needs, for example, 30, 60, 90, or 120 days. Such reassessments may include repeat evaluations in the home.
I can imagine situations where some workers are in dire need of assistance yet fall through this definition. That might include workers who are not strictly homebound but are prone to fall , or those with mental/behavioral challenges which interfere with their safety and judgment.
But the current version of the regs is an improvement.
The proposed new regs contain a definition of domestic services (housekeeping, laundry, food preparation, shopping, etc.) and personal care services (bathing, dressing, toiling, transferring bed/chair etc.).
Some confusion may be generated by the fact that the a section of the definitions defines home heath care services (including personal care services and domestic services) “in their place of residence”, yet obviously some of the defined domestic services would be outside the residence (shopping for instance).
Here is a link to the current version of the proposed Home Health Care Fee Schedule:
For some background on assorted issues with the proposed regs, here are the CAAA comments submitted in June 2016 at the time of the first 15-day comment period:
Governor Brown will be acting any day now on a raft of workers’ comp bills that are on his desk.