Advertisement

Home Health Agency Characteristics and Quality Outcomes for Medicare Beneficiaries With Rehabilitation-Sensitive Conditions

Published:September 21, 2017DOI:https://doi.org/10.1016/j.apmr.2017.08.483

      Abstract

      Objective

      To examine associations between organizational characteristics of home health agencies (eg, profit status, rehabilitation therapy staffing model, size, and rurality) and quality outcomes in Medicare beneficiaries with rehabilitation-sensitive conditions, conditions for which occupational, physical, and/or speech therapy have the potential to improve functioning, prevent or slow substantial decline in functioning, or increase ability to remain at home safely.

      Design

      Retrospective analysis.

      Setting

      Home health agencies.

      Participants

      Fee-for-service beneficiaries (N=1,006,562) admitted to 9250 Medicare-certified home health agencies in 2009.

      Interventions

      Not applicable.

      Main Outcome Measures

      Institutional admission during home health care, community discharge, and institutional admission within 30 days of discharge.

      Results

      Nonprofit (vs for-profit) home health agencies were more likely to discharge beneficiaries to the community (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.13–1.33) and less likely to have beneficiaries incur institutional admissions within 30 days of discharge (OR, .93; 95% CI, .88–.97). Agencies in rural (vs urban) counties were less likely to discharge patients to the community (OR, .83; 95% CI, .77–.90) and more likely to have beneficiaries incur institutional admissions during home health (OR, 1.24; 95% CI, 1.18–1.30) and within 30 days of discharge (OR, 1.15; 95% CI, 1.10–1.22). Agencies with contract (vs in-house) therapy staff were less likely to discharge beneficiaries to the community (OR, .79, 95% CI, .70–.91) and more likely to have beneficiaries incur institutional admissions during home health (OR, 1.09; 95% CI, 1.03–1.15) and within 30 days of discharge (OR, 1.17; 95% CI, 1.07–1.28).

      Conclusions

      As payers continue to test and implement reimbursement mechanisms that seek to reward value over volume of services, greater attention should be paid to organizational factors that facilitate better coordinated, higher quality home health care for beneficiaries who may benefit from rehabilitation.

      Keywords

      List of abbreviations:

      CMS (Centers for Medicare & Medicaid Services), HHA (Home health agency), HRR (Hospital referral region), OASIS (Outcome and Assessment Information Set)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Mechanic R.
        Post-acute care–the next frontier for controlling Medicare spending.
        N Engl J Med. 2014; 370: 692-694
        • Newhouse J.P.
        • Garber A.M.
        Geographic variation in Medicare services.
        N Engl J Med. 2013; 368: 1465-1468
        • Medicare Payment Advisory Commission
        Report to Congress: Medicare Payment Policy.
        Medicare Payment Advisory Commission, Washington (DC)2014
        • US Senate Committee on Finance
        Staff report on home health and the Medicare therapy threshold.
        US Senate Committee on Finance, Washington (DC)2011
        • United States Senate Committee on Finance
        Baucus, Grassley question for-profit home health agencies on relationship between operating procedures and reimbursements.
        United States Senate Committee on Finance, Washington (DC)2010
      1. Centers for Medicare & Medicaid Services (CMS). Medicare Geographic Variation Public Use File (GV-PUF). Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Geographic-Variation/GV_PUF.html. Accessed October 30, 2017.

      2. Goldberg H.B. Delargy D. Schmitz R.J. Moore T. Robel M. Case-mix adjustment for a national home health prospective payment system. Second interim report. Abt Associates, Cambridge (MA)1999
        • Harrington C.
        • Woolhandler S.
        • Mullan J.
        • Carrillo H.
        • Himmelstein D.U.
        Does investor-ownership of nursing homes compromise the quality of care?.
        Int J Health Serv. 2002; 32: 315-325
        • Li Y.
        • Cai X.
        • Yin J.
        • Glance L.G.
        • Mukamel D.B.
        Is higher volume of postacute care patients associated with a lower rehospitalization rate in skilled nursing facilities?.
        Med Care Res Rev. 2012; 69: 103-118
        • Liu K.
        • Black K.J.
        Hospital-based and free-standing skilled nursing facilities: any cause for differential Medicare payments?.
        Inquiry. 2003; 40: 94-104
        • Murray P.K.
        • Love T.E.
        • Dawson N.V.
        • Thomas C.L.
        • Cebul R.D.
        Rehabilitation services after the implementation of the nursing home prospective payment system: differences related to patient and nursing home characteristics.
        Med Care. 2005; 43: 1109-1115
        • O’Neill C.
        • Harrington C.
        • Kitchener M.
        • Salidba D.
        Quality of care in nursing homes: an analysis of relationships among profit, quality, and ownership.
        Med Care. 2003; 41: 1318-1330
        • Toles M.
        • Anderson R.A.
        • Massing M.
        • et al.
        Restarting the cycle: incidence and predictors of first acute care use after nursing home discharge.
        J Am Geriatr Soc. 2014; 62: 79-85
        • Aldridge M.D.
        • Schlesinger M.
        • Barry C.L.
        • et al.
        National hospice survey results: for-profit status, community engagement, and service.
        JAMA Intern Med. 2014; 174: 500-506
        • Carlson M.D.
        • Gallo W.T.
        • Bradley E.H.
        Ownership status and patterns of care in hospice: results from the National Home and Hospice Care Survey.
        Med Care. 2004; 42: 432-438
        • Wachterman M.W.
        • Marcantonio E.R.
        • David R.B.
        • McCarthy E.P.
        Association of hospice agency profit status with patient diagnosis, location of care, and length of stay.
        JAMA. 2011; 305: 472-479
        • Haldiman K.L.
        • Tzeng H.M.
        A comparison of quality measures between for-profit and nonprofit Medicare-certified home health agencies in Michigan.
        Home Health Care Serv Q. 2010; 29: 75-90
        • Cabin W.
        • Himmelsein D.U.
        • Siman M.L.
        • Woolhandler S.
        For-profit Medicare home health agencies’ costs appear higher and quality appears lower compared to nonprofit agencies.
        Health Aff (Millwood). 2014; 33: 1460-1465
        • Decker F.H.
        Profit status of home health care agencies and the risk of hospitalization.
        Popul Health Manag. 2011; 14: 199-204
        • Grabowski D.C.
        • Huskamp H.A.
        • Stevenson D.G.
        • Keating N.L.
        Ownership status and home health care performance.
        J Aging Soc Policy. 2009; 21: 130-143
        • Han B.
        • McAuley W.J.
        • Remsburg R.E.
        Agency ownership, patient payment source, and length of service in home care, 1992-2000.
        Gerontologist. 2007; 47: 438-446
        • Smith L.M.
        • Lapane K.L.
        • Fennell M.L.
        • Miller E.A.
        • Mor V.
        Home health agency profit orientation and risk for hospitalization: a propensity score analysis of population weighted data.
        Home Health Care Serv Q. 2008; 27: 240-257
        • Jung K.
        • Shea D.
        • Warner C.
        Agency characteristics and changes in home health quality after Home Health Compare.
        J Aging Health. 2010; 22: 454-476
        • Dartmouth Medical School
        Appendix on the geography of health care in the United States.
        Dartmouth Medical School, Lebanon, NH1998
        • United States Department of Agriculture, Economic Research Service
        2003 rural-urban continuum codes.
        United States Department of Agriculture, Economic Research Service, Washington, DC2004
        • FitzGerald J.D.
        • Boscardin W.J.
        • Ettner S.L.
        Changes in regional variation of Medicare home health care utilization and service mix for patients undergoing major orthopedic procedures in response to changes in reimbursement policy.
        Health Serv Res. 2009; 44: 1232-1252
        • Buntin M.B.
        • Garten A.D.
        • Paddock S.
        • Saliba D.
        • Totten M.
        • Escarce J.J.
        How much is postacute care use affected by its availability?.
        Health Serv Res. 2005; 40: 413-434
        • Ottenbacher K.J.
        • Graham J.E.
        The state-of-the-science: access to postacute care rehabilitation services. A review.
        Arch Phys Med Rehabil. 2007; 88: 1513-1521
        • Rabe-Hesketh S.
        • Skrondal A.
        Multilevel and longitudinal modeling using Stata.
        2nd ed. Stata Pr, College Station2008
        • Williams R.L.
        A note on robust variance estimation for cluster-correlated data.
        Biometrics. 2000; 56: 645-646
        • StataCorp
        Stata Statistical Software: release 10.
        StataCorp LP, College Station2007
        • SAS Institute
        Release 9.4 for Windows.
        SAS Institute, Cary2014
      3. Centers for Medicare & Medicaid Services. Medicare & Medicaid statistical supplement, 2010 Edition. Table 2.3-Medicare enrollment: hospital insurance and/or supplementary medical insurance enrollees, by demographic characteristics, type of entitlement, buy-in status, and residence, as of July 1, 2009. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareMedicaidStatSupp/2010.html. Accessed July 15, 2014.

        • Russell D.
        • Rosati R.J.
        • Andreopoulos E.
        Continuity in the provider of home-based physical therapy services and its implications for outcomes of patients.
        Phys Ther. 2012; 92: 227-235
        • Probst J.C.
        • Towne S.
        • Mitchell J.
        • Bennett K.J.
        • Chen R.
        Home health care agency availability in rural counties.
        South Carolin Rural Health Research Center, ColumbiaJune 2014
      4. CY 2016 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements (proposed rule).
        Fed Regist. 2015; 80: 39839
        • Schade C.P.
        • Brehm J.G.
        Improving the home health acute-care hospitalization quality measure.
        Health Serv Res. 2010; 45: 712-727
        • Plotzke M.
        • Christian T.J.
        • Fout B.
        • Keane N.
        • White A.
        Medicare home health prospective payment system case-mix methodology refinements: overview of the home health groupings model.
        Abt Associates, Cambridge, MA2016

      References

        • Bettger J.P.
        • Stineman M.G.
        Effectiveness of multidisciplinary rehabilitation services in postacute care: state-of-the-science. A review.
        Arch Phys Med Rehabil. 2007; 88: 1526-1534
        • Bilney B.
        • Morris M.E.
        • Perry A.
        Effectiveness of physiotherapy, occupational therapy, and speech pathology for people with Huntington’s disease: a systematic review.
        Neurorehabil Neural Repair. 2003; 17: 12-24
        • Blake M.L.
        • Frymark T.
        • Venediktov R.
        An evidence-based systematic review on communication treatments for individuals with right hemisphere brain damage.
        Am J Speech Lang Pathol. 2013; 22: 146-160
        • Bowen A.
        • Knapp P.
        • Gillespie D.
        • Nicolson D.J.
        • Vail A.
        Non-pharmacological interventions for perceptual disorders following stroke and other adult-acquired, non-progressive brain injury.
        Cochrane Database Syst Rev. 2011; : CD007039
        • Bowen A.
        • Lincoln N.
        Cognitive rehabilitation for spatial neglect following stroke.
        Cochrane Database Syst Rev. 2007; : CD003586
        • Cherney L.R.
        • Patterson J.P.
        • Raymer A.
        • Frymark T.
        • Schooling T.
        Evidence-based systematic review: effects of intensity of treatment and constraint-induced language therapy for individuals with stroke-induced aphasia.
        J Speech Lang Hear Res. 2008; 51: 1282-1299
        • Choi M.
        • Hector M.
        Effectiveness of intervention programs in preventing falls: a systematic review of recent 10 years and meta-analysis.
        J Am Med Dir Assoc. 2012; 13: 188.e13-188.e21
        • Chudyk A.M.
        • Jutai J.W.
        • Petrella R.J.
        • Speechley M.
        Systematic review of hip fracture rehabilitation practices in the elderly.
        Arch Phys Med Rehabil. 2009; 90: 246-262
        • Crotty M.
        • Unroe K.
        • Cameron I.D.
        • Miller M.
        • Ramirez G.
        • Couzner L.
        Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people.
        Cochrane Database Syst Rev. 2010; : CD007624
        • Deane K.
        • Jones D.E.
        • Ellis-Hill C.
        • Clarke C.E.
        • Playford E.D.
        • Ben-Shlomo Y.
        Physiotherapy for Parkinson’s disease: a comparison of techniques.
        Cochrane Database Syst Rev. 2001; : CD002815
        • Deane K.
        • Whurr R.
        • Clarke C.E.
        • Playford E.D.
        • Ben-Shlomo Y.
        Non-pharmacological therapies for dysphagia in Parkinson’s disease.
        Cochrane Database Syst Rev. 2001; : CD002816
        • Di Monaco M.
        • Vallero F.
        • Tappero R.
        • Cavanna A.
        Rehabilitation after total hiparthroplasty: a systematic review of controlled trials on physical exercise programs.
        Eur J Phys Rehabil Med. 2009; 45: 303-317
        • Dixon L.
        • Duncan D.C.
        • Johnson P.
        • et al.
        Occupational therapy for patients with Parkinson’s disease.
        Cochrane Database Syst Rev. 2007; : CD002813
        • Duncan P.W.
        • Horner R.D.
        • Reker D.M.
        • et al.
        Adherence to postacute rehabilitation guidelines is associated with functional recovery in stroke.
        Stroke. 2002; 33: 167-177
        • Duong T.T.
        • Englander J.
        • Wright J.
        • Cifu D.X.
        • Greenwald B.D.
        • Brown A.W.
        Relationship between strength, balance, and swallowing deficits and outcome after traumatic brain injury: a multicenter analysis.
        Arch Phys Med Rehabil. 2004; 85: 1291-1297
        • Fakhry F.
        • van de Luijtgaarden K.M.
        • Bax L.
        • et al.
        Supervised walking therapy in patients with intermittent claudication.
        J Vasc Surg. 2012; 56: 1132-1142
        • Frankel J.E.
        • Marwitz J.H.
        • Cifu D.X.
        • Kreutzer J.S.
        • Englander J.
        • Rosenthal M.
        A follow-up study of older adults with traumatic brain injury: taking into account decreasing length of stay.
        Arch Phys Med Rehabil. 2006; 87: 57-62
        • Halbert J.
        • Crotty M.
        • Whitehead C.
        • et al.
        Multi-disciplinary rehabilitation after hip fracture is associated with improved outcome: a systematic review.
        J Rehabil Med. 2007; 39: 507-512
        • Hand C.
        • Law M.
        • McColl M.A.
        Occupational therapy interventions for chronic diseases: a scoping review.
        Am J Occup Ther. 2011; 65: 428-436
        • Handoll H.H.G.
        • Madhok R.
        • Howe T.E.
        Rehabilitation for distal radial fractures in adults.
        Cochrane Database Syst Rev. 2006; : CD003324
        • Handoll H.H.G.
        • Sherrington C.
        • Mak J.C.S.
        Interventions for improving mobility after hip fracture surgery in adults.
        Cochrane Database Syst Rev. 2011; : CD001704
        • Hoffmann T.
        • Bennett S.
        • Koh C.L.
        • McKenna K.T.
        Occupational therapy for cognitive impairment in stroke patients.
        Cochrane Database Syst Rev. 2010; : CD006430
        • Hopper T.
        • Bourgeois M.
        • Pimentel J.
        • et al.
        An evidence-based systematic review on cognitive interventions for individuals with dementia.
        Am J Speech Lang Pathol. 2013; 22: 126-145
        • Kennedy M.R.
        • Coelho C.
        • Turkstra L.
        • et al.
        Intervention for executive functions after traumatic brain injury: a systematic review, meta-analysis and clinical recommendations.
        Neuropsychol Rehabil. 2008; 18: 257-299
        • Khan F.
        • Ng L.
        • Gonzalez S.
        • Hale T.
        • Turner-Stokes L.
        Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy.
        Cochrane Database Syst Rev. 2008; : CD004957
        • Kim S.Y.
        • Yoo E.Y.
        • Jung M.Y.
        • Park S.H.
        • Park J.H.
        A systematic review of the effects of occupational therapy for persons with dementia: a meta-analysis of randomized controlled trials.
        Neuro Rehabil. 2012; 31: 107-115
        • Kortebein P.
        • Bopp M.M.
        • Granger C.V.
        • Sullivan D.H.
        Outcomes of inpatient rehabilitation for older adults with debility.
        Am J Phys Med Rehabil. 2008; 87: 118-125
        • Legg L.
        • Drummond A.
        • Langhorne P.
        Occupational therapy for patients with problems in activities of daily living after stroke.
        Cochrane Database Syst Rev. 2006; : CD003585
        • Lincoln N.
        • Majid M.
        • Weyman N.
        Cognitive rehabilitation for attention deficits following stroke.
        Cochrane Database Syst Rev. 2000; : CD002842
        • Muller M.
        • Tsui D.
        • Schnurr R.
        • Biddulph-Deisroth L.
        • Hard J.
        • MacDermid J.C.
        Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review.
        J Hand Ther. 2004; 17: 210-228
        • Outpatient Service Trialists
        Therapy-based rehabilitation services for stroke patients at home.
        Cochrane Database Syst Rev. 2003; : CD002925
        • Padilla R.
        Effectiveness of interventions designed to modify the activity demands of the occupations of self-care and leisure for people with Alzheimer’s disease and related dementias.
        Am J Occup Ther. 2011; 65: 523-531
        • Paltamaa J.
        • Sjögren T.
        • Peurala S.H.
        • Heinonen A.
        Effects of physiotherapy interventions on balance in multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials.
        J Rehabil Med. 2012; 44: 811-823
        • Pollock A.
        • Baer G.
        • Pomeroy V.M.
        • Langhorne P.
        Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke.
        Cochrane Database Syst Rev. 2007; : CD001920
        • Rietberg M.B.
        • Brooks D.
        • Uitdehaag B.M.J.
        • Kwakkel G.
        Exercise therapy for multiple sclerosis.
        Cochrane Database Syst Rev. 2005; : CD003980
        • Roy R.R.
        • Harkema S.J.
        • Edgerton V.R.
        Basic concepts of activity-based interventions for improved recovery of motor function after spinal cord injury.
        Arch Phys Med Rehabil. 2012; 93: 1487-1497
        • Ryan T.
        • Enderby P.
        • Rigby A.S.
        A randomized controlled trial to evaluate intensity of community-based rehabilitation provision following stroke or hip fracture in old age.
        Clin Rehabil. 2006; 20: 123-131
        • Ryburn B.
        • Wells Y.
        • Foreman P.
        Enabling independence: restorative approaches to home care provision for frail older adults.
        Health Soc Care Commun. 2009; 17: 225-234
        • Silver J.K.
        • Gilchrist L.S.
        Cancer rehabilitation with a focus on evidence-based outpatient physical and occupational therapy interventions.
        Am J Phys Med Rehabil. 2011; 90: S5-S15
        • Simons M.
        • King S.
        • Edgar D.
        Occupational therapy and physiotherapy for the patient with burns: principles and management guidelines.
        J Burn Care Rehabil. 2003; 24: 323-335
        • Sirtori V.
        • Corbetta D.
        • Moja L.
        • Gatti R.
        Constraint-induced movement therapy for upper extremities in stroke patients.
        Cochrane Database Syst Rev. 2009; : CD004433
        • Spiliotopoulou G.
        • Atwal A.
        Is occupational therapy practice for older adults with lower limb amputations evidence-based? A systematic review.
        Prosthet Orthot Int. 2012; 36: 7-14
        • States R.A.
        • Pappas E.
        • Salem Y.
        Overground physical therapy gait training for chronic stroke patients with mobility deficits.
        Cochrane Database Syst Rev. 2009; : CD006075
        • Stelmack J.
        Emergence of a rehabilitation medicine model for low vision service delivery, policy, and funding.
        Optometry. 2005; 76: 318-326
        • Steultjens E.M.
        • Dekker J.
        • Bouter L.M.
        • Cardol M.
        • Van de Nes J.C.
        • Van den Ende C.H.
        Occupational therapy for multiple sclerosis.
        Cochrane Database Syst Rev. 2003; : CD003608
        • Steultjens E.M.
        • Dekker J.
        • Bouter L.M.
        • Jellema S.
        • Bakker E.B.
        • van den Ende C.H.
        Occupational therapy for community dwelling elderly people: a systematic review.
        Age Ageing. 2004; 33: 453-460
        • Steultjens E.M.
        • Dekker J.
        • Bouter L.M.
        • van Schaardenburg D.
        • van Kuyk M.A.
        • van den Ende C.H.
        Occupational therapy for rheumatoid arthritis.
        Cochrane Database Syst Rev. 2004; : CD003114
        • Thomas M.J.
        • Simpson J.
        • Riley R.
        • Grant E.
        The impact of home-based physiotherapy interventions on breathlessness during activities of daily living in severe COPD: a systematic review.
        Physiotherapy. 2010; 96: 108-119
        • Tomlinson C.L.
        • Patel S.
        • Meek C.
        • et al.
        Physiotherapy versus placebo or no intervention in Parkinson’s disease.
        Cochrane Database Syst Rev. 2012; : CD002817
        • Tomlinson C.L.
        • Patel S.
        • Meek C.
        • et al.
        Physiotherapy intervention in Parkinson’s disease: systematic review and meta-analysis.
        BMJ. 2012; 345: e5004
        • Vissers M.M.
        • Bussmann J.B.
        • Verhaar J.A.
        • Arends L.R.
        • Furlan A.D.
        • Reijman M.
        Recovery of physical functioning after total hip arthroplasty: systematic review and meta-analysis of the literature.
        Phys Ther. 2011; 91: 615-629
        • Wilkins S.
        • Jung B.
        • Wishart L.
        • Edwards M.
        • Norton S.G.
        The effectiveness of community-based occupational therapy education and functional training programs for older adults: a critical literature review.
        Can J Occup Ther. 2003; 70: 214-225
        • Winter J.
        • Hunter S.
        • Sim J.
        • Crome P.
        Hands-on therapy interventions for upper limb motor dysfunction following stroke.
        Cochrane Database Syst Rev. 2011; : CD006609
        • Zhang W.
        • Moskowitz R.W.
        • Nuki G.
        • et al.
        OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines.
        Osteoarthritis Cartil. 2008; 16: 137-162
      1. American Academy of Physical Medicine and Rehabilitation (AAPM&R). Conditions & treatments. Available at: http://www.aapmr.org/about-physiatry/conditions-treatments. Accessed October 30, 2017.

      2. American Academy of Physical Medicine and Rehabilitation (AAPM&R). Practice guidelines created or endorsed by AAPM&R. Available at: http://www.aapmr.org/quality-practice/clinical-practice-guidelines/aapm-r-endorsed-guidelines. Accessed October 30, 2017.

      3. American Occupational Therapy Association. Productive aging. Available at: https://www.aota.org/Practice/Productive-Aging.aspx. Accessed October 30, 2017.

      4. American Occupational Therapy Association. Rehabilitation, disability, and participation. Available at: https://www.aota.org/Practice/Rehabilitation-Disability.aspx. Accessed October 30, 2017.

      5. American Physical Therapy Association (APTA). Practice areas. Available at: http://www.moveforwardpt.com/forhealthcareprofessionals/detail/practice-areas. Accessed October 30, 2017.

      6. American Physical Therapy Association (APTA). Symptoms & conditions. Available at: http://www.moveforwardpt.com/SymptomsConditions.aspx. Accessed October 30, 2017.

      7. American Speech-Language-Hearing Association (ASHA). Adult speech and language. Available at: http://www.asha.org/public/speech/disorders/AdultSandL.htm. Accessed June 13, 2014.

      8. American Speech-Language-Hearing Association (ASHA). Swallowing disorders (dysphagia) in adults. Available at: http://www.asha.org/public/speech/swallowing/Swallowing-Disorders-in-Adults/. Accessed June 13, 2014.

      9. Moyers P. Dale L. Guide to occupational therapy practice. 2nd ed. AOTA Pr, Bethesda2007
        • American Occupational Therapy Association (AOTA)
        Scope of practice.
        American Occupational Therapy Association, Bethesda2009
        • American Physical Therapy Association (APTA)
        Guide to physical therapist practice.
        Revised second edition. American Physical Therapy Association, Alexandria2003
      10. American Speech-Language-Hearing Association (ASHA). Scope of practice in speech-language pathology. Available at: http://www.asha.org/policy/SP2007-00283/. Accessed June 13, 2014.

      11. U.S. Government Publishing Office. Title 42: Public Health. Part 484-Home Health Services. Available at: www.ecfr.gov. Accessed March 15, 2015.

      12. Aetna. Occupational therapy. Available at: http://www.aetna.com/cpb/medical/data/200_299/0250.html. Accessed February 15, 2013.

      13. Aetna. Physical therapy. Available at: http://www.aetna.com/cpb/medical/data/300_399/0325.html. Accessed February 13, 2013.

      14. Aetna. Speech therapy. Available at: http://www.aetna.com/cpb/medical/data/200_299/0243.html. Accessed February 13, 2013.

      15. American Specialty Health. Commonly used ICD-9 codes for physical and occupational therapy. Available at: http://www.ashcompanies.com/Providers/Claims/ICD9codes.aspx. Accessed February 13, 2013.

      16. Anthem. Clinical UM guideline: Occupational therapy. Available at: http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051173.htm. Accessed February 13, 2013.

      17. Anthem. Clinical UM guideline: Physical therapy. Available at: http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051172.htm. Accessed February 13, 2013.

      18. Cigna. Cigna medical coverage policy: Occupational therapy. Available at: http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0232_coveragepositioncriteria_occupational_therapy_outpatient.pdf. Accessed February 13, 2013.

      19. Cigna. Cigna medical coverage policy: Physical therapy. Available at: http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0096_coveragepositioncriteria_physical_therapy.pdf. Accessed February 13, 2013.

      20. Cigna. Cigna medical coverage policy: Speech/language therapy. Available at: http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0177_coveragepositioncriteria_speech_therapy.pdf. Accessed February 13, 2013.

      21. ForwardHealth. Allowable ICD-9-CM codes for occupational therapy. Available at: https://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Display/tabid/152/Default.aspx?ia=1&p=1&sa=87&s=3&c=226&nt=Allowable+ICD-9-CM+Codes+for+Occupational+Therapy+%28Organized+by+Codes%29. Accessed February 13, 2013.

      22. ForwardHealth. Allowable ICD-9-CM codes for physical therapy. Available at: https://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Display/tabid/152/Default.aspx?ia=1&p=1&sa=87&s=3&c=226&nt=Allowable+ICD-9-CM+Codes+for+Physical+Therapy+%28Organized+by+Codes%29. Accessed February 13, 2013.

      23. ForwardHealth. Allowable ICD-9-CM codes for speech and language pathology. Available at: https://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Display/tabid/152/Default.aspx?ia=1&p=1&sa=87&s=3&c=226&nt=Allowable+ICD-9CM+Codes+for+Speech+and+Language+Pathology+SOI+Approval+%28Organized+by+Codes%29. Accessed February 13, 2013.

        • Brega A.
        • Schlenker R.
        • Hijjazi K.
        • et al.
        Study of Medicare home health practice variations: final report.
        Center for Health Policy Research, Univ of Colorado, Aurora, CO2002
        • Caffrey C.
        • Sengupta M.
        • Moss A.
        • Harris-Kojetin L.
        • Valverde L.
        Home health care and discharged hospice care patients: United States, 2000 and 2007.
        Natl Health Stat Report. 2011; 38: 1-27
        • Coleman K.
        • Wu N.
        • Goldberg H.
        • Deitz D.
        • White A.
        Refinement of Medicare’s home health prospective payment system: final report.
        Abt Associates, Cambridge (MA)2008
        • Dey J.G.
        • Johnson M.
        • Pajerowski W.
        • Tanamor M.
        • Ward A.
        Home health study report. Prepared for Centers for Medicare & Medicaid Services.
        L&M Policy Research, Washington (DC)2011
        • Gage B.
        • Ingber M.J.
        • Morley M.
        • et al.
        Post-acute care payment reform demonstration: final report. Prepared for Centers for Medicare & Medicaid Services.
        RTI International, Research Triangle Park2012
        • General Accounting Office
        Medicare home health care: payments to home health agencies are considerably higher than costs. Report to Congressional Committees.
        GAO, Washington, DC2002 (Report No. GAO-02–663)
        • Jones A.L.
        • Harris-Kojetin L.
        • Valverde R.
        Characteristics and use of home health care by men and women aged 65 and over.
        Natl Health Stat Report. 2012; 52: 1-7
        • Latham N.K.
        • Jette A.M.
        • Ngo L.H.
        • Soukup J.
        • Iezzoni L.I.
        Did the 1997 Balanced Budget Act reduce use of physical and occupational therapy services.
        Arch Phys Med Rehabil. 2008; 89: 807-814
      24. Medicare Payment Advisory Commission. A data book: healthcare spending and the Medicare program. Available at: http://www.medpac.gov/documents/Jun11DatabookEntireReport.pdf. Accessed January 15, 2013.

      25. Medicare Payment Advisory Commission. Report to Congress: Medicare payment policy. Available at: http://www.medpac.gov/documents/Mar12_EntireReport.pdf. Accessed January 15, 2013.

      26. Medicare Payment Advisory Commission. Report to Congress: Medicare payment policy. Available at: http://www.medpac.gov/documents/Mar10_EntireReport.pdf. Accessed January 15, 2013.

      27. Medicare Payment Advisory Commission. Report to Congress: Medicare payment policy. Available at: http://www.medpac.gov/documents/Mar09_EntireReport.pdf. Accessed January 15, 2013.

        • Murtaugh C.
        • Peng T.
        • Moore S.
        • Maduro G.
        Assessing home health care quality for post-acute and chronically ill patients: final report.
        Visiting Nurse Service of New York, Center for Home Care Policy and Research, New York, NY2008
        • Ottenbacher K.J.
        • Smith P.M.
        • Illiq S.B.
        • Linn R.T.
        • Ostir G.V.
        • Granger C.V.
        Trends in lengths of stay, living setting, functional outcomes, and mortality following medical rehabilitation.
        JAMA. 2004; 292: 1687-1695
        • White A.
        • Plotzke M.
        • Goldberg H.
        • Robinson C.
        Analysis of 2000-2008 home health case-mix change.
        Abt Associates Inc, Cambridge, MA2010