Why CMS’s Home Health Therapy Proposal May Not Be Enough

As part of its Patients Over Paperwork initiative and as a way to make home health requirements more consistent with other settings of care, the Centers for Medicare & Medicaid Services (CMS) is proposing to allow therapist assistants to furnish maintenance therapy.

Under current home health rules, only physical therapists (PTs), occupational therapists (OTs) and speech therapists are allowed to perform maintenance therapy, broadly defined as periodic monitoring or adjustments of patient care plans to ensure health status doesn’t decline.

“Maintenance therapy is not different therapy interventions,” Cindy Krafft, founder and owner of consulting firm Kornetti & Krafft Health Care Solutions, told Home Health Care News. “It’s the issue of what is the end result of care, recognizing that if we don’t put certain things in place — whether due to co-morbidities or functional issues — [the patient] is anticipated to decline.”


CMS proposed allowing therapy assistants to deliver maintenance therapy in its proposed payment rule for calendar year 2020, released July 11.

Specifically, the proposed change comes in response to comments CMS received from its 2018 proposed rule on regulatory flexibilities and efficiencies. Commenters argued that the Medicare regulations pertaining to the provision of maintenance therapy were largely inconsistent, particularly noting discrepancies compared to the skilled nursing setting.

“There have been some conversations over the years about why maintenance therapy has a different standard in home health than it does in other areas of post-acute care,” Krafft said. “I think this was partially a cleanup.”


Finalizing the maintenance therapy proposal would ensure that therapy assistants practice at the top of their state licensure and would provide home health agencies more flexibility in meeting the needs of their patients, according to CMS.

While CMS cited the Patients Over Paperwork initiative when introducing the proposal, the move to open up maintenance therapy to assistants wouldn’t actually eliminate a ton of red tape, Anthony D’Alonzo, director of clinical strategy and innovation for Bayada Home Health Care, told HHCN.

“The potential issue is that maintenance therapy visits tend to occur at a lower frequency,” D’Alonzo said. “And CMS isn’t easing up on the [therapy] reassessment rule, which requires PTs, OTs or speech therapists to reassess the patient every 30 days.”

Additionally, therapy assistants can’t make changes to a patient’s plan of care, so PTs, OTs and speech therapists would likely have to be brought into the equation regardless.

“Because frequency is low … there’s a high likelihood that there may need to be changes to the plan or to what therapists are doing,” Krafft said. “Both of those things would be difficult if you had an assistant doing the visit.”

Although CMS’s maintenance therapy proposal may not be game-changing, it could afford agencies more adaptability in how and when they send out staff.

At the very least, the proposal is also a reminder that therapy is still an important part of the home health ecosystem — even under the Patient-Driven Groupings Model (PDGM).

“I think there are a lot of positives in this,” Krafft said. “Big-picture — from all the conversation of reducing therapy — this is a reminder that there is still maintenance and that you should still be treating your patients [properly].”

Home health agencies have until early September to comment on CMS’s proposed rule.

D’Alonzo plans on taking advantage of that opportunity to suggest an even bigger change to therapy guidelines.

“What really would have been a benefit under Patients Over Paperwork would have been, ‘We’re removing the therapy reassessment rule,’” he said. “That’s no longer really [needed] because therapy isn’t driving payment under PDGM. That’s probably something I’ll write to CMS about as part of the feedback for the proposed rule.”

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