The Path For Occupational Therapy To Lose Its ‘Second-Tier’ Status In Home Health Care

If a senior or homebound patient is eligible for home health care, there are a number of caregiving professionals who can open a case and begin an assessment. Those include nurses, physical therapists and others.

One profession that is not on that list is an occupational therapist.

However, a new proposed bill could change that.


The Medicare Home Health Accessibility Act — which has bipartisan support — would establish occupational therapy (OT) as a qualifying Medicare home health benefit and would allow occupational therapists to open home health cases.

“It’s been a long time coming,” Cindy Krafft, owner of consulting firm Kornetti & Krafft Health Care Solutions, told Home Health Care News.

OT in home health

Occupational therapy in home health care generally focuses on helping people regain independence in activities of daily living (ADLs). Oftentimes, that process includes hands-on techniques, therapeutic exercises, functional activities and education to help a patient improve their physical and cognitive functioning.


It’s been over 40 years since occupational therapy was a Medicare qualifying service under the home health benefit.

In the early ‘80s, the Carter Administration brought OT services into the Medicare home health benefit, only for it to be taken out soon after by the Reagan Administration. Since then, advocates for occupational therapy in the home have been fighting for it to be included — with little success.

It’s difficult to calculate the volume of new patients the new piece of proposed legislation would bring to the space, Dombi said, but any spike in new patients is good news for providers.

“It certainly would bring value because OT is a very important part of the multidisciplinary team that can care for patients at home,” National Association for Home Care & Hospice (NAHC) President Bill Dombi told HHCN. “You can hit occupational therapy if it is along with another one of the two therapies — physical and speech language pathology — or as a continuing need when the other therapies are not being provided.”

Occupational therapy has been cast aside and treated like a non-core element of home health, Dombi added.

“There’s no other part of the Medicare program where occupational therapy is given a second-tier status,” he said. “It’s very difficult to rationalize why occupational therapy is not a qualifying skilled service to begin with.”

A shift in thinking

Prior to the pandemic, occupational therapists were not allowed to start any kind of assessments for home health cases. That changed slightly in the years following. As of January 2022, OTs were allowed to perform start-of-care assessments for therapy-only referrals.

However, for a patient to be admitted into home health services for therapy only, physical, speech therapy or both services must also be ordered.

The added flexibility offered by the U.S. Centers for Medicare & Medicaid Services (CMS) was a welcomed development for home health agencies, Krafft said.

“I think the pandemic and the flexibilities around that gave OT an opportunity to step into that space — apart from trying to get legislation changed,” Krafft said. “We’re approaching it now with a body of evidence that shows that having OTs admitting patients, being more involved at that qualifying criteria level, didn’t cause chaos. It didn’t cause an explosion in home health aide visits — which I think historically was one of the arguments against this.”

In fact, home health aide utilization has continued to fall, largely because of a reduction in reimbursement rates for home health agencies.

The proposed bill is coming at a good time, Krafft said.

“I think it has the best shot that I’ve seen in a long time,” Krafft said. “During the pandemic, when some of the rules got lessened to try to manage that situation, it didn’t cause ridiculous aide spikes. It didn’t cause OT to quadruple. It didn’t cause any of the things I think some folks were concerned about. That adding a qualifying service was going to exponentially increase costs. It’s almost like they got a live demo.”

The bill’s benefits

Allowing occupational therapists to start a home health case has several benefits, both from an agency’s point of view and the patient’s.

“[This bill] gives physicians, clients and home health agencies an opportunity to really elevate how they’re delivering care,” Alyson Stover, president of the American Occupational Therapy Association (AOTA), told HHCN. “At a time when we know there are staffing shortages, burnout, long drives in between different home health clients. When we can utilize each professional to its full capacity, then we can actually eliminate or reduce some of those barriers.”

It’s never made sense to Stover and other stakeholders that OTs — who are autonomous health care practitioners who can deliver an OASIS assessment, develop goals and make recommendations — don’t have the ability to open a home health case.

There are also unique skills occupational therapists have that others may not. .

“We are the professionals that know how to — and are trained in — evaluating the person,” Stover said. “Most of my colleagues have specialized training in environmental assessment modification, so it makes sense in a home health experience for us to have this opportunity. It makes sense for us to be able to go in and really facilitate, not just plans for the patient to be able to be more successful in their home, but for their home to be more successful to accommodate the patient.”

Stover also pointed to an independent study done in 2016 that showed when you spend more money on occupational therapy in the acute care setting, hospital readmissions are reduced.

That’s significant to home health agencies that are trying to reduce costs, improve their reimbursement rates under the Patient Driven Groupings Model (PDGM) and improve outcomes.

“This is going to be able to facilitate new opportunities in which we can develop protocols and to trial PDGM under a more health care-driven model,” Stover said. “Instead of a situation where we’re saying, ‘Hey, whoever can get in there, and let’s try to work with what we’ve got in these 20 visits.’ Let’s go ahead and see what happens when we put the occupational therapist in there first and then that can alleviate the stress on nurses and other professionals in the space.”

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