Standard of Care (SOC)

In my PA area.  RN does the initial eval + OASIS admission assessment for all home care clients and confirms need for skilled care services.  If no SN needed (rare -usually need at least medication instruction + eval compliance), SN will admit when only Physical Therapy need identified; PT then performs initial PT eval assessment thereafter will case manage client.

When I worked as a case manager in OR, our process was to place a Stat PT or OT consult in the ED. The therapist would come down and provide their formal evaluation and recommendation. If the patient did not qualify for SN (which most do not), the next steps would depend on their baseline level of function and mobility. If it was difficult for them to leave home, we would set them up with home health PT/OT (or whatever therapies PT/OT recommended). Alternatively, if preferred and available, we would help set them up or start setting them up with a temporary assisted living situation and therapy services. They would then be discharged home, and outpatient case management would finish up any loose ends.

This makes it sound easy, but other factors that go into this are out-of-pocket costs and social determinants of health, including finances and family support. Many times, patients expect insurance to cover everything, but sadly, insurance does not cover these services in most situations. Many times, the family expects the healthcare team to manage it all and feels they shouldn't have to help their loved one because they have work or XYZ -- which is very unrealistic. 

This really isn't a one-size-fits-all solution. Different systems have different processes, and different ALFs have varying criteria based on their level of care. ALF is an alternative for SNFs when patients don't hit the SNF needs benchmark, as patients can still get support and the therapies they need, but these ALFs come with hefty out-of-pocket costs, not to mention the struggle of finding ALFs with available beds.

So really there are a lot of moving parts to consider and each patients outcome plan will be different. 

At my agency, we are told not to admit the patient/finish the admission visit, but to do a "non admit" due to lack of nursing skill or need or what have you, then notify the clinical manager and I guess the PT's visit is changed to a "PT00" or whatever.  Are the visit codes universal? :)

Visit billing codes are universal, however different software vendors have varying discipline codes.