Occupational Therapy in Home Health: Start-of-Care and Eligibility Explained

When asked whether an occupational therapist (OT) can initiate home health services, I often respond, “Yes, an OT can complete the Start-of-Care (SOC) OASIS—but they cannot establish initial eligibility.” This answer usually sparks more questions, and understandably so.

Occupational Therapists (OTs) play a vital role in home health care. Regulatory changes in 2022 have expanded the role of OTs at the Start of Care (SOC), but the rules can be confusing at first glance, hence the reluctance to allow OT to complete the SOC assessment. OT can now complete the SOC OASIS, but cannot be the sole qualifying service. OT can be the only service provided, only after another discipline has established eligibility. OT can even recertify the patient for another episode of care.  Here's what you need to know about when OTs can initiate home health services.

As of January 1, 2022, occupational therapists may perform the Start-of-Care (SOC) comprehensive assessment for therapy-only cases, but OT alone is not a qualifying service for admission.

Conditions That Must Be Met:

1. Therapy-Only Case: The referral must be for therapy services only (i.e., no skilled nursing).
2. At Least One Qualifying Therapy Must Be Ordered:
   • Physical therapy (PT) or
   • Speech-language pathology (SLP)

   
   OT can initiate the SOC assessment, but PT or SLP must also be ordered to qualify the patient for home health admission.

   PT or SLP should be initiated early to establish ongoing eligibility.

3. OT Cannot Be the Sole Qualifying Service:
   • OT can complete the initial and comprehensive assessments but must document the need for the qualifying service (PT or SLP) to establish Medicare eligibility during the SOC visit.
   • OT cannot independently qualify a patient for home health admission, so even though the OT provided a skilled service during the SOC OASIS, the eligibility is not established until PT or SLP makes the qualifying visit.
   • Once a patient has eligibility established based on PT or SLP skilled need, OT can continue care independently even if the other services are discontinued later in the episode.

Nursing visits must be intermittent to establish eligibility; however, therapies can establish eligibility on a single visit – the therapy evaluation. The order of the services no longer matters, as CMS confirmed. CMS clarified in the 2022 Final Rule that “the order of services is no longer a concern,” as long as the OT documents the need for a qualifying service (PT or SLP) during the SOC assessment.

Example Scenario

• A physician orders OT and PT for a patient.
• SOC: The OT performs the Start-of-Care assessment and documents the need for PT.
• Soon after the SOC, the PT must still conduct at least one visit to establish the qualifying service.
• After that, OT can continue providing care independently if PT is no longer needed.

Key Takeaway

Occupational therapists can initiate home health services when the case is therapy-only and includes PT or SLP on the plan of care. It is important to remember that OT can initiate services at any time during the home health stay once eligibility has been established. OT services can continue into subsequent 30-day periods and episodes as long as the patient maintains eligibility (e.g., orders, skilled need, homebound). The OT is considered a qualified clinician for the completion of the OASIS at the other timepoints even if nursing is ordered. The flexibility allowing OT to complete the SOC assessment supports timely access to care and leverages the full scope of OT practice.

For more information, refer to the official CMS rule here.