Guest Blog: An Adapted Cardiac Rehabilitation Program for the Home Care Setting

Cardiovascular disease (CVD) remains the leading cause of death in the United States. Due to significant advances in health care, there is an increase in the number of individuals living with CVD. These individuals may struggle with self-management and symptom control, and 25% patients with heart failure discharged from the hospital are readmitted within 30 days. CVD is a particularly diagnosis common among the home care population, with heart failure (HF) and acute myocardial infarction/ischemic heart disease as leading conditions. Home care clinicians are often the first line of rehabilitation and support for patients post-hospitalization. An adapted home-based cardiac rehabilitation (CR) represents a promising approach to improving care and reducing hospital readmissions among patients with CVD. The services of CR can reduce all-cause mortality and cardiac mortality rates, and benefit patients through exercise and modifications of controllable risk factors. Despite the clinical effectiveness of CR, participation rates in these programs remain low. There is a need for alternate models of secondary preventative cardiac care to increase adherence to CR services and prevent poor outcomes. Home-based programs are potentially an effective and low-cost method of care. However, there are limited evidence-based evaluations that home care agencies are implementing the core competencies of CR programs into their episodes of care and that home care clinicians receive education on these competencies.

Our pilot program, Home Heart Health, is an adapted CR program for the home care setting. Home Heart Health is an interdisciplinary CR program that emphasizes CVD risk factor modification and management for home care patients. In our program, home care registered nurses, physical therapists, and occupational therapists were educated to provide adapted CR services to patients as a complement to traditional home care. This training for home care clinicians was adapted from the American Association of Cardiovascular and Pulmonary Rehabilitation professional core competencies for outpatient CR. It was developed based on literature and guideline reviews, as well as themes identified among patients and clinicians. During the program, patients received visits from these home care clinicians, who provided an exercise plan, nutrition counseling, and self- management education, with accompanying patient teaching tools. Clinicians practiced in accordance with standardized interventions checklists. We conducted a multi-phase study to develop, implement and evaluate this adapted CR program.

The first phase of the pilot was to develop and implement the CR training program adapted for home care clinicians, incorporating the viewpoints of homebound patients with cardiovascular disease. Literature and guideline reviews were performed to glean curriculum content, supplemented with themes identified among patients and clinicians. Semi-structured interviews were conducted with homebound patients regarding their perspectives on living with cardiovascular disease and focus groups were held with home care clinicians regarding their perspectives on caring for these patients. A questionnaire was administered to home care nurses and rehabilitation therapists and compared for pre- and post-training. Three themes emerged among patients: (1) awareness of heart disease; (2) motivation and caregivers’ importance; and (3) barriers to attendance at outpatient CR; and 2 additional themes among clinicians: (4) gaps in care transitions; and (5) educational needs. Questionnaire results demonstrated significantly increased knowledge post-training compared with pre-training among home care clinicians. There was no significant difference between scores for nurses and rehabilitation therapists, indicating the feasibility of interdisciplinary training. As a result of this study, we concluded that home care clinicians respond well to an adapted CR training to improve care for homebound
patients with cardiovascular disease. Clinicians who participated in the Home Heart Health
training demonstrated an increase in their knowledge and skills of the core competencies for CR. Read the full manuscript depicting the development and implementation of the Home Heart Health program and training for clinicians here.

The second phase of the pilot was to conduct a mixed methods analysis to determine the
feasibility and acceptability of Home Heart Health. Surveys measuring patient self-care and
knowledge were administered to patients at baseline and at 30-day follow-up. Semi-structured interviews were conducted with patients and home care clinicians at completion of the program. All survey indicators demonstrated a trend towards improvement, with a statistically significant increase in the self-care management subscale. Qualitative analyses identified three patient themes: (1) self-awareness; (2) nutrition; and (3) motivation; and three clinician themes: (1) systematic approach; (2) motivation; and (3) patient selection process. We concluded that incorporating CR into the home care setting proved to be a feasible and acceptable approach to increasing access to CR services among elderly patients. As acute care transitions to the home and outpatient settings, coupled with efforts to meet patients were they are, studies demonstrating the feasibility of alternative methods to care are vital. Our pilot study supports the need for further testing with a larger sample to determine the efficacy of adapted cardiac rehabilitation for the home care setting. Read the full manuscript examining the feasibility andacceptability of Home Heart Health here.

Please contact Jodi.feinberg@homehearthealth.org with questions or comments!

November #HomeHealthChat: Physical Therapy in the Home

The November #HomeHealthChat was co-hosted by the APTA Home Health Section.

The #HomeHealthChat focused on physical therapy in the home.

The Alliance hosts a home health-focused Twitter chat on the fourth Tuesday of every month at 2 pm ET. Be sure to check here for updates on topics, co-hosts, and questions!

If you have topic ideas for future Twitter chats, or are interested in co-hosting a chat, please contact the Alliance’s Director, Policy Communications & Research Jen Schiller here.

Below are some of the highlights from the chat:

Moving into 2018 Without HHGM, For Now

Based upon feedback and efforts from the home health industry and other key stakeholders, the Centers for Medicare and Medicaid Services (CMS) decided not to finalize implementation of the Home Health Groupings Model (HHGM) in the CY 2018 Home Health Prospective Payment System final rule, released last Wednesday, November 1st. HHGM was the centerpiece of the proposed rule regulation and would have drastically changed care delivery and payment, moving to 30-day episodes and cutting an estimated $950 million in reimbursement.

While this is a encouraging step for the numerous individuals and organizations who wrote letters and reached out to CMS and policymakers with their concerns about the model, it is important to note that HHGM was not withdrawn, but simply not finalized. Per CMS’s own language in the final rule, “We are not finalizing the implementation of the HHGM in this final rule. We received many comments from the public that we would like to take into further consideration.”

There are ongoing legislative efforts surrounding HHGM, of which the Alliance is continuing to stay abreast. Additionally, as stated in our comment letter, the Alliance welcomes the opportunity to work with CMS further on a patient-centered model of care that puts the patient first and does not threaten access nor quality.

HHGM, however, wasn’t the only component of the proposed rule. CMS finalized a number of changes outlined in the proposed rule, including a reduction to the national, standardized 60-day episode payment rate for CY 2018 of 0.97 percent and case-mix weight adjustments.

Though nowhere near the cuts projected had HHGM been implemented, CMS does project an overall reduction of 0.4 percent in payments to HHAs or -$80 million for CY2018 in the final rule.

Additional changes for implementation included in the final rule relate to Home Health Value Based Purchasing Model (HHVBP) and the Home Health Quality Reporting Program (HHQRP).

The final rule amends the definition of “applicable measure” in HHVBP to mean a measure for which an agency has at least 40 completed surveys  for HHCAHPS. Additionally, the final rule finalizes the removal of the OASIS-based measure, Drug Education on All Medications Provided to Patient/Caregiver during All Episodes of Care, from the set of applicable measures.

While CMS did finalize some of the proposed changes to QRP, CMS decided not to finalize three of the categories for standardized patient assessment data elements in QRP: Cognitive Function and Mental Status; Special Services, Treatments, and Interventions; and Impairments.

The changes to QRP finalized within the rule include the replacement the current pressure ulcer measure, Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678), with a modified version of that measure entitled, Changes in Skin Integrity Post- Acute Care: Pressure Ulcer/Injury, effective starting with the CY 2020 HH QRP. Further, CMS finalized the removal of 235 data elements from 33 current OASIS items, effective with all HHA assessments on or after January 1, 2019.

A copy of the final rule is available through the Federal Register here, and you can read the Alliance’s comments to CMS on the proposed rule here.

October #HomeHealthChat: Health Information Exchange in Home Health

The October #HomeHealthChat was co-hosted by the Massachusetts eHealth Collaborative (@MAeHC_org) and Home Healthcare Hospice & Community Services (HCS).

The #HomeHealthChat focused on implementing and integrating health information exchange in home health transitions of care settings.

The Alliance hosts a home health-focused Twitter chat on the fourth Tuesday of every month at 2 pm ET. Be sure to check here for updates on topics, co-hosts, and questions!

If you have topic ideas for future Twitter chats, or are interested in co-hosting a chat, please contact the Alliance’s Director, Policy Communications & Research Jen Schiller here.

Below are some of the highlights from the chat:

Remembering NAHC President Val J. Halamandaris

The Alliance and our Board of Directors would like to express our deepest sympathies and condolences to the family of Val J. Halamandaris, President of the National Association for Home Care & Hospice, on his passing.

Val spent countless hours fighting for the respect of the home health care and hospice industry, and for the rights of older Americans, the chronically ill, and those with disabilities to receive high quality health care at home. His efforts as a standard bearer for the industry spanned more than 50 years and ushered in an era of respect for home health care.

We are grateful for Val’s enduring legacy, which will continue as so many in the industry follow his lead in the fight for the rights of home health care and hospice patients, caregivers, and providers.

June #HomeHealthChat: Patient Refusals of Home Health Care

The June #HomeHealthChat was co-hosted by the United Hospital Fund (@UnitedHospFund).

The #HomeHealthChat focused on patient refusals of home health care. The conversation stemmed from the Aliance and United Hospital Fund co-sponsored roundtable report, released in May 2017. You can read the full report here.

The Alliance hosts a home health-focused Twitter chat on the fourth Tuesday of every month at 2 pm ET. Be sure to check here for updates on topics, co-hosts, and questions!

If you have topic ideas for future Twitter chats, or are interested in co-hosting a chat, please contact the Alliance’s Director, Policy Communications & Research Jen Schiller here.

Below are some of the highlights from the chat:

April #HomeHealthChat: Home Health’s Role in Caring for People with Alzheimers and Dementia

The April #HomeHealthChat was co-hosted by the LEAD Coalition (@LEAD_Coalition).

The #HomeHealthChat focused on home health’s role in caring for people with Alzheimer’s and dementia.

The Alliance hosts a home health-focused Twitter chat on the fourth Tuesday of every month at 2 pm ET. Be sure to check here for updates on topics, co-hosts, and questions!

If you have topic ideas for future Twitter chats, or are interested in co-hosting a chat, please contact the Alliance’s Director, Policy Communications & Research Jen Schiller here.

Below are some of the highlights from the chat:

March #HomeHealthChat: Hospice & End-of-Life Care

The March #HomeHealthChat was co-hosted by the Visiting Nurse Associations of America (@VNAA) and Zen Hospice Project (@ZenHospice).

The #HomeHealthChat focused on hospice and end-of-life, and previewed discussions from the 2017 National Leadership Conference, April 19-21 in San Diego, Calif.

The Alliance hosts a home health-focused Twitter chat on the fourth Tuesday of every month at 2 pm ET. Be sure to check here for updates on topics, co-hosts, and questions!

If you have topic ideas for future Twitter chats, or are interested in co-hosting a chat, please contact the Alliance’s Director, Policy Communications & Research Jen Schiller here.

Below are some of the highlights from the chat:

News from the Board of Directors

The Alliance’s Board of Directors has regretfully accepted Teresa Lee’s resignation as Executive Director of the Alliance effective Feb. 15, 2017 and wishes her all the best in her future endeavors. She has added tremendous value to the work of the Alliance over the past five years and her leadership has been an asset to the organization. Jennifer Schiller, Director of Policy Communications & Research, will continue to provide operational management of the Alliance and work directly with the Board of Directors to guide the future strategy of the organization. Please contact Jennifer for any questions or information at jschiller@ahhqi.com or by phone at 571-527-1532.

January #HomeHealthChat: Home Health and Private Duty

The January #HomeHealthChat was co-hosted by the Home Care Association of Florida (@HomeCareFLA)

The Home Care Association of Florida (HCAF) is the premiere trade association for the home care industry in Florida.

The #HomeHealthChat focused on home health and private duty.

The Alliance hosts a home health-focused Twitter chat on the fourth Tuesday of every month at 2 pm ET. Be sure to check here for updates on topics, co-hosts, and questions!

If you have topic ideas for future Twitter chats, or are interested in co-hosting a chat, please contact the Alliance’s Director, Policy Communications & Research Jen Schiller here.

Below are some of the highlights from the chat: