CMS introduces new Pre-Claim Review Demonstration proposal

Yesterday, the Centers for Medicare & Medicaid Services (CMS) announced a request for public comment on a new Pre-Claim Review Demonstration proposal. The new demonstration proposal offers home health agencies in the five proposed demonstration states three different options for payment. Under the new proposal, agencies can choose either potential full payment with pre-claim or postpayment reviews, or agencies can choose to forego the review process altogether with a 25 percent reduction in payments on all home health claims submitted. Agencies that choose the third option and payment reduction may still be eligible for review by Recovery Audit Contractors (RACs). The unpublished memo is currently available here, while the published version will appear on Thursday, May 31st in the Federal Register here.

The five states included in the new proposal are: Illinois, Ohio, North Carolina, Florida, and Texas. Ohio and North Carolina are new additions to the current proposal, replacing Massachusetts and Michigan in the original demonstration. The original demonstration did begin in Illinois in 2016 but was paused on April 1, 2017 and never re-started. At the time, CMS provided a brief Q&A on the pause here.

As in the past, the Alliance will be working with our membership as well as colleagues across the industry, to formulate a comment letter to CMS. You can read the Alliance’s comments to the Office of Management and Budget (OMB) from 2016 on the original PCRD proposal here. In those comments, the Alliance highlighted concerns related to the burden on home health agencies, process consideration, and legal authority.

CMS is said to be providing further updates this week so stay tuned for more information.

Alliance members interested in joining the discussion on PCRD and other regulatory and legislative efforts, as well as clinical and quality improvement should reach out to the Alliance’s Director, Policy Communications & Research, Jen Schiller at, to join the Alliance’s monthly Quality & Innovation Work Group.

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.

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.

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 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:

Framing the Future of Home Health Care in America

On June 30th, the Alliance hosted “Framing the Future of Health Care in America,” which included the release of case studies and appendices that will inform the upcoming independent publication of the Future of Home Health paper.

Leading experts and stakeholders provided an overview of the report and shared an initial vision to support the transformation of home health and home-based care as an integral part of the overall health care delivery system. Our panel included Kathleen Gilmartin, CEO of Interim HealthCare, Sally Rodriguez, Director, Avalere, and Dr. Steven Landers, President and CEO of VNA Health Group.

Briefing materials, appendices, and a full video recap of the briefing are available here.

Prioritizing Care From Hospital to Home

Last week, the Washington Post published the heartbreaking story of Joyce Oyler, a home health patient who passed away after receiving the wrong medication; an error which failed to be caught at all levels, including home health. Ms. Oyler’s story is a terrible reminder of the critical nature of care transitions from setting to setting.

Care transitions are a central area of both focus and improvement for the home health care community. Recognizing the importance of quality and safety issues in the transition from hospital to home, the Alliance developed the Home Health Model of Care Transitions. The model lays out an evidenced-based approach to successfully complete a transition and prevent rehospitalization. The model specifically emphasizes medication management as a core component of an effective care transition, and specifies that a home health agency identify the name of each drug prescribed, what it’s used for, dosage, and when and how often the patient should take each medication. Medication allergies and pharmacy name and phone number should also be listed.

Other organizations are also dedicated to putting care transitions at the forefront of emphasis. For instance, the Visiting Nurse Associations of America (VNAA) compiled the Blueprint for Excellence, which features a module of patient safety including medication reconciliation. The Blueprint defines medication reconciliation and adherence, outlines the impact it has one patient outcomes and safety, and identifies best practices for medication reconciliation and adherence in the home. You can access the VNAA Blueprint for Excellence guidelines and resources on medication reconciliation here.

Federal initiatives are further driving quality improvement and patient safety in home health. Just recently, the Centers for Medicare and Medicaid Services (CMS) began assigning Home Health Star Ratings for quality and patient experience, on top of the existing publicly reported quality measures on Home Health Compare.

Star ratings are one mechanism to help consumers access better quality and patient preferred outcomes in home health care, however a number of additional models are currently being implemented to drive home the idea of value over volume in care. The Home Health Value Based Purchasing Model is tying payment to performance, while bundled payment arrangements and accountable care organizations are using payment models that seek to incentivize efficiency.

At the end of the day, policymakers, home health agencies, hospitals, and patient advocates must work collaboratively on ways to best tackle gaps in care from hospital to home.

Preventing tragic deaths, such as Ms. Oyler’s, is so critically important. We simply need to do better for patients and their families. Federal policy initiatives are paving the way, and the work of the Alliance, VNAA, and others are helping by addressing, compiling, and disseminating evidence-based practices and tools.

Together we as an industry and community can work to prevent critical medication errors, hospital readmissions, and most importantly, unnecessary patient deaths.

Street Medicine Brings High-Quality Healthcare to the Homeless

Home health care most often occurs in a rather obvious location: a patient’s home. What though happens when a patient doesn’t have a traditional home? Enter street medicine, an emerging model that delivers care to patients where they are, be that in shelters or in the streets, in an effort to improve public health and care for some of the country’s most vulnerable patients.

Street medicine is, in many ways, similar to traditional forms of house calls, with a physician or physician assistant treating a patient where they live. The difference is the location, and sometimes the transitive nature of the patients.

A mostly grassroots model, a few health systems are keying in to the benefits of street medicine, while the Department of Veteran’s Affairs also already employs a similar model. The VA’s program, Homeless Patient Aligned Care Teams (H-PACT), serves over 5,000 patients a year in 31 locations.

One of the pioneers of street medicine, Dr. Jim Withers, founded Operation Safety Net more than 20 years ago within Pittsburgh Mercy Health System. Operation Safety Net offers a number of focused initiatives for homeless patients, treating the patient as a whole through partnerships with the area agency on aging, the VA, shelters, food banks, and more. The innovative program trains more than 100 residents and students each year and offers a one-month residency for University of Pittsburgh School of Medicine fourth-year students.

Lehigh Valley Health Network also runs a street medicine program, led by physician assistant Brett Feldman. Feldman, who was recently profiled by the Associated Press, treats about 100 patients a month in the program.

What these programs have in common is reduced rates of emergency room visits saving hospitals and health systems money while improving the overall health of the communities they serve. Estimates have shown a decrease in 30-day readmission rates at Lehigh Valley hospital down to 13 percent from 51 percent. Add to that the fact the rate of uninsured homeless has gone up nearly three fold from 24 percent to 73 percent and that’s a lot of savings for the hospital and health system. Many of the other health systems discussed in the AP article have seen similar savings and outcomes improvement.

Just like traditional home health providers are increasing their focus on preventative care, street medicine seeks to treat repeat patients before they wind up in emergent care, where care delivery is much more costly. Focusing on preventative care, and treating patients where they can be or need to be treated is a critical piece for the future of health care delivery. Street medicine, like home health care, aims to reduce readmissions and provide high-quality healthcare that truly serves the patient, especially those who are most vulnerable.

Improving Health Care for All This April and Beyond

April marks the Department of Health and Human Services’ Minority Health Month for 2016, focusing on “Accelerating Health Equity for the Nation.” As a critical piece of the health care system, home health care is a vital ally in the mission of improving health equity.

Data from the Alliance’s 2015 Home Health Chartbook shows that home health care already serves a disproportionate share of racial and ethnic minority patients as compared with the general Medicare population. However, there are still plenty of areas of focus with regard to health equity in home health care. Black and Hispanic home health users are more likely to have an income under 100 and 200 percent of the federal poverty level compared to all Medicare home health users, as well as being half as likely as all Medicare home health users to have an income over $25,000 per year. On top of that, both black and Hispanic home health users are more likely to have two or more activity of daily living limitations.

Work is being done to improve home health care for all, and a number of providers are already utilizing innovative programs to improve care for minority patients. In 2014, the Alliance released a Faces of Home Health profile highlighting the racial and ethnic diversity of home health patients and how one agency is meeting the needs of such patients. The profile featured Asian American Home Care, an agency based in Oakland, California, serving a diverse array of patients. Staff at AAHC speak nine different languages and have extensive knowledge of, and sensitivity to, cultural, ethnic, and racial diversity. Staff undergo training courses and are offered teaching materials in a variety of languages, meeting once a month to coordinate patient care. It’s not just languages in which AAHC staff are fluent. Emphasis is placed on being sensitive to unique considerations for minority patients in many areas of communication, including non-verbal communications, dietary customs of various cultures, understanding political and natural disasters that patients may have endured, and financial and socioeconomic barriers to care. Taken in combination, these specialized skills and tailored approaches help provide more well-rounded care to minority patients, improving overall health care and increasing the likelihood of adherence to care plans and improved outcomes.

Specifically, the profile shares the story of a 91-year old native Chinese speaker being treated by AAHC who prefers Traditional Chinese medicine (TCM) to Western medicine. The patient’s nurse utilized a series of tools to help improve the patient’s care, including making flash cards for her patient to use with doctors to address the language barrier, and finding dietary substitutions that improve the patient’s condition while still maintaining a sensitivity to the customs of the patient’s culture. These small things had a tremendous impact on the patient’s overall health, while still maintaining empathy for the patient’s culture and preferences.

Tailoring care to include cultural, ethnic, and racial sensitivities is vital to not only achieving better clinical outcomes, but to truly providing patient-centered and patient-preferred care. In doing so, home health care can continue to strive toward health equity, and improved patient outcomes and experience. The quicker health equity is achieved for all, the better we all are.

More information on National Minority Health Month is available online at: Follow on Twitter using #NMHM16.

New Research and Initiatives Pave Way for Better Home Health Care for All

A few weeks ago the Huffington Post highlighted some new and emerging models of home care being utilized by the Visiting Nurse Service of New York. Some of these models involve treating chronic conditions, such as congestive heart failure (CHF), including front-loading visits in the first week and an evidence-based screening tool.

Additionally, the VNSNY is looking at the demographics of home health users in order to discern ways of providing higher quality, more patient-centered care. One new study looks at language barriers between patients and nurses, while another focuses on access to care for LGBT patients.

To read the full article, click over to the Huffington Post here!