What’s in A Star Rating?

Co-authored by the Alliance and Visiting Nurse Associations of America

Over the past few months, the Centers for Medicare and Medicaid Services’ (CMS) introduction of patient experience survey star ratings to Home Health Compare, as a way to better understand the overall patient experience with care provided through Medicare-certified home health agencies, has gained a lot media attention.

While the jury is still out on the star ratings as a whole, home health agencies recognize that both quality of care and patient experience are critical. Agencies are learning from the issuance of the star ratings and are committed to improving their performance on both quality of care and patient experience.

Outlined below, the Alliance and VNAA breakdown the top five takeaways from the Patient Survey Star Ratings:

  1. The new patient survey star ratings do not replace, but instead are in addition to, the Quality of Patient Care Star Ratings used to describe the quality of clinical care provided by a Medicare-certified home health agency.
  2. Health care is moving towards a system that rewards value over volume and more readily engages consumers; as such, performance data will become increasingly important.
  3. The Home Health Compare Star Ratings are the first step towards streamlining communication regarding home health quality and patient experience in a way that is digestible to health care consumers.
  4. The discrepancies in the patient and quality ratings among individual agencies stem from several factors, including the limitation of the Medicare home health benefit, as well as the understanding of skilled versus non-skilled home health health services. For example, Medicare home health care provides skilled, clinical care, not services such as meal planning and house cleaning. Unfortunately, there is a disconnect for many patients when those needed non-clinical services are not met by their home health care team, despite receiving excellent clinical care.
  5. The patient experience survey is a positive step in the right direction, and is essential to capturing the overall home health care experience, but CMS must refine its metrics to capture more accurate data.

As organizations committed to advancing home health care, the Alliance and VNAA stand ready to work with the Administration to perfect the use of patient survey data so that it is balanced with necessary quality data.

Celebrating Women in Home Health Care

Happy International Women’s Day!

Women are vital to home health care, both as employees and patients, and today we celebrate the contributions of women in the industry and the patients who benefit from their care.

The National Women’s History Museum credits Lillian D. Wald, founder of what is today the Visiting Nurse Service of New York, with inspiring the New York Board of Health to organize the first public nursing system in the world.

Nationally, women are tremendous assets to our healthcare industry, and this is especially true for home health care. In 2014, a whopping 88.6% of persons employed in home health services were women; that’s over a million women employed in the industry! Nationwide, women make up roughly 47% of the workforce, and while women are more likely to work in the health care industry writ large (78.6%), home health care is still even more female-dominated than the industry as a whole. Within the Bureau of Labor Statistics’ “health care and social assistance” industry marker, home health care services employ the second greatest percentage of women.

It’s not just in the workforce where women are prominent. Looking at information from the 2015 Home Health Chartbook, home health patients are also more likely to be women, with females comprising 61.5% of home health users (compared with 54.6% of all Medicare beneficiaries). Women actually comprise a smaller percentage of home health users than males under age 85, but over a quarter of female home health users are over 85.

Diving deeper into the demographics, women are three times more likely than their male counterparts to be widowers, while less than a third are married. Women who receive Medicare home health services are also much more likely than male users to have an income below $25,000 a year.

According to the Kaiser Family Foundation’s 2009 fact sheet on “Medicare’s Role for Women” across the Medicare population, women are more likely than men to suffer from arthritis, hypertension, and osteoporosis. Almost 50% of women, compared with 38% of men, suffer from three or more chronic conditions. That same paper noted that while Medicare plays a critical role for women, women are still more likely than men to spend a greater share of their incomes on medical care. It is therefore crucial to continue finding ways to both ensure funding of the program and new innovation and models to help women face the challenges posed by a rapidly aging population.

Home health care is shaped very much by women, as patients, providers, and innovators. Today we thank them, and look forward to their continued role in molding the home health care delivery system of the future.

Home Health is Where the Heart is

This February, in celebration of American Heart Month, don’t overlook the importance of the home as a critical place of care for those with heart conditions.

A quick look at the most recent year available shows that heart failure, hypertension, and other heart conditions are common among the home health care population.

  • Heart failure and shock (with and without major complication or comorbidity) are the third and fourth most common MS-DRGs for home health Medicare Part A episodes
  • Heart failure is the fifth most common diagnosis (using ICD-9 codes) among all Medicare Home Health claims.
  • Ninety-eight percent of the time on average nationally, home health teams met the quality measure for treating heart failure symptoms.

Nationally, hypertension is the most common chronic condition among Medicare beneficiaries with 27.5 million beneficiaries aged 65+ diagnosed. Other heart conditions, which include coronary artery disease, peripheral vascular disease, and peripheral artery disease, is third, and congestive heart failure is 12th, in front of mental illness/disorder, Alzheimer’s Disease, and broken hips.

The Home Health Quality Improvement (HHQI) National Campaign sheds further light on the common symptoms on a heart attack, as well as some of the risk factors for heart attack and heart disease in a recent blog post.

Given both the preference to age in place and the lower cost to the system home health care affords, more and more Boomers will be receiving home health care in the future. And it turns out, the home can be a critical care provider for many suffering from various heart conditions.

A few years ago, the Alliance did a series of profiles on utilizing new programs and technology to reduce readmissions, all with a focus on heart failure patients. These case studies showed a decrease in rehospitalization rates for heart failure patients using an array of telehealth programs. Interventions in the programs included patient education on how the heart works, care transitions from hospital to home, and telemonitoring measurements.

For instance, in 2007 the Visiting Nursing Association of Western New York began a hospital to home program in conjunction with what was then Cardiocom (now Medtronic Care Management), which utilized telehealth data to track patient progress and identify a need for possible early intervention. The program was instituted for cardiac patients including those with heart failure, hypertension, post coronary artery bypass graft surgery, atrial fibrillation, coronary atherosclerosis, and chronic obstructive pulmonary disorder (COPD). Typically, patients would digitally check-in with weight and blood pressure measurements, as well as a few health-related questions. A telehealth team would receive the information almost instantaneously, and would review whether a patient was following their prescribed medical regime. If the team spotted an issue, they worked with the patient’s physician to make adjustments. During the course of the program, the Visiting Nursing Association of Western New York saw an 11 percent decrease in acute care hospitalizations and high patient satisfaction ratings.

Programs such at the one implemented by VNA of WNY demonstrate one way in which home health can be a vital resource for those with an array of heart conditions. Working hand-in-hand, technology and home health are poised to continue serving many more happy hearts in the future.

Opening the Front Door to Better Care

Published by Huffington Post
By Steve Landers MD,MPH
January 25, 2016

This article is co-authored with Dr. Bruce Leff, Professor of Medicine and Director of the Center for Transformative Geriatric Research at Johns Hopkins@HopkinsMedicine.

America is experiencing a dramatic population shift — one that will turn the country on its head. As Baby Boomers age, more people will live with chronic conditions, like heart disease or dementia, and many will have difficulty with basic abilities like walking and managing their household.

These shifts will create enormous challenges for our country. We must do everything possible to ensure that older Americans remain independent and healthy at home, without experiencing the suffering, indignity, and costs associated with unnecessary hospitalizations and institutionalization.

Our success in answering this call will dictate quality of life vs. suffering for millions of people. The country’s economic health is also at stake as the growing costs of Medicare and Medicaid threaten to squeeze out funding for other priorities. A key to solving this vexing problem is improving access to quality care at home.

In the wake of the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act of 2015, we are seeing a shift toward more care coordination and “value-based” care. These trends have led to more interest by doctors and hospitals in helping people succeed in home and community-based settings.

This new attention is a good start, but it’s not enough.

The focus of current reform efforts has centered on insurers, hospitals, physicians, and employers. Home-based care has been left out of high profile national policy conversations, despite the fact that most older Americans prefer to stay at home and “age in place.”

Our policymakers aren’t putting enough time and resources into strengthening home health care and developing new home-based care strategies. Further, some home care policy proposals actually risk hurting the positive programs that already exist.

Out of this leadership void, the Future of Home Health (FOHH) Project was born. Developed by the Alliance for Home Health Quality and Innovation , the FOHH Project has taken on the challenge of starting a national conversation on these issues and the project really picked up steam when the Institute of Medicine (IOM) and National Research Council (NRC) hosted ‘The Future of Home Health Care’ workshop. The summary book and videos from the workshop are available online.

A few overarching themes recurred throughout the workshop, these themes could provide a head start for leaders interested in improving care:

1. There’s no place like home. Stakeholders from many backgrounds called for a shift towards community based care–making the home the center of care whenever possible. Family caregivers at the workshop were especially passionate about the importance of home care.

2. Better care at lower costs. Home health care of the future must be a solution to high costs and quality of care concerns. One example is Medicare’sIndependence at Home Demonstration, which is showing that medical teams that make house calls to Medicare’s sickest and most costly patients at home can support these individuals and save lots of money.

3. Payment policy and regulations need improvement. To build and grow new approaches to home care there will need to be policy and payment changes that support innovation. Many current policies and programs are fragmented and outdated. There should be more coordination, integration, and alignment around addressing both medical and social issues. Several historical policies and programs have created an unnatural separation between medical and social concerns even though high quality care for an aging population requires both to work in concert.

4. Don’t forget about the workforce! We must improve training, especially in geriatrics and palliative care, for all types of health professionals. Developing people to work in team-based care will be key.

5. Technology, technology, technology. Smart use of mobile health, health information, remote monitoring, telemedicine, independent living, and point of care technologies are essential for the shift towards home and community based care.

6. Accurate report cards. Quality and outcomes will need to be measured in order to reflect the value of community and home-based care. We must take care to ensure appropriate quality measures that fit the needs and goals of older people with multiple medical problems, rather than current measures that often focus on single diseases.

The ultimate goal of the FOHH Project is to develop a framework for home health delivery in the future and to take advantage of the many promising innovations that have not been scaled widely due to gaps in policy and for lack of attention.

These efforts serve as a foundation for beginning a discussion, but more national dialogue is required, with input from a wide range of leaders. To truly have a person-centered, compassionate, and responsible healthcare system we must work on building a bright future and prominent role for home health care.

CMS Continues Advancing Alternative Payment Models

Alternative models of payment are a trending topic for the Centers for Medicare and Medicaid (CMS) as the agency hits the half-century mark. Given that the Secretary of Health and Human Services has specified a goal of moving 50 percent of Medicare payments to alternative payment models within the next two years, the health care system—and home health care as part of it—lies at a critical juncture. It is more important than ever to understand these new models, and several recent publications shed critical light.

In the November 19th issue of The New England Journal of Medicine, Paul Ginsburg and Alice Rivlin explored the challenges facing CMS in a changing healthcare delivery environment (available here). Given CMS’s commitment to alternative payment models and quality care initiatives, the health care delivery landscape of the future appears to be approaching more quickly than ever, and Ginsburg and Rivlin see this as an opportunity to improve both quality and efficiency.

Though CMS has been clear about making bundled payment arrangements a high priority alternative payment model, there are multiple programs and approaches that are testing bundled payments. The Center for Medicare and Medicaid Innovation’s (CMMI) Bundled Payment for Care Improvement (BPCI) initiative. BPCI aims to change both the delivery and payment of health care services, and consists of four different models under which the initiative operates. Models 1 and 4 refer to inpatient acute care hospital stays alone, but models 2 and 3 include either inpatient stay plus post acute or post acute care only. Health Affairs recently issued their policy brief focused on BPCI and the opportunities, concerns, and early findings from the program. The full brief is available online here.

Although BPCI is still underway, the newly finalized Comprehensive Care for Joint Replacement (CJR) Model will quickly disseminate bundled payments across the country. Starting on April 1, 2016, hospitals in 67 geographic, or metropolitan statistical areas (MSAs), will be mandated to bundle payments for all traditional Medicare MS-DRG 469 and 470 cases. The episode begins with the admission to a participating hospital and includes the 90 days of care post-discharge for all services paid under Medicare Parts A and B, with limited exceptions. The final rule for the CJR Model is available in the Federal Register here. The CJR model does not apply to those already in BPCI Models 1, 2, or 4.

Bundled payment and other alternative models of payment provide unique challenges and opportunities for home health care. The focus on higher quality, lower cost care puts home health care in a critical place in the health care delivery system. In general, home health care is least costly and patient preferred in post-acute care, and therefore of increasingly recognized importance.

As the healthcare landscape, and especially Medicare, continues to reinvent itself and push toward alternative models of payment and delivery, providers, policymakers, and those at CMS must continue to work together to ensure that quality care is not sacrificed for cost-effectiveness, and that patient-centered care remains at the forefront of this mission.

Alliance and Peers Announce Formation of Home Health and Hospice ICD-10 Transition Workgroup

On October 8th, leading home health and hospice associations, including the Alliance, joined with the Centers for Medicare and Medicaid Services (CMS) ICD-10 Ombudsman Dr. William Rogers to form the Home Health and Hospice ICD-10 Transition Workgroup.

The purpose of the workgroup is to streamline the process for ICD-10 transition and act as a conduit for addressing questions and concerns regarding the transition.

ICD-10 is the latest coding set for the diagnoses of all patients protected under the Health Insurance Portability Accountability Act (HIPAA), and is used across the U.S. healthcare continuum. It is a seven-digit coding structure, which replaced ICD-9 on October 1, 2015.

Last month, the Alliance submitted comments to CMS regarding concerns with the transition to ICD-10, including concerns about the lack of “transition flexibility” for home health agencies and other post-acute care providers, and confusion over coding of the seventh character for home health.

In addition to the Alliance, the group will include the Association for Home Care Coding and Compliance (AHCC), the National Association of Home Care & Hospice (NAHC), the National Hospice and Palliative Care Organizations (NHPCO), and the Visiting Nurses Association of America (VNAA) will also serve on the workgroup. AHCC will serve as the main conduit between this workgroup and CMS, consulting with the Board of Medical Specialty Coding (BMSC) to resolve ICD-10 issues. AHCC and BMSC are both part of Decision Health, a company that provides news, analysis resources and training for home health and hospice professionals.

The Alliance would like to invite all community members to reach out with questions and concerns for the workgroup. You can reach the Alliance’s Executive Director Teresa Lee at tlee@ahhqi.org.

Dr. Rogers is welcoming all industry members to reach out with questions and concerns individually, however, those previewed by the workgroup first may see accelerated response times. Dr. Rogers can be reached directly at ICD10_Ombudsman@cms.hhs.gov.

For more information on ICD-10, check out CMS’s website: http://www.roadto10.org/.

Recapping the Future of Home Health Southern Regional Symposium

In 2014, the Alliance launched the Future of Home Health Project, aimed at improving the understanding of the ways home health is currently used, and how it can be utilized in the future for older Americans and those with disabilities. Last week, as part of the Project, the Alliance held the first in a series of regional symposia.

Hosted in advance of the Southwest/Gulf Coast Regional Home Care & Hospice Conference and Exhibition in New Orleans, the Alliance’s Future of Home Health Southern Regional Symposium, “Preparing for the Future: Building on the IOM Future of Home Health Care Workshop,” brought together regional and national providers, thought leaders, and stakeholders for a dialogue on home health and its future in the health care landscape.

Participants heard from speakers from the Institute of Medicine (IOM), Kindred Healthcare, Case Western Reserve University, the Brookings Institution, the National Alliance for Caregiving, and Virginia Commonwealth University on how the future of home health care should look and what needs to be done to get there. The symposium panels discussed issues related to workforce, patient and caregiver interaction, measures, innovative payment models, collaboration with physicians, reducing hospitalizations, and more.

The day started out with a recap of the Fall 2014 Institute of Medicine and National Research Council Future of Home Health Care Workshop, featuring Dr. Tracy Lustig of the IOM and Dr. Elizabeth Madigan of Case Western Reserve, who served as a co-chair of the workshop. A quick look at the themes from the Workshop can be found here.

During the next panel on “Perspectives on the Role of Home Health in New Health Care Delivery Models,” Mary Van De Kamp of Kindred Healthcare spoke about shifting the focus from reducing only rehospitalizations to reducing hospitalizations overall. She explained that home health over time will position itself as being more than only a provider of post-acute care. The theme of driving home health care away from just post-acute and toward more patient-centered, community-based care is one that can be found throughout the Project, and in new and innovative models of care delivery. Both Dr. Peter Boling of Virginia Commonwealth University and Dr. Barbara Gage of the Brookings Institution and the Post-Acute Care Center for Reform (PACCR) discussed a few of the aforementioned innovative models in their presentations as well.

In the final panel, Kate Jones of Amedisys and Gail Hunt of the National Alliance for Caregiving joined Dr. Gage to discuss ways to prepare for the future of home health care. Mrs. Jones talked about the needs of the workforce and ways to achieve better workforce planning, while Ms. Hunt brought the discussion back to the patient and caregiver, and the critical need to communicate effectively with both in order to avoid readmissions and achieve the Triple Aim.

Finally, Dr. Robert Rosati of the Visiting Nurse Association Health Group led a recap of the day’s discussion and encouraged participants to share their reactions to the issues raised in each session. We collaboratively unpacked the key themes to focus on for the future of home health care.

The Alliance is thankful to all of our panelists, moderators, and participants for bringing such important topics to the table and allowing us to delve further into a critical discussion as the population ages and health care in the U.S. continues to evolve.

We’re looking forward to continuing to take the discourse outside of just Washington, DC, and we hope you’ll be able to join us at an upcoming event. Please keep checking back for more information on upcoming regional symposia in the Northeast, Midwest, and West, and follow along on Twitter using the #FutureofHH.

Next Week: Alliance Sponsored IOM Workshop

On September 30th and October 1st, 2014 the Institute of Medicine (IOM) and National Research Council (NRC) will hold a workshop on the future of home health care. Sponsored in part by the Alliance, the workshop will bring together experts from academia, think tanks, government, accrediting bodies, healthcare delivery systems, national associations and other thought leaders in the healthcare community, to shed light on the trends affecting Medicare home health care today and the changes needed in home health care to optimally serve patients and the U.S. health care system in the future. The complete agenda is available through the IOM here.

The workshop will explore the role of home health in achieving the Triple Aim – to improve the patient’s experience of care, improve population health and reduce per capita costs – by examining new models of care that make use of home health care, and workforce, technology, policy, research and infrastructure needs. Following the workshop, the IOM will release a summary detailing the proceedings and the key themes and issues identified in the workshop.

While the seats are filled for in-person participation in the event, registration is available for the live webcast here. You can also follow along with the discussion on Twitter using the #FutureofHH.

In addition to the Alliance, sponsoring organizations for the workshop include: the American Academy of Home Care Medicine, the American Nurses Association, the American Physical Therapy Association, Axxess, the Community Health Accreditation Program, Home-Instead, the National Alliance for Caregiving, and UnityPoint at Home.

The Alliance’s sponsorship of this workshop is just one part of the Alliance’s Future of Home Health (FOHH) Project, which kicked off earlier this year with the release of a white paper and a corresponding Capitol Hill Briefing. The materials from this briefing can be found on the Alliance’s website here.

The FOHH Project’s next public event will be a day-long Symposium that the Alliance will host on January 13, 2015 at the Ronald Reagan Building in Washington, DC. The event will focus on convening prominent stakeholders in the health care community and leaders in home health care to discuss the key delivery system reforms and emerging models of care that are harbingers of the future of home health care. Further details on this event will be available soon at this website.

Finally, the Project will conclude with a research-based strategic plan on the future of home health care in the United States. Scheduled for completion in 2015, the goal is development of a research-based framework for the future of home health care.

If you’re interested in becoming involved with the FOHH Project or would like to share your thoughts and insights, you may email futureofhh@ahhqi.org or join the conversation online. The Alliance would like to thank every Alliance member, as well as our project sponsors for their support of the FOHH Project: Axxess, the Community Health Accreditation Program, UnityPoint at Home, and The Corridor Group.

August #HomeHealthChat: Home Health Partnerships with Skilled Nursing Facilities

On Tuesday, August 26th, the Alliance hosted its monthly #homehealthchat on Twitter.

The topic of the chat was workforce development, featuring co-host Long-Term Living (@LongTermLiving). Long-Term Living Magazine is the industry-leading media source of practical, in-depth, business-building and resident care information.

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 Special Assistant to the Executive Director Jennifer Schiller here.

Below are some of the highlights from the chat:

May #HomeHealthChat: Living Independently at Home

On Tuesday, May 27th, the Alliance hosted its monthly #homehealthchat on Twitter.

The topic of the chat was living independently at home, featuring co-host AARP Home & Family, a group within AARP that focuses on caregiving and livable communities.

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 email the Alliance’s Special Assistant to the Executive Director Jennifer Schiller at jschiller@ahhqi.org.

Below are some of the highlights from the chat: