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News Roundup: October 16, 2015

The Future of Pediatric HomeCare

Published by HomeCare Magazine
HomeCare
October 16, 2015

Lexi lost both kidneys to cancer at 17 months. Allison was born with a condition that progressively robbed her of the ability to breathe and grow. And at 6-days-old, Lucas had surgery to remove most of his large intestine.

Thirty years ago, these children would likely have been hospitalized for long periods of their lives—if they survived at all.

Today, children with medical complexities not only survive, they live full lives at home rather than in a hospital. While home care is most often associated with the elderly, thanks to advanced technology and techniques, more and more medically complex children have the option to live at home and be part of the community.

That was not true 25 years ago. There were no in-home health services tailored to meet the needs of children with complex medical conditions when Pediatric Home Service (PHS) opened its doors in 1990. The demand for pediatric home care has since grown substantially, along with the array of services, providers and technology. Today, the pediatric population thought to have special health care needs ranges from 0.7 percent (those with highest level of medical complexity and need) to 18 percent (anyone who falls in the "children and youth with special health care needs" category).

At the same time, aging baby boomers are contributing to a growing need for home care services. By 2017, the over-65 population will be greater than the under-five population for the first time in history, putting more strain on an industry already competing for too few resources, particularly skilled professionals.

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The evolving segment of pediatric home care is facing multiple challenges, including a lack of fair payment for services, restrictive coverage and benefit exclusions, shortages of home health nurses with pediatric expertise, a lack of meaningful data on the complex pediatric population, and even a lack of a clear understanding of how pediatric home care will integrate into the overall health care system in the future.

These challenges must be addressed—not only to ensure access to high quality home care for medically complex children, but as part of an overall solution to remedy our nation's health care problems. Home-based care for all ages is increasingly seen as a strategy to help achieve the Triple Aim of the U.S. health system outlined in the Affordable Care Act, which is to improve the health of the population, lower total cost of care, and improve the patient experience.

Here is a look at what our industry can do to help make sure that happens.

Define and Pediatric Home Care Services
The name seems self-explanatory, but pediatric home care includes a wide range of services not always understood or recognized. Services can be as simple as a home health aide regularly assisting with patient daily living activities or as complex as a highly trained nurse administering and monitoring infusion therapy or skilled assessments and interventions. Staff in different disciplines with advanced skill levels move in and out of a home in shifts. Comprehensive care plans and designation of essential skill level requirements are critical in caring for children with medical complexities. Family caregivers are also trained by these clinicians to deliver appropriate care.

Pediatric home health providers deliver needed stimulation in all areas of a child's development.Pediatric home health providers deliver needed stimulation in all areas of a child's development.
The challenge for pediatric home care providers is to put the right people in the right places with the right resources for the best possible outcomes for patients and their families. As the market expands for a variety of home care services—including the provision of sophisticated medical devices commonly referred to as durable medical equipment (DME)—roles, qualifications and services must be clearly defined to make sure patient needs are met.

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Adequately Reimburse Services
Payment must be sufficient to allow specialized home care companies to deliver evidence-based care consistent with pediatric medical standards. Medicare rates—not Medicaid—are used as the basis for pricing applied to DME, supplies and home health services for most payers, yet treating a pediatric patient as if they were a geriatric patient would yield catastrophic results. Our challenge as providers is to highlight the differences for all stakeholders, so that we are assured fair compensation for care provided.

Other reasons that current reimbursement rates and regulations haven't kept pace include:

A lack of awareness among payers and policy makers of the complexity and variety of pediatric home care products and services, and the costs incurred in their delivery. Some payers use the "lower the total cost of care" to justify their significant rate compression.
Insurance coverage that does not account for the comprehensive nature of home health services.
State coverage and Medicaid payment that varies greatly from state to state.
No standard definition of what constitutes "medically necessary care."
The payment system for pediatric home health care is a model in need of change, one that recognizes the unique nature of pediatric home care.

Recruit and Retain Professionals
Home health care resources—particularly the number of skilled or experienced professionals—are in short supply. It's a situation that will worsen as the aging population creates even greater demand for home health care services.

A pediatric home health nurse administers medication through a portA pediatric home health nurse administers medication through a port
In Minnesota, we are lucky to graduate more nurses than there are positions open. But these nurses have many opportunities and they often want hospital experience. Some of this can be attributed to wages, but the environment is also different. Because hospital nurses see a wide variety of patients, it is perceived that they get to use assessment skills more and learn about a variety of different diseases, making it an attractive option.

How do we attract nurses to careers in home health care?

It is important to make sure people understand that home care is a specialty. It requires a single nurse or professional to apply a broad set of skills to perform all the services and care. Home health nursing is a meaningful, challenging and rewarding career with plenty of opportunities to grow. At PHS, we partner with area colleges and universities to provide nursing students with learning opportunities ranging from an introduction to the field to a more in-depth experience that includes job shadowing and hands-on care. In 2015, we sponsored a pediatric nursing conference with leading Minnesota physicians and focused on the evolving home health care market.

Additionally, the industry must advocate for pay that crosses all locations of care and compensates home care nurses for what they do, not where they do it. Home care nurses provide intensive and appropriate care for patients with medical complexities on a daily basis. They are highly trained and skilled and often have sole responsibility for their patients, yet they are paid less. Equitable pay is critical in attracting talent, and it is a primary focus of our legislative efforts in Minnesota.

DME professionals have an opportunity in the pediatric home care market.DME professionals have an opportunity in the pediatric home care market.
Prove Value with Improved Evidence Base
Health care organizations and policy makers need data to make informed decisions on how to best deliver home care services to children with special health needs. While there is a national database of Medicare patients, that type of information is fragmented in the pediatric market because Medicaid systems differ state by state. In the adult world of home care, there are clear measures of health improvement—the ability to walk independently or feed oneself more reliably, for example.

Outcomes measurements differ in the pediatric world where kids are continually growing. We often begin with an infant incapable of supporting life without help and then progress through all kinds of normal development processes to reach appropriate milestones. An adult can be in a bed or wheelchair and use short ventilator tubing, while a child needs to roll, crawl and then walk to develop, so the equipment has to be configured differently to allow for that movement. In pediatrics, we need to get kids over different hurdles—getting them to eat, helping their brain, lungs, and heart develop, and allow for—in some cases—weaning off technology completely, whereas the aging population is likely to become more reliant on machines over time. Families often measure success by how long it's been since their children have been admitted to the hospital, and for some, that's been more than a decade.

There is significant evidence that pediatric home care is a cost-effective, patient-preferred alternative to hospital care with demonstrably positive outcomes. But there is a woeful lack of nationwide, comparable data that is needed to truly quantify the benefits of pediatric home health care overall. Research will require collaboration to compile sufficient data on hospital and home health care service utilization, re-hospitalization rates, costs and other factors.

Integrate a Fragmented Health Care System
As an industry, we must determine how pediatric home health care can align and integrate our services into new, more collaborative models of care. That includes identifying funding priorities that focus our resources on efforts that truly improve population health, reduce costs and improve patient experience.

The future of pediatric home care—and sustaining safe, effective, and affordable health care for all Americans—depends upon tearing down walls, eliminating redundancies, and working with others to optimize and share technology, information and precious resources.

Health care is going home, and not only because it is generally the patient-preferred environment. As the U.S. health care system changes to improve the health of its population, lower total cost of care, and improve the patient experience, home-centered care is a key solution in achieving that Triple Aim. As an industry, home care agencies must work together to design a new system that will safely meet patient needs today and in the future. That includes collaborating to define and differentiate these services, demonstrate their value with quantifiable evidence, and ensure fair payment to support sustainability. Meeting these challenges will determine our role in the future of health care, and enhance our ability to contribute to an improved, more integrated health care system.

Telehealth: The next phase in health care

Published by HME News
Theresa Flaherty
October 16, 2015

YARMOUTH, Maine – Could the trend of pushing more health care into the home finally push telehealth to the forefront?

While the concept of telehealth—the use of electronic information and technology to support health care, patient and professional education, public health and health administration—has been around for several years, it’s been slow to catch on, particularly in the HME industry.

“I am aware that a number of home health agencies are doing it on select patients,” said Woody O’Neal, vice president of Pelham, Ala.-based O2 Neal Medical. “DME companies need to be more involved in that somehow. I think it’s the next phase of health care.”

With the Affordable Care Act requiring hospitals to reduce readmissions, the time may be right for an expansion of telehealth services, say providers.

“I think that HME is uniquely qualified to play a critical component of that,” said Dan Heckman, president and general manager of Heckman Healthcare in Decatur, Ill. And, as sicker patients are being care for in the home acute, “I think there are lots of things we can be doing in the home.”

In fact, telehealth services have been used to monitor CPAP patients, they say.

Barry Berger, a former HME provider, added telehealth services in 2010, monitoring blood pressure, weight and pulse ox, but eventually dropped it because it hadn’t really caught on among medical professionals. Now, as president of Accredited Nursing, a Woodland Hills, Calif.-based home health agency, he’s taking another look.

“I believe that there’s a definite clinical value in being able to determine whether someone’s health is declining and being able to catch that,” said Berger. “But, it’s a question of whether the physicians are ordering it.”

Bring Back House Calls

Published by The New York Times
SANDEEP JAUHAR
October 16, 2015

A FEW weeks ago, in the hospital where I work, I was telling a 92-year-old patient about her discharge plan. I wanted her to follow up in my office in a week. Frail and soft-spoken, she asked me if instead I could visit her at home. “I’m afraid not,” I said automatically, but when she asked me why, I didn’t have a good answer.

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Before World War II, about 40 percent of all doctor-patient encounters were house calls. Today, the proportion has dwindled to less than 1 percent. The major reason, not surprisingly, is money: Traveling to patients’ homes is inefficient and almost never profitable for doctors or hospitals. But I believe that if we revived the house call, the overall savings to the health care system, not to mention the impact on patient care, would be enormous.

I have made an occasional house call, and what I’ve learned about my patients has been invaluable. One patient of mine had severe heart failure that rendered him too weak to come see me, unless he was brought to the E.R. by ambulance. He lived only a mile from the hospital, so I went to visit him. In his kitchen sink was a mess of dirty dishes. I looked in the fridge; it was nearly empty. There were canned soups on the counter, all loaded with sodium, precisely what he should not have been consuming. His wife was sitting silently at the dining table, appearing exhausted. It was then that I learned she had stopped driving. It didn’t matter which medications I ordered at the pharmacy; he had no way to get them.

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My patient had been hospitalized four times in six months — in part because we didn’t know what was going on at his home.

Rehospitalization is a huge and costly problem in this country, where the rate has increased 50 percent over the past three decades. Today, about one in five Medicare patients discharged from the hospital is rehospitalized within a month. A third of those patients are rehospitalized within a week. Removing elderly patients from their homes and sending them back to the alien environment of the hospital is often traumatizing.

Neither doctors nor hospitals have tried very hard to tackle this problem. We don’t ensure that patients released from the hospital obtain their medications and know how to take them. We don’t secure timely medical follow-ups. Most of the time we don’t communicate with patients’ primary care physicians. And of course, we almost never visit them at home.

This goodbye-and-good-luck attitude costs us a lot of money. The price tag of unplanned readmissions is $17 billion a year for Medicare alone. Given the huge costs, it is no surprise that the Obama administration has been penalizing hospitals with higher-than-average readmission rates. Last year about 2,600 hospitals across the country were docked up to 3 percent of their total Medicare revenue, for a total of $420 million.

You would think such penalties would have a big impact on the discharge planning at most hospitals, which operate with very narrow profit margins. They don’t.

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From the standpoint of the bottom line, it makes more sense for hospitals to keep their beds filled, even with readmitted patients. Daily hospital bed outlays dwarf readmission penalties. Our current payment system rewards hospitals much more for letting patients in than for keeping them out.

A majority of readmission costs could be saved with better care coordination, including home visits. At a recent conference in Concord, Calif., I heard about all sorts of good Samaritan work focused on providing care at home, such as churches’ partnering with hospitals to reduce hospitalizations in “vulnerable populations,” especially the elderly.

One company, MedStar, a Texas-based ambulance service, consults with hospitals to determine if patients calling 911 really need to be taken to the emergency room. In 2008, 21 residents of the greater Fort Worth area went to the E.R. more than 2,000 times, costing nearly $1 million in ambulance charges alone. MedStar identified the “frequent fliers” and developed care plans for them, including regularly scheduled home visits. The result, the service reports, was an 80 percent reduction in readmissions in this high-risk group.

The readmission problem will not be easy to solve. Some patients decline home visits. Some have dementia, a known predictor of readmission. Some things, like progressive debility, you can’t prevent. And we can’t make follow-up appointments for our patients if there aren’t enough primary care physicians available to see them.

But poor communication and coordination, big drivers of readmissions, can be remedied. Anemic penalties are a start, but they won’t get the job done. There is substantial variation in readmission rates across the country, suggesting that improvement on a national scale is possible.

The key to improving the hospital-to-home transition is a better understanding of the home component. For doctors, patients’ homes shouldn’t be a black box.

Telemedicine Is Vital to Reforming Health Care Delivery

Published by Harvard Business Review
Joseph C. Kvedar, MD
October 16, 2015

Health care remains one of the few services that require people to have a face-to-face interaction to obtain access. But more and more consumers are questioning that reality, and change is on the way. In January 2015, the Centers for Medicare and Medicaid Services (CMS) issued a new provider reimbursement code for non–face-to-face health care services for patients who have chronic medical conditions. A new CMS code may seem like a tiny matter, but this one emblemizes a larger shift toward delivering health services independently of time and place, enabled by technologies such as smartphones, sensors, and wireless health-monitoring devices — what we in the field call telemedicine.

The concept of telemedicine is not new (its roots go back to the late 1950s). In the 21st century, the widely held goal of improving health care outcomes while lowering costs is accelerating the shift from a one-to-one to a one-to-many model of care delivery, which telemedicine makes possible. Understanding telemedicine has now become crucial for decision makers in the health care industry, and I aim to help in that effort. Let me start by exploring some industry fundamentals.

The rising prevalence of chronic illnesses in an aging population puts pressure on the supply side of health care. Clinicians are not being trained fast enough to keep pace with the rate of service demand. In addition, given the rising cost of care, new models for reimbursing hospitals and other providers have begun to emphasize quality and efficiency rather than units of delivered services. And consumers are increasingly shopping on open markets for health insurance policies that require significant deductibles and out-of-pocket expenses. These trends underpin the need for a one-to-many model of care delivery that offers flexibility and transparency.

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Telemedicine is well positioned in this environment, particularly given patients’ growing comfort with technology in their consumer endeavors. The core technologies of telemedicine include those that collect data (such as wearable and ingestible sensors, and vital-sign and health-status monitoring) and those that enable communication (videoconferencing, text-messaging, mobile apps, and voice calls). These types of virtualized services will become an integral part of care delivery. Indeed, several commercial payers are now reimbursing providers for video-based visits, not to mention the CMS’s new telemedicine-friendly reimbursement code.

How does telemedicine work in practice? Here are some common examples:

When patients with congestive heart failure use a home-based weight scale and a blood pressure cuff, and then check in routinely by phone with a nurse, their survival rates improve, and costs decline. A nurse can care for hundreds of patients at a time in this way, keeping them healthy and happy in their homes and away from costly emergency rooms and hospital beds.
For patients with mental illness, video follow-up visits with a mental health provider have been shown to improve quality and efficiency of care. The provider can more easily assess environmental influences on the patient’s condition, and patients more accurately reveal their daily state of being because they don’t always have to endure the stress of traveling to an office and the social anxiety of sitting in a waiting room with other patients.
Text-messaging interventions can aid in smoking-cessation efforts. My institution is collaborating on a texting intervention for smokers who try “practice quits” (quitting for a short period, such as an hour or a week). Timed text messages help the smoker cope with cravings, encourage longer practice-quit commitments, and applaud successes. The smoker can also text in the word “crave” and receive text-based coaching on the spot. Relatively automated systems like this one have great potential for improving public health.
Both Walgreens and CVS offer virtual video care as an extension of their retail clinics. Many health plans, led by UnitedHealth Group, are doing the same. These offerings will push hesitant providers to offer these services as well.
Despite those examples, most telemedicine efforts are still in early, small-scale phases of implementation. Countervailing forces, like these, stand in the way:

Although most young doctors are digitally savvy, they represent a much smaller group than the physicians who were trained in an era when a face-to-face interaction with a patient was the only option.
Fee-for service reimbursement, still the dominant payment model in the U.S., is fundamentally at odds with a one-to-many model of care delivery.
Some doctors worry that virtual care will mean greater liability, even though most malpractice insurance carriers are telemedicine-friendly and the case law on virtual care is almost nil.
State physician-licensure laws in the U.S. create false geographic barriers that have impeded some forms of telemedicine. For example, some laws require that a physician be licensed in the state where his or her patient is located.
Many health insurers fear that telemedicine will lead to overutilization — such as a doctor looking at an image of a patient’s mole, submitting a bill for the virtual service, and then saying he needs to see the patient in person to be sure.
Frequent users of health care services are typically disproportionately less tech-savvy and place great value on their social interactions with their clinicians.
Privacy concerns about remotely delivering care persist.

Even if all of these obstacles are overcome, face-to-face care visits will not become obsolete, given the complexity of some patients’ clinical profiles and illnesses, especially when a doctor needs to arrive at an initial diagnosis. And some highly sensitive communications (such as news of a newly diagnosed cancer) are obviously best conveyed in person. But for health care interactions that are algorithmic in nature (think: blood pressure checks and acne follow-up visits) or that have a low emotional impact, virtual encounters can be ideal for both parties.

Pressure to lower costs also bodes well for innovation in telemedicine’s one-to-many model of care delivery. Early results suggest that new payment models that reward providers for higher quality and efficiency (including virtual care) are working.

I am excited about the possibility of automating certain care-delivery processes and using technology to enable patients to obtain better care. The advertising industry now has a model for collecting and analyzing consumers’ digital fingerprints so that ads can be personalized. In a somewhat similar vein, people can now have their walking steps counted, purchasing behavior tracked, and mood and other health indicators monitored to create a highly personalized messaging program that motivates them to improve their health.

If we do telemedicine right — with the direct and enthusiastic consent of the patient — I believe that most people will make the privacy tradeoffs. Realizing the potential of telemedicine will indeed require those tradeoffs if we want to improve the current system of health care delivery.

As U.S. Population Ages, Doctor House Calls Are Making Comeback

Published by Space Cast Daily
Dr. James Palermo
October 16, 2015

Although still relatively uncommon, physician house calls for a specific healthcare demographic are making a comeback because of logistics and economics.

The concept of a doctor visiting a patient at home rather than a patient going to a doctor is hardly revolutionary.

According to a Clinics in Geriatric Medicine article, in 1930 about 40 percent of doctor-patient interactions were through house calls, but by 1980, the rate was down to 1 percent.

doctor-house-call
In 1930 about 40 percent of doctor-patient interactions were through house calls, but by 1980, the rate was down to 1 percent. There has been a slight resurgence up to 13 percent of family physicians making regular house calls in 2013.

More recently, according to the American Academy of Family Physicians, only 13 percent of family physicians surveyed made regular house calls in 2013, and only 3 percent made more than two per week.

Traditional visiting-nurse services send clinicians to patient’s homes in the few weeks after they are discharged from the hospital—but increasingly, primary care providers are making regular house call visits to the chronically ill and infirm elderly with a goal to prevent costly emergency room visits, hospital admissions, and long term facility stays.

House calls can be expensive, but may end up costing less in the long-run, research suggests.

doctor house call
Research shows that home-based care decreases costly emergency room visits, hospital admissions, and long term facility stays, improves outcomes and enhances patient satisfaction.

A 2014 study published in the Journal of the American Geriatrics Society compared the Medicare costs and outcomes of more than 700 patients enrolled in a house call program to a control group of more than 2,100 Medicare patients.

Patients in the house call group had 17 percent lower health care costs during a two-year period.

They also had 9 percent fewer hospitalizations, 20 percent fewer emergency department visits, 23 percent fewer visits to sub-specialists and 27 percent fewer stays in skilled nursing facilities.

A similar study in the same journal also suggests such patients have higher patient satisfaction.

The Center for Medicare and Medicaid (CMS) is also exploring the model through a pilot project called Independence at Home, which includes 20 medical practices across the country providing home-based care to more than 8,400 patients. The program targets high-risk, high-cost Medicare patients who have large gaps in care coordination and many hospital admissions per year.

dr. bag and steth
A rapidly growing elderly population, 60 percent of which have multiple chronic healthcare conditions, and many of whom would likely need regular health care visits and have difficulty accessing care, will create an increasing need for home-based care.

In June, CMS released the results of the pilot program showing a savings of more than $25 million in the first year through lower admissions, readmissions, and ED visits.

Program providers that successfully reduced costs by at least 5 percent less than their spending targets were awarded $11.7 million in incentive payments via a shared-savings model, which makes the model more economically feasible for physicians to make a living and expand across the nation.

Many seniors are not receiving regular care simply because they are unable to leave home.

With research consistently showing that house calls improve care and lower costs, and a rapidly growing elderly population, 60 percent of which have multiple chronic healthcare conditions and likely would need regular health care visits, which they may have difficulty accessing, home-based primary care will likely play a more significant role in healthcare delivery in the future.