News Roundup: August 26, 2016
How Expanded Roles For Home Health Aides Can Improve The Health Of Older Americans
Published by Huffington Post
By Marki Flannery
August 26, 2016
Millions of older Americans have a home health aide (HHA) come into their home on a daily basis to assist with essential activities such as bathing, dressing and preparing meals, and to help keep them connected in their communities. But what if that HHA is also trained to check on any changes in her client’s medical condition, and uses a pre-programmed computer tablet that automatically notifies a clinical manager whenever a change occurs? And what if that same HHA goes over all prescribed medications with the client as well, makes sure doctors’ appointments are scheduled and kept, and works with the client and their home care agency to identify effective alternatives to the hospital emergency room, should pain or other worrisome symptoms suddenly arise? That’s exactly what’s been happening these days where I work.
A recently concluded pilot program trained HHAs to do exactly these things for their managed care clients — and it found that this additional training significantly improved these clients’ health outcomes. The 18-month study, funded by a $1.9 million grant from New York State’s Department of Health, was implemented by the Bronx-based Paraprofessional Healthcare Institute (PHI) in collaboration with Independence Care System (ICS), a New York City-based nonprofit that coordinates home-based care for seniors and people with disabilities, as well as three local home care agencies. The study tracked 1,100 home care clients who were cared for by HHAs with advanced training, and found that this group had 24% fewer visits to the emergency room compared to those clients whose HHAs did not receive advanced training.
This is exciting news for those of us in the home care industry who believe that expanding the skill sets of our nation’s HHAs is one of the keys to helping America’s growing population of seniors age in place successfully. Since HHAs are in their clients’ homes for multiple hours each day, they can play a critical role in protecting clients’ health — provided we give them the right tools. Last year, for example, I described in this column how my own organization, Visiting Nurse Service of New York (VNSNY), is training our HHAs to serve as health coaches so they can help their clients adopt better diets and healthier lifestyles. We’ve also developed specialized HHA training programs in rehabilitation support and hospice care.
The recent PHI pilot pioneered several other important innovations designed to help empower HHAs and expand their skill sets. Perhaps the most important of these was the creation of a new, salaried “senior aide” position. Senior aides are experienced home health aides who in the pilot program received extensive education that prepared them to coach other HHAs to carry out medication review, physician appointment oversight and symptom monitoring with clients in the home. The senior aides then served as an ongoing resource for the HHAs in case they had questions or ran into difficulties carrying out these tasks — a role that included mediated any issues that might arise between the HHA and the client.
“One of the chief goals of the pilot was to demonstrate the value of this new senior aide position,” says Sara Joffe, PHI’s Vice President for Organizational Learning, who oversaw the study. “Besides the value of senior aides as trainers, we found from interviewing HHAs in the field that they were much more comfortable sharing their problems with their supervising senior aide, as opposed to an agency manager, because they saw the senior aides as peers rather than agency superiors. The quality of compassion we saw in these senior aides was absolutely remarkable. They truly were on everybody’s side.”
The computer tablets used by the HHAs in the pilot program are another interesting innovation. The tablets’ software, developed by the firm Practice Unite, employs a simple and highly effective approach: Near the start of each day’s visit, the HHA uses the tablet to tick through 12 “yes-no” questions related to the client’s primary medical conditions, all intended to detect any changes in health status — whether any skin breakdown has occurred, for example, or whether the client is experiencing increased fatigue or confusion. If one or more “yes” answers are recorded, the tablet sends an automatic alert to a clinical manager at the HHA’s agency, who then contacts a physician or other clinician — enabling emerging health problems to be caught as early as possible, before they result in an emergency.
“The tablets included a function that lets the HHA directly phone or text their clinical manager if they felt a need to elaborate on the ‘yes-no’ questions,” adds Joffe. “This was very important in terms of the study — the fact that HHAs had the capacity to quickly get someone’s attention.”
The pilot was also able to reduce clients’ reliance on the ER for relatively minor complaints, by bringing senior aides together with the HHAs and their clients to talk through various scenarios that might have triggered a trip to the ER in the past. “For instance, an HHA may say ‘We go to the hospital a lot,’ and the senior aide will then suggest trying a local urgent care center or clinic instead,” says Joffe. “Afterwards, we’ve had clients tell us, ‘I don’t know why I was using the ER before.’ Simply being able to discuss the matter with the senior aide allowed HHAs and their clients to change their paradigm.”
On the heels of the PHI pilot, the concept of a senior aide position — including how this new category of employees might be paid for — is now getting a serious look from home care organizations. At the same time, other approaches to expanding the role of HHAs are being actively explored across the U.S. In New York, for example, a Medicaid workgroup has proposed that HHAs be allowed to take on additional responsibilities under a nurse’s supervision, including administering routine medications. New Jersey has carried out a demonstration program testing a similar option. In addition, the federal Centers for Medicare and Medicaid Services (CMS) has funded pilot programs that are providing enhanced training for HHAs in Arkansas and training HHAs in California to serve as health monitors, coaches and navigators.
Besides their direct impact on the health of home care customers, these advanced HHA training initiatives have another important potential benefit: By offering an enhanced career path for our nation’s one million HHAs, they should help reduce turnover, enabling home care agencies to retain our most experienced HHAs as a vital resource. That, together with the increasing embrace of advanced training for the nation’s home health aide workforce, adds up to a major win for the well-being of older Americans.
Copayment Woes Drive Agenda for Home Care Advocates
Published by Home Health Care News
By Amy Baxter
August 26, 2016
There’s another new regulation in the future for home health care that some in the industry are calling doomsday: copayments.
Copayments for home health care, which were eliminated from Medicare several decades ago, have been reintroduced into the health care reform dialogue and could make a full come back, with some proposals placing implementation as early as 2018. That is, unless home care advocates can shift the momentum around copayments in Washington.
The Council of State Homecare Association and the Pennsylvania Homecare Association recently held a public policy summit and “advocacy day on the hill” in Washington D.C. to meet with legislators and lobby against payment cuts and new regulations. The aims of the group were three-fold: prevent the implementation of a home health care copayment, repeal the rebasing cuts from the Centers for Medicare & Medicaid Services and utilize a targeted enforcement approach to combat fraud.
Efforts to combat fraud have come down the pike in more sweeping initiatives, such as the pre-claim review demonstration, which rolled out in Illinois on August 3 and will soon begin in Michigan, Massachusetts, Florida and Texas. With the pre-claim demonstration already underway, home care groups and industry leaders are focusing their lobbying efforts on copayments, which have the potential to greatly impact home health care clients.
Co-Pays? No Way
Industry groups have vehemently opposed to proposals to resurrect copayments, which were eliminated more than 40 years ago. The re-introduction of copayments have been included in President Obama’s budget proposals for the last few years, with potential implementation as early of 2018. The copayment only applies to newly eligible Medicare beneficiaries in the year of implementation.
The proposals call for a $100 copayment per home health episode. Critics of copayments argue that copayments for Medicare beneficiaries did not work years ago, and therefore, they won’t work now. Medicare beneficiaries would circumvent using home health care because of the cost when copays existed.
“Congress eliminated the home health copayment in 1972 for the very reasons it should not be resurrected now,” the National Association for Home Care & Hospice (NAHC) wrote in comments to House Ways and Means Committee back in 2013. “The home health copayment in the 1960s and the 1970s deterred Medicare beneficiaries from accessing home health care and instead created an incentive for more expensive institutional care.”
President Obama’s most recent budget proposal for 2017 aimed to implement home health copayments for new beneficiaries in 2020.
In an election year, political candidates at the state and national levels are taking home care issues to heart, and home care insiders are pushing hard for their causes. With copayments back on the table, home care leaders are utilizing public policy channels to keep any new implementation at bay.
“We met with Medicare, CMS, and MACs locally,” Constance Morrison, president and CEO of Berks Visiting Nurse Association (VNA), Pottstown VNA and Advantage Home Care, said of the advocacy day in July on Capitol Hill. “We were able to probe and educate others about things that are coming down the pike in the industry. We were able to lobby, throw tomatoes. There were 19 states represented, and about 130 people representing home care.”
Berks VNA and Pottstown VNA are Pennsylvania-based registered non-profit home and community based health care services providers that, along with Advantage Home Care, are externally managed by their parent company, Home Health Care Management, Inc. Berks and Pottstown VNA serves nine Pennsylvania counties. Morrison, on behalf of Pennsylvania residents, has taken her aims of expanding access to “top-notch, affordable home health care” to Capitol Hill.
“The home health benefit is such a valuable piece of Medicare altogether,” Morrison said. “It was really clear across the board [at the meeting] that, big or small, we were all on the same page that this is a terrific benefit. We should not make cuts, not add a co-pay because then there will never be services.”
In addition to advocating against future copayments, Morrison continued to lobby for anti-fraud measures that don’t burden the entire home health landscape, as the pre-claim review does by mandating the new regulations on a state-wide basis. It is expected the model will eventually spread to a national level.
“We asked our legislators to support [new ways of targeting fraud] instead of washing us all in the same bathwater,” Morrison told HHCN. “We can do targeted fraud prevention. For the rest of us, the rules must be suitable.”
Lobbying, Throwing Tomatoes
Copayments are just one change to the home health industry stemming from the Affordable Care Act (ACA), which also required rebasing payments for home health agencies and a greater shift toward value-based purchasing. The copayment could potentially provide a financial incentive for Medicare beneficiaries to become more involved in their own care. In other words, a copayment could make care recipients more inclined to follow care directions. However, the price is not set on how much recipients will pay for a home health care episode.
“As part of the ACA, one of the ways to limit or make people responsible for their home care and cut costs is not just have Medicare pay for the 60-day episode,” Morrison said. “Right now, we aren’t sure what [the copayment] will look like, but likely $100 for every 60-day episode.”
However, the expense of copayments could have an opposite effect by deterring Medicare beneficiaries from using the benefit, according to Morrison. For home care recipients who may have to choose which bills to pay, home care will likely come as a last priority.
The group of people who are served through Medicare’s home health benefits are also some of the oldest, sickest and most vulnerable Americans, according to NAHC. About 25 million seniors and people with disabilities lived on income below $22,000 in 2010—200% below the federal poverty level. Medicare beneficiaries also already spend three times as much as the non-Medicare population on health care, about 15% of their total income.
“We know that people who have copays and have to choose between medication or food will choose food,” Morrison said. “If it’s home care versus medication, they will choose medication. It’s not a good topic.”
On demand senior home care via smart phone
Published by East Bay Times
By Tammerlin Drummond
August 26, 2016
OAKLAND -- When Charles Norcross, 87, fell over backward on his front steps and broke two vertebrae, the Oakland hills resident spent three weeks in Highland Hospital and at a Kaiser Permanente rehab facility. When he was discharged home in February, he was weak and barely mobile. His wife, Mary, was overwhelmed.
So, she contacted Honor, a company that provides on-demand nonmedical, in-home care for physically and mentally impaired seniors. But this wasn't your traditional brick-and-mortar agency. The San Francisco-based startup uses technology that enables seniors or their families to hire a caregiver using the company app or by logging onto its website.
The company performs an initial in-person assessment of the elder's needs, then the senior or whoever is responsible for his or her care can order a caregiver in much the same way one would an Uber ride.
For three months, the Norcrosses hired Honor caregivers, called "care pros," for two hours every other day. They could log onto their account to see a picture of the person who would be coming to their home. A succession of caregivers bathed Norcross and helped him with his physical therapy exercises. It cost $60 per visit, which the couple said was worth it.
"They were all very pleasant and good at what they did," Mary said. "I felt while they were here I could take an hour or so off and do a little shopping. It gave me a lot of support."
With more people living longer, the need for competent in-home care has never been greater. According to the U.S. Census, the 65-plus population is expected to double to 84 million by 2050. A January study by Caregiving Innovation Frontiers, released by the AARP, projected that the caregiving field will be a $279 billion market between 2016 and 2020. The report said technology provided a "huge opportunity" for improving caregiving services to older Americans.
Honor is among a crop of companies that has emerged in recent years looking to use technology to modernize how we care for seniors. It began as a pilot program in Contra Costa County and has since expanded throughout the Bay Area and to Los Angeles. The company's goal is to create a large pool of home care professionals. Computer algorithms match patients with caregivers, said CEO and co-founder Seth Sternberg.
"If mom has dementia and cats in the house, we want to insure that the caregiver is trained in caring for people with dementia and isn't allergic to cats," said Sternberg, whose company is now expanding to Dallas. "It ensures that the person you get is the best match for you and if that person is sick, there is someone to back them up with the same qualifications."
The caregivers are state-certified home health aides, nursing assistants, licensed vocational nurses or others with recent elder care experience. They must pass a background screening that includes a criminal records and DMV check and must be registered with the state Department of Social Services.
According to the company, just 5 percent of applicants get hired. Honor pays more than $15 an hour, compared with the national median of $10 per hour that caregivers earned in 2015, according to the U.S. Bureau of Labor Statistics.
Sternberg, who founded Meebo, an instant messaging and social network provider that sold to Google in 2012, has raised $62 million in venture capital funding for his new company.
He said he got the idea while visiting his mother in Connecticut. She was driving much slower than she had in the past, and she told him it was getting harder for her to do. He realized his mother, then 65, was getting older and that one day she would need help.
That day is already here for millions of elders like Olga Mos, 93, who lives with her son and daughter-in-law in Concord. She's still sharp and witty but is frail and uses a walker.
While her son Henry Domingo and daughter-in-law Rhoda Wilkinson Domingo are at work at their San Francisco law firm, an Honor caregiver helps Mos get out of bed and dressed. They remind her to take her blood pressure pills. They take her shopping and watch her favorite TV shows with her.
"It works so well for all of us," said Wilkinson Domingo, who uses a telephone to schedule her mother-in-law's care appointments, also an option offered by the company.
Caregivers get client notifications through the app and choose which jobs to take. At the end of a shift, they write up their client notes in the app to pass on to the next caregiver. They also use the app to communicate with the person responsible for an elder.
"I'll write a note telling them how our caregiving appointment went, like, 'Oh, your mom had a great day and she didn't have any Sundowner behaviors,' " said caregiver Tammy Won, referring to the symptoms associated with Alzheimer's.
Ruth Linden, an independent health advocate, has referred three clients to the company.
"They had the ability to come up to speed without a lot of lead time," said Linden, founder of Tree of Life Health Advocates in San Francisco. "That's what people want and what they need. When people are hiring in-home care, they needed it two weeks ago."
Tax Credits for Ramps, Grab Bars to Help Seniors Stay at Home
Published by The PEW Charitable Trusts
By Jenni Bergal
August 26, 2016
Most seniors and aging baby boomers want to remain in their homes as they grow older. But to do that, many will have to retrofit their homes to accommodate them if they become frail or disabled — and that can be prohibitively expensive.
It can cost $800 to $1,200 to widen a doorway to accommodate a wheelchair, $1,600 to $3,200 for a ramp, and up to $12,000 for a stair lift. Major remodeling, such as adding first-floor bedrooms or bathrooms, can cost much more.
Virginia and at least three counties in the U.S. have approved tax credits for residents who make their homes more accessible. Modifications include adding ramps to create step-free entrances, widening doorways and putting grab bars in bathrooms.
For states, giving tax credits to allow people to stay in their homes may be a money-saver, since it’s much more expensive for Medicaid, the joint state-federal program for the poor and disabled, to pay for nursing home care.
Violet Peyton, of the Virginia Department of Housing and Community Development, said her state’s Livable Homes Tax Credit is available to homeowners of all ages, but it’s especially important to seniors and baby boomers — now between the ages of 52 and 70 — who want to remain at home as they grow older.
“Often, this is the home where they raised their families or spent most of their lives,” she said. “If there is any way they can retrofit it, they want to do that and remain in that environment.”
In Virginia, homeowners or contractors can get a tax credit to retrofit a house for 50 percent of the costs up to $5,000. Or they can get as much as $5,000 in credits to buy or build a new home with accessibility features.
The state allocates $1 million a year for the tax credits, which have been given to more than 1,100 homeowners and nearly 400 contractors since 2008. Recipients got on average $3,536 in credits for the 2015 tax year.
This year, legislators in more than a half dozen states, including Maryland, South Carolina and New Mexico, considered tax credit measures modeled after Virginia’s. None were approved.
In Rhode Island, John DiTomasso, an associate state director for the AARP, said a similar bill failed there this year because of the cost to the state — up to $500,000 a year.
He said he thinks the bill will be refiled next session and is optimistic about its passage because it faced no opposition and had strong support from a coalition ranging from disability advocates to real estate agents.
“Rhode Island is facing a huge increase in the 65-plus population in the next decade. We have baby boomers every day who are moving into that age group. This is where are future housing needs are going to be.”
In Illinois, a tax credit bill that would have applied only to seniors and people with disabilities also failed this year. Its sponsor, Democratic state Sen. Linda Holmes, said it had bipartisan support but died in a subcommittee as legislators wrangled over an 18-month budget impasse with Republican Gov. Bruce Rauner.
Holmes called her bill “a simple fix” that made sense both fiscally and from a quality of life perspective.
“Ultimately, it’s more cost-effective for us as a society. It makes more sense to help people who are aging make their own home a little more accessible so they can maneuver, rather than end up in a nursing facility, which ultimately could cost the state a lot more money in Medicaid spending.”
The senior population in the U.S. is expected to explode in the coming decades, as the number of those 65 and older jumps from 48 million in 2015 to 77 million by 2035. Many live in multistory single-family homes that have lots of stairs, front entrances with steps and no full bathroom or bedroom on the first floor.
As people age, they often grow feeble and start falling, aging experts say. Home safety modifications can help keep older adults living independently and stop them from getting hurt.
A report in May concluded that there would be an increase in housing that is accessible to an aging population if state and local governments created more tax credits for home modification.
“In many cases, it’s less expensive to retrofit than it is to move to another house or condo or apartment,” said Kathy Robertson, an associate director of the Virginia housing agency.
Livable home tax credits also are available in Howard and Montgomery counties, in Maryland, and Allegheny County, Pennsylvania. Participants can get a break on their county property taxes, and as in Virginia, they don’t have to be a certain age or have a disability to qualify.
In Howard County, homeowners can get a tax credit of $2,500 or 50 percent of eligible costs, whichever is less. The county applies any credit above what is owed in property tax to future tax years.
Some communities also have changed zoning laws to encourage developers to build single-family homes using “universal design,” with features such as no-step entry and wider hallways and doorways. Those standards are mandatory in a few areas, such as Pima County, Arizona, and Bolingbrook, Illinois.
A livable housing tax credit proposal also has been pitched in the U.S. Congress.
In May, U.S. Reps. Patrick Murphy, a Florida Democrat, and Bruce Poliquin, a Maine Republican, introduced a bill that would give federal tax credits to people 60 and over who spend up to $30,000 to make home modifications so they can grow old there.
“This isn’t an individual problem; it’s a national housing issue,” said Louis Tenenbaum, a former contractor from Maryland who recently started a group, Homes Renewed, that advocates for more housing that meets people’s needs as they grow older.
Tax credits are a good way to help middle-class seniors who don’t qualify for government programs, Tenenbaum said. “The better you prepare your home, the better it will be for you, and you won’t be forced to move because you can no longer stay there.”
Disability and Aging Advocates Unite
The push to create home modification tax credits was started by disability advocates. People with disabilities often need expensive retrofitting in their homes and many can’t afford it, said Karen Mariner, a vice president at the National Multiple Sclerosis Society.
Mariner’s group has made tax credits a policy priority in the last three years and advocated for legislatures to offer them as a way to give financial relief to people with disabilities who wanted to maintain their independence and mobility.
“People with MS are younger, and as they progress, it becomes a safety issue,” she said. “They have a high number of falls, and this [the retrofitting] minimizes the number of [emergency room] visits they may have to make.”
A handful of states, including Kansas and Missouri, have enacted laws granting tax credits for people with physical disabilities. This year, Maine passed legislation offering up to $9,000 for homeowners to retrofit if they meet certain disability and income requirements.
Recently, the MS society started working with AARP in some states to push for homeowner tax credit measures not only for people with disabilities but also for seniors, Mariner said.
This year, legislators considered tax credit bills in at least a dozen states. Most were drafted broadly, with no age or disability requirements. Some were targeted only for people with disabilities. And a few applied only to that group and to older adults.
Mariner said she expects most of the measures will be reintroduced in 2017.
“We feel confident we’re going to see more states recognize that these types of programs end up benefitting them. It’s cheaper to keep people in their homes. And that’s what we want.”
How One Home Health Agency Took Staff Communication Mobile
Published by Home Health Care News
By Kourtney Liepelt
August 26, 2016
At work or on the go, it seems that everyone is attached to their phones these days, and home health agencies stand to benefit by streamlining staff communication via mobile. Given the widespread use of cell phones and SMS texting outside of personal communication, the sooner organizations can implement a mobile strategy, the better.
Eighty percent of people use texting for business, according to a survey of 254 U.S. adults age 18 and over conducted in 2015 by consumer insights platform Instantly and commissioned by cloud-based phone systems provider RingCentral. Meanwhile,15% said more than half of their sent or received text messages are for business purposes.
“Texting has become our primary form of communication,” Stacey Epstein, CEO of mobile messaging app Zinc, said Wednesday during a Home Health Care News webinar. “It’s widespread and affordable. It’s not expensive to text people, and you get a quick response. The same benefits apply to businesses and organizations.”
However, health care-related companies have unique needs when it comes to mobile communication, given sensitivities around personal health information, security, data ownership and compliance, Epstein said. Home health agency workers can’t simply send details about a patient’s case via standard text messaging to another coworker, for example, given the Health Insurance Portability and Accountability Act of 1996 requirements and patient privacy standards.
One home health agency, Summit Home Health Care in Wyoming, wanted to address the challenge of staying compliant while using consumer apps for company communication. Consumer-facing products wouldn’t always allow business associate agreements, or had the potential for patient information vulnerabilities, said Michael Rocha, assistant administrator at Summit.
As such, Summit elected to work with Zinc to implement an app where the company’s 85 workers could text message, send photos, access a directory and more in one safe place, with an interface that mirrors what most users are accustomed to. The transition has allowed Summit to improve operations, accelerate decision-making and enhance coordination, Rocha said. Additionally, it lets different groups keep in touch and share specific information.
“It not only allows them to get the information relevant to them, but also filters out the things they don’t need to see,” Rocha said.
Though discussed originally, Summit doesn’t provide smartphones for its workers, as it was a cost challenge. Purchasing a smartphone isn’t deemed necessary for employees, but very few choose not to have one and use the app, Rocha said.
However, Summit does require that employees keep their devices secure through a passcode or touch identification to protect any information shared. With three branches, Rocha said the agency is small enough to maintain security standards without any extreme measures in place.
Securely messaging via mobile has been quite a savvy investment, too. When taken into consideration that each HIPAA violation can cost thousands of dollars, Rocha said there’s “no comparison” in terms of how much is spent to use the app. Plus, the app is software-based, so it can be updated without new equipment as opposed to hardware-based items.
The Hospital at Home Model: Bringing Hospital-Level Care to the Patient
Published by The Commonwealth Fund
By Sarah Klein, Martha Hostetter, and Douglas McCarthy
August 26, 2016
In June, 67-year-old Felimon Bailon showed up in an emergency department at Presbyterian Healthcare Services in Albuquerque, New Mexico, with a large and painful abscess on his leg. The infection had been under way for nearly two weeks, turning his leg a deep purple. Doctors feared that Bailon, who is diabetic and receives oxygen therapy, might develop sepsis. They recommended admitting him to the hospital so he could receive antibiotics intravenously but he refused, insisting the infection would go away on its own if he simply took medication.
Bailon’s reaction was not unusual. For many frail, elderly patients, the prospect of being admitted to a hospital can be upsetting. It means separating from the people, pets, and familiar surroundings that create a feeling of safety. It also means disrupting the routines—a favorite meal or weekly card game—that provide joy. And, as many are probably aware, hospitalization means being at higher risk for infections, falls, delirium, functional decline, and even death.
Presbyterian, a large integrated delivery system with eight hospitals and 30 clinics, offers adult patients like Bailon who are sick enough to be hospitalized but stable enough to be treated at home that option—and more than 92 percent take it. “Hands down, it’s people’s preference,” says Karrie Decker, administrator of home and transition services at Presbyterian. To the relief of doctors, Bailon overcame his reluctance to have visitors to his home. After several daily visits and I.V. antibiotics, he fully recovered.
Presbyterian’s Hospital at Home program, launched in 2008, is based on a model developed in the mid-1990s by Bruce Leff, M.D., a geriatrician and health services researcher at Johns Hopkins University, who noticed that many of his patients suffered poor outcomes after hospital stays.1 At Johns Hopkins, teams of physicians, nurses, and other clinical staff make house calls to treat elderly patients, many of whom either refuse to go to the hospital or are at such high risk for adverse events that physicians prefer not to admit them. For select patients, this approach produces superior outcomes at a lower cost than hospital care (see Results).
The Hospital at Home model has struggled to gain traction elsewhere in the United States, however, in part because Medicare’s fee-for-service program will not pay for its services. Presbyterian is able to secure reimbursement from its health plan, which covers 470,000 Medicare Advantage, Medicaid, and commercially insured members throughout the state and has incentives to reduce costs and improve care.
Presbyterian’s program fits within a suite of services designed to deliver care in the home. These include home-based primary care, home health, hospice, and Complete Care, a care management program designed to improve coordination of services for patients with advanced illness and, when desired, avoid unwanted aggressive care at the end of life.
Hospital at Home's Target Population
Like the Johns Hopkins model on which it is based, Presbyterian’s Hospital at Home program admits patients who have one or more specified conditions that can be safely treated in a home environment. To participate, patients must live in metropolitan Albuquerque (within 25 miles of a Presbyterian-designated emergency department) and be covered by the system’s health plan. They also must meet criteria for hospitalization established by Interqual, a proprietary tool for determining whether services are medically necessary.
Since 2008, the program has treated more than 1,200 patients with a range of clinical characteristics and an average age of 77. The program treats about two patients a day.
Key Program Features
Identifying Appropriate Patients
Patients enter the program in a variety of ways: as transfers from Presbyterian’s emergency departments (EDs) and hospitals; through referrals from primary care doctors, specialists, and urgent care facilities; and via referrals from Presbyterian’s home health agency and its house calls and Complete Care programs. Ideally, patients receive referrals for at-home hospital services before they have reached the ED. By that point, patients and families are often exhausted, making a transfer back home less appealing.
Before admitting a patient to the program, staff verify that the patient’s home environment will support treatment—for example, it has basic utilities. “Safety is really important,” says Melanie Van Amsterdam, M.D., one of two physicians making home visits. They also assess the patients’ functioning, making sure they can walk and get to the bathroom. The program does not require that a caregiver be present in the home.
In all cases, Presbyterian’s goal is to distinguish patients who truly need hospital-level care at home from those who could benefit from less-intensive oversight through its home health, hospice, and palliative service programs.
Extended Home Visits
While the average length of stay for Presbyterian patients who receive Hospital at Home care is shorter than that for hospitalized patients (3.2 vs. 4.11 days), such patients typically have more face-to-face time with clinicians. Physicians, who visit once daily, may spend up to an hour with patients on assessment, diagnosis, treatment, and care planning. Nurses may spend up to two hours with patients once or twice a day to administer infusions and medications, conduct lab tests, and provide education to patients and their families. Home health aides also may spend up to an hour a day in the home helping to bathe patients, and prepare light meals if needed. When needed, Presbyterian also sends social workers and rehabilitation specialists (including occupational therapists, physical therapists, and speech therapists).
Spending more one-on-one time with patients allows clinicians to get to know them better and have in-depth conversations, says Van Amsterdam. “We’re on their territory and patients are much more vocal about what they want and what they will and will not do,” she says. In contrast, “in the five or 10 minutes a hospitalist spends with them in the hospital, they may say, ‘Yes, doctor.’ But when they are at home they will say, ‘I have no idea what you just said.’”
Being in the home also allows providers to see the problems patients face coping with their disease, including managing their medications and maintaining a healthy diet. “[We’ll find] bags of medications and supplements that are outdated—they may be someone else’s from five years ago,” she says. In one case, a caregiver discovered a patient was taking his son-in-law’s medication instead of his own—a 600-milligram dose instead of the 100 milligrams he was prescribed. As a result, he was sleepy, dizzy, and occasionally falling. A home visit also gives providers time to review what patients are eating and negotiate manageable changes in diet. For a patient with congestive heart failure, this can mean eating a smaller portion of lox at breakfast to reduce salt intake.
Providers discharge patients from the program using the same criteria that hospitals use. Discharge summaries are sent to primary care physicians in Presbyterian’s medical group through the shared electronic medical record system, or relayed by phone or email if a patient has a non-Presbyterian primary care physician. To promote continuity of care, Hospital at Home staff may provide the first follow-up visit after discharge, and program nurses may continue to see patients who receive home health services.
The program’s narrow geographic radius helps to ensure physicians and nurses can get to a patient’s home within a half-hour should a patient’s symptoms worsen. A response time of two hours or less is required from vendors who deliver durable medical equipment, intravenous medication, oxygen, ultrasound, mobile X-ray technology, and electrocardiogram equipment.
Because the daily census fluctuates and patient needs vary, ensuring adequate staff can be tricky. “If you have five patients, and three of them have twice-daily IV infusions and they live in three different counties, then you’re going to have to be very creative” in planning and prioritizing visits, Van Amsterdam says.
A Continuum of Care
While Presbyterian’s home health, hospice, primary care house call, and Complete Care programs operate largely independently—rarely sharing staff—they frequently make referrals to one another. This enables providers to respond quickly when a patient shows signs of deterioration.
Having complementary business lines also made the process of developing them easier. “It’s not an easy build,” Leff says of Hospital at Home programs generally. “The implementation is always dependent on highly local factors. For instance, you have to be able to get IV meds to the home, and every place you implement Hospital at Home there’s going to be a slightly different way of doing that.” Presbyterian convened 12 interdisciplinary teams to create the processes needed to roll out the service lines, build physician support, and find ways to increase patient awareness of Hospital at Home.
Presbyterian’s health plan pays the Hospital at Home program a bundled rate for each admission, based on diagnosis codes (calculated as a discount of Medicare’s Prospective Payment System rates). The payment covers fees for provider visits, nursing visits, home health aide visits, ancillary services such as durable medical equipment, and diagnostic tests. The vast majority of patients (90%) are covered by Presbyterian’s Medicare Advantage plan; the rest are covered by its commercial health plan. It cannot bill for its service under traditional fee-for-service Medicare or Medicaid, a factor that limits the size of the program.
A national demonstration of Johns Hopkins’ Hospital at Home model conducted in 2001 and 2002 in Medicare managed care plans and the Veterans Administration found that providing acute-level care at home for a discrete set of conditions was not only significantly cheaper—by 32 percent—but safer as well, owing to a dramatically lower incidence of delirium, among other complications.2 Two meta-analyses of randomized controlled trials of Hospital at Home programs came to similar conclusions: they found that patients treated at home instead of the hospital had lower mortality rates and lower costs. Patient satisfaction was higher as well, as patients remained close to their support networks and had less disruption to their lives.3
Insights and Lessons Learned
Finding the right staff can be challenging. At Presbyterian, finding physicians who are the right fit for the program proved harder than expected. They need to be comfortable with the independence, the time on the road, and the unpredictable tempo of the job. Hospitalists—who are accustomed to managing hospitalizations from start to finish—seemed like a logical choice. But Karen Thompson, who directs both the Hospital at Home program and Presbyterian’s hospice program, says that while they loved the concept of the program, many felt they would be uncomfortable treating patients without immediate access to the resources of the hospital—including CT scanners, immediate lab results, and other staff. The program has had more success recruiting primary care physicians like Van Amsterdam, who sought out the job because she wanted to spend more time with patients than the 20 minutes scheduled in primary care practices.
Presbyterian administrators also have found that nurses who’ve worked in EDs or critical care units—accustomed to making decisions based on quickly changing circumstances—are a better fit for Hospital at Home than are home health nurses. The nurses they ultimately hired “are all very skilled at clinical assessment,” says Darren Maestas, R.N., patient care manager, who had previously worked for a regional hospital as director of medical, surgical, and intensive care services and has several years of experience in home health.
To support the required staffing and infrastructure, Hospital at Home programs need to draw on a critical mass of patients. Because only a fraction of patients needing acute care qualify for Hospital at Home as currently designed, such programs may be more viable in larger urban areas where a sufficient and predictable number of patients can be enrolled. Decker estimates that metropolitan areas of 5 million or more people might provide enough economy of scale to support a full-time team treating at least five or six patients a day.
Presbyterian sometimes falls short of this number in its smaller metropolitan market, making it important to embed the program in a larger suite of continuing care services. Using Hospital at Home programs as alternatives to observation stays, subacute care, or postsurgical care may be another way to increase the patient census. “We do sometimes branch out,” Van Amsterdam says. “There have been occasions when the health plan has come to us and said, ‘Could you just take these influenza patients? Because they don’t need to be in the hospital but do need to be monitored, and they need support in the home.’”
Payment and medical culture may be barriers to spread of this model. Payment is likely to remain a barrier to the spread of hospital care delivered at home unless and until this service become reimbursable under fee-for-service Medicare and Medicaid. Paying through Medicare Advantage or accountable care contracts is an option, but this would require a high degree of market penetration to yield the volume of patients needed in any given region.
Variations of Hospital at Home programs have been more successful in countries where government controls both the funding and delivery systems, such as Australia and England, and in facilities run by the U.S. Veterans Health Administration, which has been able to successfully implement programs at 11 sites.4,5 Even when payment and delivery system incentives are aligned, however, many programs here and overseas continue to encounter some resistance from referring physicians who are concerned about safety and liability risks. With experience, they usually become more comfortable with the idea, but it takes time.