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News Roundup: September 9, 2016

Gaps In Care Persist During Transition From Hospital To Home

Published by Kaiser Health News
By Anna Gorman
September 9, 2016

SAN DIEGO — Alton Rodgers had just come in from gardening when he suddenly blacked out and collapsed on the floor. The 89-year-old Kentucky native spent about 10 days at Palomar Hospital, where doctors told him a build-up of fluid around his heart was the culprit.

Now, shortly after being released, Rodgers got a knock at the door.

Nurse Tiffanie Abrajano and social worker Valerie Ellis were there to make sure his transition home had gone smoothly. They checked his medications one by one and made sure he knew how to take them. They walked through the house looking for loose rugs and other obstacles that could cause him to fall again. They also asked about safety bars in the bathrooms, and whether he needed a caregiver to help with bathing and dressing.

“We are trying to see if there is anything you might need here in your home to potentially keep you from going to the hospital,” Ellis said. “Do you feel like you have enough assistance?”

“I think I do,” said Rodgers, who lives with a friend. “I feel much stronger… And if I need any help, I can get it.”

For elderly patients like Rodgers, leaving the hospital is fraught with risk. Most are sent home or to nursing facilities after just a few days, still reeling from acute illnesses — not to mention the chronic conditions they are also confronting.

“Just because they have had four days in a hospital doesn’t mean they are better,” said Mary Naylor, a gerontology professor at the University of Pennsylvania School of Nursing.

It’s during that critical time when problems can occur. Patients may get sicker because they don’t have access to medications, transportation, food or crucial equipment such as oxygen tanks. And many don’t have relatives or caregivers to help with the daily tasks that they were able to perform unassisted before being hospitalized.

“There are gaps in care, there are gaps in communication, there are gaps in adequate preparation for patients and families,” said Naylor, who designed a transitions model to address these problems.

In recent years, federal health officials have begun penalizing hospitals for high rates of readmission and sponsoring pilot projects — like the one that sent a social worker and nurse to see Rodgers — to help ensure smoother discharges.

Hospitals and community groups are experimenting with different methods to improve the transition of elderly patients from the hospital.­

Some of them seek to strengthen communication with primary care doctors, or use technology to track patients across different health systems. Others emphasize closer partnerships between hospitals and community groups that provide meal delivery, transportation and other social services.

A program developed at the University of Colorado, for example, follows patients for the first month after their discharge, helping them manage their medications, schedule follow-up appointments and recognize signs of trouble.

San Diego County received a federal grant to improve handoffs from the hospital using an adaptation of the University of Colorado’s program. The county’s Aging and Independence Services agency partnered with four hospital systems — Scripps Health; University of California, San Diego; Palomar Health, and Sharp HealthCare — to serve more than 50,000 Medicare beneficiaries at the highest risk of medical complications after discharge.

The efforts aim to improve care and save money. Poorly managed transitions can waste medical services and increase health care costs. The federal government has estimated that nearly 20 percent of Medicare patients return to the hospital within 30 days, costing more than $26 billion annually.

The penalties and programs around the country are starting to make a dent in the problems associated with poorly handled discharges, experts said. The San Diego County program saved Medicare an estimated $13.8 million over a two-year period between 2013 and 2015, primarily because of reduced hospital readmissions.

But experts are quick to note that more needs to be done. Naylor said providers can’t stop looking after patients just a month after they are discharged. “It’s not just thinking about today or tomorrow or the next 30 days,” she said. “For chronically ill, older people, what is their long-term trajectory?”

Programs like the one in San Diego County aren’t a panacea. It serves only a portion of Medicare beneficiaries, and people aren’t eligible for the help while they are in a nursing facility.

John Statler, 88, for example, returned to the emergency room at Palomar Hospital three times within the first week of his discharge to a nursing home. Statler had spent several days at the hospital after a fall left him with a severe head wound. His daughter said the hospital saved his life but didn’t then ensure that he had what he needed to recover after being discharged. In the end, he had to be readmitted.

Transition difficulties often start for elderly patients when they’re preparing to be discharged from the hospital. That’s when medical staffers quickly read a list of instructions to patients and hand them new prescriptions. Older patients may not understand what they are being told because they have dementia or are weakened and confused from their time in the hospital. Some are simply anxious to leave and not paying close attention.

“You are trying to reach them and do that education at such a critical time, but they are nowhere near cognitively ready to receive that,” said Joe Parker, lead nurse of care transitions at Palomar Health. “And we don’t have the luxury of time to wait.”

Back at home, family members and caregivers are often asked to take on medical tasks that would make “most first-year RNs shake in their boots,” said Robyn Golden, director of health and aging at Rush University Medical Center in Chicago. That can lead to medication mix-ups, infections and other problems — especially since the average hospital stay has shrunk.

“People are going home sicker, quicker and they are not returning to their prior selves as quickly – if at all,” Golden said.

Adding to the potential complications is the fact that primary care doctors are often unaware their elderly patients are in the hospital, so they can’t step in to ensure treatment plans are followed.

The main issue the San Diego program is designed to address is the disconnect between hospitals and social services agencies, which have traditionally operated in separate silos, San Diego County and hospital officials said.

“There is a point where the hospital can’t do any more” for patients who have been discharged, said Cecile Davis, coordinator of the remote patient monitoring for Sharp HealthCare. “The key is to know when to turn them over to the community.”

To figure out what patients like Alton Rodgers need, nurses and social workers ask critical questions, said Carol Castillon, who manages the care transitions program for the county.

Do they have transportation to get to the doctor? Do they understand their medications? Do they need an in-home caregiver?

The over-arching question, Castillon said, is: “What are the long-term services we can bring in so that this person isn’t coming back to the hospital?”

Castillon said that before starting the project with the hospitals, the county regularly found older people in their homes who had been recently discharged and were unable to care for themselves. “They were sick, they were unable to get medications, they didn’t have food,” she said.

Participating hospitals identify patients for the program before they are discharged.

At Palomar Hospital one spring day, nurses Patrice Gadd and Rachel Ricchio stood at the bedside of 88-year-old Joseph Taylor, a former physical therapist who had come to the hospital with pneumonia and was diagnosed with congestive heart failure.

Gadd told him that he could get a home visit and a month of follow-up to help keep him out of the hospital. Taylor and his wife, who had recently moved from Colorado, both agreed that any help would be welcome.

Gadd urged Taylor to call the doctor if he started feeling sick again. “The problem is that the older we get, the less reserves we have in our gas tank,” she said. Things “can go south really, really quickly.”

Nearly three months after his hospitalization, however, Taylor hadn’t returned to the hospital.

This story was reported while its author, Anna Gorman, participated in a fellowship supported by New America Media, the Gerontological Society of America and The Commonwealth Fund.

VNAA to Challenge Pre-Claim, Medicare Cuts

Published by Home Health Care News
By Mary Kate Nelson
September 9, 2016

A national, nonprofit organization that promotes, advances and supports mission-driven providers of community-based health care has revealed the specific home health and hospice legislation it will focus on and which causes it will seek to advance on Capitol Hill in the coming months.

The Visiting Nurse Association of America (VNAA), based in Arlington, Virginia, outlined two pieces of home health legislation and four pieces of hospice legislation that it intends to advocate for* in Congress in a policy call Tuesday. The organization also identified two additional home health-related policies—with no current associated bills—it intends to push in the upcoming months, which involve delaying the rollout of the pre-claim review demonstration, as well as preserving and protecting access to home-based services.

Specifically, VNAA plans to ask all Congressmen to tell the Centers for Medicare & Medicaid Services (CMS) that slashing home health payments by $180 million in 2017 will place beneficiary access to care at risk and surpass the statutory limits Congress placed on rebasing home health payment rates.

VNAA also plans to ask Congress to urge CMS to postpone the rollout of the pre-claim review demonstration in Massachusetts, Florida, Texas, and Michigan in the next three years. The pre-claim review demonstration, VNAA says, imposes additional documentation requirements on high-quality home health agencies that are already burdened. Moreover, the implementation could lead to poor care transitions, as well as confusion for seniors receiving care at home and the seniors’ doctors.

The pre-claim review demonstration has already proven plenty controversial among home health providers and U.S. Senators alike; earlier this month, two Senators from Florida called for the program to be delayed in their state, and the National Association for Home Care & Hospice (NAHC)’s Vice President for Law Bill Dombi called the rollout in Illinois a “complete mess.”

Legislation-wise, the organization stands behind the Home Health Planning and Improvement Act (S. 578 / H.R. 1342), a bipartisan bill which would enable clinical nurse specialists, nurse practitioners, certified nurse midwives and physician assistants to order home health services under Medicare in accordance with state law. The legislation, according to VNAA, would improve access to critical home health care services and possibly prevent additional skilled nursing and hospital admissions.

VNAA also plans to advocate for the passage of the Home Health Documentation and Program Improvement Act of 2015 (S.1650), another piece of bipartisan legislation that, in VNAA’s view, provides “common-sense improvements to currently unworkable and administratively burdensome rules regarding Medicare home health ‘face-to-face’ documentation requirements.”

Currently, VNAA is also seeking the introduction of a similar piece of legislation in the House of Representatives.

On the hospice side, VNAA plans to advocate for the passage of the Care Planning Act of 2015 (S. 1549), which would establish Medicare reimbursement for health care professionals to provide a voluntary discussion about the treatment options and goals for patients with serious illness, resulting in a documented care plan that reflects the informed choices made by patients working with members of their health care team, family members, faith leaders and friends. Additionally, the legislation provides resources for professional and public care planning educational materials.

VNAA also plans to advocate for the passage of the Palliative Care & Hospice Education and Training Act (PCHETA) (S. 2748 / H.R. 3119), a piece of bipartisan legislation that would establish education centers and career incentive awards to improve the training of physicians, social workers, physician assistants, nurses and other health professionals in palliative care.

The Compassionate Care Act (S. 2961), bipartisan legislation that would create and implement provider and consumer education programs to increase awareness and develop skills on how to help patients and their loved ones with advance care planning and palliative care, also has VNAA’s support. The bill establishes a demonstration project to reimburse eligible entities for expenses related to the use of telemedicine services to provide advanced care planning.

The last bill VNAA plans to advocate for—Removing Barriers to Person-Centered Care Act of 2016 (S. 3096)—would test a shared savings payment model in as many as 20 “advanced care collaboratives” to deliver coordinated, person-centered care to Medicare beneficiaries with advanced illnesses. Each collaborative would receive a planning grant to perform a needs assessment; upgrade, change or buy health information technology; and support training and education on documenting and communicating beneficiary treatment goals and preferences. As part of the pilot program, the Secretary would waive specific Medicare payment regulations and rules, as well as cover two new services under the hospice benefit.

Home health scrutiny heating up as industry enters pre-claims review

Published by Fierce Healthcare
By Evan Sweeney
September 9, 2016

Home health providers are facing calls for lower reimbursement along with double-digit fraud sentences as several states prepare for what one expert is calling the “chaos” of pre-claims review.

According to an op-ed published in the The National Law Review by healthcare attorney Bob Morgan, the new pre-claims review for home health providers designed to prevent fraud will cause “chaos” as new payment regulations lead to “ambiguity and confusion” regarding reimbursement requirements. Morgan notes that several questions still surround the program, including how to document a face-to-face encounter between a physician and patient eligible for home health services.

The pre-claims review program has faced resistance from the home health industry, while the Centers for Medicare & Medicaid Services' previous plan involving prior authorization drew criticism from more than 100 legislators.

But there is still widespread concern regarding overpayments among home health agencies, as demonstrated by a letter from the Medicare Advisory Payment Commission (MedPac). The agency advised CMS to lower reimbursement rates for home health services noting that “Medicare has overpaid for home health care since the inception of the prospective payment system in 2000, and more reductions are necessary to stop this pattern from continuing.”

On the enforcement side, home health owners are facing extended prison sentences for fraud schemes. Last week, the owner of three Miami home health agencies was sentenced to 20 years in prison and ordered to pay $36.4 million in restitution for a seven-year scheme in which he paid kickbacks to doctors, patient recruiters, and staffing groups. The Office of Inspector General has highlighted home health fraud as a top priority by identifying common billing outliers associated with overpayments.

Patients With Dementia Present Communication Challenges In Hospice Care

Published by Kaiser Health News
By Rachel Bluth
September 9, 2016

Dementia took over Pauline Finster’s 91-year-old mind long ago and she may die without having another real conversation with her daughter.

After Finster broke her hip in July 2015, Jackie Mantua noticed her mother’s speech ebbing until she only said “hi,” or that she felt fine. Mantua last heard Finster speak six months ago.

Finster’s hip surgery led to a series of medical interventions that left her with poor circulation in her legs. Then gangrene set in. Mantua won’t look at the dead tissue on her mother’s right foot that is now creeping from the toes to heel.

She has instructed the staff at the AlfredHouse assisted living home in Rockville, Md., where her mother has been in hospice care since earlier this summer, to keep Finster on Tylenol to hold back the gangrene’s discomfort.

Is that enough? It’s really all she can do for her mother at this point, Mantua said.

Hospice’s purpose, at least one of them, is to ease a dying patient’s pain at the end of life and improve the quality of that life. But what’s to be done when a dementia patient in her waning days can’t communicate her pain or help identify the cause? Or resists taking medications?

All those concerns can be troubling for family caregivers for loved ones with dementia and in hospice care, according to a recent study in the American Journal of Alzheimer’s Disease & Other Dementias.

Families often describe a cancer patient’s last months as stressful but meaningful. That isn’t the case with dementia patients because the disease changes the patient’s personality and causes behavior issues, according to George Demiris, one of the study’s authors and a professor of biobehavioral nursing and health systems at the University of Washington’s School of Nursing.

Caregivers who took part in the study said they worried that their loved ones were in pain, but unable to properly express it — and that possibility disturbed them, according to interviews with families taking care of dementia patients in their last stage of life.

Multiple participants described feeling frustrated and defeated by patients’ cognitive difficulties and changing emotions, the study reported. Some described the patients as “prisoners” inside their bodies.

Helping a dementia patient in pain can be challenging for hospice care providers, too.

Previous research, cited in the recent study, found patients with dementia were prescribed lower doses of opioids than patients with cancer with similar pain scores.

Other research cited found that hospice nurses caring for such patients frequently asked relatives to interpret patients’ “pain signals” to help them assess pain. For example, one caregiver knew her mother was in pain when she moved a certain way in her chair. Another recognized his wife was in pain when a home health care aide gave her a bath by observing how she squeezed the aide’s hand.

Sometimes, patients gasp for air or repeatedly touch the same part of their bodies.

Mantua said she watches her mother’s face and stays vigilant for winces or grimaces. Her face is still expressive, Mantua said. Still, there are no words, only moans to indicate something is wrong.

Recently, Mantua said her mother has been acting “strange.” Instead of her usual vacant but happy smile, Finster looked at her daughter with a “horrified” expression. Mantua told the hospice chaplain that it looked like her mother had seen the devil.

The cause?

“You have no idea because she can’t say anything,” Mantua said. “I was saying ‘What’s wrong? What’s wrong?’ and she’s just looking at me like crazy.”

Finster has had dementia for 10 years. She has spent most of that time in facilities with increasing levels of care, moving from an independent living facility, to assisted living to memory care. Mantua has felt some of the frustration that caregivers of other patients with dementia have experienced. Three or four years ago, when Finster still had a phone in her room, she sometimes called her son Les — Mantua’s older brother — 10 times to leave him the same message that people were coming into her room and stealing her food. She simply forgot that she had called before.

Finster’s years of cognitive decline have taken a toll on Mantua and her family.

“You get to the point you want them to die because it’s hard,” Mantua said. “It’s hard to deal with. It’s a very helpless feeling.”

Now 53, Mantua is a mother of three children between the ages of 27 and 31 and grandmother to twin five-year-old boys. She said she doesn’t have the patience or natural caretaking abilities to tend to her mother full time.

It comforts her to know that her mother is looked after by a trained staff 24 hours a day, but for families who find themselves as the primary caregivers for dying dementia patients, the job can lead to anxiety, depression and grief, according to the recent study.

“Caregivers stated that patients were combative because they could not understand that interventions were meant to help them, or that they forgot about past pain and so rejected attempts at assessment and treatment,” the study said.

For families, a loved one with dementia can become like a stranger who grows angrier and more aggressive than the person they remembered, said Demiris, which “complicates the caregiving experience.”

Pauline Finster isn’t aggressive anymore. Mantua remembers when Finster’s dementia made her paranoid and angry. She was once so combative, the staff at her former assisted living facility wouldn’t try to feed her unless Mantua or her brother were present.

The decision to begin hospice care wasn’t easy for Mantua or her family. She said it feels like her mother is already gone.

There isn’t much for Mantua to do when she visits her mother at AlfredHouse. She chatters as Finster dozes, cradling a baby doll that is always with her. Someone at the assisted living home regularly changes the doll’s clothes, which amuses Mantua.

For now, she keeps driving an hour once every other week from her home on Maryland’s Eastern Shore to Finster’s room in Rockville where they wait for the end together.

Handymen, home care helps seniors trying to age in place

Published by Fox News Health
September 9, 2016

WASHINGTON – Where you live plays a big role in staying independent as you age. Now researchers say an innovative program that combined home fix-ups and visits from occupational therapists and nurses improved low-income seniors' ability to care for themselves in their own homes.

Still to be answered is whether that better daily functioning also saves taxpayer dollars — by helping enough older adults with chronic health problems avoid costly hospital or nursing home stays.

"We're improving people's lives, improving their abilities," said Sarah Szanton, a Johns Hopkins University associate nursing professor who leads the experimental program reported Wednesday in the journal Health Affairs.

Surveys show most older adults want to live at home for as long as possible. Yet chronic diseases and their resulting disabilities — problems walking, bathing, dressing, cooking — can make that difficult in homes with steep stairs, doorways too narrow for walkers, and other obstacles.

And seniors who have trouble with those so-called activities of daily living are costly for Medicare and Medicaid, too often ending up in hospitals or nursing homes because they couldn't care for themselves at home, or had a bad fall while trying.

Szanton's team aims to help those seniors maintain their independence through CAPABLE — it stands for Community Aging in Place, Advancing Better Living for Elders — a program testing modest home modifications and strategies for daily living.

The fixes sound simple. A double banister let people rest their weight on both sides to get up and down stairs safely. Handymen fixed trip hazards, installed grab bars and lowered shelves so seniors could reach without climbing. Occupational therapists bought assistive devices to help people with tremors feed themselves, and taught the frail how to get in and out of high-sided tubs.

Even simple fixes can be life-changing, like the reaching gadget therapists gave Bertha Brickhouse to help tug on her socks and shoes.

"You just don't want to ask someone, 'Can you come to my house and help me put my boots on?'" said Brickhouse, 69, of Baltimore, who has diabetes, high blood pressure and cholesterol, and uses a cane for damaged knees. "It was like I was born all over again from their help, the things they did to make my life much easier."

In a demonstration project funded by the federal Center for Medicare and Medicaid Innovation, the Hopkins researchers provided 234 Baltimore residents with 10 home visits by handymen, occupational therapists and nurses. Interventions were tailored to each senior's priorities: Did they want to bathe without help? Cook? Be able to climb the stairs, or make it out of the house to go to church or visit friends?

After completing the five-month program, three-quarters of participants improved their ability to take care of themselves — on average, able to perform two more tasks of daily living on their own compared to before receiving the care, Szanton reported Wednesday.

Two-thirds of participants also were better able to perform related tasks such as grocery shopping, and half experienced fewer symptoms of depression.

The aid cost about $2,825 per participant, including the home repair, home visits from health professionals, and assistive devices.

Szanton's team still is calculating if that translates into cost savings for Medicare or Medicaid. Separately, a more rigorous study funded by the National Institutes of Health is under way with an additional 300 Baltimore residents, to prove if the interventions really work.

Federal Medicare officials declined comment on Wednesday's findings. But state Medicaid and aging officials are closely watching the research.

Michigan has opened its own pilot project, testing a version of CAPABLE with more seriously disabled seniors who are eligible for a nursing home but don't want to move, said Sandra Spoelstra, an associate nursing dean at Grand Valley State University who is leading the study with state Medicaid officials.

"It's a different way of talking to people and listening to what they desire to make their life better," Spoelstra said.