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News Roundup: October 21, 2016

3 Myths Holding Back Aging in Place

Published by Home Health Care News
By Alana Stramowski
October 21, 2016

The majority of the aging population in America, which is responsible for at least $7.1 trillion in annual economic activity, has the desire to stay in their homes, but many are hesitant to call themselves “old” or even have conversations about aging in place.

The myths and stigmas that surround these conversations are why many people are hesitant to even bring up the idea, so debunking them is the first step in opening a dialogue, according to HomeAdvisor’s Aging in Place Report 2016.

Based in Golden, Colorado, HomeAdvisor is a provider in digital home services with tools and resources for home repair, maintenance and improvement projects. The 2016 Aging in Place Report is based on the results form a survey conducted between August 10, 2016 and August 23, 2016 to 279 professional respondents and 586 homeowners 55 years and older.

A top myth among the older generation is that aging in place is about aging, the report said. This assumption can easily be debunked because aging in place is really just about livability.

Even for homeowners who are 55 and older, 40% say that they aren’t completing aging-related renovations because they don’t have physical disabilities. Though aging-related renovations are not just for homeowners with physical disabilities, Marianne Cusato, author of the report and HomeAdvisor’s housing expert, explained.

“Making homes safe and accessible for seniors is an important and primary objective of aging-in-place projects,” Cusato wrote. “Thriving in place, however, is about much more than adding grab bars and wheelchair ramps. In fact, many popular aging-in-place improvements—wider doorways, open floor plans, zero-step entrances, remote-controlled window coverings and motions-tenor lights, just to name a few—can enhance the quality of life in a home even as they make the home safer.”

Another myth believed by the 55 and older population is that aging in place is only practical in the suburbs. Among older homeowners, suburban/rural homeowners are less likely than urban homeowners to have completed or considered an aging-in-place renovation, the report said.

But what many of those homeowners may not know are the benefits of aging in place in cities. Larger cities often have better public transportation systems and increased social opportunities, which can be ideal for aging adults who may not want to drive anymore but want to maintain a social life.

Technology also brings up mixed feelings when it comes to homeowners 55 and older. Of those surveyed, 67% think smart home technology could be useful as they age, but just 19% say they have considered installing smart home technology. This could be because technology is still considered a luxury convenience instead of a necessity, Cusato pointed out.

“Older homeowners’ reluctance to adopt smart-home technology for aging in place is not surprising,” she wrote. “Older adults are less likely than younger adults to be familiar with technology in general, and smart home technology in particular is still coming into existence—and, therefore, still expensive.”

No matter what age someone is, many aging in place upgrades—such as seating in the shower, or lower cabinets—can improve quality of life, the report stresses.

“Looking at aging in place through a new lens that acknowledges how we live—not just show long we live—will usher in a new generation of home-improvement project that benefit the young, the young at heart and everyone in between,” Cusato said.

Pre-Claim Tests Home Health, Physician Relationships

Published by Home Health Care News
By Tim Mullaney
October 21, 2016

As Illinois home health agencies have grappled with numerous challenges imposed by the Medicare Pre-Claim Review (PCR) demonstration, making sure home health can work hand-in-hand with physicians has emerged as an acutely important issue.

Under the PCR demonstration, agencies must submit claim documentation to a Medicare administrative contractor (MAC) for audit; affirmed claims may be submitted for payment, while non-affirmed claims must be resubmitted. The requirement of having a physician signature on the home health plan of care was an early concern voiced by agencies, after the Centers for Medicare & Medicaid Services (CMS) announced in June that the pre-claim review would be implemented.

The program rollout has been blasted as a fiasco in Illinois, and CMS delayed a planned expansion to additional states after pressure from Congressional lawmakers. However, pre-claim remains in effect in Illinois, and agencies there continue to say that a major complicating factor is communicating with physicians about the new requirements and getting timely documentation that fits auditor expectations.

It appeared early on that CMS was not doing a thorough job of educating physicians about the pre-claim review, Cheryl Meyer, director of clinical excellence at Advocate Health, said Tuesday at the Home-Based Care: Financial Leadership Forum in Chicago. The event was jointly organized by the Visiting Nurse Associations of America (VNAA) and the Alliance for Home Health Quality and Innovation (AHHQI).

Physician associations began calling Advocate during the summer asking what the pre-claim review entailed, suggesting that they were not getting that information from CMS, Meyer said. Based in the Chicago area, Advocate is the largest health system in Illinois. Advocate at Home has about 1,100 Medicare episodes monthly.

Recognizing that pre-claim would indeed increase the importance of the physician documentation, Advocate has taken certain steps. Its chief medical officer sent a letter to Advocate physicians explaining pre-claim requirements, and why it is important for physicians to take the time and effort to meet the needs of the program—including that keeping transitions to home running smoothly is important to initiatives related to population health.

Advocate also has stopped accepting home health referrals until all the documentation is furnished up front, Meyer said. This is a change from the prior approach, which generally was to take accept the patient and then chase the paperwork.

If a patient’s care is delayed due to the lack of documentation, that is entered into a patient safety database, she said. Collecting data about the impacts of pre-claim on access to care is one important step that providers should be taking, so that CMS and lawmakers can have hard numbers showing the negative impacts of the program.

“We’ll have a story to tell,” Meyer said, of having that kind of data.

It was a point strongly echoed by Joy Cameron, VNAA vice president of policy and innovation. Cameron also said one of her “key concerns” is about the need for physician involvement in pre-claim, and how difficult it can be to communicate the program requirements to them. Adding to this issue is that MAC auditors seemingly are looking for very specific language, perhaps because they need further education and training themselves.

“I don’t think they’re doing this purposefully,” Cameron said of physicians not hitting all the necessary marks related to documentation. “It’s extremely confusing to have a home health agency say, ‘When you’re describing homebound status, can you make sure to use the following phrasing, because this is what our MAC really likes.’ I think physicians might have their hackles raised a little bit, because they say, ‘I said they’re homebound.’ Yes, but the MAC is looking for specific language.”

Changing Systems—and the Culture

A more long-term effort at Advocate involves working with the hospital to put in tools and processes with the goal of getting more consistently high-quality documentation for home health and other post-acute providers, Meyer said.

This is the sort of project that would have made sense to embark on even prior to pre-claim, given that health care reforms generally are increasing the importance of smooth transitions and sending patients to most appropriate, lowest-cost setting. Meyer said she is somewhat regretful that it was not executed earlier, and says that a certain home health mindset about physicians may need to change.

“It’s a culture that we have with medical documentation, that we always try to make things easy for physicians, [who] say they’re busy,” Meyer said.

Neither Meyer nor Cameron supports PCR—Cameron went so far as to call it “an evil that needs to be stamped out.” However, while it is ongoing, agencies may be well-advised to not get too defensive, Meyer suggested.

“The very first [pre-claim] I submitted was not affirmed,” she said. “I’m looking at the non-affirmed reason and [the MAC said] it doesn’t appear this patient is homebound. I could see where they could say that, but it’s then going back to the physician, asking them to do better documentation, and then it went through. That’s that quality assurance process … you have to look at it with a very critical eye, not defend it.”

Still, the unpredictability of what is affirmed versus not affirmed seems to be undeniable, and so even with a robust QA process and diligent communication with physicians, perseverance is the name of the game.

“You just can’t give up,” Meyer said.

Average Home Health Medicaid Rate Increased in 2015

Published by Home Health Care News
By Tim Mullaney
October 21, 2016

The average Medicaid reimbursement rates for home health and personal care providers ticked up slightly last year, newly released data show.

Home health agencies received $93.93 per home health visit on average in 2015, up from $92.69 the year before, according to information compiled by the Kaiser Family Foundation. In states that paid registered nurses directly, the average rate per visit was $87.26 in 2015. For home health aides, the average rate was $52.19 per visit.

Within personal care services Medicaid plans, the average rate for providers in 2015 was $18.82 an hour. That was a slight increase from $18.73 a year prior.

Variations existed among states, of course. New Mexico home health agencies received $331.57 per visit in 2015, for example, while those in Wyoming received $52.

For personal care providers, reimbursement in North Dakota was on the high end at $19.76 per hour, while Nebraska came in at $8.68 an hour.

State legislatures often set these payment rates as part of the budget process, the report notes. The reimbursement data was gathered through surveys conducted by the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured (KCMU) and researchers at the University of California, San Francisco (UCSF).

These surveys have been tracking the growth in the three primary Medicaid programs providing home- and community-based services: home health services state plan benefit, the personal care services state plan benefit, and services under § 1915 (c) HCBS waivers.

Participation in these three programs declined by 6% between 2012 and 2013, according to the latest report, released Tuesday. This was the largest decline in the study period, and it may be due to increasing home- and community-based care being offered through other plans and waivers, the report states.

Even as participation declined, expenditures for these three programs increased slightly between 2012 and 2013, from $55 billion to $56.5 billion.

And 2013 also marked a watershed moment in the continued expansion of Medicaid-supported HCBS.

“As states continue to implement various aspects of the Affordable Care Act (ACA), developing and expanding home and community-based alternatives to institutional care remains a priority for many state Medicaid programs,” the executive summary states. “2013 marked the first time that home and community-based services (HCBS) accounted for a majority (51%) of national Medicaid long-term services and supports (LTSS) spending, increasing from 18% in 1995.”

Minimum Wage Spurs Changes

While 2013 was the most recent year for which the report authors could collect usage and expenditure data, they gathered more current information on how states are responding to the new extension of minimum wage protections to home care workers.

In situations where a Medicaid beneficiary directs his or her own care, home care workers may be considered to be jointly employed by that beneficiary as well as the state or another entity. State Medicaid programs therefore need to meet the new mandates to pay the workers minimum wage, and need to adjust budgets or policies accordingly.

Last year, 11 waivers in seven states planned to control caregiver hours, such as Maine setting a 40 hours per week limit. The other six states were California, Kentucky, Maryland, New Mexico, Oregon and Washington. Cost or service caps on § 1915 (c) services were being implemented under 12 waivers in six states—Louisiana, New Mexico, New York, Oregon, Texas, and Washington.

Waivers in certain states also showed state funds budgeted for worker overtime pay (California, Connecticut, Kentucky, Oregon, Pennsylvania, South Carolina, Washington) or travel time pay (California, Connecticut, Oregon, South Carolina, and Washington) in fiscal year 2016.

How Home Health Can Win ACO Partners

Published by Home Health Care News
By Alana Stramowski
October 21, 2016

Since the implementation of the Affordable Care Act in 2010, the home health industry has become more involved in accountable care organizations (ACOs), seeing it as an opportunity to stay relevant as payment shifts to reward value rather than volume. However, there are challenges to being selected to be a part of these provider groups, and agencies must continue to pursue strategies that will make them competitive.

Home health agencies need to know how to sell themselves and make themselves known in the industry as valuable partners within ACOs, Scott Vasey, senior vice president of strategy at the Visiting Nurse Service of New York (VNSNY), explained at the Home-Based Care: Financial Leadership Forum in Chicago this week. The event was put on jointly by the Visiting Nurse Associations of America (VNAA) and the Alliance for Home Health Quality and Innovation (AHHQI).

The basic concept of an ACO is that various types of Medicare providers work together to coordinate care better for their patient population, and then they get to share in savings—or have to pay the Medicare program back, if they exceed cost thresholds.

There are now 477 Medicare ACOs participating in the savings programs, and together, those agencies saved the Medicare program $411 million in 2014, according to the U.S. Department of Health and Human Services. While growth in ACOs has been somewhat touch-and-go, with notable participants dropping out, the Centers for Medicare & Medicaid Services (CMS) has introduced new ACO models in an effort to keep the program growing.

Given that CMS is aggressively pushing to move Medicare over to ACOs and other alternative payment models, home health agencies must continue to adapt and fight for a place at the table.

Building partnerships

One strategy to help agencies look more attractive to ACO partners is to re-focus business development plans within the agency, Vasey said.

If agencies can shift their focus to be more community-based by initiating partnerships and getting to know other health care providers in the community, and zero in on physician referrals with potential ACO participants, it could help solidify those relationships down the road.

“This is what we’re focusing on right now,” Vasey said. “We are partnering with hospitals in the community and talking to them so they understand the cost savings that can be made from home care.”

The VNSNY is also focusing on aligning the agency with sub-acute providers, health information technology providers and pharmacy partners to boost their attractiveness.

“We are trying to align ourselves because sub-acutes are looking for strategy and they are looking to see how agencies are going to deal with the transition to value-based [care],” said Vasey.

Leading with data

Even further, agencies should be discussing the costs of an emergency department visit at hospitals and readmission costs versus the costs of a home health admission.

Lower costs coupled with a better patient experience can help push some ACO partnerships to form, but, ultimately, agencies need to be their own advocates to prove this.

“Emphasize a better patient experience to be cared for in the home rather than in a facility,” Vasey said.

Agencies should go out and share their data with potential partners and make relationships. But they also need to react to what their market needs and what opportunities are available.

Exploring those opportunities may not always end in an ACO. There are many other pathways agencies can discover that could work better than only ACOs. It may be best to explore all potential options in the value-based care market than just focus on one option.

In addition to ACOs, VNSNY is participating in the Bundled Payments for Care Improvement (BPCI) initiative for patients who have heart disease and who have had heart attacks, Vasey explained. The agency is currently in year three of the bundle, which is focused exclusively on episodes of post-acute care.

“The approach to value-based care should be strategic and also reactive. Agencies should be experimenting in various arrangements.”

Surviving Pre-Claim: Where We Are Today & What Tomorrow May Bring

Published by Home Health Care News
By Tim Mullaney
October 21, 2016

Home health agencies have been dealt a blow by the Pre-Claim Review Demonstration. Providers are reeling in areas where the program is underway, and they are gripped with uncertainty in areas where it still is set to be implemented.

Since the program began in August, agencies in Illinois have been required to submit Medicare claims for pre-authorization before filing them for payment—and by all accounts the rollout has been a mess, squeezing cash flow and causing administrative upheaval. In response, the Centers for Medicare & Medicaid Services (CMS) has hit pause on the planned expansion to additional states, but it is only a matter of time before that occurs.

With federal lawmakers calling on CMS to scrap the demonstration, industry associations pushing back against it, and agencies working hard to get a handle on mounting challenges, it seems there’s a new wrinkle to keep track of with each passing day. We’ve gathered a panel of experts to give an update on where the program stands and what we’ve learned so far about best operational practices.


During this webinar, experts will cover:

– Up-to-date information on the status of the pre-claim program and a briefing on efforts to halt it.

– Important information on what the pre-claim requirements are, and why CMS has put the program in place.

– Tips for how agencies can put themselves in a sustainable position on pre-claim.

How the ‘Re-Engineered Hospital’ Presents a Home Health Opportunity

Published by Home Health Care News
By Tim Mullaney
October 21, 2016

Some big thinkers believe that the heart of the U.S. health care system is shifting away from hospitals and other institutional settings, into people’s homes. Those who need proof that this occurring may find some in New York City, where Mount Sinai Health Network is in the vanguard of providing hospital-level care for patients at home.

Hospital at Home has been a concept at least since the 1980s, when it was pioneered at Johns Hopkins University School of Medicine in Baltimore. It has been slow to gain momentum, in part because Medicare does not have a system to reimburse this type of care.

However, the Centers for Medicare & Medicaid Services (CMS) has been testing many alternative payment methods since passage of the Affordable Care Act in 2010, with the goal of reducing costs while improving outcomes. Through these experimental payment models, hospital at home programs have been able to gain a foothold in some areas. In 2014, the agency awarded nearly $10 million to the Icahn School of Medicine at Mount Sinai to launch its Mobile Acute Care Team services.

Under this three-year project, certain patients who arrive at Mount Sinai emergency departments are given the option to be technically admitted to the hospital but receive their care at home, through visits from specially trained doctors and other clinicians. Equipment such as IVs and X-ray machines can be brought into the home as well.

With the project now entering its last year under the CMS grant, Mount Sinai Health Network President Arthur Klein, M.D., spoke with Home Health Care News about the commitment to serve more patients at home, the “re-engineered hospital” of the future, and the opportunity for home health providers.

HHCN: What patients qualify for hospital-level care at home, and how many have participated?

Klein: At Sinai, we have a project to look at our capabilities to provide safe care at home for a group of patients who would otherwise be hospitalized, under the medical supervision of our Department of Geriatrics’ Visiting Doctor program, one of the oldest and largest in the country.

In the hospital at home program, we have a group of patients who show up at our ER, who have a relatively low-acuity diagnosis that otherwise would have mandated their admission to the hospital. Cellulitis, CHF [congestive heart failure] tune-up, rehydration, et cetera.

When these patients are evaluated in our ER and our doctors deem them worthy of admission, they’re offered the opportunity to be treated at home. That means they get prescribed a number of doctor visits, nurse visits, all the medical devices they may need—IV fluids, poles, pulse oximeter, and so on—and they go home.

We have treated over 150 patients in this program.

HHCN: What feedback have you gotten from these patients?

Klein: Assuming they get good and safe care at home, it’s not destabilizing, they don’t become disoriented [as they might] at the hospital. They’re home with family, with pets. We’re seeing that patient satisfaction is excellent.

What happens to an elderly patient in the hospital, you can’t predict. Even if it’s a relatively low-acuity condition, they can fall, they’re in an unfamiliar environment. They can become depressed. They can become agitated.

HHCN: Are you seeing good clinical outcomes as well?

Klein: [We’ve recorded] no increase in morbidity, mortality, and overall, it’s more cost-effective than getting admitted to the hospital.

HHCN: It seems to make sense to treat more patients at home, but do you think hospitals are possessive of their patients? Might it change their revenue model if more care moves into the home setting?

Klein: I think it’s just a truism that we can’t afford health care delivery as it is now. Progressive providers don’t want to put their head in the sand.

We’re saying that a re-engineered hospital should deal with the sickest. Otherwise, commit to good outcomes in the most cost-effective manner possible. Will hospital revenues change? Sure. But I think hospitals already have experienced a tremendous change from inpatient to outpatient [services]. This is a continuation along that trend.

There is certainly a role for inpatient subacute rehab. There’s no question there are some patients who really need it. On the other hand, there are clearly patients who are in relatively good condition who could go directly from a surgical procedure to being treated at home. As in all things in medicine, there’s a spectrum. Our desire is to pick the right points on the spectrum where people could be treated at home versus in an institutional setting. A lot depends on the home environment, [considerations such as] are there stairs? There’s no cut-and-dried answer.

Having said that, as you know, in orthopedic and increasingly in cardiac cases, the federal government is looking at bundled payments, payments for episodes of care, and that includes a rehab component.

And we will be anxiously waiting for the federal government and private insurers to take this [hospital at home model] to a commercially viable way to deliver health care, from being a pilot.

HHCN: What’s the role or opportunity for home health or personal care agencies if this hospital-at-home trend gains more steam?

Klein: Our challenge is to make this scalable. In my estimation, to make it scalable, [you’re] going to have to reach out and have new partnerships. When testing the validity [of the model], you want to keep the provider network very controlled to get good data and feedback, but once you’ve established that, think about scalability. Obviously you need partners to do this.

HHCN: Even if these are low-acuity patients from the hospital’s standpoint, they’re still sick enough to be considered hospital inpatients. So what do home health providers need in order to be good partners?

Klein: From our vantage point, one of the things we want to do is make sure they’re appropriately resourced. The first part is help them in their recruitment needs for skilled nursing [clinicians], medical directors. That’s a crucial part of it. We want to help them recruit and get the committed and quality people we need.

HHCN: What about hospitals running their own home health companies, or acquiring one, versus partnering up with providers in the space?

Klein: I think hospitals needs to be very careful about what their sweet spot is, in terms of effective management. The verticalization of the industry often can’t be achieved by the skillsets that currently exist within the hospital system. I and many of my colleagues are supportive of partnership rather than ownership and acquisition.

If you’re an academic health system, as we are, tremendously interested in keeping your labs viable, with genomic medicine investments, the question you ask yourself is, do I diversify and also start running a home health agency or insurance company? You’ll find different answers across the spectrum, but we can’t be everything to everyone.