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News Roundup: October 28, 2016

AHHQI Releases Report on Optimizing Home Health Value

Published by Home Care Magazine
October 28, 2016

ARLINGTON, Va. (October 20, 2016)—The final report from the Alliance for Home Health Quality and Innovation (AHHQI)’s Future of Home Health Project was published online this month in the peer-reviewed journal Home Health Care Management and Practice. The article, “The Future of Home Health Care: A Strategic Framework for Optimizing Value,” outlines a vision for the role and relevance of home health and home-based care and recommends a framework for the Medicare-certified home health agency of the future.

Critical to the strategic framework for the future are three key roles that the home health agency of the future will play. The authors state that home health agencies will play critical roles in: 1. providing post-acute care and acute care at home; 2. partnering with primary care; 3. partnering with home and community-based long-term care programs. In these roles, home health agencies will provide time-limited rapid escalation of skilled nursing, therapy and other support to enable patients to avoid hospitalization and to be integrated into community life.

“By designing a strategic framework for the future of home health care delivery, we hope to enhance the ability of home health agencies to provide high quality care to ensure patients improve or remain as healthy as possible,” said Steven Landers, MD, President and CEO of VNA Health Group and Vice-Chairman of the Alliance Board of Directors. “The report provides direction on how new and alternative models should be structured to ensure home health agencies can participate in, and add value to, new payment structures designed to decrease spending by reducing hospitalizations and keeping patients healthy at home.”

The report is highlighted by three key recommendations to help enable future home health agencies to recognize their full potential:
1. Reduce regulatory barriers to risk-sharing and empower home health agencies to be a full partner in care coordination.
2. Allow more flexibility in delivering home health care through alternative payment models. This includes testing waivers of certain regulatory limits to encourage clinically appropriate and cost-effective practices.
3. Crack down on home health care fraud by identifying hot spot areas of aberrant claim patterns. Tackling fraud in this targeted fashion will enable greater confidence in the Medicare system and cut down on overall program waste.

Qualitative research, a literature review, case studies and the themes collected at the 2014 Institute of Medicine and National Research Council workshop, “The Future of Home Health Care,” were all utilized in completing the analysis, which discusses the current challenges the home health care industry faces, and lays out a framework for stakeholders to adapt to this changing environment. Specifically, the report describes the current home health care landscape, the status of proposed reforms, and where the industry is headed. The report also offers recommendations for Medicare officials to improve the way home health care is delivered to better serve a rapidly growing patient population.

As the American population ages, living longer with more acute and chronic conditions, the role of home health providers is expected to grow and change significantly. Policymakers will need to address these challenges so that home health agencies can fulfill their critical roles under Medicare’s Triple Aim goals, which seek to improve patient experience of care, increase the health of populations and reduce the per capita cost of health care. The shift toward value-based health care provides new opportunities for home health agencies to adapt to alternative payment models and to pursue more care coordination and risk sharing.

“As we move into the future of home health care, it is critical that Medicare and home health care evolve alongside each other to actively promote risk sharing and better manage patient care,” said Teresa Lee, Executive Director of the Alliance. “In the long-term, we expect to see home health agencies expand their role under alternative payment models and serve as key coordinators of care.”

In order to adapt to this critical role, future home health agencies will need to have newly strengthened capabilities. The FOHH report outlines four pillars that describe what a home health agency of the future would be expected to look like. Future home health agencies must:

Provide care that is person-centered, respectful and responsive to individual patient needs. This will require the home health care industry to clearly define person-centered care and develop new measurement indicators to ensure its effectiveness.

Provide care that is seamlessly connected and coordinated. The report found that there is an enormous role for home health agencies to play in coordinating care for Medicare beneficiaries. The current shift toward value-based care will likely lead to beneficiaries interacting with a wider range of health care providers—and often well after an acute event—so the home health agency of the future will be in a unique position to take a leading role in care coordination.

Prioritize quality. Medicare’s recent efforts to transition to value-based care will require home health agencies to be more flexible in responding to changes in patient populations. The research performed for this report confirmed that an overwhelming majority of Medicare patients want to stay in their own homes and that many who use home health services are more likely to be older, have multiple chronic conditions and live alone. Home health agencies must provide high-quality care that allows patients to remain safely at home.

Be technology enabled. Recent innovation has allowed patients to easily connect with providers to receive more intensive and specialized services. While this is critical for improving patient care, future home health agencies can expect to face significant challenges in adapting to new technologies because Medicare does not currently reimburse for many types of health information technology. Thus, agencies will find themselves under pressure to implement new technologies under increasing financial constraints.

“This framework reflects the enormous potential home health agencies have to be the primary driver of quality, patient-centered care,” added Lee. “The home health agency of the future will be a leader in care coordination and play a critical role in patient health that goes far beyond post-acute care management. They have the opportunity to be a key partner in improving patient health, breaking down barriers to access and lowering costs for everyone.”

Leslie Dallas: Hold off on Medicare 'pre-claim' review

Published by Times-Call
By Leslie Dallas, PT, DPT
October 28, 2016

The federal Medicare agency recently began imposing a demonstration that requires third party contractors to approve physician-prescribed home healthcare for beneficiaries before Medicare will pay for the service. Home health leaders, physicians and patients have expressed concern that this policy could result in dangerous delays and denials for clinically necessary care, particularly for patients recently discharged from the hospital who are particularly vulnerable.

Since the program was implemented, home health agencies have reported problems navigating the so-called "pre-claim review" process, including care denials for patients following major joint replacements who need home health to safely transition from hospital to home.

While Medicare launched the program with the hopes of reducing fraudulent claims, there is little evidence that pre-claim review will be effective in rooting out bad actors from the Medicare program. Instead, compliant and quality home health agencies are subject to increased administrative requirements that mean more time with paperwork and less time with patients. More targeted solutions are needed to achieve Medicare's goal, which I support.

Fortunately, bipartisan lawmakers in Congress have introduced the Pre-Claim Undermines Seniors' Health (PUSH) Act of 2016. This much-needed legislation delays pre-claim review of home health services for one year to allow Congress, Medicare and home health stakeholders to work together to strengthen the program and improve education to ensure patient care is not delayed or unjustly denied.

I urge our state's lawmakers in the U.S. House to cosponsor the PUSH Act to protect the timely delivery of care in the home setting patients prefer and physicians trust.

3 Obstacles to Creating the Home Health Agency of the Future

Published by Home Health Care News
By Tim Mullaney
October 28, 2016

In-home care stands to become ever more central to the U.S. health care system in the years ahead, but for providers to reach their full potential, there still are important steps that need to be taken. Specifically, regulatory barriers need to come down, more flexibility needs to be baked into payment models and efforts to root out fraud need to be more targeted.

These recommendations come in conjunction with the publication of “The Future of Home Health Care: A Strategic Framework for Optimizing Value” in the peer-reviewed journal Home Health Care Management and Practice. To prepare the report, the Alliance for Home Health Quality and Innovation (AHHQI) conducted and/or commissioned qualitative research, a literature review, and case studies, and used themes from a 2014 Institute of Medicine and National Research Council workshop as a jumping-off point.

The overall takeaway from this report is positive for home health.


“In our interviews with policy leaders, including former policymakers at the highest levels of CMS, in addition to leaders in caregiving and health care system leaders, all really are in agreement that in the new models that are going to be the focus of health care delivery system reform, like bundling and ACOs, home health care is going to be a big winner,” Teresa Lee, executive director of AHHQI, told Home Health Care News. “So, in that context, what we’ve tried to build out in a discussion of this project is that we need to be leveraging that opportunity as a home health community.”

Preliminary findings from this project already have been shared in various formats and venues, and the report published this month contains a final version of the framework that has been shared in these previews. Notably, it lays out the four “pillars” that will differentiate a home health agency of the future: providing care that is person-centered; providing care that is seamlessly connected and coordinated; prioritizing quality; and being technology enabled.

The future home health agency also will play three critical roles, the final report states. Namely: providing post-acute and acute care at home; partnering with primary care; and partnering with home- and community-based long-term care providers. By playing these roles, home health agencies will be able to both support hospitalizations and other medical escalations, and enable patients to have lives that are integrated in their communities.

Yet, to achieve this vision of the future, there are some important issues to address, according to the report authors.

3 Areas for Change

Regulatory barriers: Regulatory barriers present one such challenge, specifically to enable home health agencies to share risk in new payment models and fully participate in coordinated care with other providers, the report states.

“Stakeholder interviews … highlighted several regulatory barriers within the structure of the home health benefit that preclude effective care coordination, provisions that prevent the necessary level of integration and coordination with other providers,” the report authors wrote.

One issue that has hampered integration and care coordination—and created an obstacle for agencies seeking to become more tech-enabled—is that home health agencies have not been eligible for the same financial incentives for implementing electronic health records (EHRs) as other types of providers. While the Centers for Medicare & Medicaid Services (CMS) has stated the home health agencies may be eligible for some of these payments moving forward, it is “unclear” whether this will be sufficient for supporting the health technology investments needed of the future, according to the report.

More flexibility: Alternative payment models are shifting the health care system away from rewarding providers for the volume of services provided, in favor of tying payments more to quality outcomes and coordinated services. Home health is an important player in these models, as it is often the lowest-cost setting and also is the place where patients themselves would prefer to receive care. However, related to the issue of regulatory barriers, the way that some of the alternative payment models are designed does not allow home health to fully maximize its value.

The requirement that Medicare beneficiaries be “homebound” in order to utilize home health services was one such constraint identified in the report. For alternative payment models, such as bundled payments or accountable care organizations (ACOs), there is the potential that waivers can be tested to provide more flexibility in who can tap home health benefits.

These sorts of waivers should indeed be tested to help encourage practices that both are clinically appropriate and cost effective, the report recommends.

Targeted fraud crackdowns: Government watchdogs and other oversight bodies have singled out home health fraud as a major issue, and have launched aggressive efforts to identify and root out bad actors.

While such efforts are needed to ensure program integrity and reduce waste, when crackdowns become overly broad, they risk imposing unsustainable burdens on high quality providers, the report notes.

While it is not specifically mentioned in the report, one such problematic fraud prevention program is the Pre-Claim Review (PCR) demonstration currently underway in Illinois, according to AHHQI’s Lee.

“Pre-claim review’s focus is the review of home health documentation,” Lee said. “The irony is that truly bad actors may be fabricating documentation that can look perfect. But for a good, compliant home health provider that knows the importance of coordinating care and working well with the physician, who should be providing appropriate documentation, the pre-claim review process is a major obstacle to operation.”

Moving Forward

In addressing these three areas, the home health industry will need to engage multiple stakeholders, including patients, caregivers, policymakers, and payers, the report states. Another essential strategy is going to be collecting the data to make a compelling argument to the necessary individuals and organizations, according to Tracey Moorhead, CEO and president of the Visiting Nurse Associations of America (VNAA) and an author of the report.

“I think that the most critical component of overcoming the current regulatory and administrative burden is effectively developing and communicating the evidence case for the value of home-based care,” Moorhead told HHCN. “It’s going to take real data, it’s going to require us to show that we have a cost savings opportunity in health care to help improve value, to get us that seat at the table we need in the deisgn of those health care delivery models.”

One effort she singled out is AHHQI’s research into the value that home health contributes in episodes of care related to joint replacements.

“VNAA has also developed a database where we’re collecting data from many of our members, and we’ve developed a dashboard that demonstrates outcomes and impact,” she said. “We can track how our agencies are doing against a national average for specific conditions and populations, and this, too, is another component to that evidence-case for home-based care.”

The fact that CMS recently delayed the further rollout of pre-claim review is one reason to believe that policymakers indeed are receptive to the sort of evidence-based case that the home health industry can put together, Lee said.

The three areas foregrounded in the report are far from the only challenges facing home health agencies—for example, workforce issues also are top-of-mind for many providers, as the AHHQI paper also described. But while creating change across all these domains and creating the “home health agency of the future” may not be easy, the rewards of doing so could be profound—as the report concludes, “the pursuit of this transformation process has the potential to improve the way health care is delivered in America.”

Senior-Specific ERs, Home Care Could Reduce Hospital Admissions

Published by Home Health Care News
By Elizabeth Ecker
October 28, 2016

Hospital admissions have always been a major concern for the aging population, but the sheer numbers will make a rising problem even worse without alternatives to help take pressure away from hospitals.

With an influx of senior patients using emergency health care services, some health systems are exploring the ways in which they can improve the experience for seniors, specifically, and they’re also looking closely at care provided in the home before and after ER visits to help cut down on senior ER admissions and readmissions.

The University of California, San Diego, which operates multiple hospital campuses in greater San Diego, through grant funding of $12 million from San Diego-based West Health, is under way with plans to build a senior-specfic emergency room. It also has piloted a project to provide acute care at home. The care at home project is not restricted by age, but 90% of the patients are over age 65.

In the period of time 24 to 72 hours after a hospital admission, nurses provide care in the home such as blood draws, intravenous antibiotics administration and other medical services.

An additional layer involves encrypted text messaging between the nurse and the physician who assumes the care at home and can intervene if needed.

The Senior-Specific ER

The acute care at home project is one avenue UCSD is pursuing to improve the care process for seniors and all patients while taking some pressure away from emergency rooms. A senior-specific ER is also being designed with a similar goal in mind.

The $14 million, 8,500-square-foot project anticipates completion in 2018.

Current emergency medical facilities do not have the capacity to serve the wave of senior patients that is coming via the “silver tsunami,” said Dr. Ted Chan, chair of the Department of Emergency Medicine at UC San Diego.

“When we look at the numbers in emergency medicine, there is one emergency department visit for every two folks over the age of 65,” he said on a panel last week during MedCity’s Engage conference in San Diego. “That’s over 500 visits per 1000 people over 65… As the population grows, we imagine that will grow. It’s a significant challenge.”

There are currently around 100 emergency rooms nationwide that market themselves as geriatric ERs, Chan said, although few are taking such a comprehensive approach as UCSD’s. The university is collaborating in its research with a couple of figureheads when it comes to geriatric ERs, including Northwestern Memorial Hospital in Chicago and Mt. Sinai Hospital in New York City.

The approach to developing a senior-specific ER involves both research and data analysis, said Dr. Zia Agha chief medical officer for West Health, on the same panel.

“On the research side we are doing research with UCSD and on a national level,” he says. “We are looking at data from three EHRs. One initiative is to create a data warehouse, allowing more rapid cycle research. [We’re] also looking at using data as an opportunity to create quality measures.”

Redesigning Emergency Care

In very loose terms, a geriatric ER is one that has specific accommodations for senior patients. This could mean materials used for flooring that can help prevent falls, for example. The UCSD project, which will break ground in 2017, is also looking at a number of other elements: ample windows for natural light; ambient light that will prevent patients from becoming disoriented; acoustics and sound absorption to help patients who are hard of hearing; considerations for mobility issues including fall prevention; and ample space for caregivers in the ER, since in many cases the caregiver accompanies the patient.

But in addition to the physical aspects of the ER, training of medical staff is a major consideration. UCSD and West Health are exploring the approach of staff, including care processes and transitions.

“The first element is much more extensive screening in terms of cognitive decline,” Chan says. “We are missing opportunities to pick up on early cognitive decline.”

All nursing staff will be trained on this screening, as well as in care transitions. Post-discharge planning and communication is yet another prong of the research where opportunities lie, Chan says of an acute care at home project aimed at reducing hospital readmissions.

“If we can get [patients] home or to assisted living, but we’re not able to make it to their home, there’s [some service we can provide] from the ED that may result in some significant costs saving,” he said.

That might include nurse visits within the first 72 hours post-discharge to perform IV antibiotic administration or blood draws as in the acute care at home program. And as construction gets under way, the researchers and partner institutions will learn more about what works in the senior ER, in hopes to help address a rising issue before it becomes a problem.

“Forty-two million [seniors] in 2030 will be seen in the ER,” Chan says, citing projections. “We don’t have the resources to manage that.”

Tips for Getting Face-to-Face, Homebound Status Right

Published by Home Health Care News
By Tim Mullaney
October 28, 2016

With margins tight, staffing pressures constant, client acuity rising, and a host of other challenges for home heath agencies, they can’t afford to see their Medicare reimbursements jeopardized or delayed.

To make sure they’re getting the basics right, agencies may want to double-check their practices against the following information on face-to-face documentation and supporting homebound status, which was shared by Medicare Administrative Contractor (MAC) CGS at the National Association for Home Care & Hospice (NAHC) annual conference this week in Orlando.

Face-to-Face Basics
“I get a lot of questions when I’m out and about, when do I have to get a new face-to-face?” said Sandy Decker, RN, senior provider education consultant at CGS. “It’s really simple. If you have the need for a new start of care OASIS, then you need a new face-to-face. If you have a readmission OASIS, anything like that, you don’t.”

The face-to-face also has to be for the main reason a patient is coming to home health, Decker noted. For instance, if a patient sees a physician numerous times in the 90 days before the start of care for COPD, but then falls and breaks an ankle and that precipitates the home health episode, that is what the face-to-face has to cover.

Also, the face-to-face should focus on the main condition rather than a side effect, Decker explained. As an example, one provider turned in a face-to-face that was all about a patient’s depression and anxiety, even though the individual just had undergone a surgery.

“I understand that having surgery can cause depression and anxiety, but it never mentioned the surgery, so we couldn’t accept the face-to-face,” she said.

Other face-to-face issues sometimes crop up when the patient is coming to home health right after a hospital or skilled nursing stay. In these cases, the face-to-face does not have to be done by the certifying physician, but the certifying physician must document the date of the face-to-face.

“There’s a real easy way to do that,” Decker said. “On your 485, [include] a sentence that says ‘The face-to-face encounter was performed on [blank date], by doctor so-and-so.’ Then the certifying physician signs the 485, and they [may] never even know the sentence was on there. But if that sentence is on there, and they sign it, it means they’ve documented the date of the face-to-face encounter, and you’re good.”

If, say, the hospitalist performed face-to-face and also signed the certification, then they have to identify who will be the community physician taking care of that patient, she added.

“This is showing continuity of care,” she said. “There are a lot of face-to-face forms out there, especially that come from hospital software, that have enough information on there to count as a certification. If it talks about homebound status or need for skilled care, then it could be considered a certification, and the person who fills it out has to identify the name of the community physician.”

Homebound Status

Another area of focus was supplemental documentation to the face-to-face to support the need for home health. This is needed because the face-to-face encounter documentation often is not explicit about the patient’s homebound status.

“I don’t mean to be derogatory, but physicians don’t care about the patient’s homebound status,” Decker said. “They are concerned with the need for skilled care and what needs to happen to get that patient better.”

Therefore, it falls on the shoulders of the home health provider to bolster the physician’s documentation for the homebound status. This supporting documentation can be created or generated by the agency or be information that the agency has obtained, such as a discharge summary.

Once that documentation is sent to the physician’s office, the physician needs to sign and date it. A rule of thumb is that every time there is a physician’s signature, it needs to be followed by a handwritten date, Decker said. Another MAC in attendance at the conference, Palmetto, also confirmed that dates need to be handwritten as opposed to stamped.

As for whether the physician needs to sign every page, this is not necessary, as long as the pages are numbered in such a way that it is clear a signature at the end covers the entire document. For example, numbering pages “1 of 12,” 2 of 12,” and so on.

Finally, keep in mind that homebound status does not mean that the beneficiary can never leave the house, Decker said. They can leave their house if it’s infrequent, for periods of relatively short duration. Not only leaving the house to receive medical treatments, but also to attend religious services, or even attending adult day care on a daily basis, all could be allowed without compromising someone’s homebound status.

Special events such as weddings and funerals also are acceptable, as are other uncommon occasions—a home health patient leaving the house to attend the Iowa State versus University of Iowa football game was one example Decker provided.

“When you have a patient with something like that, what you’re wanting to put in your documentation is, what was the aftermath of that?” she said. “He probably had to rest up for at least a week, maybe two weeks. He may have been completely in bed for three days because he was so exhausted.”