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News Roundup: December 9, 2016

Bill Could Loosen Home Health Assessment Regulations

Published by Home Health Care News
By Amy Baxter
December 9, 2016

A new bill could expand who can conduct initial assessments for home health visits in certain cases. The bill, the Medicare Home Health Flexibility Act of 2016, would loosen some restrictions at a time when the industry has seen an influx of new, burdensome regulations.

The bill would permit occupational therapists to conduct the initial home health assessment for certain rehabilitation cases. Occupational therapists would be allowed to conduct the assessment if the referral is ordered by a physician when the order does not include skilled nursing care; if it includes occupational therapy; and for cases that include physical therapy or speech language pathology.

The bill, which has been brought up in Congress in the past, was introduced by Sen. Charles Boustany (R-LA 3rd District).

Currently, occupational therapists are allowed to conduct the initial home health assessment for therapy-only patients “for home occupational therapy ‘establishes eligibility,’” according to The American Occupational Therapy Association, Inc. (AOTA). Medicare restricts occupational therapy for home health eligibility to only when there is a continuing need. The AOTA advocates for fewer restrictions outside of Medicare, as well.

“Occupational therapy can be a valuable resource to conduct the initial visits, increasing the number of available staff to conduct initial visits, addressing home safety issues earlier and identifying established routines to share with team members for improved participation by the patient in the plan of care,” the AOTA says on its website.

Expansions Wanted

The bill comes as industry groups have pushed for more expansions in duties across the home health field. In some instances, regulations requiring strict assessment and certifications processes are challenging for agencies. For example, some agencies in Illinois have found that acquiring a physician’s signature as part of the Pre-claim Review Demonstration (PCRD) in a timely matter is difficult and adds additional administrative burdens.

In keeping with this sentiment, New York Governor Andrew Cuomo recently signed into law a bill that allows home health aides in the state who receive additional training to give medication to patients. Currently, home health aides are not allowed to administer medications, often leaving the responsibility to family caregivers.

The state will still have to draft regulations that specify training requirements, and the law is limited to home health aides who have worked at least one year, according to NYup.com. It will be up to 18 months before home health aides with this additional training are in the field, the news outlet reported.

House Passes Bill with Telehealth, Home Infusion Provisions

Published by Home Health Care News
By Alana Stramowski
December 9, 2016

A bill that was passed by the House of Representatives last week, if passed by the Senate, will have an impact on several areas of the home health and hospice industry.

The 21st Century CURES Act is a combination of the original CURES legislation, which was intended to make the FDA drug review process more efficient, and a bill on mental health reform that was previously passed by the House.

There are four sections of the bill that will affect home care, which were described by the National Association for Home Care & Hospice (NAHC) in an online post Thursday. These parts of the bill include the use of telehealth services, Medicare coverage for home infusion therapy, mandatory use of electronic visit verification and a new moratoria.

The telehealth provisions of the CURES bill require CMS to provide a report on the populations of Medicare beneficiaries “whose care may be improved most in terms of quality and efficiency by the expansion … of telehealth services,” according to the bill.

The CMS report also must include information on any ongoing telehealth demonstration projects, the types of services that might be suitable for the use of telehealth and an explanation of barriers that are currently being faced regarding telehealth under current Medicare laws, according to NAHC.

“This provision is a clear indication that significant inroads have been made in establishing the value of telehealth,” NAHC said. “While it does not get us to where we should be, it is a good step in that direction.”

NAHC raises the question of if this provision goes far enough. The bill says that eligible originating sites for telehealth should be expanded, but it doesn’t explicitly state that the home should be one of those sites.

In terms of home infusion therapy, the bill would include a new home infusion therapy benefit to begin in 2021. Since the 1989 repeal of the Catastrophic Coverage Act, home infusion therapy has not been covered by Medicare as a stand-alone benefit. It is estimated that the new benefit of coverage will save Medicare $372 million by 2026.

The new benefit will require a plan of care by a physician, nurse practitioner or physician assistant as well as requiring a pharmacy, physician, or other provider of services, which includes a home health or hospice agency, to provide the home infusion therapy.

The other provisions regarding home infusion therapy in the bill include a mandatory 20% copay for home infusion therapy by Medicare beneficiaries as well as the exclusion of the term “home infusion therapy” from the definition of “home health services.”

NAHC shows some concern over this part of the bill and worries it won’t help expand access to home infusion therapy. This is in part because currently home infusion services can be covered under the home health Medicare benefit but that is not the case under the new bill. Under the new definition, it’s possible that a patient could lose access to home health aide services currently being provided in conjunction with home infusion.

Another aspect of the bill involves Medicaid electronic visit verification. The provision will require state Medicaid programs to implement an electronic visit verification for personal care and home health care services. If the states do not comply, they will face financial penalties, NAHC’s post said.

The last provision of the CURES legislation that relates to home care and hospice is a prohibition for payment and services given by newly enrolled providers. This particular provision is expected to save $11 million through 2026.

CMS has implemented a moratoria on new providers in several states as a way of curbing home health fraud. But because the current moratoria is based on where an agency’s office is located, some providers have set up shop outside the moratoria area yet provide care within it.

“This reform is intended to address the work-around that some providers and suppliers found with current moratoria that are focused on the location of the provider/supplier rather than the location of the service,” NAHC said in the press release. “NAHC had long been critical of the “bricks and mortar” approach taken by CMS on the application of moratoria given that home health services is about the patient location, not the office site.”

The Senate is expected to pass the 21st Century CURES bill before the end of the year.

Visiting Nurse Association: Tidal wave coming

Published by Asbury Park Press
Michael L. Diamond
December 9, 2016

RED BANK - Dr. Steven Landers sees a tidal wave approaching.

The number of people aged 85 and older is expected to triple in the next 25 years, Landers said, and he worries that they will not only strain Medicare and Medicaid, but also will suffer through services and procedures that don't lead to a longer life.

"It’s never been more exciting," Landers said, "but you also feel like you’ve got a big weight on your shoulders."

Landers is president and chief executive officer of the Visiting Nurse Association Health Group, a nonprofit organization that is trying to capitalize on its age-old service – house calls – that is coming back in favor. And he is in the middle of a whirlwind.

The organization is equipping its health care workers with technology to help them treat patients more efficiently. It is trying to raise $10 million through a fundraising campaign. It is participating in pilot projects with Medicare, searching for new ways to pay for a service so that the nation can afford to care for its aging population.

But he's convinced that if he succeeds, the Visiting Nurse Association can bring financial and emotional relief to millions of New Jerseyans.

The state, experts say, could use it. Medicare in 2012 spent $84,489 for each New Jerseyan in the last two years of their life, more than any state except California and almost 20 percent more than the national average, according to the Dartmouth Atlas of Health Care.

"We see the most specialists, and we get the most treatment and spend the longest number of days in the ICU compared to everywhere else across the country," said Linda Schwimmer, president and chief executive officer for New Jersey Health Care Quality Institute, a research group. "It's very, very expensive care, very intensive care."

And at times, not very effective. Catherine DiDonato, 83, has lived in a middle class Toms River neighborhood since 1995 with her adult son, Sal, in a home that she owns outright. Her husband died almost 30 years ago. She has four other children who live nationwide. And she survives on the income she gets from Social Security.

DiDonato landed in the hospital more than a year ago after a series of falls that she attributed to her multiple sclerosis. She was sent to a nursing home to rehabilitate, but she contracted a bedsore and complained that the food wasn't suitable because she also has diabetes, she said.

DiDonato went home and remained bedridden. She had a home health care aide, but she couldn't afford the service for long. But the aide told her about the VNA. And soon she was visited by social workers, a physician and, on a recent November day, nurse practitioner Kathryn Corbet, who set up a laptop on a nearby table and went through a checklist of potential health issues.

Medicare covers 80 percent. A supplemental Medicare policy covers the rest. And DiDonato hasn't needed to return to the hospital since. Asked if she might want to move somewhere that had more help, she said no.

"I'm not going back," DiDonato whispered with a smile.

Landers, 41, lives in Little Silver with his wife, Allison and their three sons, Eli, 10, Sammy, 8, and Harley, 5. A family doctor who specialized in geriatric medicine, Landers joined the VNA in 2012 after managing the home and community care programs at the Cleveland Clinic, close to his hometown of Shaker Heights, Ohio.

Today, the VNA has 2,100 employees and an annual budget of $180 million. Its services range from skilled home health care to end-of-life hospice care. And it has partnerships with RWJBarnabas Health, whose hospitals include Monmouth Medical Center in Long Branch, its southern campus in Lakewood, and Community Medical Center in Toms River – as well as CentraState Medical Center in Freehold Township.

Landers talked to the Asbury Park Press recently about where the organization – and home health care – are headed.

Where does the Visiting Nurse Association fit in the changing health care landscape?

If you think about what’s going on with health care broadly, this has been a really neat thing in to be involved with. It’s a 100-year-old organization, but it’s never been more relevant than today. It’s kind of waxed and waned, but you’ve got this aging population that wants to, as much as possible, remain healthy at home, avoid unnecessary hospitalization if they can. So home care and hospice care are incredibly relevant for the older population. We have significant challenges of financing. Medicare and Medicaid are the major payers for health care for older Americans. Home care can be a solution because it can be less costly if done well.

How do we get a handle on end-of-life care?

I think for people who are both concerned about the quality of care and the cost of care is that there are many opportunities to better match the services offered to people with what they want. It's just the culture of medicine and our training in medicine has not optimized the use of palliative care and home care to the extent possible. In New Jersey, we’ve got a lot of low-hanging fruit.

Like what?

I think it’s basically having more conversations with the physicians and their patients about their goals. I think it doesn’t seem to happen as often as it needs to be because if you look at the statistics … there appears to be opportunities for more use of home care and hospice care, and I suspect that’s just because the conversations are not happening to the extent that they are in some of the other markets.

It seems like a tough conversation to have.

In some instances these are difficult conversations. In other instances, it's actually not that different than anything else we do in medicine, which is try to listen to people and understand what’s going on and match what we’re doing to what their own needs are. Not every circumstance is overly dramatic. It's more about planning ahead and thinking through what people might want in terms of the types of care. For frail elders, I’ll speak as a geriatrician, it is not always the case that more aggressive medical care means longer life. So there’s a false dichotomy in a lot of these discussions, which needs to be rejected, that it’s either about more care and more life or less care and less life. It's just not the case.

Do we need to change the business model to support that?

I think that’s happening. I think the business model is changing and certainly you look at what’s going on both nationally and locally, there’s been more and more of an emphasis on what we would call value-based care, on incentivizing the providers of health care to be cognizant of certain outcomes, including the cost of care. And that’s happening. What pace and the specifics I think are evolving, but it’s happening. ... As people look at value based care, what they’re going to do is say, "Where is there a lot of spending and a lot of suffering?" Because if the goal of these initiatives is to improve quality and improve the cost trajectory, they're going to look for scenarios where there is a lot of spending and questions about quality.

What is at stake?

We’ve got to make sure we do health care in an efficient way that doesn’t bankrupt our federal and state governments, so there’s a lot of need for creativity. … I’m concerned about the aging issues, about are we really going to be ready for tripling the number of people age 85 and older in this country? And for going from 50 million or so people eligible for Medicare to over 80 million? Are we going to have the right systems in place, the right providers? Are families going to be prepared for the long-term care decisions and choices they need to make? That, I’m worried about. But that provides a lot of passion and enthusiasm to get up every day because those are big issues we face.



As house calls make a comeback, doctors need to learn new skills

Published by STAT
By KATHERINE T. O'BRIEN and JUNE M. MCKOY
December 9, 2016

When Donald Trump takes the oath of office in January, he will be the oldest president Americans have ever elected. That also makes him some doctor’s geriatric patient, joining 46 million Americans in the age 65 and older group. By 2060, that number will double, reaching a staggering 98 million people. Taking care of older patients can be a challenge. Some have multiple health conditions, and many are homebound, making a trip to see their primary care doctor almost impossible.

House calls will almost certainly become a way to improve the care of our geriatric patients and will become an essential piece of the provision of care in the future. In fact, legislation being discussed in Congress would help make home-based medical care a financial reality.

Making house calls sounds simple. But we worry that physicians-in-training aren’t learning the skills they need to care for their patients at home.

The American Board of Internal Medicine and the Council of Academic Family Medicine, two bodies that help certify doctors in fields likely to provide home care, have lists of procedures that they deem essential to the independent practice of their respective fields. The list for internal medicine graduates is surprisingly short, with knowledge of how to draw blood, insert a needle into a vein, and do a pap smear on a woman as the only essential skills required. The list for family medicine graduates is slightly longer, including some basic women’s health and obstetric skills. Glaringly missing are the procedural skills needed to provide quality, and arguably, crucial care to patients at home. These include management of urinary tubes, feeding tubes, breathing tubes, chest tubes, infected wounds and sores, and more.

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Today’s — and undoubtedly tomorrow’s — medical technology makes it possible for patients with multiple medical conditions, such as diabetes and heart failure, to thrive in their own homes and be treated there. That means the scope of knowledge and technical skills required for a home care doctor has become increasingly complex.

When doing a house call, a doctor does not have the luxury of sending his or her patient to a specialist for immediate attention. The patient may be on a breathing machine or ventilator with a tracheostomy tube that needs to be changed. He or she may have a feeding tube that malfunctions, or arthritis so bad that an injection of steroid into a joint is needed.

In the past, such procedures were familiar to most young physicians in all fields of medicine largely because there had been a generalist, competency-based approach to medical education. However, as the scope of medicine has widened, those in today’s training programs often forego mastery of these basic procedural skills in favor of procedure-oriented services, such as interventional radiology. Young doctors must then rely on simulation centers or shadow specialty doctors to gain the out-of-hospital skills they weren’t able to master during their training.

If the house call is to truly make a comeback — and it should for both patient convenience and cost — training programs and the organizations that oversee them must revolutionize their curricula to help young physicians develop the skills necessary for home care medicine.

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Training programs can easily do this. Many large academic medical centers already have simulation centers where residents could spend time working with experts to hone essential skills like removing fluid from a joint or draining it from the abdomen (abdominal paracentesis). Many physicians-in-training already spend time on rotations in which they learn to perform procedures, though these have traditionally been limited to ones needed for in-hospital practice. Simulation centers would give residents the ability to really practice with experts, without major disruptions to the current curriculum.

It might even be necessary for interns and residents to do three to six months of extra training to really master the complexities of taking care of patients at home.

Home visits can be an effective way of providing medical care to the burgeoning senior population in the US. But making home care a reality will require training programs to provide future doctors with the skills to provide proper home care. Once that happens, house calls may no longer be a part of your grandmother’s past but a viable solution for your new president’s health care, and yours.

Telemedicine bill could get House vote this week

Published by Modern Healthcare
By Joseph Conn
December 9, 2016

The House this week is expected to vote on a bill that promotes telemedicine and was unanimously passed by the Senate last week.

The Expanding Capacity for Health Outcomes Act, or ECHO Act, co-sponsored by Sens. Orrin Hatch (R-UT) and Brian Schatz (D-HI), asks the HHS to study whether telemedicine could promote collaborative clinical learning and disseminate best practices among healthcare professionals, primarily those in medically underserved areas.

The Act had broad support in the provider community.

The HHS would study “technology-enabled collaborative learning and capacity building models” used in clinical settings that address mental health and substance abuse, chronic diseases, prenatal and pediatric care, pain management and palliative care.

The study must also address technology's potential impact on healthcare workforce issues, such as specialty care shortages, primary care workforce recruitment and retention and “support for livelong learning.”

In addition, the HHS also should look at the effects of technology on public health as well as delivery of health services for rural and medically underserved populations and Native Americans.

The report should list any HHS-funded care models that have been using the technology in the past five years. And it should make recommendations on integrating into broader care systems those models as appropriate. It also charges HHS with making recommendations on which technology-enhanced care models might be used in continuing medical education and lifelong learning in conjunction with academic medical centers and other provider organizations.