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News Roundup: May 13, 2016

Patients' experiences, assessment of health provides greater clinical insight

Published by Fierce Healthcare
By Paige Minemyer
May 13, 2016

As patient-centered medical care initiatives continue to take hold in the industry, better documenting patient experiences can offer needed insight for providers, a study published in Health Affairs has found.

Patient-reported information was typically used mostly in research settings and not in day-to-day clinical care, according to the study abstract. That is beginning to change, the study team discovered.

"This provides insights into patients' experiences of symptoms, quality of life and functioning; values and preferences; and goals for healthcare," the team wrote. "Previously embraced in the research realm, patient-reported outcomes have started to play a role in successful shared decision-making, which can enhance the safe and effective delivery of healthcare."

Danielle Lavallee, a research assistant professor at the department of surgery at the University of Washington and the lead author of the study, told Kaiser Health News that finding the best way to document these patient responses is the challenge. "The challenge is that we don't capture [the response] in a way that we can use [like] we do for blood pressure," she said.

Patricia Franklin, a professor of orthopedics and physical rehabilitation at the University of Masschusetts Memorial Medical Center and another of the study's authors, told KHN that a pilot program at the UMass facility is an example of incorporating the patient experience into care. At the hospital's arthritis and joint replacement center, doctors track pain and joint function over time for potential replacement candidates, and use these reports to decide if surgery is the right method for treatment."

In addition to determining the best way to use patient feedback, transitioning into a model of patient-centered care will also require the time to educate patients on the potential benefits, FierceHealthcare previously reported.

The missing patient voice in value-based care

Published by Modern Healthcare
By Shannon Muchmore
May 13, 2016

While healthcare providers are getting ready to implement more value-based payment programs, such as the new Medicare reimbursement system for physicians, regulators are trying to improve and speed up feedback from providers and patients.

Dr. Kate Goodrich, director of the CMS Center for Clinical Standards and Quality, said during a panel discussion at the annual Health Datapalooza conference in Washington D.C. Tuesday that Medicare's new Quality Payment Program was developed by deploying CMS employees into the field, and having them observe providers as they collected and reported data used to determine quality measures.

The CMS also looked at how quality measures affect rural and safety net providers, as well as teaching hospitals, she said.

In a separate address at the conference Tuesday, acting CMS Acting Administrator Andy Slavitt said the way technology is used in healthcare now is too often frustrating for physicians, and presents patients with a fragmented system when they need help and guidance the most.

There is an urgent need for healthcare technology and data gathering to be designed around patient and provider needs, not regulations, Slavitt said.

Those in healthcare who want to keep their data in a silo or not use standards that allow for collaboration should “pick a new business model or pick a new business,” Slavitt said.

Patient involvement should be an important facet of value-based payment models and has so far been lacking, Goodrich said, adding that patients' input needs to be more than just the viewpoints of patient advocacy groups.

“There is a voice that is not really being brought to the table and that is the average American with an illness,” said Dr. Paul Bleicher, CEO of Optum Labs.

Dr. Helen Burstin, chief scientific officer with the National Quality Forum, said data used for determining quality need to better capture care coordination and communication to patients. What may look like high-quality care based on a few data points could still leave a patient confused and unsatisfied, she said.

“The limitation there is that it's really hard to do with the data we have available now,” Burstin said.

There are some barriers to making the most of health data, she said. The data must be useful, shareable and obtained from a large enough sample size. Limited time and financing makes that data gathering and analysis difficult for many providers.

Patient information like genetics, demographics, socio-economic factors, environment and health behaviors are important to understand how well treatments work. But it is also important to understand the patients' perceptions of the value of care and their descriptions of symptoms, Burstin said.

Home care nurses provide many services

Published by The Inner Mountain
By Brooke Binns
May 13, 2016

ELKINS - Nurses who work in a home care atmosphere provide many services to their patients on a personal level.

Currently serving as the RN supervisor at Mountaineer Home Care Services LLC, Nancy Miller has worked as a registered nurse for 46 years in different capacities.

Miller said during her years of nursing, she has seen the field evolve.

"I've seen it come and go and come back again," Miller said. "Nursing has evolved, and I mean, the technical aspect of it is just unbelievable."

In a home care setting, registered nurses may provide an array of services by working directly with patients. Nurses in the home care setting may assist with advising patients and their families, follow up after hospital or rehabilitation visitations, teach patients and their families how to manage their illnesses or injuries, monitor patient health, assist with bathing, dressing and grooming, and so on.

Miller said the time spent with patients typically depends on the services each patient requires.

"We wear a lot of different hats around here," Miller said. "Sometimes someone may call and say, 'can you come check this,' and we go to the homes and do the best that we can to advise them."

At Mountaineer Home Care Services LLC, an RN works to develop a Plan of Care that tells the homemaker specifically how to care for each patient, assesses and updates the plan of care at least every six months, ensure that homemakers have the proper training necessary, and also completes various other tasks.

Miller noted, through her role as a supervisor, she works to ensure homemakers with Mountaineer Home Care Services LLC are following their plan of care and doing their job appropriately.

"Basically, I'm what they call an RN supervisor, and what we do is we provide a homemaker service through the Medicare waver program through the state to provide helpers in the home for the elderly and disabled," Miller said.

"I'm at a point in my career where retirement is just over the next fence, but in a position like this, I'm still active, I'm still out and about, and I still feel like I'm helping," Miller said.

Miller believes working as an RN in the home care atmosphere, she and other nurses and homemakers are able to create and maintain a personal level with their patients.

"Being able to provide information to people and that type of thing makes me feel like I'm contributing, and that's what we look to do," Miller said.

Mountaineer Home Care Services LLC, owned by Rob and Katina Elbon, works to provide assistance to people in their home as an alternative to a nursing home.

"It's a good program in the sense that this is basically their last step before nursing home placement," Miller said.

"What we're doing is trying to keep them in their homes for as long as possible."

Local home health nurse highlights demand for more

Published by Lubbock Avalanche-Journal
May 13, 2016

Jace Clark has been a nurse for 13 years, but seven years ago, she decided to shift her career focus to home health and hospice nursing.

The schedule was more flexible and allowed Clark to spend more time with her growing family, she said.

But her job, she said, became a bit more challenging.

Working as a home nurse is different than working for a hospital, she said.

Jenny Stroud, administrator of Direct Health Care Inc., said nurses in hospitals and home health nurses work in two different worlds.

“Home health is just a very demanding field,” Stroud said. “You do your shift at the hospital and then go home. You do your shift in home health, but you take it all home with you. It’s a very different world.”

There are numerous potential distractions in an environment the health care provider might not be able to control, Stroud said.

And the required paperwork has gotten more extensive, she said.

“It all starts with government rules and regulations,” she said. “I know they’re trying to prevent fraud and abuse, but I feel like it does trickle down into patient care because nurses go into a patient’s home, they can’t just worry about going in and taking care of the patient. They have to worry about ‘am I doing the paperwork right so that my company is going to get paid to pay me?’ It’s not just about going in and taking care of the patient.”

Clark said she’s worked in both a hospital and now a home health and hospice setting.

“In home health, you actually have the time to spend with your patients to advocate for them and to educate them,” she said.

The atmosphere in a home health setting is different.

“You have to think outside the box sometimes,” said Amanda Fernandez, nurse manager at DHC.

The job of a home health nurse provider is becoming increasingly more important with changes in health care, Fernandez said. There’s more pressure from hospitals to be held accountable for good quality care.

“Patients are going home sicker,” she said. It’s difficult to pinpoint why, she said.

But with hospitals now being held accountable for readmitted patients, the home health market has become more competitive, she said.

It can get overwhelming, Stroud said, so sometimes nurses might seem interested but back out.

“It’s difficult for home nurses that went to nursing school, everything is done a certain way and then you get to the patient’s home and you’re on their turf. It’s challenging. Even nurses who come into home health sometimes leave because they don’t handle those home dynamics very well.”

Clark was one of the relatively few nurses who have chosen to stay in the home health field.

She never pictured herself as a nurse, Clark said. The sight of blood used to make her uncomfortable.

“One day, my momma got sick,” she said. “I had to help take care of her.”

Something changed for Clark.

“I felt like it was, God’s intervened,” Clark said. “He was saying, ‘Hey, you can do this.’ ”

Through caring for her mother, Clark began to love the idea of nursing, so she applied for nursing school.

As her family grew, so did her passion for her chosen profession, despite the changes in the field.

Stroud said demands for RNs like Clark has always existed but it’s become more prominent within the past several years.

And as health care continues changing, Stroud said she expects the demand, especially for home health, to keep rising.

“There is a shortage of nurses in Lubbock and then with sicker patients, we’re needing more,” she said.

Home Health Prior-Authorization: Unfortunately, this analogy, is no joke.

Published by Morning Consult
May 13, 2016

You have probably heard the joke about the guy who walks into a bar and asks the bartender for a drink.

Well, here is one that you probably have not heard: A mother walks into a grocery story to buy food for her family for the week. She selects everything she will need to feed her husband and children for seven days. She pays the cashier by credit card and signs the charge slip. What happens next? She should go home to unload her grocery bags into her refrigerator and pantry and then prepare dinner for her family.

Instead, the mother is sent home. Without any food for her family.

Before she is permitted to provide the food she selected to feed her children, she is required to complete a series for documents for the cashier, explaining calorie-count, nutritional-value-content detail, why she needs to purchase the food and why her children need to eat. Then, the grocery store manager decides if she really needs the food to feed her family. The mother is told she can expect to hear back from the store manager in 10 days as to whether or not she has been authorized to bring the food home and feed her family…tonight, tomorrow and for the rest of the week.

No, you didn’t read that wrong. There is no punchline here. And unfortunately, this is not a joke.

This process is exactly what the Centers for Medicare & Medicaid Services (CMS) is essentially proposing through a process called “Prior Authorization” for Medicare home health services. To translate the analogy: The mother is the “doctor.” The food is the prescribed “health care in the home.” The signed credit card charge slip is the “doctor’s signed plan of care for home health services.” Her family is the “patient.” And, the store manager is the “government bureaucrat” making decisions about the need for health care.

CMS’ surprising proposed rule for Prior Authorization of Medicare home health care services will mean that patients will have to wait for the health care prescribed by their doctor, while government Medicare officials review the doctor’s recommended course of health care to determine if it is necessary or not. Again, this is not a joke.

While the role of a middleman is suggested to be a fraud deterrent, it places a government bureaucrat between the doctor and their patient. And to continue the analogy, the Prior Authorization proposal does not stop fraud at the grocery store. The shop-lifter is still stealing food, while the mother is waiting to learn if she can feed her family.

Prior Authorization only stands to have a negative and disruptive impact on necessary health care and the patient’s clinical outcomes. Medicare home health beneficiaries are already documented as being older, poorer, sicker, more likely to be female, a minority and disabled than all other Medicare beneficiaries combined. Adding a bureaucratic layer to the process will impede the delivery of timely, necessary health care to a very vulnerable and frail patient population. These delays in the provision of health care put our seniors at risk for medical crises during the “review” period that could result in the patient returning, unnecessarily to the hospital, because the health care they needed, that was ordered by their doctor, was not provided.

Keep in mind, other health care sectors have experience with Prior Authorization and have documented wait-time delays. Durable Medical Equipment (DME) providers have noted delays of up to 10 days to receive authorization to deliver medical equipment, but key differentiators exist. For example, in a DME scenario, a patient is in a wheel chair, but may be better served by a power wheel chair. But the patient still has a wheel chair while they wait.

The 89-year-old gentleman, living alone after his surgery waiting for a nurse to change his wound care dressing, reconcile his medications to ensure there is not a harmful medication interaction between his old pills and new pills, and teach him about what to do to accelerate his recovery, does not have 10 days to wait for the health care his doctor has already ordered. Ten days provides a long time for medical emergencies, missed medication, infection and various other adverse events to occur, while a frail patient waits for the government bureaucrat to review his or her need for home health care.

Important to note, one of the primary goals of home health care is monitoring the patient who is sent home from the hospital, to prevent medical emergencies that needlessly send the patient back to the emergency room or the hospital, which then unnecessarily increases costs to the Medicare program. If unable to provide these home-based health care services for up to 10 days after a hospital discharge or a doctor’s office visit, we are jeopardizing patients’ health during the very window when they are most at risk. Medicare’s Prior Authorization policy is setting the patient up for an unnecessary admission or readmission to the hospital, inherent in what is a flawed design that will do absolutely nothing to decrease fraud.

The bottom line, not the punchline, is that if finalized and implemented, this Prior Authorization proposal needlessly and recklessly will prolong the wait time for delivery of the patient’s health care, jeopardize the health of frail seniors, drive up unnecessary hospital readmission rates and increase both Medicare spending and taxpayer costs.

Instead, Medicare should continue their efforts to promote policies that reward and encourage effective health care coordination to the benefit of home health patients as well as the Medicare program, while simultaneously reducing costs, by keeping patients who do not need hospital-based care, out of the hospital.

Prior Authorization is a bad joke, which does not need repeating.

Home care experiment could mean fewer hospital stays

Published by Marketplace Today
By Dan Gorenstein
May 13, 2016

There’s a little $10 million health care experiment going on in New York that could mean fewer of us will end up in the hospital.

In the past year and a half, Mt. Sinai Hospital has started treating a number of patients at home, and early signs suggest this improves care, lowers spending and leaves patients more content. The stakes are high.

If this project goes well, hospital at home could soon be popping up around the country.

Mt. Sinai has been working with about 200 patients — often fragile people, like 82-year-old Alicia Perez, who suffers from high blood pressure, diabetes, hypertension and vision problems.

A few weeks back, Perez went to the hospital’s emergency room to get treatment for a urinary tract infection. Typically, someone like Perez goes from the ER to the hospital, often as a precaution. But it’s a precaution that costs $8,500 for admission and treatment at Mt. Sinai.

Instead, Perez opted to get treated by Mt. Sinai staff in her Upper West Side high-rise apartment for about $1,500 less.

“I have lots of people from this team come to my home. They even gave me IV fluids, and they’ve been checking my blood pressure, my pulse,” Perez said.

For 20 years, a few hospitals and Veterans Affairs have offered a hospital-at-home program. It’s designed for people who have a solid diagnosis, like pneumonia, dehydration or congestive heart failure. Studies have shown patients are 19 percent more likely to be alive six months after receiving at-home treatment.

Mt. Sinai’s Dr. Al Siu said the promise here is obvious.

“We’ve known we can do this. We can do it safely,” he said. “That patients have fewer complications, that patients like it and are satisfied. But we haven’t been able to disseminate this because there’s no way of paying for this.”

Halfway through the three-year project, Mt. Sinai’s data suggest the hospital is saving money and cutting readmissions.

Medicare is watching closely, and sustained stats like that will certainly get its attention.

But Karrie Decker, who runs a hospital at-home program for Presbyterian Healthcare Services in New Mexico, said replicating this work is tricky.

“Somebody is putting a shingle up that they do hospital at home, and yet when things start to go sideways, or a patients starts to have a problem, they don’t end up being available to that patient,” she said.

In other words, hospital-at-home programs raise safety and fraud prevention challenges.

When it works, Alicia Perez said it’s the kind of care we all want.

“Being at home, you can save way more money. You are going to be more comfortable, and you are going to be well taken care of,” she said. “The hospital may be magnificent, but the home is way better.”

Confined to Nursing Homes, but Longing (and Ready) for Home

Published by The New York Times
May 13, 2016

Marvin L. Dawkins was a 53-year-old AT&T manager when a blocked blood vessel left him paralyzed. It took 11 years, one lawsuit, repeated tangles over Medicaid rules — and a chance meeting on a church van — before he could extract himself from a nursing home outside Baltimore.

Now he lives in an apartment with the assistance of an aide, gets out for a job that he says gives him purpose, socializes with new friends and old ones, and revels in his freedom. “I determine what happens to me,” he said. “I was there at the nursing home basically just laying in bed and watching TV. I didn’t think it was much of an existence.”

Across the nation, many other Americans who could live elsewhere with help are unwillingly confined to nursing homes or long-term care facilities. Nearly 20 years after the Supreme Court ruled that disabled people requiring public support were entitled to live in their community, rather than in institutions unless medically necessary, the federal government and states are still far from achieving that goal. Because of budget cuts, inflexible rules, a patchwork of programs and a widespread failure to bolster alternative care, others like Mr. Dawkins describe feeling stuck in deeply unsatisfying, sometimes miserable, settings.

“Those people are not in view,” said Eve Hill, the deputy assistant attorney general in the civil rights division at the Department of Justice. “We forget about them because they are not in our everyday lives. And that just can’t be the answer. We can’t ignore this.”

Since 2009, the department has conducted investigations, brought lawsuits and settled with eight states over compliance with the court decision, which Ms. Hill said changed the assumptions of what people can do. “That requires us to unbuild something,” she added, “and to build it differently.”

Some states, including Minnesota, Oregon and Washington, have made real progress, taking steps like shifting more Medicaid dollars to home support, training caregivers to administer medications and paying family members who provide assistance. But in many others, government inaction and structural obstacles like a shortage of home health care aides has often made nursing homes the only option. South Dakota was singled out last week by federal officials who threatened to sue if the state did not fix its problems.

More than 1.4 million Americans live in nursing homes, but it is hard to know how many of them could move back home. Federal data suggests that about 155,000 nursing home residents have a low need for round-the-clock assistance. And about 217,000 people are of working age, another group that experts say could function well at home. But long-term care experts said that some residents who are sicker might also be good candidates to leave.

Sharon Overall of Fenton, Mo., 65, who entered a nursing home for what was to be a month of rehabilitation after injuring her spine, ended up spending 18 months there, losing her house, car and life insurance policies with nearly all her income going to the nursing home.

When Latrell Head, a 32-year-old single father in Atlanta, entered a nursing home after a leg amputation in October, workers there for a while would not allow him to leave to see his 8-year-old son or search for an apartment. Such facilities typically require relatives to sign residents out. “A prisoner has more rights than I have,” he said he felt.

Mariussi Ogando-Rodriguez, 29, said she feels lonely among the hundreds of mostly older residents at the Manhattan nursing center where she has lived for three years. A former accounting student and cashier at Chipotle, she needs dialysis three times a week, but could care for herself. Gesturing toward a group of people watching television last week in a recreation room that smelled like urine, she said, “Sometimes I feel desperate.”

A range of factors conspire to prevent residents from leaving. In many states, Medicaid programs restrict home health services, limiting the hours of care, for example. Waiting lists are common. Mentally ill people, for whom nursing homes are shelters of last resort, are particularly difficult to place. And everywhere, it seems, affordable, accessible housing for disabled people is in short supply.

Living at home is not the right choice for everyone, of course, even with assistance. Some people are too ill. Managing aides can be daunting, and family members might not be able — or willing — to care for relatives or share their homes, particularly when cognitive skills are impaired. For those without family, living alone can be isolating.

Still, about half of Medicaid spending on long-term care now goes toward services in the home or community, compared with less than 20 percent two decades ago, though that varies widely by state. Health care officials predict demand for in-home services will only grow as the population ages. Emily Johnson Piper, commissioner of the Minnesota Department of Human Services, said, “The baby boomers in Minnesota and across the country have the expectation that they will be offered and afforded availability of services for them to live out their retirement years in their communities.”

Many states have concluded that caring for people at home is more cost-effective. Washington State, for example, has found that its costs for one nursing home resident would pay for home care for seven people. Alabama calculated that it cost the state about $25,000 a year less, per person, to offer care at home.

The few studies that have compared the outcomes of people in nursing homes with those cared for at home have reached mixed conclusions. In one recent study, researchers surveyed thousands of former nursing home residents. They reported significant improvements in satisfaction and fewer unmet needs for help with personal care. However, more than three-quarters of them said they had visited an emergency room or been admitted to a hospital or nursing home during the first year of living in the community. Some advocates have also raised concerns about abuse in unregulated home care.

Representatives of the nursing home industry acknowledged that many residents do not need to remain in their facilities. But they said better alternatives were required.“If there is no one with the state to help coordinate that transition process, then there is nowhere for that person to go,” said Mike Cheek, a senior vice president at the American Health Care Association, which represents for-profit nursing homes.

South Dakota has one of the worst records in the country. Nearly 17 percent of its nursing home population is classified as having a low need for the services provided in an institution, among the highest percentages of any state, according to an AARP report.

Shane Bear Heels, 48, has spent more than a quarter of his life in a small nursing home in White River, S.D., overlooking a horse pasture and open field. Most residents there are members of the Rosebud Sioux Tribe, whose reservation is nearby.

A quadriplegic since crashing his car in 2001, Mr. Bear Heels said he receives good medical care and takes pride in helping his fellow residents. But he also yearns for more independence. He said he would like to spend more time outside, but the unpaved roads and dearth of sidewalks in the area made that difficult.

“I definitely would like to be in a different setting,” said Mr. Bear Heels, who worked as an electrician before his injury. “Who wants to be like elders?”

He needs help repositioning his body while sleeping and getting into his motorized wheelchair. But once situated there, he is mostly self-sufficient until bedtime. He uses his mouth to maneuver the chair, flip through television channels and send emails. But for now, he appears stuck.

Like some other nursing home residents, Mr. Bear Heels said he has no one who could serve as his advocate and does not know where to turn for help to live elsewhere. (Federal rules now require nursing homes to ask residents at least quarterly whether they want to talk with someone about living in the community and, if so, connect them with a local agency.) He does not own a house, and even if he did, finding reliable home health care workers would be difficult. Many aides, who are relatively low paid, cannot afford cars to reach clients in rural areas like his.

In its report, the Justice Department acknowledged that South Dakota’s geography and limited work force posed challenges, but it also said that the state had not made better use of existing programs, including one that places disabled people in small, family-style group homes. The state has moved only 10 people home from nursing facilities since 2013 as part of a federal grant to do so, according to the federal report. Kim Malsam-Rysdon, South Dakota’s secretary of health, said state officials agreed that community-based care was preferable in many cases, but that “it’s just a balancing act of the ideal and reality.”

Minnesota faces some of the same challenges, but it has managed to move more than 3,000 people from nursing homes to the community since 2010 through one program. Others provide alternatives so people do not have to enter nursing homes.

Accomplishing that has not been easy, state officials said: Each person needing support requires a network of people and organizations to address housing needs, provide assistive technologies and find grants and programs to cover these costs.

Minnesota and other states, such as California, allow public funds to be used to pay family members for the care they provide. In San Francisco, Alice Wong’s parents turn her at night to prevent bedsores and work with aides hired by Ms. Wong to provide much of the near-total care she needs because of a progressive nerve disorder, spinal muscular atrophy. “It’s the best of both worlds,” said Ms. Wong, 42, the founder of the Disability Visibility Project. “All disabled people should have that choice across the country.”

Mr. Dawkins, the former nursing home resident from Baltimore County who was paralyzed, said the vulnerability he sometimes feels at night when he has no aides to help him is outweighed by the control he has over his daily activities. At the nursing home, he often had to wait up to an hour for a response after pushing his call button, he recalled in an interview, and aides would wake him at 3 a.m., when it suited their schedule, to dress him for church services hours later.

It was on a ride to church that he met an advocate who helps nursing home patients apply for support services to live independently. He sued the State of Maryland, which had denied him Medicaid funding for at-home care, but he won the assistance two years ago. Now he has a job going door to door at nursing homes, including the one he left, identifying residents interested in following the same path.

“I’ve had people when I told them about the program cry, break down and cry,” he said.