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News Roundup: August 12, 2016

Majority of U.S. Seniors Against Pre-Claim Review

Published by Home Health Care News
By Mary Kate Nelson
August 12, 2016

The start of the Centers for Medicare & Medicaid Services’ (CMS) pre-claim review demonstration has drawn harsh criticism from many stakeholders in the home health care industry. Now, they may be able to say that seniors themselves don’t like the initiative, either.

Bring Home the Vote, which sponsored the poll, is a national initiative that home health associations and providers use to encourage seniors to register to vote and vote in elections. Bring Home the Vote is supported by the Partnership for Quality Home Healthcare, a coalition of home health providers that recently expressed concern about CMS moving forward with the pre-claim demonstration.

While the results of the recent poll of seniors largely back up the position of the home health associations supporting Bring Home the Vote, the poll itself was undertaken on behalf of Bring Home the Vote by an independent entity—specifically, the polling and market research division of Morning Consult. The organization polled 1,931 registered voters over age 65 nationwide between July 29 and July 30, 2016.

As part of the Medicare pre-claim review demonstration program, home health providers in certain states are required to submit their claims for review to Medicare Administrative Contractors (MACs), who decide if they are correct or send them back to be submitted again. The demonstration is meant to give CMS more control over reimbursements in an industry that has dealt with its fair share of fraudulent billing activity.

Providers, however, have argued that the pre-claim review is not the best way to resolve issues of improper documentation—and seniors across the country tend to agree.

In fact, 83% of the seniors polled by Morning Consult believe that a doctor should be able to prescribe medications and services they choose for their patients without any government interference.

Additionally, 80% of seniors believe that requiring a government contractor to approve claims for Medicare home health care services will likely lead to delayed care for patients who require prompt care, the findings show.

Still, though seniors may not like the idea, almost half—45%—of the respondents believe that government contractor approval of home health services will in fact lead to a reduction in fraudulent home health claims.


Published by NJ Spotlight
August 12, 2016

As healthcare continues to evolve, homecare providers are playing an expanding role protecting the health of senior citizens, disabled individuals, patients with chronic diseases, and those discharged from the hospital with a need for follow-up care.

And, with funding becoming increasingly scarce, there is a growing focus on how to deliver effective, efficient services that enable patients to stay healthy at home.

Among those searching for answers is Olga F. Jarrín, an assistant professor at Rutgers University School of Nursing. An expert on nursing-care models with hospice and homecare experience, Jarrín is using a $1 million grant from the Agency for Healthcare Research and Quality to launch a study on how organizational strategies can help or hinder a homecare agency’s ability to deliver quality care to patients from different ethnic and cultural backgrounds.

The study will build on work Jarrín did with the University of Pennsylvania School of Nursing — considered the largest survey of its kind of nursing care and patient outcomes — that involved caregivers at nearly 1,000 home healthcare agencies in California, Florida, Pennsylvania, and New Jersey. Those reports will be assessed along with data on crime, segregation, socio-economic status, and access to care to determine what models are most likely to provide effective care for diverse groups of patients.

With help from New Jersey’s Visiting Nurse Association Health Group, Penn nursing, Rutgers Institute for Health, Health Care Policy and Aging Research, and 10 undergraduates from various Rutgers programs, Jarrín will start to analyze the findings this fall. The goal is to see how adopting best practices, encouraging continuing education, using new technology, and improving office management – impact patient health.

“I was interested in seeing how vulnerable populations specifically are receiving care, and their level of care, and the improvement in outcomes,” Jarrín said. “People need a lot of help navigating our healthcare system,” she added. “It is really easy for people to fall through the cracks.”

The 2010 Affordable Care Act vastly expanded health insurance coverage for low-income Americans and reformed the way medical care is provided, shifting from a fee-for-service model to one that rewards doctors, nurses, and other providers for keeping patients healthy. One element of this approach is to penalize hospitals when patients are readmitted with infections or other avoidable complications within a month of their discharge.

Federal officials have withheld up to 3 percent of a hospital’s Medicare funds if they were readmitted within a month of being treated for a half-dozen conditions including heart attack or pulmonary blockage, pneumonia and knee or hip replacement surgery. Nearly three quarters of hospitals nationwide faced penalties the first year.

The new requirement has triggered numerous changes for homecare agencies, which dispatch personnel to treat recently discharged patients, a growing population of homebound seniors and disabled individuals who in the past may have lived in a long-term residential facility. While they vary in size and capacity, these agencies employ a mix of registered nurses, licensed home health aides and other caregivers and companions.

The requirement prompted Lenny Verkhoglaz, owner and CEO of Hackensack-based Executive Care, to develop training programs to help staff better care for patients who are dealing with the six conditions flagged by the federal Centers for Medicare and Medicaid Services for readmission penalties. Founded 12 years ago by Verkhoglaz and his wife, the company now employs 300 people at its main office and has satellite sites throughout New Jersey, as well as franchise operations in other states.

Jarrín, who worked as a visiting nurse in poor communities in Connecticut, said this new emphasis on post-acute care is important. “But homecare is really much larger than that,” she added.
For low-income clients, those from a different cultural background, or those without strong English language skills, it can be challenging to stay healthy or manage a chronic disease, Jarrín said.

In her experience, clients benefit when homecare agencies don’t just focus on clinical services, but aim to connect individuals with a full safety-net of resources to help keep them healthy and safe. And often this requires a caregiver to have the resources and flexibility to visit patients regularly in person and spend time getting to know them, their companions, and the community where they live.

Jarrín recalled a visit to a diabetic client who kept having high blood-sugar readings, despite taking medication. While chatting with the client at her kitchen table, Jarrín learned the woman’s stove had been disconnected and – instead of cooking meals in which she could control salt and sugar – the family was feasting on donated food from friends and neighbors and take-out. In situations like this, a caregiver might need to talk to the landlord or call the utility company in order to help their patient stay healthy.

“It takes time and interest to develop the relationship with a patient,” she said. “A lot of these families just work around the problem. And their health would suffer.”

In her analysis, Jarrín will examine how clients are helped by “front-loading” home visits, or ensuring that they receive extra help and attention during the first few weeks following a hospital discharge or new diagnosis. She will also explore the impact of continuing education programs and mentoring from advance practice nurses can help caregivers do their job.

In addition, Jarrín will look at the impact of electronic recordkeeping and other technology that allows caregivers more freedom to work from the road. The study will also review how caregivers can benefit from interacting with colleagues in an office setting and explore how management’s attitude and the weight of their workload can effect how nurses provide care.

Training for In-Home Caregivers Cuts Hospitalization Rates

Published by Home Health Care News
By Kourtney Liepelt
August 12, 2016

When in-home caregivers participate in intensive training, their patients are less likely to go to the emergency room or be hospitalized, according to a recent case study conducted in California.

In fact, the rate of repeated emergency room visits among patients cared for by trained workers dropped by 24% in the first year after undergoing an intensive training program, and by 41% in the second year, according to an analysis by researchers at the University of California-San Francisco. As part of a pilot program carried out in Los Angeles, San Bernardino and Contra Costa counties, almost 6,000 aides were trained in CPR and first-aid, along with infection control, medications, chronic diseases and other areas. All were workers of the In-Home Supportive Services (IHSS) program, who are paid by the state to care for low-income seniors and people with disabilities.

Researchers then based their analysis on the results from Contra Costa County, which they said produced the most complete and reliable data. They compared insurance claims on 136 at-risk elderly and disabled residents whose caregivers had been trained to the claims of more than 2,000 similar residents whose caregivers hadn’t been trained.

Despite the small sample size, UCSF professor emeritus Bob Newcomer found the analysis encouraging.

“Training shows a lot of promise,” he said.

Currently, there are no federal training requirements for in-home caregivers, according to California Healthline. Even so, training programs have been developed and tested across the country, according to the Paraprofessional Healthcare Institute, an advocacy group that provides training. Massachusetts, North Carolina and Michigan have attempted to implement different types of instruction, for example.

Workers who participated in California’s pilot program and analysis were trained through the California Long-Term Care Education Center as part of a three-year, $11.8-million grant from the Centers for Medicare & Medicaid Services. Those who participated across the three counties attended about 60 hours of classes and completed 13 hours of related work at home, and the people they cared for also took part in some classes.

Beyond the effect on patients, training had a profound impact on caregivers, as they said they felt prepared to handle their jobs and communicate with their patients and doctors, according to the analysis. For example, Andrew O’Bryan cares for his 67-year-old mom in Contra Costa County, and he said she has diabetes, congestive heart failure, arthritis and high blood pressure. The training gave him the skills to conduct CPR in case of an emergency, and instilled a sense of when his mother needs to go to the hospital.

“Now I am more equipped to spot things” before they get worse, he said.

Most Sick, Aging Americans Live Far From In-Home Care

Published by
By Karen Pallarito
August 12, 2016

TUESDAY, Aug. 9, 2016 (HealthDay News) -- Most older Americans struggling with chronic illnesses live too far from "in-home" medical care providers to get the help they need to stay in their homes, a new study finds.

At least 2 million Medicare beneficiaries are homebound, compared to fewer than 2 million beneficiaries who receive care in nursing homes, the researchers said. Yet, seven times more primary-care providers visited nursing homes than patients at home during the two-year study period.

And more than half of Americans live more than 30 miles from a high-volume provider of "home-based medical care," the study also revealed. These services are mostly concentrated in large urban areas.

Home-based medical care is a modern twist on the old-fashioned doctor's house call. It involves a team-based approach to managing the care of functionally limited, chronically ill older adults, the researchers explained. Physicians, nurse practitioners and physician assistants manage patients' medical needs in collaboration with nurses, social workers and subspecialists.

Services provided in patients' homes run the gamut, from IV therapy and wound care to EKGs and X-rays, the researchers said.

"It's not just making house calls. If they go to the hospital, you're responsible for them there as well," added Dr. Eric De Jonge, director of geriatrics at MedStar Washington Hospital Center in Washington, D.C. He was not involved in the analysis.

People with chronic medical conditions who are frail, functionally limited and homebound account for about half of the costliest 5 percent of patients, the study authors noted. But using home-based medical care appears to reduce their reliance on specialty care, they added.

As the population ages, demand for in-home medical care is expected to swell.

"The Baby Boomer generation, they're aging fast and they are living longer with multiple health conditions," said study lead author Nengliang (Aaron) Yao. He is an assistant professor in the department of public health sciences at the University of Virginia School of Medicine.

For the study, Yao and his colleagues used Medicare fee-for-service provider data from 2012 and 2013 to map the service areas of home-based medical care providers and identify gaps in coverage.

"It's fascinating, because it gives probably the first picture of the geographic spread of the home-based medical care workforce in the United States," said De Jonge, co-founder of MedStar's Medical House Calls Program.

About 5,000 primary care providers made 1.7 million home visits to Medicare fee-for-service patients each year of the study, Yao's team reported. Almost 10 percent of these providers were responsible for almost half of the home care visits.

It appears that lagging reimbursement remains an obstacle to attracting more doctors and nurses to home-based health care.

For example, internal medicine physicians made only about half a million home visits, versus 8 million nursing facility visits, in 2012. Medicare paid those providers $500 million for nursing facility visits. That's 10 times more than what it paid for home visits.

In some states, Medicare spent more than $10 per beneficiary on home-based medical care. In others, it spent less than 10 cents per beneficiary, the study authors reported.

"We need to find a financial model to attract young doctors, nurse practitioners and physician assistants to come into this field," Yao said.

The U.S. Centers for Medicare and Medicaid Services (CMS) is testing home-based care as part of an ongoing "shared savings" project. The Independence at Home Demonstration saved CMS an average of $3,070 per participant in the first year, when compared with what Medicare would have otherwise spent on these patients, the study authors said.

The American Academy of Home Care Medicine is involved in setting up training programs for new staff and new programs across the country, said De Jonge, president-elect of the Chicago-based organization.

"You have to train the new workforce, and you have to pay them fairly so you don't pay a financial penalty for doing this type of work," he said.

Teaching In-Home Caregivers Seems To Pay Off

Published by Kaiser Health News
By Anna Gorman
August 12, 2016

Low-income Californians who are elderly and disabled were less likely to go to the emergency room or be hospitalized after their in-home caregivers participated in an intensive training program, according to a report.

Under a pilot program, nearly 6,000 aides in Los Angeles, San Bernardino and Contra Costa counties were trained in CPR and first aid, as well infection control, medications, chronic diseases and other areas. All were workers of the In-Home Supportive Services program, who are paid by the state to care for low-income seniors and people with disabilities, many of them relatives.

Researchers at the University of California, San Francisco based their analysis on the results in Contra Costa County, which they said produced the most complete and reliable data.

UCSF professor emeritus Bob Newcomer said they compared insurance claims on 136 at-risk elderly and disabled residents whose caregivers were trained with the claims from more than 2,000 similar residents whose caregivers did not receive the training. Though the sample was small, Newcomer said he was encouraged by the findings.

“Training shows a lot of promise,” he said.

The rate of repeated emergency room visits declined by 24 percent, on average, in the first year after caregivers were trained and 41 percent in the second year, according to the UCSF analysis.

The demand for in-home caregivers is rising nationwide as the population ages and people develop dementia or live longer with chronic diseases. Caregivers typically help elderly and disabled people with bathing, dressing, eating and getting to medical appointments. The work is largely unpaid and done by family members, but some states pay caregivers for eligible low-income residents through their Medicaid programs.

There are currently no federal training requirements for in-home caregivers, even if they are paid with taxpayer dollars. Around the country, however, training programs have been developed and tested, according to the Paraprofessional Healthcare Institute, an advocacy group that also provides training. Among the states that have tried different types of instruction are Massachusetts, North Carolina and Michigan.

California’s In-Home Supportive Services program pays caregivers to help about half a million elderly and disabled people stay in their homes rather than be placed in institutions. To qualify for the care, seniors must be eligible for Medi-Cal, be 65 or older, and be blind or disabled.

The goal of the pilot program was to determine whether educating IHSS caregivers and integrating them into the medical team would improve the health of their patients. The training was conducted by the California Long-Term Care Education Center under a three-year, $11.8 million grant from the federal Centers for Medicare & Medicaid Services. The center, which released the report on the results of the pilot program, worked in conjunction with UCSF.

The caregivers in all three counties, 44 percent of whom did not have a high school education, voluntarily attended about 60 hours of classes and completed 13 hours of related work at home. The people they cared for also took part in some of the classes, which were conducted in several languages.

Caregivers who were trained told researchers they felt better equipped to do their jobs and communicate with clients and their doctors, according to the report.

One of the caregivers, Andrew O’Bryan, said he was especially happy to learn CPR in case his mother has an emergency. For more than eight years, he has been paid by IHSS to care for his 67-year-old mom, Anabelle O’Bryan, who he said has diabetes, congestive heart failure, arthritis and high blood pressure.

O’Bryan, who lives in Oakley, a city in Contra Costa County, said he also learned what to ask when he accompanies her to the doctor and how to decide if she needs to go to the hospital.

“Now I am more equipped to spot things” before they get worse, he said.

For example, O’Bryan said he knows to elevate her feet when they get swollen rather than immediately take her to the ER.

Annabelle O’Bryan said she is more confident in her son’s abilities after he took the class, and she knows that he is helping her stay healthier.

“He is really on top of me not eating the sugar,” she said. “He is really careful about that.”

Newcomer of UCSF said that because the caregivers are in the patients’ homes for hours, they can be the “eyes and the ears” for physicians and other medical providers. They can tell the doctors “if the person is more confused, or is refusing to eat, or that the status is changing,” he said.

The results of the study show that caregivers play a pivotal role in helping keep people out of the hospital, said Corinne Eldridge, executive director of the California Long-Term Care Education Center. The nonprofit center was founded in 2000 by members of the Service Employees International Union, which represents many IHSS workers.

During the training sessions, Eldridge said, the caregivers learned skills such as how to read medication labels or provide the best diet for a diabetic patient. Like Andrew O’Bryan, they also became more confident about handling worrisome situations, such as deciding when to call a doctor or dial 911.

Eldridge said the center is now hoping to gain support from Medi-Cal health plans to help pay for the training as a way to reduce health care costs.

“We really see training as part of the solution in order to provide better care … and frankly as a way to invest in the workforce,” she said.

PACE Program Gets First Update in a Decade

Published by Home Health Care News
By Amy Baxter
August 12, 2016

A relatively small program that provides medical and social services to older adults and enables aging in place is getting its first facelift since 2006. Some of the changes include proposals lawmakers have pushed since 2014.

A new rule proposal from the Centers for Medicare & Medicaid Services (CMS) would update the Programs of All-Inclusive Care for the Elderly (PACE) to modernize the program and improve care to beneficiaries. The proposal also aims to expand the program.

“The goal of this proposal is to strengthen beneficiary protections and provide PACE organizations with more administrative and operational flexibility so they can do what they do best—caring for our nation’s most vulnerable individuals,” Andy Slavitt, acting administrator for CMS, wrote in a statement. “While PACE serves a relatively small number of people today, our proposal is intended to encourage states to further expand these programs.”

PACE provides medical and social services to more than 34,000 older adults in 31 states, enabling them to remain living in the community instead of in institutional care. With about 100 PACE organizations, enrollment in PACE has jumped 60% since 2011, according to CMS.

“The proposed changes would provide greater operational flexibility, remove redundancies and outdated information and codify existing practice,” CMS’ announcement reads.

Greater Flexbility

Specifically, the proposal calls for more flexibility for the interdisciplinary team, allowing them to “participate in more aspects of a participant’s care than is currently the case.” PACE team members are only allowed to perform one role under current rules. The flexibility applies to care access as well, with CMS proposing that non-physician primary care practitioners provide some services to PACE beneficiaries in place of primary care physicians.

CMS also proposes to modify its PACE Program Agreement, the contract between CMS, the state administering agencies and PACE organizations. The change would allow more frequent updates to PACE organizations and improve efficiencies in the development of program agreements.

“Our proposed changes would make PACE regulations and guidance more consistent, transparent and comprehensible,” according to the announcement. “Our proposed changes include clarification to enrollment policies, quality improvement and other requirements for PACE organizations.”

The rule also includes a few specific beneficiary protections:

—Clarity that PACE organizations with prescription drug coverage must be in compliance with Medicare Part D requirements

—Changes to sanctions, enforcement actions and terminations to decrease risk of harm to program participants and hold PACE organizations accountable

—Add language to exclude individuals with convictions for physical, sexual or drug or alcohol abuse from employment in any capacity that could put PACE beneficiaries at risk

The proposed rule will be published on the Federal Register on August 16 and be open for a 60-day public comment period until October 17, 2016.