Feature Article
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The AAHCP Home Medical Care Forum Skilled Home Health Care in 2003
House calls are the cornerstone of optimal medical care at home. There is evidence, both anecdotal and from formal studies, that home-based assessments provide better information about patients.1,2 Furthermore, gathering accurate information about functionally limited individuals is done more efficiently in the home than in the office: a picture is still worth a thousand words. Even more important is access to regular medical care. About 2 million persons with chronic immobility, among the sickest in our nation, are often disenfranchised from regular medical care.3 Another several million are temporarily homebound and find it difficult to access outpatient medical care.
Since 1998, changes to the Medicare fee schedule for house calls, plus other incentives (Table I), have made home medical care fiscally feasible in most settings. In addition, portable technologies are available to enhance home-based medical practice. If all primary care physicians made home visits one half-day per week, the access problem would be largely solved. If a five-physician group operated the office practice required by four physicians and had one “rover” every day who saw patients at home and in nursing homes, such a practice could cover its mobile care costs as a separate cost center. It is time to restore the quality of medical management for this population.
Given that house calls are not yet restored to mainstream medical practice, the focus of this article is on skilled home health agency services—care that is ordered by most physicians. Medicaid and private insurers pay for a substantial portion of skilled home care services, but Medicare still dominates the picture. Medicare Part A skilled home care has undergone major changes in recent years that physicians should understand.
Medicare home care grew between 1988 and 1997 to reach 9% of the Part A budget. This included marked regional variation,4 some overt misuse of the Medicare benefit, and much supportive care for chronic illness, which was not part of the original Medicare home health charter (post-acute care and rehabilitation). More than half of episodes lasted six months or longer, and nearly half started without a recent hospitalization. Budget cuts required by the 1997 Balanced Budget Act (BBA) brought financing that sharply curtailed services. Home health services are now about $9 billion, less than 5% of the Part A budget. Between 1997 and 1999, the proportion of Medicare beneficiaries using skilled home health services dropped 21%; visits per user declined 41%.5
The new financing model is the Prospective Payment System (PPS), which pays agencies in 60-day increments, based on patient case-mix (80 categories called Home Health Resource Groups [HHRGs]). Rehabilitation, if more than 10 hours of care in 60 days, increases the case-mix weight. Under these incentives, agencies reduced visits and became more efficient. The largest decline was in home health aide visits, plus a substantial decline in nurse visits.
Preliminary evidence suggests that reduced services may be associated with a 10-15% increase in emergency room utilization.6 Further, informal caregivers have been given significant additional burden, as they are required to accept more responsibility for wound care and other technical services previously provided by nurses. Ironically, these services are considered too advanced for home health aides to perform safely. Assessing the ultimate impact on patients and caregivers awaits more research. The larger societal issue of providing chronic care for the aging population is a policy issue beyond the scope of this discussion.
With PPS and the BBA came other changes, one being mandatory use of the Outcome and Assessment Information Set (OASIS) and systematized quality improvement. The OASIS tool (89 items addressing patient symptoms, physical function, and home care needs) was created and refined over a decade, using rigorous research methods to enable accurate measurement of outcomes adjusted for case-mix, and thus comparable across agencies. A large, two-part national demonstration providing 73 agencies with training on performance improvement plus structured feedback using OASIS produced consistent gains for targeted clinical outcomes. This approach is called outcomes-based quality improvement (OBQI).
Demonstration agencies were also asked to target hospitalization. Remarkably, intervention patients had about 25% fewer annual re-admissions compared with controls.7 This study of over 250,000 patients provided compelling evidence. The OBQI demonstration succeeded largely because of the care taken in staff training by the project directors, high data quality, reliable feedback, and commitment to quality improvement by participants. Subsequently, the findings were replicated using state Quality Improvement Organizations (QIOs) as a vehicle for implementing OBQI (P.W. Shaughnessy, personal communication).
The OASIS instrument has engendered considerable debate, based largely on concerns about its length and the time required to gather data. There is a staff training cost, a data gathering cost, and some burden on patients. In the OBQI demonstration, experienced nurses conducted OASIS assessments in the same time that older assessment methods required, and during instrument development, all OASIS variables contributed significantly to risk-adjusted outcomes. Efforts to further improve OASIS and streamline OBQI are underway, guided by a national technical expert panel.
Physician responsibilities under PPS have not changed. Whether physicians refer to home health from a hospital, office practice, house calls program, or a nursing home, the following paragraphs and Table II outline their responsibilities.
The first responsibility is to correctly identify patients who qualify for skilled care. Beyond the obvious cases with complex wounds or infusion care, skilled home health may be started for nursing education of a new patient with diabetes or patients repeatedly hospitalized for heart failure. Examples of appropriate scenarios are shown in Table III. Rehabilitation therapy needs alone (no nursing issues) are sufficient to open skilled home care when there is a new functional deficit or immobility. Since February 1998, sending nurses for the sole purpose of drawing blood is no longer allowed, but sending nurses to educate and monitor the impact of medical management while obtaining lab specimens is covered. Skilled home care referrals must be for patients who are homebound, which means that they leave home infrequently for social reasons and with difficulty. Usually, in a month’s time, this framework permits a few trips locally, but not regular social outings. There is no limit on excursions for medical care. The home care must be intermittent (not needing continuous skilled observation as in a hospital), medically necessary, and ordered by a physician.
Once identified, appropriate patients should be referred to quality agencies, and physicians should provide specific direction on what care they want performed and what information they want reported. The orders should include directions for maintaining communication. As care progresses, physicians should be available if there are problems or questions. Paperwork should be signed and returned promptly. There is no legally specified time limit, but agencies cannot bill until all orders are signed. Unsigned orders remain a major industry problem that physicians must address.
Under PPS incentives, physicians must be advocates for patients. In some cases agencies may seek to truncate services prematurely or provide too few visits. Without insisting on services that are fiscally unreasonable, physicians should contact agencies when they feel more care is needed and understand PPS enough to have an informed discussion. For example, there are cases, such as certain heavy-care patients with advanced pressure ulcers or patients with poorly controlled diabetes with weak support systems and active co-morbid medical conditions where it is difficult to manage care within PPS limits. Physicians should know that each HHRG is an average, like a hospital Diagnosis-Related Group; some cases in a category are profitable and some less so. There are home care outlier payments that cushion but do not erase losses that agencies may incur in very complex cases, and there is a mechanism to increase payment mid-episode if the patient’s condition changes dramatically. Patients who need ongoing skilled care may have extended episodes that last months or years, with no specific limit as long as patients meet Medicare criteria.
Transition from one setting to another, such as from hospital or nursing home to home, is a time fraught with potential for errors. Physicians and their affiliated practitioners must take responsibility for ensuring continuity of information and of care. Often, this is done poorly; a few minutes of thoughtful effort can make an enormous difference. Physicians with larger home care practices may develop systematic approaches that reduce the chance for errors; this is a worthwhile focus for agency medical directors.
An Achilles heel for current Medicare fee-for-service providers (physicians and nurse practitioners) is the cost of case management, which often constitutes 30-35% of total work.8 Recent Medicare initiatives have somewhat ameliorated the situation. Although patients are receiving Medicare skilled home health care, there are reimbursement codes for care certification and re-certification (January 2001) plus Care Plan Oversight codes (1995) for patients who require 30 minutes or more of active physician or other advance practice provider work in a calendar month. However, these codes apply to only a minority of cases, and only intermittently. A better method of compensating medical care teams is needed for continuing care of frail individuals with multiple complex illnesses and needs.
Implementation of the 1997 BBA is in its second five years, with reductions being faced of at least another $250 billion in Medicare spending after the $150 billion in reductions slated for the past five years. Moreover, state budgets, which largely determine Medicaid expenditures for chronic care, are in serious trouble. Combined with the elderly population explosion and already unmet needs of many “Medicare poor” who do not qualify for Medicaid, this scenario suggests the need for advocacy and major system reform. The numbers of immobile community dwellers, young and elderly, temporarily and chronically homebound, will continue to rise from the current baseline of several million; the need for work in this area will double in the coming two decades.
The new array of services and incentives should include models for delivery of complete medical care at home, and the OBQI program should provide critical insights into the characteristics of the patient population and outcomes of care. Physicians should continue to learn about the changing world of home health care and engage actively with this important aspect of medical practice. G
References
1. Ramsdell JW, Swart JA, Jackson JE, Renvall M. The yield of home visits in the assessment of geriatric patients. J Am Geriatr Soc 1989;37(1):17-24.
2. Yang JC, Tomlinson G, Naglie G. Medication lists for elderly patients: Clinic-derived versus in-home inspection and interview. J Gen Intern Med 2001;16:112-115.
3. Boling PA. Present and projected needs for home health. In: The Physician’s Role in Home Health Care. New York, NY: Springer; 1997:193-213.
4. Welch HG, Wennberg DE, Welch WP. The use of Medicare home health services. N Engl J Med 1996;335:324-329.
5. Komisar HL. Rolling back Medicare home health. Health Care Financ Rev 2002;24(2):33-55.
6. McCall N, Korb J, Petersons A, Moore S. Constraining Medicare home health reimbursement: What are the outcomes? Health Care Financ Rev 2002;24:57-76.
7. Shaughnessy PW, Hittle DF, Crisler KS, et al. Improving patient outcomes of home health care: Findings from two demonstrations of outcome-based quality improvement. J Am Geriatr Soc 2002;50(8):1354-1364.
8. Boling PA. Attributes and practices of the home health care physician. In: The Physician’s Role in Home Health Care. New York, NY: Springer; 1997:10-41 Nurs 1995;20(2):84-89. Annals of Long-Term Care - ISSN: 1524-7929 - Volume 11 - Issue 10 - October 2003 |