Issues in Home Rehabilitative Care
Neil J. Nusbaum, MD, JD

(Annals of Long-Term Care 2000;8[11]:43-48)

This article was adapted from a session at the 1999 American Geriatrics Society Annual Meeting.

Moving health care into the home when it becomes the most appropriate care setting for a patient is an issue of great importance. The availability of home rehabilitative care, or the lack of it, may be an important factor in determining whether a patient with rehabilitative needs can manage to remain at home rather than becoming a resident of a long-term care facility. This article will examine some recent policy developments regarding the home as a setting for rehabilitative care.

The Growth of Home Health Care Home care in much of the 1990s had been one of the most rapidly growing areas in U.S. health care and had come to represent nearly one-tenth of the total Medicare budget. Statutory and regulatory changes in the last three years sharply altered this picture and will be significant in the future course of home care.

Several factors have driven the use of home care. Market forces and legal forces have both been important. Clinical issues have sometimes been overshadowed, however, and it is hoped that they will get more attention in the future.

Home health care services are a combination of several different kinds of services that may be vital to patients. There has been interest on the part of the American Geriatrics Society, as well as the Academy of Home Care Physicians, in looking at the role of physician house calls. However, house calls are a relatively small component of home care services.

Home care is often used as a device to prevent hospitalization for frail outpatients, or to shorten hospitalization. It can also be used as a high-tech substitute for hospitalization and can include the use of intravenous therapy. Home care is a philosophically different service from acute care hospitalization, as shown most dramatically in home hospice programs. When examining the various aspects of home care, one needs to examine the factors that bring about a need for home care and the individuals who are likely to require home care in the future.

Advanced age is only one of the risk factors that create the need for home care. The Institute of Medicine looked at the demographics of the population that receives home- and community-based care, and noted that the majority (55%) of the individuals were over age 65.1 However, there are also a substantial number of younger adults and a small number of pediatric patients receiving such services. The need for home care can arise throughout the lifespan, with some of the best data about the efficacy of home care and how it can be applied coming from the pediatric setting. A study that was published in 1998 in the Journal of the American Medical Association,2 specifically looking at perinatal home care, aimed to improve pediatric outcomes by intervening in high-risk pregnancies, prenatally and postnatally, and tried to incorporate educational interventions in the home. Like many other similar studies, short-term benefits arose. What made this study different, however, was the extremely long follow-up on the patients—15 years and more. In this particular pediatric study, important behavioral improvements were seen, even after 15 years, from administering home care early on.

Availability of Resources Individuals who most frequently require home health care are those from middle age to old age who may currently be independent but are at risk as they age and become more frail. One survey, conducted by the American Association of Retired Persons in 1996,3 examined more than 1000 households to attempt to determine which persons were living at home and what services they might need at that time and in the future. One of the findings was that, even though the study dealt with a relatively young stratum of residents in the community, nearly one-third of them lived alone and half of them lived with only one other person, usually a spouse. The social support network immediately at hand was often limited. Most of the individuals had lived in their current residence for many years and did not wish to move. A few of them had made modifications to their home to help them cope with their disabilities. As expected, the modifications tended to be minor ones, such as more appropriate lighting to help persons with visual impairment, rather than elevators or ramps for those who can no longer manage climbing stairs.

One of the most critical variables that people cannot change concerning their homes is the availability of neighborhood resources. Transportation and accessibility become crucial issues as patients become more dependent at home. The vast majority of individuals from the survey typically managed to get around by driving themselves. When asked how they planned to travel if subsequent disability prevented them from driving themselves, two-thirds of the individuals answered that they hoped they would be able to rely on a family member or a friend for transportation.

The resources that were available within the homes themselves were very limited for most of the residents. If the strategy of maintaining access to the community failed, these patients would have a difficult time managing their own transportation. They would have to consider only locations within walking distance. Half of them could manage to do food shopping, a little less than half could get to public transportation, less than half could get their pharmaceutical prescriptions filled, and only a small minority would be able to travel to the doctor's office. What is meant by walking distance can vary not only from individual to individual, but also for a given individual over time.

If an individual becomes more disabled, the definition of what is within that individual's walking distance is likely to become severely constricted, and this can translate into problems of poor nutrition, noncompliance with medications, or noncompliance with physician follow-up. Thus, as already stated, transportation and access to community services are crucial issues in a strategy to keep frail people at home. To enable older persons to travel out of their homes and to function in the community, effective rehabilitation options are necessary.

Federal Home Health Care Programs Federal policy makers have had a very different perspective on home care. What they have seen is a program that grew dramatically in structure and size, during the early 1990s in particular, when the number of home health care agencies nearly doubled to more than 10,000. The cost of home health care rose even more dramatically, and home health care tripled its share of the Medicare budget. As expenses climbed, the question arose as to the benefit, from a policy-making point of view, from the money being spent.

The intensity of service was one issue that caught the eyes of policy makers, since the home care program had more than doubled in visit intensity. The nationwide average number of visits per home health user was 36 in 1990 but had risen to 73 in 1997. The question was posed as to whether or not this increasing care was better care.

One way in which this question may be approached is to look at how well this increasing care has been focused. If it is examined on a national basis, the intensity of care may have doubled, but on a state-by-state basis wide variations are apparent. State averages for number of visits in 1997 ranged from 32 in Washington state to five times that (161) in Louisiana.4 Particularly in a state that is at the high end, questions arise about whether the average home care patient really requires three visits per week, and whether the average home care patient needs to be seen twice as often as the national average.

The wide variation among states in visit frequency for home care enrollees in some cases mirrors wide state variations in enrollment rates in home care. In Washington state in 1997, home health users were 8% of the Medicare fee-for-service population, while in Louisiana the corresponding figure was 16%, compared to a national average of 11%.4 The 1997 figures demonstrate that states vary strikingly both in the likelihood that a patient will receive an order for home care, and in the likely visit intensity of the home care if it is ordered.

This pattern, over the course of much of the 1990s, clearly showed that there was an increase in the intensity of services. It was unclear, however, whether this increase was meeting a clinical need. Regional variation suggests that some of the increase might not have been directed to where it would have been most beneficial. Although physicians were signing documentation, physician visits to the home were a very small part of the Medicare budget, and the role of physician oversight was silent in many cases.

The answer from the regulatory perspective was clear: a federal report in the mid-1990s looked at home care expenditures in five states and suggested, using the often heard language of "waste," "fraud," and "abuse," that nearly one-half of the Medicare payments for home health care should not have been made.5 For a program whose overall size was growing and whose focus in providing care was seen to be somewhat ill-defined, the next step could well be predicted and came rather quickly.

Controlling Home Health Care Growth In 1997, a number of vigorous steps to rein in home care took effect. The President imposed a brief moratorium on enrolling new home health agencies in Medicare, but that moratorium was lifted several months later. Meanwhile, some steps were taken to deal with what was viewed as a burgeoning fiscal emergency. New reimbursement rates for home care, under a so-called interim system, were put in place. They were meant to lower reimbursement and to provide enough time to devise a Prospective Payment System (PPS) for home care. The initial hope was to accomplish this task by 1999. However, the regulatory bodies involved decided that, because of the "Y2K" concern, the task could not be accomplished that year, and the deadline was postponed until October 2000.

The concern was still to control the demand for the program, whose increase in intensity of service had grown significantly, and particularly to address what was perceived as inappropriate demand. One issue that was discussed on Capitol Hill was instituting a copayment methodology to try to limit the demand for home care. While such a strategy might have further contributed to restrain demand, copayments would have been expected to be less popular with patients, and an array of other strategies proved able to quickly reverse the growth trend of Medicare home care. The 1997 Balanced Budget Act (BBA) and related regulatory action did quickly produce some of the effects that were intended. In 1997 itself, home care expenditures in the Medicare budget rose by only 5.5%—a dramatic drop from the prior rate of increase. In 1998 data, even more dramatic effects were apparent. In a January 10, 2000, press release, for example, the Health Care Financing Administration (HCFA) noted that "home health costs had a negative 4% growth rate in 1998, compared to a high of 28.2 % in 1990, a change attributed largely to cost containment provisions of the BBA."6

The primary focus was on governing what was seen as an excessive program that was growing in cost and patient intensity of visits. There was a corollary theme of improving the quality, as well as controlling the quantity, of home health services. One of the steps taken, in the array of regulations, was a new requirement that, from the beginning of 1998, home health agencies had to have at least some small track record that could be studied. The requirement was modest: (1) agencies had to have provided care to at least 10 patients before they could enter the Medicare program; and (2) they had to have at least seven of the patients on active care so that there would be some database that Medicare surveyors could examine, should the surveyors choose to.

One of the recent developments for home care is the Outcome and Assessment Information Set (OASIS) system (home page: http://www.hcfa.gov/medicaid/oasis/oasishmp.htm), which rates individuals in terms of their function on activities of daily living and instrumental activities of daily living. One of HCFA's stated purposes in collecting these data is that the data provide a guide to ensuring that quality care is being delivered. It is intended that the data be used in part to identify those who have rehabilitative needs, and to make sure that those needs are met.

For home care agencies, the recent changes have meant more expense in meeting some of the regulatory requirements and lower profitability. The effect has varied a great deal from state to state. Some states, like Louisiana and Texas, have had closures of numerous home health agencies. In other states, the effects have been much less dramatic. The effects of accessibility of home care, rehabilitative or otherwise, have been mixed. In urban areas, where there are numerous agencies, some closures have not had as much impact as in rural areas, where fewer agencies are available.

Transitioning to a Prospective Payment System In the coming months, a HCFA PPS for home care will come into play. The likely shape of that prospective system is indicated by the draft regulations. Some perspective on the future shape of home care under the coming PPS can also be drawn from the HCFA actions that have been taken in the past and the policies that are already in place under the current payment system.

HCFA in the past has taken a distinct approach in deciding what is and is not appropriate home care, in terms of reimbursement standards and durable medical equipment, and in deciding where coverage is inappropriate. A raised toilet seat, for example, which many physicians have recommended for many patients with disabilities, is considered a convenience item or hygienic equipment and therefore is not covered. A white cane is considered an identifying and self-help item that does not make a meaningful contribution to treatment of illness or injury, and therefore it is also excluded.

The same problem applies to documentation. The language that is used to prove that rehabilitation has worked for the patient and should be reimbursed is often considered insufficient to achieve that goal. For example, saying that a given male patient has shown significant improvement in his ability to make himself understood does not support coverage. Additionally, saying that his auditory comprehension has improved from moderately impaired to mildly impaired is not objective enough and is considered insufficient.

The effort by HCFA to control rehabilitative care expenses had already found expression in the payment caps that have been seen in some other outpatient settings. These are rather complex in their applicability. The overall scheme for outpatient settings is an annual beneficiary limit of $1500 for physical therapy, including speech-language pathology, and a separate $1500 limit for occupational therapy. The Balanced Budget Refinement Act of 1999, which imposed a two-year moratorium on the payment caps, in turn limited this approach to therapy expenses.

The focus by HCFA on rehabilitative care expenditures has carried over into the home care setting, and attention to rehabilitative care has been included in crafting the draft PPS for home care. The draft PPS rule calls for consolidated payments based on the estimated costs of the home care needed by the patient, including therapy services. While the draft Medicare payment system treats rehabilitative care under prospective payment, it also includes provision for retrospective review of rehabilitative and other services: "Prepayment and postpayment review activity will continue with the capability to deny claims in total or adjust payment to correct case mix . . . [and] medical review should ensure that the therapy was actually furnished and intensity (for example, time) of those services were reasonable and necessary for the beneficiary's condition. Information, such as the patient's OASIS, medical records, and the billing history will be considered in determining payment for covered services."7

Conclusion The role of physicians as advocates for their patients, to maintain quality of care for their patients, is a vital one across the continuum of care. This role includes prescribing appropriate home care, such as rehabilitative services. It will be of great interest to see how the introduction of PPS may affect the ease with which physicians may secure appropriate home rehabilitative services for their patients.

--------------------------------------------------------------------------------

References 1. Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings. Washington, DC: Institute of Medicine; 1996. 2. Olds D, Henderson CR Jr, Cole R, et al. Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA 1998;280:1238-1244. 3. Understanding Senior Housing: Into the Next Century. Washington, DC: American Association of Retired Persons; 1996. 4. Health Care Financing Administration. A Profile of Medicare Home Health: Chart Book. August 1999. Figures A.1 and A.2. Available at: http://www.hcfa.gov/stats/cbookhha.pdf. 5. Testimony of Kathy Buto, Deputy Director, Center for Health Plans and Providers, Health Care Financing Administration on Home Health Care Payment Reforms before the Senate Permanent Subcommittee on Investigations; June 10, 1999. Available at: http://www.hcfa.gov/testimony/1999/homcarl.htm. 6. Health Care Financing Administration Press Office. January 10, 2000. Health care spending growth rates stay low in 1998: Private spending outpaces public. Available at: http://www.hhs.gov/news/press/2000pres/20000110.html. 7. Federal Register, October 28, 1999. Medicare Program; Prospective Payment System for Home Health Agencies; Proposed Rule. Section E.

--------------------------------------------------------------------------------

Suggested Reading Rehabilitation Overviews Alexander DN. Geriatric neurorehabilitation. Neurol Clin 1998;16(3):713-732. (Discusses particularly stroke rehabilitation.)

Hoenig H, Nusbaum N, Brummel-Smith K. Geriatric rehabilitation: State of the art. J Am Geriatr Soc 1997;45:1371-1381.

Specific Topics of Interest Covinsky KE, Wu AW, Landefeld CS. Health status versus quality of life in older patients: Does the distinction matter? Am J Med 1999;106:435-440. (Explores the relationship, at two months after hospital discharge, between quality of life and health status measures in patients age 80 and over.)

Gill TM, Robison JT, Tinetti ME. Predictors of recovery in activities of daily living among disabled older persons living in the community. J Gen Intern Med 1997;12:757-762. (Identifies age and other factors that help predict likelihood of recovery in ADLs.)

Guerette P, Anthony P. Assistive technology for older adults: Opportunities for advocacy. Home Health Care Management & Practice 1999;11:17-24. (The article includes data sources [addresses, phone numbers and websites] regarding assistive technology relevant to the home care patient.)

Hansen K, Mahoney J, Palta M. Risk factors for lack of recovery of ADL independence after hospital discharge. J Am Geriatr Soc 1999;47:360-365. (Proposes a strategy using risk factor analysis to identify patients at high risk for lack of recovery of independence after hospital discharge.)

Holtzman J, Chen Q, Kane R. The effect of HMO status on the outcomes of home care after hospitalization in a Medicare population. J Am Geriatr Soc 1998;46:629-634.

Naylor M, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders. JAMA 1999;281:613-620. (In this randomized trial, discharge planning and home follow-up by gerontological advanced practice nurses decreased hospital readmissions and decreased costs, but did not improve functional status.)

Nusbaum N, Gant L. Focused nutritional intervention in the home care setting. Home Health Care Management & Practice 1999;11:53-57. (Care of diabetic patients.)

Olds D, Henderson CR Jr, Cole R, et al. Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA 1998;280:1238-1244.

Reifler BV, Henry RS, Rushing J, et al. Financial performance among adult day centers: Results of a national demonstration program. J Am Geriatr Soc 1997;45:146-153. (Of interest regarding economic considerations in an ambulatory [non-home] care setting.)

Sherry D. Reinventing home care. Home Healthcare Nurse 1994;123:9. (Commentary regarding the concept of a transdisciplinary home care rehabilitation team.)

HCFA and Other Regulatory Issues Carpenter-Mason B. Implications for home health and hospice care under the new prospective payment system. Home Health Care Management & Practice 1998;10:19-24. (Discusses some of the effects prospective payment may have on home health service delivery.)

Federal Register, November 2, 1998. Medicare program; Revisions to payment policies and adjustments to the relative value units under the physician fee schedule for calendar year 1999. Federal Register Online via GPO Access [wais.access.gpo.gov]. (Discusses Medicare coverage of outpatient rehabilitation services.)

Health Care Financing Administration. Consolidation of program memorandums for outpatient rehabilitation therapy services. Program Memorandum Transmittal No. AB-00-39, May 2000. (Discusses effect of the Balanced Budget Refinement Act of 1999.)

Health Care Financing Administration. Coverage Issues Manual: Durable Medical Equipment. http://www.hcfa.gov/pubforms/ archived%20html%20manuals/a06%5Fcim/ci60b.htm (Discusses HCFA rules regarding coverage for a variety of types of durable medical equipment.)

Health Care Financing Administration. Home Health Agency Manual, chapter IV: Billing for Part B intermediary outpatient speech-language pathology (SLP) services. http://www.hcfa.gov/ pubforms/11%Fhha/hh451.htm (Discusses HCFA rules regarding coverage and needed documentation for speech-language pathology services.)

Health Care Financing Administration. Medicare Fact Sheet. The home health prospective payment system (PPS). November 29, 1999.

Health Care Financing Administration. Program memorandum intermediaries/carriers Transmittal No. AB-98-63. http://www.hcfa.gov/pubforms/transmit/AB986360.htm ("Subject: Prospective payment system for outpatient rehabilitation services and application of financial limitation.")

Testimony of Nancy-Ann DeParle, Administrator, Health Care Financing Administration, on Medicare payment reforms before the Senate Finance Committee, March 17, 1999. http://www.hcfa.gov/testimony/1999/medpay2.htm (Discusses plans for October 2000 implementation of home health prospective payment system.)

International Perspectives Chiu L, Shyu W-C, Chen T-RJ. A cost-effectiveness analysis of home care and community-based nursing homes for stroke patients and their families. J Adv Nurs 1997;26:872-878. (A report from a study in Taiwan, emphasizing the value of the care provided by the family members.)

Crawford VLS, Beringer TRO, Stout RW. Comparison of residential and nursing home care before and after the 1993 community care policy. BMJ 1999;318:366. (Suggests that a change in NHS funding patterns served to promote more appropriate choice of care setting—ie, with the choice better matched to the individual's level of dependency.)

Hébert R, Brayne C, Spiegelhalter D. Incidence of functional decline and improvement in a community-dwelling very elderly population. Am J Epidemiol 1997;145:935-944. (Quebec data on change over time in the functional status of patients 75 years or older living in the community.)

Logan PA, Ahern J, Gladman JRF, Lincoln NB. A randomized controlled trial of enhanced Social Service occupational therapy for stroke patients. Clin Rehabil 1997;11:107-113. (British data showing improved outcomes, at least in the short term, from enhanced use of occupational therapy postdischarge.)

Lorentsen Ø. National structures in the delivery of rehabilitation technology services. Int J Technol Assess Health Care 1995;11:174-186. (Discusses one national system, that of Norway, for the provision of technical aids to patients).

Sim TC, Lum CM, Sze FK, et al. Outcome after stroke rehabilitation in Hong Kong. Clin Rehabil 1997;11:236-242. (Discusses a model relying predominantly on inpatient rehabilitation, without much use of outpatient rehabilitation).

--------------------------------------------------------------------------------

Dr. Nusbaum is Service Line Director, Geriatrics/Long Term Care Service Line, VA Capitol Network, Washington, DC. Address for correspondence: Neil J. Nusbaum, MD, Geriatrics/Long Term Care (11G), Washington DC VA Medical Center, 50 Irving St, NW, Washington, DC 20422. (Affiliation for identification only. Personal opinions are those of the author.)

Annals of Long-Term Care - ISSN: 1524-7929 - Volume 8 - Issue 11 - November 2000