A Future Trend in Family and Community Services Is Solving Problems Through

Larger contextual issues (eastward.g., population health, payment policy) take implications for how home health care may demand to alter to encounter future needs. This chapter describes iii presentations that explored overarching trends currently existence seen and how they may affect planning for the future role of home wellness intendance.

TRENDS IN POPULATION HEALTH

Authors

Tricia Neuman.

Affiliations

Kaiser Family Foundation

Home Health Care Nether Medicare and Medicaid

In home health intendance, the typical silos of Medicare and Medicaid do occasionally interact and overlap, but they are not truly integrated, affirmed Neuman. Medicare is an entitlement programme that covers Americans ages 65 years and older and people under age 65 years with permanent disabilities in a uniform way across the country. Medicaid, by definition, is more complicated considering of the combination of federal requirements and the different eligibility and benefit rules of each of the 50 states. The low-income people who are eligible for Medicaid and who receive habitation health intendance services frequently are as well covered under Medicare (and are referred to equally dually eligible), which is their primary coverage.

Medicaid is frequently thought of every bit a program for long-term services and supports (LTSS), but home wellness care is not really that entity, Neuman said. Home-based medical services (including nursing services; domicile wellness aides; and medical supplies, appliances, and equipment) are mandatory benefits under Medicaid, just the broader array of dwelling- and community-based services is optional. ^one Even so, states may impose limits on their Medicaid home wellness care programs. Five states have put limits on plan costs, and 25 states and the District of Columbia limit service hours. The do good is typically covered under fee-for-service arrangements, although many states are moving toward the apply of capitation, she said. As in Medicare's home health care program, a physician needs to provide a written plan of care for recipients to be eligible for habitation health intendance services.

Mandatory benefits for individuals who qualify for Medicaid domicile health care include function-fourth dimension or intermittent visits by a registered nurse; home health aide services provided past credentialed workers employed by participating home wellness agencies; and advisable medical equipment, supplies, and appliances. Physical and occupational therapy and speech pathology and audiology services are optional benefits. Fifteen state Medicaid programs allow recipients to arrange their own services, including providing payment to family unit caregivers. These self-directed services programs have mostly proved successful in reducing unmet patient needs and improving health outcomes, quality of life, and recipient satisfaction at a cost comparable to that of traditional home wellness agency–directed service programs.

In the traditional Medicare program, which uses fee-for-service payments, it has been relatively easy to runway how much that public insurance pays for various types of services, including home health care, Neuman said. Notwithstanding, equally increasing numbers of Medicare and Medicaid beneficiaries are moving into capitated plans, interpretation of the number of people receiving services, how much they are receiving, and what government source is paying for these services becomes harder. Under fee-for-service programs, Medicare currently pays the largest share of habitation wellness intendance expenditures (44 percent), fifty-fifty with its relatively narrow eligibility criteria, followed past Medicaid (38 percent) (see Figure four-1). Individual health insurance and other third-party payers pay about x percent, and another viii percent is paid out-of-pocket. Neuman noted that the amount of out-of-pocket spending is probably understated, because no reliable ways of capturing these data be.

Effigy 4-ane

Total home wellness care spending, 2012: $78 billion. NOTE: Estimates of national health care expenditures on home wellness care besides include spending on hospice by home health agencies. Total Medicaid spending includes both land and federal spending. Dwelling house (more...)

Home health care remains a relatively minor piece of total Medicare and Medicaid spending. As noted higher up, the Medicaid expenditure may exist an underestimate considering such a large percentage of Medicaid recipients are in managed care plans, which are paid on a per capita and non a per service basis.

Who Is Served

The utilization of home health care rises with the number of chronic atmospheric condition and the functional impairments that people have, Neuman said (come across Effigy four-ii).

Figure 4-ii

Percentage of beneficiaries using domicile health care, by feature, 2010. NOTE: ADLs = activities of daily living; IADLs = instrumental activities of daily living. SOURCE: Kaiser Family unit Foundation assay of Medicare Current Beneficiary Survey, 2010. (more...)

About ii-thirds of all Medicare home health care users have iv or more chronic conditions or at least one functional harm. "When you are talking about [people receiving] abode health intendance," Neuman said, "y'all're talking almost a population that is often physically compromised and cognitively compromised. These are people with multiple challenges." Although most of these challenges arise in the context of aging, they also face the population of people with disabilities covered by Medicare.

Neuman presented data indicating that dwelling house health care usage overall, the number of abode health care visits per user, and Medicare spending per user all rise with historic period, every bit does the use of many other wellness care services, including inpatient care, skilled nursing care, and doc services, and the use of some drugs (but not hospice care). The age–per capita spending curve for each of these services has a top. For example, Neuman noted that physician services and outpatient drug spending height at age 83 years, declining thereafter, and that afterwards age 89 years, hospital expenditures outset to drop. Spending on home health care does not pinnacle until historic period 96 years, and spending on skilled nursing facilities peaks at age 98 years.

Although but 9 per centum of the traditional (i.e., not-managed care) Medicare population receives domicile health care services, the health care spending for these individuals accounts for 38 percent of traditional Medicare spending. This is another reflection of their loftier degree of damage and need. Neuman posed key questions nigh these patterns of care, including the following:

• Are beneficiaries receiving intendance in the most appropriate setting?

• Are they receiving good-quality intendance in the place where they desire to be?

• Does this pattern of care optimally balance federal, land, and family budgets?

• How volition the nation finance care for an aging population?

Overall, the employ of dwelling health care services has increased in recent years, Neuman said, reflecting both an aging population and the rise in the incidence of chronic conditions noted earlier. However, spending on home health care, which had been rise concomitantly, has leveled off in contempo years, even though abode health care serves more people. It is not absolutely clear why this is, Neuman said, and and then suggested that information technology may be due in part to payment reductions from the Patient Protection and Affordable Care Deed of 2010 (ACA) ² and greater recent efforts to address fraud in some pockets of the country.

Effects of Policy Changes

Neuman stated that policy changes tin spur innovations affecting abode health care. These innovations are often aimed at the integration of systems of acute intendance and LTSS for dually eligible individuals and the development of team-based geriatric care. An example of such innovations, she said, includes the American Academy of Dwelling Intendance Medicine'due south Independence at Home initiative. ⁱⁱⁱ

How well home health care will fit into emerging models of intendance remains uncertain, Neuman said. Abode health intendance is a relatively small-scale player in these system reforms, and information technology will take attempt to ensure that it tin can continue to play its important office, she said.

TRENDS IN PUBLIC POLICY

Authors

Douglas Holtz-Eakin.

Affiliations

American Action Forum

Holtz-Eakin began his remarks by underscoring the "fundamentally unsustainable wellness care cost trajectory" that the nation is on, "fifty-fifty with the proficient news we accept had almost the pace of wellness care spending in recent years." Federal upkeep deficits will grow relative to the gross domestic product, and in a decade, interest payments are projected to exist larger than the U.S. Department of Defence force budget, producing a tight money environment.

At the center of these difficulties, he said, are the programs that pay fourscore pct of the home wellness intendance bills: Medicare and Medicaid. Medicare is spending its funds faster than payroll taxes and premiums are replenishing them and volition come under increasing financial pressure. Medicaid faces similar pressures, especially at the state level.

The habitation health care industry's financial condition looks specially precarious, said Holtz-Eakin, with some twoscore pct of home wellness intendance providers expected to exist in debt in just a few years. Moreover, new U.S. Department of Labor rules mandating overtime pay for workers non previously receiving it will boost agency costs, he said, if and when they go into outcome. In the home, LTSS take been provided by family members, but in the time to come, this source of intendance will be less bachelor, considering family members will be working.

Despite this combination of pressures, opportunities besides exist, Holtz-Eakin said. Keeping frail elders with chronic diseases and disabilities out of acute care could relieve a lot of money, so "the opportunity at the front end cease to really solve the Medicare cost problem is a serious one." Research also suggests that dwelling house wellness care tin play a substantial price-saving function in post-acute care as well. To take advantage of such opportunities, the dwelling house health care sector will exist required to certificate not just their price savings but also the quality of the care that they provide. The combination of lower toll and high quality creates a value proposition for policy makers and taxpayers, Holtz-Eakin said. Further, the traditional dichotomy between health care services and LTSS needs to cease, he believes.

Holtz-Eakin said that policy makers are "trying to fix these programs at the margins," when what is needed is "a central rethinking of how nosotros deliver all these services." Farther, he believes, the voters volition want to go with comfy proposals, and "I'm not sure that will be enough to get this right going forrad."

Although technological advances have helped resolve a big number of major policy problems, in this situation, information technology is not clear what such an accelerate would be, he said. For example, what agency will approve new health technology devices? Are wellness care applications going to be regulated by the U.Due south. Nutrient and Drug Administration (FDA) or by the Federal Communications Commission? When a service crosses state lines (as with telehealth), difficulties with state-based licensing and scope of practice regulations may arise.

TRENDS IN THE REAL WORLD

Authors

Barbara A. McCann.

Affiliations

Interim HealthCare

Several trends help describe the reality of U.S. habitation health care, every bit McCann sees it from her perspective as a medical social worker.

Limitations in the Design of the Medicare Home Health Care Benefit for Today's Population

Most people are unaware of dwelling wellness intendance services until a moment of crisis, when a staff member from the hospital, inpatient rehabilitation center, or nursing dwelling house advises them that their loved one is being discharged and arrangements for care in the dwelling house demand to be made, McCann said. Thousands of Medicare beneficiaries who are older or have disabilities and their families take had to face this crunch and are receiving home health care, merely the benefit is a poor fit to their needs, McCann said. Designed almost l years agone, the dwelling health care benefit emphasizes recovery from acute illness and the opportunity for health comeback, and it presumes that the casher's wellness bug will end. Information technology does not emphasize wellness or prevention, and it does not pay for comfort intendance or palliation at the finish of life.

Patients receiving Medicare dwelling house health care services must be homebound, and once they are no longer confined to home, the benefit ends. Notwithstanding, "chronic affliction goes on, [and] medications keep to come up into the business firm," McCann said. At that signal, domicile wellness intendance providers have no i to hand the patient over to or transition to for ongoing care and coordination. Patient-centered medical homes solve this problem, she said, but they are far from universal.

Managing Continuous Transitions

Despite these challenges, dwelling house wellness care is being reinvented to serve equally an of import piece in the continuum of chronic care. In accountable care organizations, with their capitated structure, some providers are working around the strictures of the Medicare home wellness care benefit and ensuring that patients receive the needed services. Transitions non merely between care settings—especially hospital to home—but as well during the flow of time afterward a medico'southward visit are times when patients definitely demand assistance, even with an issue equally basic as advice. "They can't call up what they talked most or who they told about which symptom," McCann said, "and they certainly can't remember what the md told them to do or what medications to take."

McCann noted that the home health care nurse can sit with the patient and family member or other caregiver and review medications, dosage schedules, and other medical instructions to aid the family become organized nearly the patient'southward wellness care needs. "The reality of wellness [care] in the home is the reality of the kitchen tabular array. That'southward where health decisions are made, and that'southward where health is managed," she said. Later in the workshop, Thomas Eastward. Edes, U.S. Section of Veterans Affairs, agreed with this characterization, saying "the golden standard of medication reconciliation happens at the kitchen table."

The virtually typical bug, McCann said, are

• Remembering to take medications,

• Knowing what the symptoms of problems are and when and from whom to seek assistance,

• Verifying that the individual or family fellow member(southward) makes an appointment with the community dr. within 1 to two weeks post-belch and that the private has transportation,

• Making certain that reliable arrangements for meal training are in place, and

• Checking the patient's power to perform ADLs safely or whether arrangements are needed to brand these activities easier or safer so that the individual can stay at dwelling house.

Finally, as a social worker, McCann emphasized the need for socialization by asking, "How [do] we proceed people engaged daily?" Taking intendance of all of these important dimensions of care will be of import to each patient and family well past the xxx or 60 days of Medicare's home health care benefit or a postal service-acute intendance service.

Data Shortfalls

McCann said that many wellness intendance data exist but that almost no information on home health care is available. Since 2000, whenever a Medicare or a Medicaid patient has received skilled care, nursing services, or therapy at abode, providers have had to collect more than 100 pieces of data near that patient and service. This requirement holds whether the patient is covered by traditional fee-for-service Medicare, Medicare Advantage, Medicaid skilled care, or Medicaid managed care. "We have information on millions of episodes of care sitting in a database somewhere that take not been analyzed," she said.

Although home health care providers receive some functioning information, they do not know what combination of service timing, staff specialty, or coverage type results in better (or worse) patient outcomes. Nor practise the bachelor data reflect what boosted personal care and support services not paid for by Medicare and Medicaid that the patient has obtained privately. It may be that these services make crucial differences to patient well-being.

New Program Models

McCann has encountered a number of hurdles to collaborative work in home wellness care that need to exist overcome. For instance, physicians appraise pain differently than practise physical therapists, and physical therapists assess pain differently than practise home health agency personnel, she said. Nor do these three groups assess dependence in ADLs in the same way, making it more than difficult to assess alter or improvement. Furthermore, piddling common linguistic communication for the establishment of effect measures exists, she said.

Collaboration is likewise a feature of the sit-in programs for dually eligible individuals, she noted, in which the goal is better programmatic coordination throughout the continuum of care. This is to be accomplished through the integration and alignment of federal Medicare and country Medicaid funds into a single source of financial support for social as well every bit medical needs.

Dwelling house health care does not hateful that a person is e'er in the habitation, McCann said. Information technology may mean having a smartphone application that reminds a person to have medication; ^iv it may be the availability of a nurse or pharmacist via e-mail or the telephone. Responsive cognitively appropriate and age-appropriate communication systems would help avoid unnecessary 911 calls.

This piece of work involves more than managing illness; information technology means taking a wellness, preventive, and habilitation arroyo. She said, "I may not be able to [offer total rehabilitation to y'all], but I can help you live improve in your home." McCann ended, "This is what we have to remember about the beauty of abode care: it'due south at home."

QUESTIONS AND COMMENTS

An open discussion followed the panelists' presentations. Workshop participants were able to give comments and ask questions of the panelists. The following sections summarize the discussion session.

Definitions

Mary Brady, FDA, said that a standard definition of home wellness care is needed. The definition used by FDA'due south Eye for Devices and Radiological Wellness includes concepts of health and the usefulness of devices not only in the domicile but besides at school, during transport, or wherever a person is and includes whatever devices are needed to keep healthy those who are living well outside of a clinical facility, she said.

Families

Amy Berman, The John A. Hartford Foundation, asked how home health care should respond to the declining numbers and availability of family caregivers. In current policy, she said, these individuals are not office of the unit of care. Innovations to address that trouble accept not worked well, said Holtz-Eakin, merely "the key to solving it is to go away from the silos" and to provide a broader range of services. Neuman emphasized that the information on the functioning of some innovative models may non exist available for a number of years. She said, "Nosotros need to get more than evidence about how well those systems are working for seriously impaired people before nosotros recall that managed intendance and capitation will be a solution for care, even though they may be clearly a solution for budgets."

Ane workshop participant commented that home health care needs to address not only cognitive and concrete impairments but besides the emotional needs of patients dealing with a new diagnosis and family members dealing with the exigencies of patient care.

Chris Herman, National Association of Social Workers, commented that hard transitions do non end for families when hospice or home wellness care services appear. They reemerge each time that a new practitioner in that program goes into the patient's home. Practitioners must continue to weave those programmatic connections together and help people empathize them, she said. Neuman agreed, stating that the issue of transitions besides needs to be thought about outside the hospital-to-abode context. People in retirement communities, assisted living facilities, and other settings may not accept family nearby for the kitchen-tabular array conversations that McCann described.

Cynthia Boyd, Johns Hopkins Academy, asked nearly what is being done to improve communication among patients and caregivers at home, habitation wellness care providers, and the rest of the wellness care system. McCann reiterated the importance of making sure that patients and their families understand their situation, what tin be done nigh information technology, and whom to call. This information tin be conveyed in multiple languages, through the employ of drawings, or in other imaginative forms of advice so that individuals and families understand what is happening and what options they take. However, what is often needed, she said, is to have someone available to answer questions at the moment that they arise. Call centers that are linked to pharmacies tin can help individuals go answers to questions about medications. Sometimes, only having a live person to talk to can reduce a person's anxiety. Communication of patient and family concerns back to other parts of the health care system is relatively easy in some of the more progressive patient-centered medical homes but is not so easy in other intendance environments. Said McCann, it should be explicit "who is responsible for those transitions and staying coordinated across fourth dimension."

Jimmo v. Sebelius

Herman besides asked about the anticipated impact of the Jimmo v. Sebelius case ⁵ and the resultant changes to Medicare for beneficiaries. Workshop participant Judith Stein, Center for Medicare Advancement and a lead counsel in the case, responded. The instance was brought on behalf of Ms. Jimmo and others every bit a national grade action, she said, to accost a long-standing problem that Medicare coverage is regularly denied on the basis of beneficiaries' restoration potential and not on the footing of whether they crave skilled care. For many people with long-term and chronic weather condition, the likelihood of health restoration may be negligible, nonetheless skilled care may well exist required for them to maintain their condition or to prevent or slow its worsening. Stein said that the Jimmo case should help people receive the benefits that they are entitled to under the Medicare law and that volition permit them to stay at home.

Price of Intendance

Several workshop participants raised the upshot of cost throughout the workshop. Namely, is home health care less expensive than the equivalent care in a nursing home setting? Neuman responded that no good studies of this question have been conducted. The provision of comprehensive services full-time in the home would be more than expensive than the provision of those services in a nursing domicile. Holtz-Eakin said that the focus should be on value and not only cost. What is needed, he said, is conquering and analysis of the information on dwelling health care to identify quality outcomes and best practices. As an illustration, Andrea Brassard, American Nurses Association, noted that her research on intensive home health intendance services in New York City in the 1990s found that these services did filibuster nursing dwelling admissions and mortality among the sickest population. Holtz-Eakin noted that many studies accept documented successful provider experiences and toll-saving business organization models with detail patient populations. However, to be suitable for adoption every bit function of the Medicare benefit, a study's positive findings demand to exist generalizable to the population every bit a whole, he said, because "Medicare is for everybody."

Co-ordinate to Brassard, the requirement that a physician sign off on orders for home health care or take a confront-to-face run into with the patient is inefficient and creates delays in dealing with patients' bug. In most instances, she said, a nurse practitioner (NP), clinical nurse specialist, or dr. assistant should be able to practise this certification. Although the U.S. Congress has been concerned that allowing other health intendance professionals to certify that a patient requires home health care would increase costs by increasing the demand for home health care, the current inefficiencies are also costly, she said. Brassard asserted that the trouble will get more acute in 25 to xxx years, when predictions point that one in every three primary care providers will exist an NP; today that number is one in five. The Congressional Budget Office (CBO), which determines the cost of proposed legislation, has difficulty with projections that are long term, given that congressional policy making is mostly short term. Moreover, said Holtz-Eakin, CBO measures only costs, and if proposed legislation has nonmonetary benefits, organizations need "to get policy makers to advocate on behalf of those benefits."

Erin Iturriaga, National Institutes of Health, raised the issue of the growing population of crumbling individuals in prisons. To save money, she said, states are releasing older long-stay prisoners early on, shifting the costs of their intendance from the prison organization to other payers, including Medicaid. Data on inmate health are non part of typical health care databases, and states have no way of budgeting for this influx.

Combining Medical Care and Social Needs

Michael Johnson, BAYADA Dwelling house Health Intendance, noted that different definitions of home health care seem to be constricted past the requirements of the programs that are paying for it. A broader conceptualization of home- and community-based services may be needed. He asked how the Medicare focus on illness and drugs tin can be rebalanced with considerations about prevention and pre-acute care or about improving function, nutrition, and mayhap even cognition. Holtz-Eakin responded that the current programs, as they exist, are not built for the future. The country's approach is ad hoc, he said, and was invented through regulation and pocket-sized policy changes. Although it makes sense to take outcomes, including functional outcomes, equally the focus, the Medicare plan was designed almost five decades agone to serve people with acute-intendance stays and is now existence asked to serve a population whose biggest problems are chronic diseases. The recent Senate Commission on Long-Term Care ^{half dozen} concluded that although significant program changes are needed, to provide more LTSS, there is no articulate way to pay for them, Neuman said. She agreed that working with people early (providing pre-astute care instead of but mail-acute care) to prevent functional turn down would be an important strategy. Which provider will do this is uncertain: "There are a lot of people competing for that space," she said. The mind ready that long-term care is nursing home care must modify, said McCann. Today, long-term intendance is simply the reality of chronic illness, crumbling, and inability. The evaluation of models from other countries—especially Commonwealth of australia—may help change that perception.

Bruce Leff, Johns Hopkins University Schoolhouse of Medicine, asked if the breakdown of silos among programs will emerge from new business models, including a greater penetration of managed care, or if it will crave another large political battle. Holtz-Eakin predicted that both are likely but that modify can certainly build on some of the essential organizational innovations currently under way. Regardless of the delivery model, however, payment should be fabricated on the basis of patient outcomes. Meanwhile, information technology should be possible to build on Medicare Advantage and expand what it covers to include non just traditional wellness care services but also a continuum of health and social supports.

Terrence O'Malley, Massachusetts Full general Hospital, asked if realigning health care payments through accountable care and managed care organizations is increasing awareness of the importance of social factors in wellness. That does not seem to be happening as quickly as anticipated, he said. The panelists counseled patience, because promising new models are still only promising and it is too before long to choice winners. If these new models are allowed to run a while, the ones that are successful in reducing costs and improving quality will exist revealed, Holtz-Eakin said. The ACA was just the kickoff of a health care reform process that will continue for many years. What this workshop is about, he said, is getting abode health care right in the end.

ane

The broad category of domicile- and community-based services includes assistance with activities of daily living (ADLs), such as eating, bathing, and dressing; assistance with instrumental activities of daily living (IADLs), such as preparing meals and housecleaning; adult day health care programs; home health aide services; and case management services.

2

Patient Protection and Affordable Care Act of 2010, Public Law 111-148, 111th Cong., 2nd sess. (March 23, 2010).

3

4

A participant noted that FDA has a guidance on mobile applications.

5

"On Jan 24, 2013, the U.S. District Court for the District of Vermont approved a settlement understanding in the case of Jimmo five. Sebelius, in which the plaintiffs alleged that Medicare contractors were inappropriately applying an 'improvement standard' in making claims determinations for Medicare coverage involving skilled care (e.g., the skilled nursing facility, home wellness, and outpatient therapy benefits)" (CMS, 2014).

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hernandezfartandence.blogspot.com

Source: https://www.ncbi.nlm.nih.gov/books/NBK315921/

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