The Role of Human Factors in Home Health Care Workshop Summary (2010) / Chapter Skim
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12 Effects of Policy, Reimbursement, and Regulation on Home Health Care--Peter A. Boling
12 Effects of Policy, Reimbursement, and Regulation on Home Health Care--Peter A. Boling
Pages 275-302
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From page 275... ...
THE LANDSCAPE OF HOME HEALTH CARE Societal Context, Costs, and Care Silos There is a growing sense of crisis. Medicare cost about $500 billion in 2009 and the Medicare Hospital Insurance fund balance will be zeroed in seven years.
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. And like health care generally, home care is organized into separately funded categories, called silos: home health agencies, hospices, medical equipment, home health aides, pharmacy managers, medical providers, and thousands of private bureaucracies.
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Reasons for this lack of emphasis include the origins of managed care models in conventional settings and finance systems, competing corporate interests for the insurer, and lack of senior management familiarity with what advanced home care can provide. However, portable technologies and experiences with caring for sick patients in the community are now lighting new paths in which fully developed and integrated interdisciplinary home care teams, which include physicians and other medical providers, work together with other providers of care and community resources to produce better care at lower cost.
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with a high burden of chronic illness (Group F)
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From page 279... ...
Group F includes most of the need for what typically comes to mind when thinking about home health care. Users vary in age from infants to very old adults, carry heavy chronic illness burden, often with end-stage organ system failure (heart, lung, liver, kidney, brain)
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From page 280... ...
These functional deficits are on the final common path, where the combination of severe illness and incapacity drive health care costs. Sorting the Medicare population by cost, the top 5 percent used 43 percent of resources, with average costs of $63,000 in 2002 (Holtz-Eakin, 2005)
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. No published national analysis directly links ADL deficits, home health use, and overall costs at the individual level.
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Chapter 7 of this volume discusses informal caregivers in detail. FIVE SERIOuS PROBLEMS OF LONG-TERM HOME HEALTH CARE Problem 1: Human ADL Support, Medicaid, and Long-Term Care Coverage The lack of a consistent national policy on long-term care or of a systems approach to care at home is a major overarching problem for home care that daily affects paid providers, care recipients, and their families, who are trying to solve these problems.
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The quality of home health aide and personal care also is a recognized national issue (Stone and Newcomer, 2009)
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From page 284... ...
. Between CAHPS and creative new models like Cash and Counseling, plus the increasing affluence of baby boomers, the personal care component of home health care is moving forward, but it will have to contend with the increasing ratio of older persons needing care to younger persons available to deliver it and will increasingly depend on an international workforce.
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. Postacute home health care is delivered by teams of nurses, therapists, aides, and social workers employed by home health agencies.
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Current home health care models perform well for individuals on a trajectory back to full recovery after an acute illness (Group E) , but there are problems in Group F when individuals have advanced chronic illness that waxes and wanes.
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When home health agency care starts, the agency team performs extensive data gathering and then provides care. If care recipients don't die, they
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Born of financing mechanisms, this is an expensive care model that is ill suited to population needs. The care model adversely affects care recipients, their families, the home health care staff, and the physicians involved.
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On balance, facing significant disincentives and lower income potential has caused all but the most committed champions to avoid home medical practice. This fact stands in contrast to the growing evidence of economic and clinical benefit from a home medical care model that includes transitional care.
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. EVIDENCE OF VALuE FROM MEDICALLY LED HOME CARE TEAMS Evidence is mounting that medically managed home care can produce outcomes far superior to 1-2 percent improvements in major endpoints (e.g., hospitalization)
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and nursing home costs generate overall savings. While the data are limited to the VA, the results are impressive and the sample is large (Beales and Edes, 2009)
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among higher risk participants, even though this was not a case management or primary care model and did not include urgent response capacity. In sum, comparing current usual home health care to office, hospital, or even nursing home settings, one finds a model that is largely missing one key ingredient: an active medical presence.
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or failed due to their care model. In any organization, unless senior management is committed to innovation, advanced home care is unlikely to evolve.
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A low-end estimate could be based on home health agency Part A rehospitalizations. Using the 29 percent national rate and 7 million episodes yields 2 million hospital admissions.
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From page 295... ...
Specialty physicians likewise will have more than enough Medicare business and would not miss seeing the IAH population subset who require more time and bring more risk-benefit issues and more complex decisions to procedural care. Specialists face the same risk as hospitals -- of working harder for lower rates unless ways can be found to target resources and lower overall Medicare costs.
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One can imagine medical home care teams emerging quickly given suitable incentives and supports, particularly within the established framework of home health agencies. Young physicians are inherently altruistic.
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Importantly, incentives are needed for members of an interdisciplinary home-based team to engage in the difficult aspects of this work for the members of Group F: Office-Based Care Chronic diseases No disease: but functional: episodic and regular office care preventive care Acute, serious illness develops Better Bett er Low risk Evaluate comorbidity and risk Transitional High risk Intermediate risk Care Zone Intensive transitional Guided or coached care team model postacute care & rehab Still homebound? Mobile Chronic Care Team FIGuRE 12-4 Movement of at-risk persons between care settings.
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From page 298... ...
The complex scenarios in which advanced medical home care providers, care recipients, and their families find themselves remind one of surgery, played out in slow motion over years. Care recipients depend heavily on a trustworthy physician-led interdisciplinary team who will see them through their entire course of care.
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. Care transitions and home health care.
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. The past, present and future of skilled home health agency care.
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From page 301... ...
. Physician evaluation and management of Medicare home health patients.
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