During the workshop, two keynote speakers addressed the state of home health care to provide a framework for the workshop discussions. Robert J. Rosati of the Visiting Nurse Association (VNA) Health Group gave a broad overview of the current state of home health care. Later, after a panel on some of the key issues and trends affecting home health care planning (see Chapter 4), Steven Landers, also of VNA Health Group, gave his vision for the ideal state of home health care 10 years from now.
Robert J. Rosati
Visiting Nurse Association Health Group
Rosati summarized the current state of home health care, with a focus on Medicare home health care, and the changes occurring in the field to provide context for discussions about the challenges and opportunities of home health care in the future.
The Medicare Population
Population trends are driving the shape and scope of home health care services. Most people enrolled in Medicare today have three or more chronic conditions (65 percent), half live below the poverty line, nearly one-third (31 percent) have a cognitive or mental impairment, and about 5 percent live in long-term care facilities (Kaiser Family Foundation, 2014).
In addition, although the tendency is to lump the Medicare population into one group, about 16 percent of Medicare enrollees are individuals with disabilities younger than the age of 65 years and 13 percent are aged 85 years and older. In addition to these challenges, Medicare beneficiaries are often in fair or poor health, according to self-ratings, and have two or more problems with activities of daily living (ADLs).1
Rosati illustrated the growth in the size of this population by comparing the numbers of Americans age 65 years and older in 2002 (35.5 million) and 2012 (43.1 million). Estimates for 2040 are that some 80 million Americans will be age 65 years and older, and about 29 million of those individuals will have some degree of disability. Meanwhile, the number of Americans ages 85 years and older is projected to grow from 5.9 million today to about 14.1 million in 2040, he said.
The number of agencies providing home health care in the United States grew from 8,314 in 2005 to 12,613 in 2013, Rosati said, with Medicare expenditures for home health care services nearly doubling from 9.7 billion in 2001 to about $18.3 billion in 2012. Nevertheless, home health care constitutes only about 3 percent of Medicare benefits payments.
The Medicare Home Health Care Program
People who are recognized as needing home health care are those who have had a recent hospitalization or those who have received a physician referral. Rosati offered several key points about eligibility for the Medicare home health services:
- The recipient must be under the care of a physician who has established a plan of care for the patient (a requirement over which the home health agency does not have control);
- The care plan must include the need for nursing care or physical, speech, or occupational therapy;
- The recipient must obtain care through a Medicare-certified home health agency; and
- The recipient must be homebound and unable to leave the home unaided without the possibility of risk.
Two major assumptions underlie these eligibility criteria, Rosati said: that the physician drives the care and that the patient has certain needs (from a clinical perspective and because he or she is homebound).
Further, Rosati added, if a beneficiary needs skilled nursing care, that
1 ADLs are the routine tasks of everyday life, such as eating, bathing, dressing, using the toilet, transferring (e.g., from a bed to a chair), and walking across a room.
care must be needed only intermittently or part-time and must be provided by a registered nurse (RN) or a licensed practice nurse supervised by an RN. Home health aide services must supplement the care provided by professionals. Additional services that may be provided include medical social services and medical supplies. Said Rosati, “What’s important to look at is what’s not covered.” Services that are not covered include 24-hour care, meals, homemaker services, and personal care not associated with therapy or nursing. In some states, however, Medicaid does cover these services for low-income residents.
Medicare beneficiaries receive skilled care in the home on an episodic basis. The skilled care is certified for a certain period of time—typically, 60 days—and skilled care can be renewed if the beneficiary needs such care for a longer period, Rosati said. In contrast, Rosati, said, commercial insurers typically authorize a certain number of visits (5 or 10, for example).
Unskilled services help people safely stay in their own home for the longest period of time, and although these services are not covered by Medicare’s home health care program, they may be covered in other ways or paid for out-of-pocket. A notable model of comprehensive noninstitutional care is the Program of All-Inclusive Care for the Elderly (PACE), a program jointly funded by Medicare and Medicaid that provides an integrated set of services at a PACE center in the community, with some home health care support, for nursing home-eligible recipients.2
National home health care quality measures compiled for the Centers for Medicare & Medicaid Services’ Home Health Compare website suggest that home health agencies provide high-quality services according to key process measures, Rosati said, with home health agencies providing:
- Checks for depression and the risk of falls 98 percent of the time,
- Instructions to family members 93 percent of the time, and
- Timely initiation of patient care 92 percent of the time.
The average performance is somewhat lower for health outcome measures, which, in part, reflects the debility of people who need home health care, Rosati said. For example, some performance measures indicate:
- Postsurgical wound improvement or healing 89 percent of the time,
- Reduction of pain when moving around 68 percent of the time,
2 See http://www.npaonline.org/website/article.asp?id=12&title=Who,_What_and_Where_Is_PACE (accessed December 24, 2014).
- Improvement in walking or moving around 62 percent of the time, and
- Readmission to the hospital within 60 days 16 percent of the time.
Rosati noted that the home health care field, on average, is achieving the same readmission rates as hospitals, although, he noted, the hospital readmission rate is calculated only on the basis of hospital readmission in the first 30 days after the patient is released and, therefore, is somewhat easier to achieve.
Finally, how do beneficiaries themselves rate the home health care services that they have received? Again, using national averages from Home Health Compare, Rosati reported that
- Seventy-nine percent of patients say that they would definitely recommend their home health care agency to friends and family (whereas 71 percent would recommend their hospital);
- Eighty-four percent gave the overall care that they received from the home health care agency a rating of 9 or 10 on a 10-point scale;
- Eighty-four percent reported that the home health care team discussed medicine, pain, and home safety with them; and
- Eighty-five percent said that the home health care team communicated well.
In recent years, the federal government has cut Medicare reimbursement for home health care services, and in the near future, another $25 billion “will be taken out of the home health care system,” Rosati said. Another source of cuts has resulted from states’ moves to managed long-term care for Medicaid recipients, which has curtailed the number of hours of patient care provided in the home. Additional reductions in commercial payers’ reimbursements, as well as in Medicare Advantage, Medicare’s managed care program, have occurred.
Further financial challenges result from the high level of scrutiny and auditing to which home health agencies are subjected, which have resulted in part from fraud and abuse in the system. Good organizations, Rosati said, “are kind of trapped with respect to what’s being said about other organizations.”
Home health care providers are involved with a number of emerging models that organize and pay for care differently. Among them are inno-
vations that were established under the Patient Protection and Affordable Care Act of 2010 (ACA),3 such as accountable care organizations (ACOs) and bundled payment arrangements. Specifically, Rosati said,
- Home health care organizations are finding opportunities to work directly with ACOs to deliver community-based care.
- Home health care organizations are involved with the provision of post-acute care services that involve the use of both home health care and skilled nursing to provide the right level of care after hospitalization.
- Increasingly, home health care organizations are involved with transitional care, in which their first visit to the patient is in the hospital and then they make perhaps one visit after the patient is discharged.
- Home health care organizations’ patient assessment skills and experience working in the home are being tapped for evaluations of high-risk enrollees in health plans.
The challenge is to cover the cost of these service expansions, Rosati said. The infrastructure of home health agencies has been built around Medicare, and these new arrangements require agencies to operate differently. Everything from software systems to care delivery models need to be redesigned, and mind sets need to be adjusted, he said. Furthermore, competition in these emerging arenas is significant: “Everybody wants to be in this space right now,” Rosati said. Coordination among the various entities providing transitional care—the hospital, the insurance company, and others—is not easily achieved, however.
For some time, even though home health care has tended to use electronic records for both the collection of clinical information and assessment, meaningful use provisions under the ACA do not apply to long-term care. Home health care also has not benefited from the exchange of clinical data with other providers, nor do home health agencies have the patient portals that hospitals are required to provide their patients. Larger home health agencies are paying close attention to reporting and analysis of quality outcomes, but smaller ones have trouble paying for data analysis expertise and electronic records systems.
Finally, telehealth applications (e.g., video, remote monitoring, automated calls) have been found to be effective and cost-effective by some organizations. However, no additional reimbursement is provided for the development and use of telehealth, a deficiency that is curtailing movement
3 Patient Protection and Affordable Care Act of 2010, Public Law 111-148, 111th Cong., 2nd sess. (March 23, 2010).
in this area, Rosati said. Expansion of telehealth may first need to occur with younger populations or those more comfortable with this technology, he suggested, reserving nurse visits for those who are not as comfortable with its use. Howeverm telehealth can be low-tech, involving no more than regular calls to the family.
In summary, Rosati stated,
- The demand for community-based care will grow substantially;
- Patients and families prefer care at home;
- The home is the least costly setting for post-acute, long-term care; and
- Home health agencies have the experience, knowledge, and infrastructure needed to support emerging models of the delivery of health care.
Visiting Nurse Association Health Group
VNA Health Group, which Steven Landers leads, is a large nonprofit home health care, hospice, and community health care organization started more than 100 years ago by Geraldine Thompson with the support of her lifelong friend, Eleanor Roosevelt. Predicting the future of home health care is a risky endeavor, but “for this workshop, let’s assume the future state is up to us,” Landers said, emphasizing the importance of the task.
Advantages of Home-Based Care
Home health care offers some basic, commonsense advantages within the continuum of health care that are as real today as when Lillian Wald and her colleagues ventured into the squalor of New York’s Lower East Side at the end of the 19th century, Landers said. These advantages include
- An enhanced view of patients and caregivers that leads to a better understanding of important issues, like how they manage medications and nutrition;
- Access to health care that is most relevant to patients with physical and socioeconomic barriers to care;
- A more intimate clinician–patient relationship “around the kitchen table,” as Barbara A. McCann of Interim HealthCare said in the workshop (see Chapter 4);
- Clinician expression of an act of humility that demonstrates that clinicians have left their comfort zone to be on their patients’ turf and that the patient and family are worth being truly known and visited;
- Lower costs for services that are desired more by many patients; and
- Sometimes, greater safety for frail elders, because they will have fewer of the common complications of hospitalization, such as delirium.
Because of these advantages, the home and community will emerge in the future as the main settings for a myriad of health care services, he said, adding that “the home setting and health services and supports will become so synonymous that they may not be called home care; rather, they will just be modern health care.”
Home-centered care is centered on the patient, offering holistic, sophisticated, and individualized care at home for people with serious and disabling conditions. Landers believes that home-centered care will grow into a major national strategy for the provision of health care because its benefits for both payers and patients are so powerful. Nevertheless, different areas of the country will accomplish this differently and along different timelines, he said, and the purchasers and organizers of care may vary from one place to another.
Meeting the Care Mission
Landers said that within the context of Medicare, the mission of home health care is to
- Help beneficiaries, especially patients with lower levels of mobility, safely transition to home from hospitals and facilities and continue their recovery and rehabilitation at home, and
- Help the highest-risk chronically ill beneficiaries age in place in home and community settings both by meeting certain primary medical care needs and by intermittently escalating the care provided at home to avoid the need for hospitalization. Aging in place in the home includes efforts to help beneficiaries remain comfortable at home in the last 6 to 12 months of life.
Emerging trends in the health care system will accelerate strategies to provide post-acute care in the home, he said. Electronic information exchange among providers and other technologies will improve the patient and family experience and ensure the use of home health care services at
the appropriate intensity. In addition, transitional care models that include posthospitalization home health care visits will become commonplace for many more people than are now eligible for them.
For high-risk chronically ill people, organizations like Independence at Home4 practices, patient-centered medical homes, and models of care for advanced illness will partner with home health agencies and community resources to reduce the amount of time patients spend in hospitals and nursing homes, improve key indicators of well-being for patients and caregivers, use technology to improve the home health care experience, and greatly increase the proportion of the oldest old who die at home with hospice care.
Ingredients for Progress
Four main ingredients will be needed to effect this evolution and can be put in place by all varieties of payers and organizations:
- Development and oversight of interdisciplinary home health care plans by physicians and advanced practice nurses informed by proven concepts of holistic geriatric medicine, palliative medicine, and rehabilitation medicine;
- Enhanced support during care transitions that addresses self-management, care coordination, information transfer, and clinical stabilization;
- An advanced capability for escalating the intensity of medical and palliative care at home in times of decline or exacerbation of a patient’s illness or medical condition (including escalation to hospital-like services at home); and
- The thoughtful use of advanced information technology between encounters to aid with the management of problems that arise between visits and to improve triage and the overall efficiency of care.
According to Landers, the single most important issue determining whether the potential of home-centered care is realized and the pace at which it will be realized is the strength of the nation’s Medicare-certified home health agencies. These organizations exist in virtually every community; employ hundreds of thousands of staff who are nurses, therapists, other clinicians, and aides; make more than 100 million home visits per year; and collectively, have many strong community ties. “I view many of these agencies as local and national treasures that should be improved,
not torn down,” he said. He noted, however, problems with the current licensure and accreditation framework and the imperfect payment model.
A set of policies that would support the home health care infrastructure and help it play the role that Landers envisions would
- Tie payments to outcomes and experience and facilitate provider participation in a diverse range of alternative payment models;
- Enable the hiring of medical directors (who would, for example, link home health care to the services offered by other key providers);
- Have interdisciplinary team case reviews, similar to the approach used by hospices;
- Make the interventions used during the transition of care a covered home health care service, irrespective of whether a patient is homebound;
- Facilitate technology upgrades to improve the flow of information among providers and between home health agencies and the patients and families served; and
- Develop training and careers for agency staff in state-of-the-art geriatric, palliative, and rehabilitation medicine, as well as in strategies for the coordination of care.
This central role would be further aided, he said, “by making major fraud and abuse concerns a thing of the past.” In the future, home health agencies should be accredited not just at the time of licensure but on an ongoing basis. Selected utilization metrics should be publicly reported. Value-based purchasing and oversight models should reduce variability across agencies, and efforts should be made to weed out less capable entities. If this were done, even the Medicare-certified home health agency of 2024 with the lowest level of performance would be “a serious and skilled clinical organization with the talent, culture, and technology [required] to be a core part of helping physicians and advanced practice nurses address Medicare cost and quality challenges.”
The best models and approaches and the resources and policies needed for success will be identified over time, and Landers offered the following advice for going forward:
As we explore these different models, let’s try to minimize the importance of the names and labels; where there are common home-centered themes and resources that can help, we should elevate those ideas irrespective of the packaging. We should avoid the temptation of trying to pick winners and losers between marginally different concepts whose success is more dependent on local execution. Instead, let’s focus on how we can ensure
that all of these well-intended and reasonably conceived efforts at advancing home-centered care are as successful as possible.
In conclusion, he said, “a bright home-centered health system is clearly and tangibly before us if we continue to nurture the seeds of change that are starting to grow, while taking steps to optimize rather than diminish our home health agencies.”
Questions and Comments
An open discussion followed Landers’s presentation. Workshop participants were able to give comments and ask questions. The following section summarizes the discussion session.
Bruce Leff, Johns Hopkins University, asked Landers about the decreasing emphasis on medical services and the creation of stronger links to social services. Landers indicated that he recognizes the importance of both medical and social supports but stated that Medicare is essentially a medical services program and not a long-term care system and that he would not advocate for it to become one. He also said that medical providers should take a biopsychosocial approach to the provision of their medical care and should make efforts to assess and coordinate social supports in high-risk situations. Furthermore, Landers said, if people are going to age in place at home with long-term services and supports, they will need both primary medical services and other types of supporting services, only some of which are covered under current Medicare rules.
In response to a question from a workshop participant on the role of the individual, Landers said that care starts with medical care based on evidence-based geriatric medicine, palliative medicine, and rehabilitation medicine, all of which take a patient-centered approach using a comprehensive biopsychosocial assessment and a multifaceted model for the planning of care. At the same time, he said, some of the population groups that would benefit the most from home health care are quite dependent, as a result of impairment in cognitive function and an inability to perform activities of daily living. Landers explained that in these situations health policy makers should still develop programs that respect the individual but should be vigilant that some individuals are so impaired that the risk of neglect and suffering without aggressive intervention is high.
Penny Feldman, Visiting Nurse Service of New York, asked Landers to indicate the one or two most important actions that home health agencies can take if they want to survive in the current environment. She also wanted to know in what ways organizations representing home health agencies can help them prepare to be vibrant agencies in the future. Landers said that home health agencies need to embrace the role of value creation. Home
health agency staff sometimes say, “these hospitals don’t know what they’re doing. They send these patients home that are so sick. They have all these needs. They’re complicated. What were they thinking?” Actually, Landers said, these are exactly the situations in which home health agencies have the most opportunity to create value. Their value cannot be established on the basis of the provision of marginal services but can be established on the basis of the provision of services that produce health and cost outcomes that are different from those that they would otherwise be without home health care. A second benefit of acquiring an attitude of value, he said, would be to eliminate efforts to manipulate the system, for example, making an extra visit to obtain additional reimbursement. This speaks to the parallel need for a culture of accountability in places where it does not exist today.
Feldman further asked if anything in the existing Medicare home health care benefit could help home health agencies have greater flexibility and even with their survival. At the national level, Landers said, the development of a common vision for where home health agencies need to be in the future would enable stronger advocacy for some of the policy issues. Because health care is so different from one locale to another, the vision needs to focus on broad themes and resources. In sum, he said, “What are the carrots and sticks that can get us closer to value rather than waste?”