Using Home Care to Improve Outcomes and Lower Costs
In most cases, home care takes place with little direct contact between the supervising physician and the rest of the home care team. In this article, I hope to demystify the process, review key features of Medicare reimbursement for home health agencies and how it may affect physicians, and outline some strategies for using home care to improve outcomes and reduce hospitalization. Home is where most of us prefer to be treated, and we should make our best efforts to honor that preference.1
THE PROCESS OF MEDICARE HOME HEALTH AGENCY CARE
When the physician refers a homebound Medicare patient for skilled home care, the home health agency performs a comprehensive assessment using the OASIS (Outcome and Assessment Information Set) plus other elements that vary by agency. The OASIS includes 89 items that describe patients’ functional abilities, symptoms and physiology (eg, dyspnea), technical needs (eg, wounds, catheters, ostomies, IVs), cognition, and behavior. Data on 41 clinical outcomes, adjusted for agency case mix and compared to national standards, are provided to the agency for quality improvement work. A subset (11 outcomes) is used for public performance quality reporting at Home Health Compare (visit cms.hhs.gov for additional information). The initial assessment is usually done by a nurse, even if the care plan focuses on rehabilitation (physical, occupational, and speech therapy). Using the assessment, the agency formulates a plan of care that incorporates specific orders given by the physician, then sends the plan to the physician for signature. This happens days or weeks after care begins. Physician signatures on all orders, including the plan of care, are required before the agency can bill Medicare, so orders often come with a request to sign and return promptly. Unsigned orders are a significant business problem for agencies. Nursing visits are the most common service, followed by home health aides (1-hour visits to help with activities of daily living) and therapy (physical and occupational). Patients are seen frequently at the start of care, sometimes daily or even twice daily, but the intensity rapidly tapers in most cases. Ongoing daily visits are difficult for an agency to sustain financially.
Agencies also must arrange for supplies related to certain aspects of care, such as wounds. The cases of homebound patients who need ongoing skilled care may be kept open indefinitely, recertifying every 60 days. This was common until 1997, but now it is increasingly rare. During the course of care, agencies may communicate actively with physicians, but often the interface involves only exchanges of paper. This is fine when care is routine. When patients develop new problems or fail to improve, communication is needed and is facilitated by working relationships built over time between agencies and referring physicians. There are more than 100,000 nurses providing home care through U.S. agencies. Typically, they each make five or six visits a day. Many work from home. Visits, planned and unplanned, are made on weekends, and sometimes at night. Weekend staffing is lighter, so agencies are cautious about opening new cases over a weekend. Agencies are increasingly using portable electronic devices to record visit data in order to move toward a paperless era.
THE IMPACT OF PROSPECTIVE PAYMENT
As shown in Figures 1 and 2, there has been a decline in the number of Medicare patients served by home health agencies and a dramatic decrease in visits since 1998. This is due to changes in payment methods. After three years of a problematic interim payment system (1997-2000), payment now uses a prospective system that provides agencies with fixed amounts for 60 days. There are 80 payment categories, based on clinical case mix determined by 23 of the OASIS items. Payment levels are higher when care is more complex and when patients need 10 or more hours of therapy in the 60-day interval. Under prospective payment, services have declined2 and there is preliminary evidence of under-service.3 There is also considerable anecdotal evidence of increased burden on family caregivers, who are typically told at the outset that agency personnel are only there for a short time, that Medicare limits the amount of service, and that the family must quickly learn to take over the care. Physicians, in turn, must understand when to push an agency for additional help in a given case and when to support the agency, which is under fiscal pressure and must carefully manage resources. Physicians should know these rules and not hesitate to discuss concerns with agency staff. In general, when the request is reasonable and conveyed in a reasonable manner, agencies are happy to help.
The 1997 Balanced Budget Act specifies that Medicare patients may not receive Part A skilled home health agency visits for the sole purpose of drawing blood. This rule became effective February 1998. However, if agency services include teaching the patient about managing his or her condition and helping the physician adjust the medical regimen, along with blood drawing, home care is allowed. When physicians make referrals that include blood drawing, remember to emphasize the teaching and care coordination. Patients disadvantaged by this rule include those who are chronically immobile and taking warfarin who need ongoing monthly international normalized ration (INR) measurement, plus any others who need frequent lab work, yet are clinically stable. Some communities have phlebotomy services that may involve a $30 or $40 transportation fee. Alternatively, patients may use nearby hospital outpatient departments or commercial laboratories for blood draws.
An important goal of Medicare home health care is to stabilize the patient following hospitalization. Still, about 28% of home care patients experience hospital re-admission during the episode. In a large national demonstration (over 157,000 cases), agencies focused on preventing emergent care and reduced hospitalization by 25%.4 If this could be generalized to all Medicare home health cases, it would be an enormous benefit. This area is the focus of a new national Medicare initiative now being planned. To be effective, one must be purposeful and proactive. Clinical circumstances that make good opportunities to reduce hospitalizations include, among others, heart failure,5 asthma, diabetes, and postoperative continuing care. In heart failure, the physician, agency, patient, and caregivers can establish parameters, such as dyspnea, blood pressure, pulse, weight, oximetry, and lab tests (eg, blood urea nitrogen, brain natriuretic peptide [BNP]) to guide therapy.
Patients should learn about sodium restriction—something taught most effectively at home—and medication compliance should be reviewed. Importantly, education of staff on contemporary treatment of heart failure, communication within the team, and prompt response to undesirable trends are critical. Monitoring patient progress is increasingly sophisticated with portable technology that includes the capacity for transmitting data electronically. Similarly, patients with asthma and chronic lung disease can be stabilized at home by strategies that include reducing allergen load, teaching energy conservation and patient awareness of early signs of decompensation, plus medication compliance. A randomized, controlled trial of “home hospitalization” reduced overall costs by 38% in a European study, mostly through decreased hospital stays.6 Poorly controlled diabetes is also amenable to improved management through home care, again focusing on diet, routines, and medication management. Avoiding emergency visits for hypoglycemia or uncontrolled hyperglycemia is often feasible. Even a complex problem with multiple causes, such as falls in high-risk patients, can be improved by in-home interventions,7 and this can be cost-effective if well targeted.8
PROACTIVE MEDICAL MANAGEMENT IN THE HOME
There is evidence that adding hospital-based advance practice nurses to the conventional home care team at the end of a hospital stay can reduce re-hospitalization of high-risk patients by 65% or more, treating a wide variety of diagnoses.9 Many of these patients were admitted for elective surgery, in addition to the chronic medical disorders often seen in home care. Preventing deep vein thrombosis, managing new catheters or ostomies, carefully reviewing medication regimens and side effects, and promoting functional recovery all may help. We found similar results at Virginia Commonwealth University using historical controls.10 Combining house calls with services through an Area Agency on Aging, a group in Philadelphia also produced approximately 50% reduction in Medicare costs and sharply reduced hospitalization rates.11
Physicians should again note the billing codes for Medicare home health care certification and recertification (G0179 and G0180), which pay about $60, plus Care Plan Oversight (G0181 for home care and G0182 for hospice), which pay about $120 but apply to fewer cases and require more documentation. The former two codes require only basic documentation and should be used more widely than they are. In view of the recent favorable studies on house calls and transitional care models, physicians and nurse practitioners are also reminded that the Medicare home visit fee schedule has been greatly improved during the past several years. Home visits should be part of active in-home management of patients with serious chronic illness.
The various programs described herein are best established and developed by physicians working in partnership with hospitals, health plans, and health systems, as well as home health agencies. There are many opportunities for creative approaches in your local communities. Remember: Carefully targeting high-risk patients, developing an effective, practical plan, controlling intervention costs, and using proactive management are all vital for success.