Clinical Geriatrics

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.