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An Introduction to Home Health Care in the United State

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An Introduction to Home Health Care in the United States: Overview and History of Home Health Care and the Medicare Home Health Care Program Tracy Gutman, MD – PowerPoint PPT presentation

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Title: An Introduction to Home Health Care in the United State


1
An Introduction to Home Health Care in the United
States
  • Overview and History of Home Health Care
  • and the Medicare Home Health Care Program
  • Tracy Gutman, MD
  • Geriatrics Fellow
  • University of Kansas

2
OBJECTIVES By the end of this module, the
learner will do the following
  • List the types of home health care providers and
    the specific tasks that they perform in the home.
  • Differentiate the focus of Medicare home health
    care services before and after the Balanced
    Budget Act of 1997.
  • Define the requirements for participation in
    Medicare home health care.
  • Explain under what circumstances Medicare home
    health care will cover personal care services.
  • Describe Medicare reimbursement for home medical
    equipment.
  • Describe a typical Medicare home health care
    episode.

3
Pretest 1. True or False
  • Home health care providers can include
  • dentists, podiatrists, psychologists,
  • dieticians, optometrists, and pharmacists.

4
Factors that shifted medical care from the home
to the hospital include all of the following
except
Pretest 2 Multiple choice
  1. There was a lack of nurses to provide care in the
    home.
  2. New medical technology required space and
    maintenance that could only be provided in the
    hospital.
  3. Physicians started to specialize more and offer
    their services in centralized locations.
  4. Increased use of cars and public transportation
    allowed patients to travel to hospitals.

5
Which of the following best describes how the
Balanced Budget Act of 1997 (BBA) impacted home
health care?
Pretest 3 Multiple choice
  1. The BBA expanded home health care to include
    chronic long term care.
  2. The BBA liberalized the Medicare criteria for
    receiving home health care.
  3. The BBA set limits on Medicare spending,
    refocused home health care to post acute care,
    and cut the increased Medicare home health care
    services available in the 1980s and early 1990s.
  4. The BBA increased the Medicare home health care
    budget.

6
Which of the following patients does not meet the
Medicare home health care homebound participation
requirement?
Pretest 4 Multiple choice
  1. Betty leaves her home for dialysis three times
    per week.
  2. John attends an adult day care program several
    times per week.
  3. Norma goes to church every Sunday.
  4. Peter goes out with friends to a restaurant every
    Wednesday.

7
Which of the following patients does not meet the
Medicare home health care skilled need
requirement?
Pretest 5 Multiple choice
  1. Victor needs help with blood sugar monitoring and
    diabetic education.
  2. Virginia needs rehabilitation for her hip
    replacement.
  3. Cecil needs a bath aid.
  4. Rose needs wound care for her pressure ulcer.

8
Pretest 6. True or False
  • A patient must meet the Medicare homebound
  • requirement in order to receive home medical
  • equipment from Medicare.

9
Pretest 7 Multiple choice
A typical Medicare home health care episode
includes all of the following except
  1. an initial evaluation including basic teaching
    and counseling
  2. development of a 60-day care plan
  3. a mandatory home health visit from a physician
  4. physician reviews and signs the care plan

10
Pretest Answers
  1. true
  2. a.
  3. c.
  4. d.
  5. c.
  6. false
  7. c.

11
Section One What is Home Health Care?1,2
  • Any diagnostic, therapeutic, or social support
    service provided in the home
  • Health care providers who provide home care
  • Home diagnostics
  • Home equipment
  • A variety of services designed to provide care
    for patients in their homes

12
Home Health Care Providers3,4
  • Physicians, nurse practitioners, physician
    assistants
  • Physical therapists, occupational therapists,
    speech therapists
  • Nurses
  • Social workers
  • Home health aids
  • Dentists, podiatrists, psychologists, dieticians,
    optometrists, and pharmacists

13
Diagnostics and Equipment2
  • Lab work, x-ray, ultrasound, EKG, holter
    monitoring, other diagnostics that can be done in
    the home.
  • Beds, wheelchairs, lifts, commodes, infusion
    therapy, and other assistive devices used in the
    home.

14
Other Home Health Care Services1,2
  • Home health aids, home attendants, housekeepers,
    and meal delivery
  • Telemedicine monitoring (using the telephone to
    provide care)
  • Hospice

15
Section Two A Brief History of U.S. Home Health
Care
  • Historically, most health care was provided in
    the home.
  • Physicians provided services in the home as well
    as nurses.
  • Visiting nurses associations played a large role
    in making home visits.6,3

16
Shift in Care to Hospitals7
  • Advances in medicine shifted care.
  • New medical technology required space and
    maintenance that could only be provided in
    hospitals.
  • Physicians started to specialize more and offer
    their services in centralized locations.
  • Increased use of cars and public transportation
    allowed patients to travel to hospitals.

17
Home Health Care for Long Term and then Post
Acute Care3,8
  • By the 1930s
  • most care of acutely ill patients had
    transitioned to the hospital and
  • visiting nurses provided long term care in the
    home to chronically ill patients.
  • In the late 1950s hospitals began to make
    referrals to home care nurses
  • to help with the discharge of patients from the
    hospital to the home and
  • to provide post acute care.
  • Home health care agencies were funded by
    charitable and public contributions until the
    passage of the Medicare Act in 1965.

18
Medicare Expanded Home Health Care2,3
  • Medicare covered care for
  • patients sent home from the hospital (post acute)
  • post-hospital home health benefit under Part A
    limited to 100 visits following a 3-day hospital
    stay
  • Medicare also covered more chronic care
  • general home health benefit under Part B limited
    to 100 home visits per calendar year

19
Medicare Home Health Care Continued to Expand in
the 1980s
  • Omnibus Reconciliation Act of 19803
  • removed the limits on the number of home care
    visits,
  • removed the prior hospitalization requirements,
  • extended participation in Medicare home care to
    for-profit home care agencies.
  • More than half of the patients receiving home
    health care did not have immediate prior
    hospitalizations, and many people received
    services for more than 6 months1

20
Increase in Home Health Care in 1980s-1990s
  • During the 1980s, the hospital prospective
    payment system was implemented resulting in
    faster discharges from hospitals and the need for
    post hospitalization home care services.3
  • During the 1980s, with the removal of the
    requirement for a recent hospitalization,
    services increased as well to the chronically ill
    needing more long term care.8,2
  • Medicare home health care payments increased an
    average of 33 per year between 1989 and 1996.9

21
Home Health Care in the1990s1
  • Throughout the 1990s, home health care services
    continued to expand due to
  • earlier hospital discharges,
  • declines in nursing home beds,
  • increased numbers of frail adults and elders,
  • cost-based financing of home care.

22
Home Health Care in the1990s (cont.)
  • In the early 1990s, Medicare reimbursement for
    home visits also increased.2,3
  • Majority of Medicare home health episodes
    extended past 6 months.2,3
  • Between 1990 and 1997, home health care was 9 of
    the Medicare budget.1
  • In 1997, there were 10,444 Medicare certified
    home health care agencies in the U.S.3

23
1997 Balanced Budget Act Curtailed Medicare Home
Health Care1,8
  • Balanced Budge Act (BBA)
  • set limits on Medicare spending,
  • refocused home health care to post acute care
    only,
  • cut the increased services available in the 1980s
    and early 1990s.
  • More stringent criteria for home health care
  • set new requirement of homebound status and
  • refocused home health care on post acute care and
    episodic care.

24
BBA Prospective Payment System1,3
  • The 1997 BBA created a home health care
    prospective payment system (PPS)
  • home health agencies would be paid a set amount
    for each 60-day episode, regardless of the number
    of visits provided and
  • payment broken down into 80 separate clinical
    categories.
  • BBA also created a requirement for agencies to
    report outcome data on all Medicare and Medicaid
    patients using the Outcome and Assessment
    Information Set (OASIS)

25
BBA PPS
  • Cost-based reimbursement with a prospective
    payment system resulted in a 20 decline in home
    health care, with more rural area agencies
    closing.1
  • BBA reduction in home health care reimbursement
    led to closure of 14 of home health agencies
    between 1997 and 1999.9
  • In 1999, home health care was 4 of the Medicare
    budget, as compared with 9 between 1990
    and1997.1
  • By 2001, more than 1/3 of home health agencies
    closed.3

26
Section Three Medicare Home Health Care
Program2,3
  • Pays for skilled nursing care, physical therapy,
    occupational therapy, speech therapy, medical
    social work, home health aide services, medical
    supplies.
  • Limits services through program participation
    requirements.
  • Focuses primarily on short term care and post
    acute, post hospitalization care.
  • A physician must make the referral for home
    health care to a home health care agency and
    oversee the plan of care.

27
Participation Requirements2,3
  • Patients must be temporarily or permanently
    homebound.
  • Patients must have a need for skilled services.

28
Homebound
  • Patients must have an inability to leave their
    homes, i.e.,2,3
  • leaving the home requires considerable and taxing
    effort on the part of the patient, caregiver, or
    both,
  • and/or requires the assistance of another person
    or an assistive device or special transportation.
  • Nonmedical absences from the home must be
    infrequent and of short duration.3

29
Skilled Care Need1,2
  • Skilled nursing
  • includes monitoring vital signs such as blood
    pressure, pulse, temperature, monitoring drains,
    dressing wounds, managing medication regimens,
    and providing patient and family education
  • Physical and occupational therapy, speech
    therapy, and other therapies
  • includes gait and balance training, home safety
    assessments, exercise instruction, and help with
    assistive devices
  • Skilled care need must be intermittent not
    continuous and must be episodic and for brief
    periods of time only.

30
Medicare Part A2,3
  • Pays for home health care if patients meet the
    two requirements.
  • Patients do not pay additional costs or
    co-payments.
  • Patients must have a referral from a physician
    who certifies home health care as medically
    necessary.
  • Pays for 60-day episodes.

31
Medicare Part A3,10 (cont.)
  • The 1997 Balanced Budget Act (BBA) created a home
    health care prospective payment system (PPS) for
    reimbursement which developed 80 separate
    clinical categories with set amounts for each 60
    day episode of care
  • Payment is based
  • in part on patient acuity and is not based on the
    actual number of visits provided
  • on the BBAs data gathering tool, the Outcome and
    Assessment Information Set (OASIS), which
    assesses severity of illness, disabilities, and
    nursing needs

32
Additional Medicare Services1,2
  • Once homebound patients meet the skilled care
    need requirement and receive skilled services
    through nursing or therapy, they can also receive
    social work and home aid services.
  • However, if patients do not have a skilled need,
    Medicare will not pay for any home aid or
    personal care services.
  • Medicare will only pay for home aid and personal
    care services for short periods, such as a few
    hours per day and only if patients have a
    concurrent skilled need for home health care.

33
Medicare Coverage of Home Equipment1,2
  • Will pay for home medical equipment
  • even for those patients who do not meet the
    homebound requirement and
  • includes such durable medical equipment as
    hospital beds, special mattresses, commodes,
    wheelchairs, walkers, lifts, and oxygen.
  • Medicare Part B pays 80 of the cost then
    patients have a 20 co-pay.

34
Medicare Home Equipment (cont.)1,2
  • Private insurance will often cover the remaining
    costs.
  • Physicians must complete a Medicare certificate
    of medical necessity.
  • Medicare does not pay
  • for nondurable, smaller medical equipment such as
    diapers, wipes, gloves, dressing materials, grab
    bars and other bathroom modifications, canes, and
    reachers,
  • but in some states Medicaid does pay for some of
    these above types of supplies.

35
Typical Medicare Home Health Care Episode3
  1. Physician makes a referral to a home health
    agency, and an initial evaluation occurs within
    48 hours of the referral.
  2. RN must complete the initial evaluation unless
    the patient requires only physical, occupational,
    or speech therapy services (then the therapist
    performs the initial evaluation).
  3. At the initial visit, the nurse determines
    eligibility, obtains consent for care, completes
    paperwork, and performs a comprehensive initial
    assessment.

36
Typical Medicare Home Health Care Episode
(cont.)3
  1. After this initial visit, the patient receives a
    number of subsequent visits based on the
    patients needs for care.
  2. The admitting nurse or therapist develops a
    60-day care plan that describes all services
    needed and establishes goals.
  3. Referring physician reviews and signs care plan.
  4. Home health care providers then proceed with the
    specific tasks and goals and update the care plan
    which the physician then periodically signs along
    with any new orders.

37
Medicare Home Health Care Focus
  • Medicare-funded home health care provides
    patients with services for discrete acute
    episodic periods based on patient acuity and
    needs.
  • Patients are discharged from home health care
    when the discrete acute defined goals have been
    met, even though they continue to have chronic
    debilitating medical conditions and functional
    limitations.
  • The focus is on post acute and episodic, not long
    term care.

38
Post-test 1. Multiple choice
Which of the following best describes home health
care personal assistance services?
  1. A nurse providing ostomy care
  2. A speech therapist evaluating swallowing
    dysfunction
  3. A home health aid providing assistance with
    bathing and dressing
  4. A physical therapist providing teaching on safe
    transfers

39
Post-test 2. True or False
  • The Omnibus Reconciliation Act of 1980 expanded
    Medicare home health care by removing the limits
    on the number of home visits, removing the prior
    hospitalization requirement, but limited
    participation to non-profit home health agencies.

40
Post-test 3. True or False
  • In the early 1990s, the majority of Medicare home
    health care episodes extended past 6 months.

41
Post-test 4. Multiple choice
Which of the following did the Balanced Budget
Act of 1997 not do?
  1. Resulted in fewer patients receiving home health
    care, fewer visits, lower payments, and shorter
    durations of service
  2. Introduced new participation requirements for
    Medicare home health care
  3. Introduced a data gathering tool, the Outcome and
    Assessment Information Set (OASIS)
  4. Improved long term home health care services for
    patients with chronic diseases

42
The Medicare home health care homebound
requirement includes all of the following except
Post-test 5. Multiple choice
  1. Permits weekly social visits
  2. Requires that patients have difficulty leaving
    their homes
  3. Permits leaving the home for doctors
    appointments
  4. Permits trips to church

43
Which of the following best describes the
Medicare home health care skilled need?
Post-test 6. Multiple choice
  1. Can be a continuous need for 24 hour care
  2. Includes physical, occupational, and speech
    therapy
  3. Includes social work needs
  4. Includes home health aids and attendants

44
Which of the following applies to the Medicare
provision of home medical equipment?
Post-test 7. Multiple choice
  1. Patient must be homebound.
  2. Medicare pays 100 of the cost.
  3. Physicians must complete a Medicare certificate
    of medical necessity.
  4. Medicare will pay for bathroom modifications.

45
Post-test Answers
  • c.
  • false
  • true
  • d.
  • a.
  • b.
  • c.
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