Medicare Home Health Benefit Research Articles

Does Medicare Care About Anxiety: Views of Home Care Social Workers

This study addresses the lack of research on the perceptions of home care social workers as to how the Medicare home health benefit addresses anxiety. The findings are based on interviews of 44 home care social workers from five home health agencies in the New York City area. Four themes emerged. Social workers believe: (1) there is extensive anxiety among Medicare home health beneficiaries; (2) Medicare home health’s mandatory assessment for anxiety is limited and not done by social workers; (3) Medicare home health does not require treatment or coverage of anxiety; (4) the lack of coverage for patients assessed with anxiety creates and exacerbates mental and physical health conditions. Policymakers should modify the Medicare home health benefit to cover anxiety.

They Live in an Isolation Chamber: Medicare Fails the Depressed Homebound Elderly

There is significant literature on the existence and adverse effects of social isolation and depression among the elderly, exacerbated by the recent COVID-19 pandemic. A literature review indicates no studies of how the Medicare home health benefit addresses social isolation and depression, including no studies of home care social workers’ perceptions of the nature and consequences of Medicare coverage. This article summarizes an initial, exploratory study to address the literature gap, based on interviews of a convenience sample of 44 home care social workers from 5 different home health agencies in the New York City metropolitan area between November 1, 2021 and May 31, 2022. Six themes emerged from the study. Social workers believe: (1) extensive social isolation and depression exist among Medicare home health beneficiaries; (2) Medicare home health policy provides no systematic measure to detect or monitor social isolation and a limited measure for depression among the homebound elderly; (3) Medicare home health policy provides no coverage to treat either depression or social isolation; (4) effective interventions are available to prevent and treat depression and social isolation. Social workers also believe that: (5) the lack of social isolation and depression coverage results in additional mental and physical health conditions; (6) lack of social isolation and depression coverage exacerbates existing mental and physical health conditions. Policymakers are urged to modify the Medicare home health benefit to improve detection and monitoring of social isolation and depression as well as coverage of appropriate evidence-based preventative and treatment interventions.

Implications of 2020 Skilled Home Healthcare Payment Reform for Persons with Dementia.

The Medicare home health benefit provides episodic skilled home-based clinical care to the growing population of community-dwelling persons with dementia. As of January 1, 2020, home health payment changed: episodes shortened from 60 to 30 days, and episodes initiated in the community are now reimbursed at lower rates than episodes following institutional stays. We aim to assess the potential impact of these policy changes on this population. Cross-sectional study using the Medicare claims-linked National Health and Aging Trends Study (NHATS). A total of 1,867 NHATS respondents who received home health between 2011 and 2017. Dementia was defined through both self-report and a validated cognitive assessment through NHATS. We described the demographic, socioeconomic, and health characteristics of older adults with dementia receiving home health compared with those without dementia. We then assessed the association of dementia with both receiving community-initiated home health (vs postinstitutional) and visit timing during the home health episode. Over a follow-up period of just over 4 years, 50.2% of persons with dementia used home health compared with 15.3% of persons without dementia. Most home health provided to persons with dementia was initiated in the community (61%), compared with 37% of episodes provided to persons without dementia. Persons with dementia were more likely to receive care in days 31 to 60 of the episode compared with those without dementia. Shortening episodes and reimbursing community-initiated episodes at lower rates may disproportionately impact the highly vulnerable population of older adults with dementia, who receive more community-initiated care over longer time periods. Our work highlights the need to better understand the unique role of home health in meeting gaps in both acute- and long-term care systems for older adults with dementia. J Am Geriatr Soc 68:2303-2309, 2020.

Reduced Awareness of Memory Deficit is Associated With Increased Medicare Home Health Care Use in Dementia

The objective of this study was to examine whether reduced awareness of memory deficits in individuals with dementia is associated with more frequent need for Medicare home health care services. Cross-sectional analyses were conducted in a multicenter, clinic-based cohort. In total, 192 participants diagnosed with dementia and their informants were independently asked whether or not the participant demonstrated cognitive symptoms of dementia related to memory and word-finding. Participant self-awareness was measured as the discrepancy between participant and caregiver report of these symptoms. Annual Medicare home health benefit use data was obtained from Medicare claims matched by year to the Predictors study visit. Participants that used home health services had lower awareness scores than those who did not. Awareness remained independently associated with home health use in a logistic regression adjusted for age, gender, education, caregiver relationship, global cognition, dementia subtype, and medical comorbidities. Reduced self-awareness of memory deficits in individuals with dementia is associated with more frequent use of Medicare home health services. The disproportionate use of in-home assistance as a function of awareness level may reflect dangers faced by patients, and challenges faced by caregivers, when patients have limited awareness of their memory deficits. Current results have implications for clinical care, caregiver education, and models of health care utilization.

FAQs: Certifying Patients for Medicare Home Health Benefit.

Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc, Lake Worth, Florida. Ms Schaum can be reached for questions and consultations by calling 561-964-2470 or through her e-mail address: [email protected]. Submit your questions for Payment Strategies by mail to: Kathleen D. Schaum, MS, 6491 Rock Creek Dr, Lake Worth, FL 33467.

The Future of the Medicare Home Health Program

Most older Americans want to age in place.1 The Medicare home health benefit is a prominent national policy supporting older Americans at home and provides for visiting nurse and therapist services from home health agencies (HHAs). In 2012, Medicare spent $18.2 billion on HHAs; 3.5 million beneficiaries received care.2 Home health can help struggling patients get support in the community and can enable successful transitions home from institutional care. However, numerous concerns have been raised about the home health benefit, including fraud, geographic variation in utilization, and poor coordination with primary medical care.3- 5 This uncertainty is untimely, as more than 70 million adults will join Medicare between 2011 and 2030 with the hope of receiving care at home. It is time to develop a stronger home health option.

Integrating Mental Health Parity for Homebound Older Adults Under the Medicare Home Health Care Benefit

Despite high rates of mental illness, very few homebound older adults receive treatment. Comorbid mental illness exacerbates physical health conditions, reduces treatment adherence, and increases dependency and medical costs. Although effective treatments exist, many home health agencies lack capacity to effectively detect and treat mental illness. This article critically analyzes barriers within the Medicare home health benefit that impede access to mental health treatment. Policy, practice, and research recommendations are made to integrate mental health parity in home health care. In particular, creative use of medical social work can improve detection and treatment of mental illness for homebound older adults.

Changing Laws Make for Interesting Times

Changing Laws Make for Interesting Times

Unleashing the Ghost of Home Care: The Case for a National Alzheimer’s Disease Home Care Demonstration Project

Keywords: Alzheimer's disease; dementia; Medicare; home health care; hospice In a recent study, 33 nurses and 39 social workers from 32 different Medicare-certified home care agencies characterized patients with Alzheimer's disease (AD) as victims of designed neglect and ghosts of home care (Cabin, 2009). These providers described the ghost as being the psychosocial being of the patient, lingering in the background and haunting both them and the patient. They said that the haunting presence was always there but that they never could unleash its being in the reality of care because of Medicare's focus on acute, physical problems. They discussed the unmet patient and caregiver needs created by a purposely designed acute care medical model that neglects the issue of preventive care, chronic care, and psychosocial care for the elderly. To them, the AD patients and their caregivers were the most emblematic of these unmet needs. The Medicare program's failure to address cost effectively the quality-of-life (QOL) issues of another group, end-of-life cancer patients and their caregivers, was recognized by the government and several private foundations in the late 1970s. The result was a national hospice demonstration project, leading to passage of the Hospice Medicare Benefit in 1982. This article explores the Alzheimer's problem further, examining how a national demonstration project similar to the Medicare Hospice demonstration project is much overdue and yet imminently feasible, particularly in a time of cost-effectiveness in health care. THE PROBLEM The problem is that AD is a significant and increasing cause of medical, psychological, physical, and financial burden to persons with the disease and their caregivers, who provide most of their care at home without any significant eligibility or coverage under Medicare or Medicaid, let alone the $15 billion annual Medicare home health benefit. This situation also creates a significant cost burden to employers through lost work and productivity of caregiver employees and to the government through increased Medicare and Medicaid hospital and nursing home costs. The remainder of this section details the nature and significance of the Alzheimer's problem. The following section details how current home care policy exacerbates the problem. AD is a major and increasing cause of illness and death in the United States, a disorder that grows along with the aging process. Symptoms include a gradual and steady decline in orientation, a decrease in memory and ability to participate in everyday activities, and personality changes. AD is the most common type of dementia identified in the United States, with over 5 million persons estimated to have the disease in 2007, including 4.9 million over age 65 (Alzheimer's Association, 2007a, 2007b; U.S. Department of Health & Human Services, 2008). It is the fourth-leading cause of death for Americans aged 65 and older, exceeded only by cardiovascular disease, cerebrovascular disease, and cancer. Care for persons with AD in the United States costs about $100 billion annually (Centers for Disease Control and Prevention, 2007; McConnell, 2004; Rice, et al., 2001; Sadick & Wilcock, 2003). The number of such persons in the United States is projected to increase to 14million to 16 million by 2050, with an annual cost of care about $300 billion. International projections are at 18 million individuals today and upward of 80 million by 2050 (Whitehouse, 2008; World Health Organization, 2008). Caregiver burden is a major issue for those who serve AD patients and others with dementias (Dartmouth Atlas Project, 2006; Kennet, Burgio, & Schulz, 2000; Levine, 2000, 2003; Levine & Murray, 2004; O'Brien, 2004; Robert Wood Johnson Foundation, 1996, 2001). An estimated 70% of Alzheimer's patients live at home, where approximately 75% of care is provided by family members and /or significant others (Leland, 2008; McConnell & Riggs, 1999). …

Lifting the Home Care Veil From Depression: OASIS-C and Evidence-Based Practice

There is a high prevalence of depression among the general elderly population. There is an even higher prevalence among elderly receiving home health care, with a conservative estimate of 13.5% having clinically defined major depression. The Medicare Home Health Benefit provides limited coverage, eligibility, and payment for mental health services, and the national Outcome Assessment and Information Set (OASIS) assessment instrument has had limited requirements on assessing, diagnosing, and treating depression. However, the new OASIS-C significantly increases the depression-related requirements, though still not requiring assessments and not adding prospective payment reimbursement for patients with depression. The new OASIS-C requirements provide a gateway to home care providers seeking to expand depression care, especially combined with evidence-based models of primary care—based collaborative depression management programs such as the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program. The article explains IMPACT, explores its cost savings and care improvement outcomes, and explores how Medicare and private duty home care providers might use IMPACT-type models to improve their patient care and agency fiscal health.

Physician Evaluation and Management of Medicare Home Health Patients

The Medicare home health benefit is predicated on physician referral and involvement. In this study, we investigated (1) the frequency and (2) implications of home health patients' evaluation and management by community physicians. The 2005 and 2006 Medicare 5% Standard Analytic Files were linked to the Outcome and Assessment Information Set to examine physician visits among 74,462 fee-for service Medicare beneficiaries with a home health episode of care between July 1, 2005 and December 1, 2006. We examined whether receipt of community physician evaluation and management visits by home health patients was associated with subsequent discharge disposition, comparing discharge from the agency as opposed to inpatient facility transfer. More than one-third (34.6%) of patients did not receive physician evaluation and management visits during their home health episode. Home health patients most commonly incurred physician office visits exclusively (51.5%) or in combination with consultations (6.8%) or house call visits (2.2%), as well as house call visits exclusively (3.3%). Patients who incurred physician evaluation and management visits during their episode of care were more likely to be discharged from home health agencies than their counterparts who did not (77.9% vs. 70.6%, respectively). The association between physician visits and home health discharge was statistically significant in both simple regression models (odds ratio = 1.47; 95% confidence interval [CI], 1.42-1.52) and in multivariate analyses accounting for socio-demographic factors, health, and functioning (odds ratio = 1.45; 95% CI, 1.40-1.51). More systematic integration of physicians in home care processes may reduce subsequent hospital and other inpatient facility use among home health patients.

Moving Toward Medicare Home Health Coverage for Persons with Alzheimer's Disease

ABSTRACT Medicare home health care policy does not incorporate research evidence of effective palliative home care interventions for Alzheimer's disease and dementia patients and caregivers. This article examines the dissonance between the needs and burdens of Alzheimer's disease patients and caregivers, research results on medical and palliative care interventions, and medicalized public policy in the Medicare home health benefit. The article asserts existing research establishes a prima facie case exists for the federal government to fund a Medicare Palliative Home Care for Alzheimer's disease demonstration project. The article cites the success of the Medicare Hospice Demonstration project and Hospice Medicare Benefit in reducing costs and improving client quality of life as precedent and a model for Alzheimer's disease. Other research implications are identified.

Actualizing “Professional Altruism”

The Medicare home health benefit and the Medicare Hospice Benefit (HMB) differ significantly in social work coverage, with social work being only 1%-2% of national Medicare home health visits compared to about 10% of national HMB visits. There has been some research on the frustrations of home care and hospice social workers. However, there is no research that compares home care and hospice social workers. The article presents results of convenience sample interviews of 34 home care social workers and 42 hospice social workers in New York City from August 2006 to October 2007. The analysis finds that, in contrast to home health social workers, hospice social workers feel more able to actualize their altruism professionally; their professional training is more relevant to actual practice; their patients and caregivers have fewer unmet psychosocial needs; and their care is less constrained, and actually enhanced to a great extent, by payer requirements.

The Impact of Policy on Nursing and Allied Health Services: Lessons from the Medicare Home Health Benefit

This article analyzes changes in Medicare home health staffing and service delivery patterns across three different reimbursement methods: cost based (1996), interim payment system (IPS) (1999), and the prospective payment system (PPS) (2002). This study combined secondary analysis of existing data (Provider of Services File and Statistical Supplement) with qualitative interviews of 22 home health agency directors to understand agency responses to policy changes created under the Balanced Budget Act of 1997. Cuts in staff and visits were greater under the IPS than they were under the PPS. Agencies cut staff and visits more dramatically for nonskilled services across both time periods. As a proportion of total services and visits, nursing and therapy services increased the most. Directors used various strategies to sustain the agency financially during these dramatic cuts in reimbursements, including eliminating staff, shifting staff roles, training staff on reimbursement methods, increasing use of telephone monitoring, increasing patient and family education and self-care, and cutting services to patients. Directors expressed concerns about staff stress related to the changes and the need to increase productivity without increasing staff. However, directors also believed the agency's position would improve under the PPS. Additional research is needed to determine whether increased staff stress, work demands, and fewer resources for patients will affect the quality of care delivered and, thus, patient outcomes under the PPS.

Phantoms of home care: regulatory constraints on home care nurse care management of persons with Alzheimer's disease.

Early indications are that the Medicare home health prospective payment system has controlled Medicare home health expenditures. However, studies indicate many unresolved questions about whether the prospective payment system improves patient quality of care and is cost-effective. The question persists as to whether the prospective payment system has intensified the Medicare home health benefit's historic focus on acute medical care, ignoring the needs of persons with chronic diseases. The article reviews effective home-based palliative care interventions and presents the views of 7 home health care nurses regarding the impact of Medicare requirements on their care decisions for one chronic disease population, patients with Alzheimer's disease. The nurses identify Alzheimer's disease symptom management and psychosocial needs as phantoms, omnipresent below the surface but not attended to by home care clinicians. Nurse coping strategies are discussed. The article asserts that the current failure to simultaneously address the cost and quality-of-life issues of persons with Alzheimer's disease who are cared for at home is analogous to the end-of-life care situation Medicare confronted in the 1970s prior to the Medicare hospice demonstration program, which preceded the Hospice Medicare Benefit. The article asserts that a similar demonstration is appropriate to determine how the prospective payment system might better address quality of life and costs of persons with Alzheimer's disease who are cared for at home.

Through the Looking Glass …

The Medicare home health benefit has come full circle. Originally, the program promoted patient self-care independence by annual visit limitations. When these limits were lifted, by some accounts, the program fostered client dependence on home health services. Under the new Prospective Payment System, with its Outcome-Based Quality Improvement (OBQI) focus, client participation and maximum outcome achievement are reemphasized. The program establishes the Out-come and Assessment Information Set as the basis for both reimbursement determination and quality monitoring. As a result of the new regulatory mandates for patient-centered OBQI, many agencies are reevaluating their quality management activities to consolidate efforts and establish processes focusing on positive outcome achievement in all aspects of organizational performance. The processes involve integrating a variety of pre-OBQI activities into a new format of quality management. This article explores several quality management considerations as potential components of a home health agency’s quality improvement program redesign.

Evolution of the Medicare Home Health Benefit (1965???2001)

Evolution of the Medicare Home Health Benefit (1965???2001)

Effects of the Home Health Care Interim Payment System on Access to Home Health Care for People on Medicare

In the Balanced Budget Act of 1997 (the BBA), Congress established an Interim Payment System (IPS), effective October 1, 1997, and directed the Health Care Financing Administration (HCFA) to promulgate a Prospective Payment System (PPS) to pay for home health care by October 1, 1999. Since the inception of IPS, the Medicare Rights Center,1 through our work with people on Medicare across the country, has seen a marked increase in the number of people who are eligible for the home health benefit, but who are unable to access it. In particular, we have found that the reduced reimbursement to home health agencies under IPS has meant that agencies have increasingly refused, reduced or terminated care to people with costly, complex or chronic illness. Because establishment of PPS has been delayed until October 2000, we recommend immediate reforms to constrain or reverse the pernicious effect of IPS on the frailest and sickest people on Medicare. MEDICARE HOME HEALTH CARE BENEFIT: BACKGROUND The Medicare home health benefit consists of skilled nursing, therapy, and related services provided by a Medicare-certified home health agency (HHA). To qualify for Medicare home health services, the patient must be homebound and require skilled nursing care or physical, speech or occupational therapy on a part-time or intermittent basis or need daily skilled services for a finite and predictable period of time.2 The services must be furnished under a plan of care prescribed and periodically reviewed by a doctor. If all of these criteria are met, Medicare will pay for home health visits provided by a registered nurse, a physical, occupational, or speech therapist, a social worker, and a home health aide. Medicare regulations do not impose limits on the length of time a patient may continue to receive home health benefits. Medicare will pay for home health care as long as the patient meets Medicare eligibility criteria (see Note 2) and home health care is reasonable and necessary for the treatment or management of a patient's illness or injury. There are no limits on the number of visits or length of coverage, and there are no copayments or deductibles for the benefit. Today, approximately 3 million acutely and chronically ill seniors and people with disabilities on Medicare depend on home health care as part of their medical care (Smith, 1999). Because patients must be homebound in order to qualify for the benefit, they are typically the sickest and the oldest people on Medicare. They are disproportionately female and 85 years of age or older. About 70 percent have incomes of $15,000 or less (Smith, 1999). Home health care has been one of Medicare's fastest growing benefits over the last 15 years. In 1990, the Medicare home health benefit was used by 57 out of every 1,000 people on Medicare. By 1997,109 out of every 1,000 were using the benefit. In the same time period, the average number of visits per user in Original Medicare, the government-run fee-for-service program, went from 36 to 73. Expenditures rose from 3.2 percent ($3.7 billion) of total Medicare spending in 1990 to 9 percent ($17.8 billion) in 1997. This translates to an average annual growth rate of 25.2 percent, compared with 8 percent for the Medicare program as a whole (GAO, May 1999). While some of this growth was attributable to fraud and abuse on the part of disreputable home health providers, much of it came as a result of improved access to the benefit by people who needed home health care and the shift in common health care practices toward an emphasis on outpatient care and managing serious illnesses at home. The United States General Accounting Office (GAO) and other researchers attribute the following factors to the rise in home health care costs over the past 10 years (GAO, May 1999, Komisar, 1998): 1. Change of home health care coverage guidelines to include patients with chronic healthcare needs as a result of a 1988 lawsuit. …

Mobilizing and Motivating the Front Line Manager

The last few years have presented enormous obstacles and challenges to the home care industry. Between the growth of managed care and the erosion of the Medicare home health benefit, home care managers have been forced to reengineer their core business processes in order to maintain their equilibrium; often on the backs of the front line manager. This article identifies some of the key stressors affecting home care managers today and explores several options available to home care organizations that have proven useful in easing those burdens.

The Medicare Home Health Benefit Implications of Recent Payment Changes

The interim payment system (IPS) for Medicare home health services, enacted in the Balanced Budget Act of 1997, was intended to slow the growth of home health expenses until HCFA could design a new prospective system. Instead, the IPS has acted like a per-case payment system without case-mix adjustment. Its impact on agencies, along with other policy pressures, has been first to slow and then to reverse the dramatic expansion of the home health sector. In this paper, we identify the impetus for payment changes in the recent history of the Medicare home health benefit. We then present emerging evidence about the effects of IPS and other recent policies on home health. Finally, we draw several lessons from this experience for the impending prospective payment system.