HCBS is at risk, will this affect senior independence?

care

Colorado VNA (CVNA) in Northern Colorado has been providing Medicaid Home and Community-Based Services (HCBS) services for over thirty years. Like many organizations that care for HCBS patients, our organization is struggling to care for these patients because the reimbursement is too low, well below our costs. In recent years, with the increase in home health care regulations; the cost to provide homemaking and personal care services has risen significantly. It is because of the gap between reimbursement and costs that CVNA is working to find other agencies to take on some of our patients. Additionally, CVNA will be kicking off a fundraising campaign to seek support from caring donors passionate about helping Colorado residents remain in their homes. The following is an overview of how CVNA came to this decision to decrease our HCBS census as well as a description of what other states are doing with HCBS.

A large challenge that CVNA and other HCBS providers struggle with is the low HCBS reimbursement rates. The rates have simply not kept pace with the increasing cost of living in Colorado. There was an increase from $15 per hour to $17 per hour in 2015 and then a 50 cent proposed increase for 2018. This increase is simply not enough and I fear that a growing number of agencies serving HCBS patients will decide to stop taking new HCBS patients and/or get out of HCBS altogether.

This is unfortunate because increased spending on attendant and homemaking care like HCBS has been shown to decrease institution costs, i.e. the more states increase and support HCBS services, the less funds are spent on skilled nursing. In fact Colorado has been a leader in supporting HCBS and as a result has had very limited to no growth in skilled nursing days for patients over 65 in the past ten years, however I fear that this trend may reverse in the near future if more money is not allocated for HCBS or other financial sources of support are not found.There is data that show systematic support for HCBS results in decreasing spending growth on institutional long-term care services. According to an article in Health Affairs “expansion of HCBS appears to entail a short-term increase in spending, followed by a reduction in institutional spending and long-term cost savings.” In fact “Nursing home spending grew by 3.4 percent in the low-HCBS states over the period, after adjusting for inflation, but declined by 15.3 percent in the high-HCBS states;” like Colorado. These findings match what CVNA hears from its own patients in Denver and Northern Colorado. Through our own patient surveys, over 93% of our patients report that the personal care and homemaking services provided by CVNA are critical to that patient’s ability to remain independent in the home. After the progress Colorado has made, I fear that there may be a decrease in patients remaining in the home and a move towards more patients returning to nursing homes. Not only that, recent success in transitioning patients from skilled nursing to the home will slow down or stall altogether. In a 2005 survey by the Centers for Medicare and Medicaid Services (CMS), 165,276 nursing home residents indicated that they would like to return to their communities; if they received HCBS waivers to do so, the public could see annual savings of $2.6 billion.

It does not have to be this way. In fact Arizona has a more expansive program called Arizona Long Term Care System (ALTCS) which emphasizes HCBS and rewards providers to keep people out of facility-based care. In addition to the higher level of incentive, Arizona also pays their HCBS providers dramatically more at $22 per hour vs. Colorado’s current $17. What is particularly telling is that Arizona has a significantly lower cost of living than Colorado; a salary of $36,000 in Phoenix needs to be $46,000 in Denver according to this cost of living calculator. Arizona is not the only state that pays more and has done more to coordinate HCBS services. Missouri pays $18.40 per hour for homemaking even though the cost of living in Missouri is much lower than Colorado and even lower than Arizona. Additionally, Missouri has rolled out its own program to keep people in their home called Aging-in-place which has seen improved outcomes by connecting HCBS services with nurse care management and traditional home health services like nursing and physical therapy services.

Colorado’s Department of Health Care Policy and Financing (HCPF), i.e. Colorado’s Medicaid organization;  does know and even acknowledges that reimbursement for HCBS is too low. In fact, a recent HCPF analysis of HCBS rates recommended a new rate of $21.48 per hour, an increase of $1.12 per 15-minute “unit” of service or $4.48 per hour (Slide 11). This magnitude of increase would make a dramatic difference for providers assisting HCBS clients and in fact HCPF would likely have a backlog of new providers requesting to become HCBS provides. However, the real issue is not really HCPF, but rather the necessary budget to support HCPF’s recommendation (Slide 14).

As you can see, HCBS is an extremely important part of the care continuum that helps people remain in their homes. Colorado has been an extremely progressive state in its implementation and support for more HCBS services than many other states and as a result, Colorado’s skilled nursing admissions and overall census has either decreased or remained stable over the past decade. However, I believe these gains may be lost if Colorado does not invest more in its HCBS providers in the coming months and years. And, the problem is only going to get worse as Colorado’s minimum wage inches towards $12 an hour. In the meantime, CVNA will reduce our own HCBS patients in order to remain sustainable unless of course we find other funding sources to support our patients as it is our mission to help people remain independent in their homes.

Christopher J. Lee

President & CEO

Colorado VNA

Home Health Care is Crucial to Better Patient Outcomes and Our Healthcare System’s Future

Dr. David Schrier–Hospice Medical Director, Colorado Visiting Nurse Association

The National Association for Home Care & Hospice (NAHC) has designated November as Home Care& Hospice Month – a time to honor millions of nurses, home care aides, therapists, and social workers who make a remarkable difference for the patients and families they serve. These heroic caregivers play a central role in our health care system and in homes across the nation.

I am taking this opportunity remind patients, physicians and other medical professionals involved in patient care outcomes that there is tremendous value in providing care in the home. Simply put, these full-spectrum services can improve patient outcomes in the least costly, and most often patient-preferred setting which equals a winning solution for everyone.

And, let’s face it – with the “silver tsunami” heading our way, there simply aren’t enough skilled nursing facilities to accommodate the rapidly growing population of aging patients who need long-term care, palliative care or hospice services. Home is going to be the long-term health care facility of the future.

Care provided by home health agencies includes skilled medical services, including chronic disease management; rehabilitative therapies to improve or stabilize the patient’s functional status; care coordination services and management of care transitions (especially from hospital to home); monitoring and management of behavioral health conditions; care that enables avoidance of unnecessary hospitalizations and re-hospitalizations; and support to patients and their family members to connect to community resources to enable and support independence.

There are, unfortunately, some common barriers to patients getting home care services when needed.
Most chronically-ill or elderly patients (and sometimes their physicians) have no idea that they qualify as being homebound and that insurance, in most cases, offer home health services benefits. To truly care for our patients, we physicians, need to do a much better job at helping our patients get the services they need and pay for.

In my opinion, skilled home care providers should be an extension of your healthcare team to ensure your patients’ safety and comfort and reduce hospitalizations, ultimately driving down healthcare costs for all consumers.

david-schrierDavid M. Schrier, MD is a practicing Hematologist & Oncologist in Englewood, CO. Dr. Schrier graduated from University of Colorado School of Medicine in 1990 and has been in practice for 25 years. He completed a residency at University of Colorado Health. Dr. Schrier also specializes in Internal Medicine. He currently practices at Swedish Medical Hospital’s Cancer Center.

In 2002, Dr. Schrier founded the Ray of Hope Cancer Foundationin memory of his patient, Ray. The foundation has given over $5 million in financial assistance to over 4,000 cancer patients in every corner of Colorado. In 2014 he received the Patients’ Choice Award and Compassionate Doctor Recognition

What To Ask To Find The Right Home Health Care Provider For You

At Colorado Visiting Nurse Association (VNA) we know that inviting someone into your home to care for you or your loved one is an incredibly important and personal choice. Having the right person can make the experience more pleasant, ensure the appropriate services and in many cases even reduce the likelihood of hospital re-admission. Whether you’re looking for home health care or non-medical support knowing what questions to ask can help ensure that you receive quality assistance.

What To Ask To Find The Right
Home Health Care Provider For You

If you’re recovering from surgery or need long-term care for a chronic illness — or you have a loved one facing a similar situation — you might be interested in home care services. Home care services range from skilled care provided by nurses or therapists to household support, such as cleaning, cooking and running errands. If you’re considering home care services, ask these questions to choose the best provider for your needs.

Qualifications

If you’re considering a home care services agency:

  • Is the agency licensed by the state? Most states — but not all — require agencies to be licensed and reviewed regularly. Reviews might be available through your state health department.
  • How long has the agency been in business?  Experience is one way to measure reliability.
  • Is the agency certified by Medicare to meet federal requirements for health and safety? If not, ask why.
  • What type of employee screening is done? Background and drug testing may go a long way toward your piece of mind.
  • Can the agency provide references? Ask for a list of doctors, hospital discharge planners or other professionals who have experience with the agency.

If you’re considering a home health aide:

  • What are the aide’s credentials? If he or she claims to be licensed, check with the licensing body.
  • Can the aide provide references from at least two employers? Check them thoroughly.

Be sure to ask your or loved one’s doctor, family and friends for recommendations.

Quality of care

If you’re considering a home care services agency:

  • How does the agency train, supervise and monitor caregivers? Does the agency provide continuing education?
  • Are the caregivers licensed and insured?
  • Do the agency’s employees seem friendly and helpful?

If you’re considering a home health aide:

  • Does the home health aide have a positive attitude?
  • Are you and your loved one comfortable with the home health aide?

Costs

If you’re considering a home care services agency:

  • How does the agency handle expenses and billing? Ask for literature explaining all services and fees, as well as detailed explanations of all costs associated with home care.
  • Will agency fees be covered by health insurance or Medicare? Check to see what kind of coverage your health insurance offers.
  • What resources does the agency provide for financial assistance, if needed? For instance, is a payment plan available?

If you’re considering a home health aide:

  • How much does the aide charge for home health services? Make sure you’re comfortable with the fees and the included services.
  • Does the aide require payment for sick days, vacation days or holidays? If so, clarify how many sick and vacation days are allowed, as well as which days are considered holidays.

Understanding services

Whether you’re considering a home care services agency or a home health aide, you might ask these questions about services:

  • Will you receive a written care plan before service begins? The care plan should include details about medical equipment and specific care needs, contain input from the doctor, and be updated frequently.
  • Will you receive a list of the rights and responsibilities of all parties involved? This is sometimes known as a patient’s bill of rights.
  • Will you or your loved one be referred to dietitians, counselors, therapists or other specialists, if needed?
  • Will the agency work directly with you or your loved one, family members and health care providers?
  • Must you identify a primary family caregiver? If so, what’s required of that person?
  • When will service be provided? Is care available round-the-clock, if necessary?
  • What procedures are in place for emergencies? Ask how the agency or home health aide will deliver services in the event of a power failure or natural disaster.
  • How are problems addressed and resolved? Whom can you or another family member contact with requests, questions or complaints?
  • When can services begin?

Monitor your home care services

After you’ve found a home care services provider, monitor the situation. If you’re concerned about the care or services provided, discuss it promptly with the agency or home health aide. If necessary, involve your doctor or your loved one’s doctor as well.

Post updated from article by Mayo Clinic.

Founded in 1889, Colorado VNA is Colorado’s first nonprofit home health care agency and provides expert care throughout the care continuum: wellness, home care and hospice services. For the past three years Colorado VNA has been awarded Home Care Elite Status by the National Research Corporation for placing in the top 25% of home care agencies based on health performance measures.

Colorado VNA earned a four star rating from the Centers for Medicare and Medicaid (CMS) for quality patient care, and is licensed by the State of Colorado to provide home health care. Colorado Visiting Nurse Association is accredited by the Community Health Accreditation Program (CHAP), a national, independent, nonprofit accrediting body for community-based healthcare entities.

Moving from home care to home-based services

Photo courtesy of Gretta Blankenship

Photo courtesy of Gretta Blankenship

It’s time to change what we call ourselves…move from thinking of the Colorado Visiting Nurse Association (VNA) as a “non-profit home health care agency” to a “non-profit organization that provides home-based services”. This may seem like a small distinction, but it there are three reasons we should make this change:
1) “Home health care” agencies are defined by outdated Medicare regulations specifically focused on controlling home care as a way to decrease fraud and abuse within a fee-for-service payment environment.
2) Second, there is very little government and/or insurance company reimbursement for para-based services focused on helping patients remain independent in the home.
3) Further, there is very little coordination of care across our various divisions because of the differing ways we are paid for care that we provide.

The Colorado Visiting Nurse Association has begun to think differently about the care we provide as healthcare transitions from a fee-for-service (FFS) payment system to one where healthcare organizations are paid for overall care and health outcomes.
Currently there are many differences between the care provided by each of our home-focused divisions; home health, paraprofessional home services and hospice/palliative. Care provided by our home health professionals is mostly regulated by Medicare and requires patients to be “home-bound” and have a documented needed for care provided by an RN, PT, LPN, etc.

By definition, paraprofessionals are workers who are not qualified or licensed to serve in particular professions but who handle tasks in support of qualified professionals in those fields. Paraprofessionals often work alongside fully qualified professionals, but they also sometimes work more independently, such as in the case of the health care paraprofessionals who provide home visits to the disabled, ill or elderly.

Care provide by paraprofessionals is more proactive in nature and is provided to help patients remain independent in the home, e.g., bathing, shopping, house-keeping, getting in and out of bed, etc. Hospice visits for appropriate patients are similar to home health visits in that hospice patients have to meet strict criteria for admission, i.e. patients must have a terminal diagnosis and patients must have a prognosis of having less than six months to live.

As one can see, there is a big barrier between the care provided by paraprofessionals and home health and hospice; the barrier has to do with the strict Medicare definitions put in place to help decrease overuse and abuse of skilled home health. Bottom line: the way home health services are reimbursed in our country is too focused on decreasing costs and abuse, rather than on improving care for patients.

The good news is that the old ways of paying for the care we provide are beginning to change as Medicare begins to move to paying for the value provided in the home, rather than just for an episode of care. Here is an excerpt taken from the recent U.S. Department of Health and Human Services Report to Congress: Plan to Implement a Medicare Home Health Agency Value-Based Purchasing Program. The report details a summary of Medicare’s view of the problem of fraud, as well as the limited connection between payments and quality of care.

“…the Medicare Payment Advisory Commission (MedPAC), the Office of the Inspector General, the General Accounting Office (GAO), and other stakeholders have raised significant concerns with fraud and abuse in the Medicare home health benefit. While the benefit is designed to encourage teams of skilled professionals to provide patient-focused care to homebound beneficiaries, there is growing concern that the existing payment system does not provide the necessary incentives to provide such high quality patient focused care.”

There is a lot that is changing in healthcare. Care provided in the home is fast becoming of vital importance to improving the health of populations of patients.

– Christopher Lee, Colorado VNA President & CEO, July 13, 2015