19: Home-Based Care

Specific home-care models have proven effective at providing high-quality care to vulnerable older adults. These models include preventive home-care programs and medical house calls that integrate medical and social supportive services focusing on the care of chronically disabled persons, home geriatric assessment, posthospital case management/transitional care models, home rehabilitation, and hospital at home.

Many models of preventive home care for older adults at risk of functional decline have been described and evaluated. Models differ in their target populations, intensity and degree of geriatric assessment, and follow-up. Results of these studies are varied, but overall, programs that target high-risk patients and provide multidimensional assessment and multiple follow-up visits have demonstrated reduction in nursing home admission, improvement in functional status, and reduction in mortality. The high initial cost currently makes this model rare in practice.

Medical house calls are visits to provide ongoing longitudinal medical care within the patient’s home environment. House call visits may be done by a physician alone, or patients may receive primary health care from a team, such as in the Home-Based Primary Care Program through Veteran’s Affairs facilities. In the house call team model, patients are cared for by a multidisciplinary team of physicians and other health care professionals, including, but not limited to nurses, home health aides, social workers, and physical and occupational therapists. Some programs include pharmacists and mental health professionals on their teams. The team meets on a regular basis, manages the care of active patients carefully, and integrates medical and social supportive services. Such programs have demonstrated improvement in function, reduced costs, decreased medication use, improved satisfaction, improved end-of-life care, and fewer nursing home admissions and outpatient visits.

Specific home-based case management strategies, especially those that are focused on conditions associated with complex management issues and high rates of early hospital readmission (eg, congestive heart failure), are associated with a significant reduction in the number of acute hospital readmissions.

Home Rehabilitation

Home rehabilitation (specifically after a stroke or a major joint replacement) has proved to be feasible, acceptable to patients and caregivers, and as effective as hospital-based rehabilitation.

Hospital at Home

Hospital at home models that provide hospital-level services in the home setting as a substitute for a needed hospital admission have been developed and have demonstrated comparable clinical outcomes, reduced length of stay, decreased readmission rates, increased patient and caregiver satisfaction, and reductions in important geriatric complications, such as delirium.

Eligibility Requirements

Medicare will pay for certain home care services. Physicians who care for older patients need to be familiar with the basic entry criteria for these services. Medicare was designed as an acute illness benefit rather than insurance to pay for the long-term care of older persons with chronic conditions. Thus, Medicare home health benefits are linked to transitions from acute care settings and to what Medicare refers to as a “skilled need.” Home health care services for Medicare patients are covered by Medicare Part A. Physicians and approved home health agencies are reimbursed for services as long as certain criteria are met. The basic requirements for Medicare to reimburse home health expenses are as follows: the physician certifies that the patient is homebound, the patient has a skilled need, the skilled need is reasonable and necessary, the rendered service is intermittent or part time, the physician completes the face-to-face encounter form, and the physician signs Form CMS-485, which is the plan of care.

Homebound Requirement

To qualify as “homebound,” a patient must have a condition resulting from illness or injury that makes it a “considerable and taxing effort to leave the home” without the aid of supportive devices such as crutches, canes, wheelchairs or walkers, special transportation, or another person or if leaving the home is medically contraindicated. However, a person does not have to be bedridden or absolutely homebound. Absences from the home must be infrequent, of short duration, or for medically relevant services. Examples of nonmedical reasons for leaving the home are attending religious services or taking a stroll or drive. No specific definitions of “short duration” or “infrequent” are provided in the Medicare guidelines. Illnesses or injuries that result in a person’s confinement to the home include stroke, blindness, dementia, amputation, or a psychiatric problem in which the patient refuses to leave the home or would be unsafe leaving the home unattended.

Skilled Need Requirement

A skilled need is required for a home care agency to receive reimbursement from Medicare for home health services. Skilled needs are those that require special training and certification to administer to be safe and effective, such as those provided by nurses or therapists. An example of a skilled need is the monitoring of a patient with a complex medical condition that requires adjustment of medicines and reevaluation by a skilled nurse. Other examples include wound care treatment, catheter care, physical therapy, training of patients or caregivers to manage medical conditions such as diabetes or wound treatment, and education and monitoring of new medications such as warfarin. Single home visits by a skilled nurse for the sole purpose of obtaining a blood specimen do not qualify as a skilled need. Once a person has home health services for a skilled need, other covered Medicare home health services such as social work, occupational therapy, and home health aide can also be obtained. Thus, the skilled nursing or physical therapy need unlocks the Medicare home health benefit for the patient, and a broad range of services may be used as appropriate for the care of the patient. Services can be provided as long as the skilled need exists.

Not all skilled needs are reimbursable. For example, if a patient has been managing his or her diabetes with injections without difficulty and the glucose is well controlled, training would not be appropriate, and payment would be denied. If the patient had been taking oral medications, however, and the physician adds insulin to the medical regimen, it would be appropriate to request nursing services to train the patient to manage diabetes with the new insulin regimen.

Reasonable and Necessary Skilled Needs

Skilled needs must be reasonable and necessary. Documentation should be provided on the plan of care (Form CMS-485) and any supplementary forms. If appropriate medical information is not present, the medical record will be reviewed by a regional intermediary designated by the Center for Medicare and Medicaid Services (CMS) to determine whether the services are reasonable and necessary. One example of a reasonable and necessary skilled need is that of the patient discharged home after hospitalization with heart failure. However, this person’s need would not qualify as reasonable and necessary if there were no documentation of changes to the medical regimen and Form CMS-485 documented the patient as having stable vital signs and no functional impairments. Another example provided in the Home Health Agency Manual is a patient who was discharged from the hospital after a hip fracture, and home health services were requested solely for monthly vitamin B₁₂ injections. Although the injection is a skilled need, if there is no documentation of approved conditions for the administration of vitamin B₁₂, there is no evidence that the injection is medically necessary or reasonable, and the claim would be denied.

Face-to-Face Encounter Requirement

A face-to-face encounter requirement for certification of eligibility for home health services was established in Section 6407 of the Affordable Care Act of 2010. It requires a physician to document that the physician, or a nonphysician practitioner working with the physician, had a face-to-face encounter visit with the patient within 90 days prior to the start of care, or 30 days after the start of care. The encounter must be related to the reason for referring the patient to home health services. This face-to-face encounter form is also required for recertification of hospice services (Table 19–1).

Part-Time or Intermittent Service

“Intermittent” means skilled nursing care that is provided fewer than 7 days per week or less than 8 hours per day over a period of 21 days or less for a medical condition that is expected to require skilled services at least once every 60 days. Therefore, a one-time intravenous infusion (eg, the condition is not expected to recur and will not require intermittent service) would not qualify for reimbursement. Exceptions to the time limit may be made on an individual basis if appropriate documentation is provided.

Plan of Care

Form CMS-485 is the comprehensive plan of care for each patient. This form lists diagnoses, medications, diet, activities, and services needed, such as wound treatments, in addition to other information. The patient must be under the care of a physician qualified to sign the physician certification at the time of enrollment into home health, and the physician must review and sign the form at least every 60 days. Additional state requirements regarding timing of signatures may also exist. Physicians can bill Medicare for certifying the plan of care.

Payment Denials

Single visits are common reasons for payment denial for nonphysician home health services. If a patient complained of urinary symptoms, Medicare would not pay for a home health nurse to make a single visit to obtain a urinary specimen, even if the patient was diagnosed and treated with antibiotics for an infection. However, if the home health agency plans to follow up for re-evaluation of a skilled need, but a patient is hospitalized, placed in hospice, or dies after a single visit, the agency would be reimbursed for that visit.

Another common reason for denial is the determination of non-acute events (eg, when physical therapy is ordered for frail patients with medically stable diseases or with gradual progressive disability). Since its inception, Medicare has operated based on an acute care model, and reimbursements are primarily for acute events with a foreseeable period of recovery. In most cases, there must be a clear end point before services will be approved. Before home health services are requested, the physician should consider whether the service is expected to improve the patient’s condition.

Other common reasons for denial are failure of physicians to complete the face-to-face encounter form and failure to sign Form CMS-485. The plan of care should be reviewed at least every 60 days, updated, if needed, and signed.

Independence at Home

The Independence at Home Demonstration was authorized by Section 3024 of the Affordable Care Act of 2010. In the Demonstration, the CMS Innovation Center will work with home-based primary care practices to test the hypothesis that comprehensive home-based interdisciplinary teams can provide high-quality care and save money for the Medicare system on care provided to high-cost Medicare beneficiaries with multiple chronic conditions and functional impairment. Quality indicators will include reduced hospitalization, improved patient and caregiver satisfaction, and improved health outcomes, among others. Practices will be rewarded financially for providing high-quality care at reduced cost through a shared-savings mechanism between CMS and the participating practices. This Demonstration program began in 2012.

Medicare Advantage Plans

Medicare Advantage plans have also developed models of care to improve quality and cost for patients with multiple chronic conditions who frequently utilize high cost care, such as emergency room visits and frequent hospitalizations. INSPIRIS is one company that partners with Medicare Advantage Plans to provide comprehensive care management for the 5% to 10% of plan members with the most complex health care needs and highest costs, and they have been shown to reduce health care utilization and readmissions, and to improve outcomes and patient satisfaction.

Program of All-Inclusive Care for the Elderly

The Program of All-Inclusive Care for the Elderly (PACE) is a model of care that is focused on keeping chronically ill adults in their community for as long as possible. To be eligible to participate in PACE, an individual must be older than age 55 years, certified by the state to qualify for nursing home placement, in a situation where the patient is able to continue living safely in the community, and living within a PACE service area. For individuals enrolled in PACE who are Medicare and Medicaid (dual) eligible, the program receives set funding from Medicare and Medicaid for each participant enrolled in the program. For participants who are not eligible for Medicaid, the participant may pay the Medicaid portion out of pocket. Services include physician and nursing care, an adult day program, transportation, home health aides, social work, complete prescription drug coverage, respite care, and physical and occupational therapy.

Medicaid

Medicare recipients may also receive Medicaid (“dual eligible”) if they meet the income and wealth requirements.

Medicaid provides reimbursement for many home health services for which Medicare does not. In addition, several states have launched Medicaid waiver programs to provide home care services for Medicare patients who are Medicaid and nursing home eligible in hopes of reducing nursing home admissions. States must assure CMS that the cost of providing these services in the home or community will not exceed that of placing individuals in an institution. Some of the services provided include personal care, respite care, and other needed assistance in the home.

Area Agencies on Aging

Area Agencies on Aging (AAAs) were established in 1973 under the Older Americans Act to provide resources for older adults. Local AAAs provide several types of assistance: information and access services, community-based services, in-home services, housing services, and elder rights services.

Information and access services include providing information and referrals for services outside the AAA, caregiver support, and retirement planning and education. Community-based services include employment services such as skill assessment, testing, and job placement. They also offer information on senior centers, congregate meals, adult day care, and volunteer opportunities. In-home services may consist of Meals on Wheels, assistance with personal care, shopping and housekeeping, telephone calls and personal visits for homebound adults, personal emergency response devices, financial assistance with gas and electric bills for low-income individuals, and respite care for caregivers. AAAs help older adults find alternative housing as they transition from independent living to varying levels of need for assistance, usually in an attempt to avoid nursing home placement. Senior housing facilities, group homes, assisted-living facilities, and adult foster care are options that AAAs help individuals to explore. AAAs can also provide information on nursing home placement. Finally, AAAs provide legal assistance and investigate elder abuse charges and neglect, including self-neglect both in the community and within long-term care facilities.

A physician may provide home care at several distinct levels: posthospitalization and rehabilitation care, acute home care, assessment visits, and home-based primary care. In providing such care, the physician often works in conjunction with the resources of a home health agency, including skilled nursing care, home health aide care, physical and occupational therapists, and social workers.

One inference to be drawn from the description of these categories is the importance of selecting appropriate patients for home care. Patient selection requires an understanding of the patient’s medical condition, suitability of the patient’s environment, including the level of available caregiver support, and ability of the home health agency to support the patient’s particular needs.

Postacute Hospitalization & Home Rehabilitation Care

In posthospitalization care and home rehabilitation care, the focus is on restoring function and completing the management of medical problems. The interdisciplinary care team provides much of the care in this setting, with a physician providing medical oversight and supervision.

Home Care & Assessments

In acute home care, the physician is actively involved in management of acute illness. Physician home visits, home health agency involvement, and close coordination of the interdisciplinary care team are crucial to assess and manage the patient. In addition, assessment home visits, which may be performed on a one-time basis, allow a physician to evaluate the impact of the home environment, caregiver, or functional disability on the patient’s health, including nonadherence, difficult diagnoses, and excessive use of health services.

House Calls & Home-Based Primary Care

In addition to the usual components of a patient encounter (ie, the history and physical examination and counseling), the house call permits and encourages functional, social, caregiver, and environmental assessments. Inspecting the home environment with patient/family permission (eg, clutter and obstacles, adaptive equipment, lighting, bathroom setup, kitchen setup, refrigerator contents, medication setup) can help the physician understand functional and medical issues. Also, observations of patient–caregiver interactions in the home are often remarkably different from those observed in the office setting and can provide valuable insight into management issues. Physicians may choose to do a single house call to assess particular aspects of a patient’s home environment or care needs, or a physician may provide primary care in the home setting. In some cases, physicians work with an interdisciplinary care team, including nurse practitioners, nurses, social workers, and home health aides, in a house call practice providing home-based primary care. Table 19–2 lists recommended equipment for house calls.

Billing for Medicare Physician Care Plan Oversight

Medicare Part B pays for physician house calls. Home visits are billed using codes 99341-99350. Visits to domiciliary care facilities are billed using CPT codes 99324-99337. In addition, Medicare Part B pays for care plan oversight (CPO) using CMS common practice coding system code G0181. Separate codes must be used for initial home health certification (G0180), recertification (G0179), and CPO (G0181). Physicians can be reimbursed for a minimum of 30 minutes per calendar month spent on home care orders and communication with home-care providers. It may also include time spent reviewing records or coordinating care with other disciplines. CPO does not include time spent in discussion with pharmacists for the purpose of calling in prescriptions, nor does it include time spent in discussions with patients or family members. Medicare Part B reimbursements are subject to 20% copayments, for which the Medicare beneficiary is responsible.

American Academy of Homecare Physicians (this organization is an excellent source of information on home care as it relates to physician practice in home care and the Independence at Home model). http://aahcp.org

Center for Medicare and Medicaid Services (various sites have excellent information on the Medicare home health and hospice program and the Independence at Home Demonstration). http://www.cms.gov

National Association for Home Care & Hospice (this site, although for a trade group that represents home care agencies, hospices, home care aide organizations, and medical equipment suppliers, provides general information and links related to the home care industry). http://www.nahc.org

National Association of Area Agencies on Aging (this site has a number of helpful links to find local services). http://www.n4a.org