The Alliance For Home Health Quality & Innovation The .

In this paper, the term “home health care”is defined as services provided by Medicarecertified home health agencies. Today, homehealth care is most commonly understoodas those services that are covered under theMedicare home health benefit. However, it iscritical to note that there are many types of“home care” services available, needed, and usedby older Americans and people with disabilities.4The scope of home care services includes theskilled home health care provided by Medicarecertified home health agencies, and long-termservices and supports, personal care services(which may be covered by Medicaid and otherstate programs as home and community-basedservices, but is often paid by individuals out ofpocket), and end-of-life and hospice care (whichmay be covered under the Medicare hospicebenefit). As we seek to understand the future ofhome health care, it is important to consider thefull scope of home care services so that we candevelop a comprehensive understanding of whatis needed in the future to improve health care inthe United States.I. The Value of ProvidingCare at HomeAlmost every person in the United States haseither personally received, or has a loved onewho has received, fragmented care that led topoor outcomes and poor patient experience,despite considerable expense. The policy focustoday on achieving the Triple Aim of betterpopulation health, better patient experience, andlower per capita cost is being driven to addressthese issues.5 The Triple Aim is becoming afocus at the same time that the baby boomerpopulation is becoming eligible for Medicareand expressing their preference to age in place.Surveys of older Americans have found thatmost prefer to stay in their own homes.6 More ofthese baby boomers are expected to live longer,7THE FUTURE OF HOME HEALTH CARE PROJECT6What is the Triple Aim?The Triple Aim is a framework developed bythe Institute for Healthcare Improvementthat describes an approach to optimizinghealth system performance. It is IHI’s beliefthat new designs must be developed tosimultaneously pursue three dimensions,which we call the “Triple Aim”: Improving the patient experience of care(including quality and satisfaction); Improving the health of populations; and Reducing the per capita cost of health care.requiring more caregiving support whetherfrom their families or from paid caregivers.8Individuals with disabilities, too, are in needof solutions to enable their independence incommunities.As a means of achieving the Triple Aim andrespecting the preference of older Americansand individuals with disabilities to age in place,home health care’s value proposition is that itoffers the ability to deliver care cost effectively athome, with improved outcomes through patientcentered care.Home health care supports improved patientoutcomes. The Medicare post-acute care paymentreform demonstration found that after riskadjustment, patients receiving home healthcare after hospital discharge were more likelyto improve self-care, although rehospitalizationrates were similar to those who received facilitybased post-acute care.9 Similarly, the publiclyavailable data from “Home Health Compare”reflect that more often than not, patientoutcomes improve after receiving home healthcare. After receiving home health care, 89% ofwounds improved or healed after an operation,

67% had less pain when moving around, 66%got better at bathing, and 64% had improvedbreathing.10Patient Outcomes AfterReceiving Home Health Care:89%of woundsimproved orhealed after anoperation66%got better atbathing67%had lesspain whenmovingaround64%had improvedbreathingThese outcomes are significant improvementsgiven that home health patients have a highprevalence of chronic disease, with 83% ofMedicare home health patients suffering from 3or more chronic conditions, compared to 60% ofthe general Medicare population who suffer from3 or more chronic conditions.11Percentage of patients suffering from 3 ormore chronic conditions83%Home HealthPatients60%General MedicarePopulationIn terms of post-acute care Medicareexpenditures, home health care is generallythe most cost-effective formal post-acute caresetting. Home health care is the least costlyalternative, representing 38.7 percent of allMedicare episodes using formal post-acute carefirst settings, but comprising only 27.8 percentof payments.12 Moreover, data shows Medicarebeneficiaries with the same diagnosis in the acutecare hospital are receiving care in various postacute care settings including: home health, skillednursing facilities (SNFs), and to a more limitedextent, inpatient rehabilitation facilities (IRFs),and long-term acute care hospitals (LTCHs).Across all Medicare diagnosis groups, the average60-day episode expenditures (including thepreceding acute care hospital admission) varywidely by formal post-acute care first setting.For example, Medicare expenditures for a patienttreated in home health after hospital dischargeaverage 20,345, compared to an average of 28,294 across all settings.13Furthermore, older Americans and Americanswith disabilities prefer to age in place and receivecare at home. According to the AARP, persons50 and older with disabilities, particularlythose age 50 to 64, strongly prefer independentliving in their own homes to other alternatives.Preferences for services at home rather than innursing homes are widespread among personswith disabilities. Even in the event they needed24-hour care, 73 percent of persons withdisabilities prefer services at home. Among thegeneral population of persons 50 and older, 58percent prefer services at home.14When care is delivered at home, patients areable to obtain truly patient-centered care. TheInstitute of Medicine (IOM) defines care thatis “patient-centered” as “providing care that isrespectful of and responsive to individual patientpreferences, needs, and values, and ensuringthat patient values guide all decisions.”15 Becausethe home is the patient’s daily environment,THE FUTURE OF HOME HEALTH CARE PROJECT7

it is the site of care that is most conducive toenabling respect for patient preferences, needs,and values. At home, patients are able to receiveone-on-one coaching and education fromhome health providers that is individualized totheir home settings, daily behaviors, and otherspecialized needs.The bias toward institutional and office-basedcare exists even though much of what determinesour health status is whether one adheres tobehavioral and medication regimens that arecarried out as daily decisions at home.16 Betterchronic condition management in home settingscan help to reduce avoidable hospital admissions,nursing home care, emergency department visits,and outpatient clinic visits. As the population ofolder Americans grows, concerns are rising aboutinsufficient space in facilities to meet growingneeds, making the home an even more importantlocus of care.Consequently, it is in the patient’s best interest,both in terms of quality of care and preferenceto age in place, to receive health care at home. Itis also in society’s best interest to have patientsreceive health care at home when clinicallyappropriate for the patient because it is the leastcostly means of receiving care. The United Stateshas not yet realized the full potential of homehealth care as a means to deliver high quality careat lower overall cost.II. Federal Policy and TrendsInvolving Medicare SkilledHome Health CareOver time, the role of home health care hasbeen influenced greatly by Federal policy,specifically the creation and evolution of theMedicare program.17 The legislation that createdthe Medicare program in 1965 included ahome health benefit, which strengthened theTHE FUTURE OF HOME HEALTH CARE PROJECT8credibility, significance, and public awareness ofhome health care.18The traditional Medicare program pays inseparate payment systems for different healthcare provider and professional services.19 Thus,Medicare pays short-term acute care hospitalsunder the hospital inpatient prospective paymentsystem; Medicare pays physicians under thephysician fee schedule; and Medicare payshome health agencies under the home healthprospective payment system. Each paymentsystem is separate and unrelated to the otherpayment systems.Under the home health prospective paymentsystem, Medicare beneficiaries are eligible toreceive home health care services delivered by acertified home health agency if the beneficiarymeets the requirements below.Home Health Prospective PaymentSystem Patient Requirements: Is homebound; Needs intermittent skilled nursing and/ortherapy services; and Is under the care of a physician and needsreasonable and necessary home healthservices that have been certified by aphysician and established in a 60-dayplan of care.20Medicare pays for home health care serviceswith both Medicare Parts A and B funds in60-day episodes of care, and pays agencies byhome health resource groups (HHRGs) that arebased on clinical and functional status (drawnfrom the Outcome and Assessment InformationSet (OASIS) instrument), and service use.21 Ingeneral, Medicare pays with Part A funds if thehome health care services follow discharge from

an acute care hospital; or Medicare pays with PartB funds if a physician refers the beneficiary forhome health care services as part of communitybased care.22Driven by changes in Medicare hospital paymentmethodology in the 1980s, home health agencieswere referred greater numbers of patients withprior hospitalizations and with higher levels ofacuity. As the approach to Medicare paymentfor hospitals changed with the creation of thehospital inpatient prospective payment system(i.e., payment by diagnosis-related group (DRG)hospital payment bundles), hospital lengths ofstay shortened, and more Medicare beneficiariesneeded post-acute care services, including homehealth care. This led to increasing numbers ofpatients with higher levels of acuity seeking care informal post-acute care settings like home health.More recent changes in hospital payment policyhave made hospitals more conscious of postacute care and the need to reduce 30-day hospitalreadmissions. As of October 1, 2012, hospitalsare subject to readmission payment penalties forpatients readmitted within 30 days of dischargefor select diagnoses. These payment penaltieshave begun to influence hospital practices relatedto both timing of discharge and interest incoordinating care with post-acute care providers,including home health care, and physicianscaring for patients post-discharge.Home health care has not only played a strongrole as a provi

The Alliance is a membership organization that is comprised of home health care providers and organizations committed to advancing research and initiatives on the value of home health care. Future of Home Health Care Project The Alliance for Home Health Quality and Innovation is supporting a research-based strategic planning project on the .