Introduction to Home Health Care in the United States

1. An Introduction to Home Health Care in the United States:The Future of Home Health Care Tracy Gutman, MD Geriatrics Fellow University of Kansas

2. OBJECTIVESBy the end of this module, the learner will do the following: Recognize that existing home health care programs including Medicare and Medicaid home health care do not fully meet the home health care needs of the chronically ill adult and elderly community dwelling population. Describe the purpose of the CLASS Act; explain its basic features and how it impacts home health care. Explain the model of care employed by the Independence at Home Act. List some of the goals of the Independence at Home Act. Define the monetary performance measure that Independence at Home Act programs must meet. Identify how the CLASS Act and the Independence at Home Act improve home health care in the United States.

3. Pretest1. True or False The length of stay in home health care decreased as did overall access to necessary home health care services after the passage of the Balanced Budget Act of 1997.

4. Pretest2. Multiple choice Which of the following is not true regarding the CLASS Act? • It establishes a national voluntary long term care insurance program for actively employed people funded by a payroll deduction system. • Individuals and employers must voluntarily opt in to the program. • Premiums can be based on age. • Benefits have no aggregate or lifetime limit.

5. Pretest3. True or False Benefits from the CLASS Act will replace any Medicaid or other federal, state, or local benefits programs.

6. Pretest4. Multiple choice Which of the following best describes the CLASS Act benefit? • The CLASS Act benefit does not cover personal care services. • Nonworking spouses are eligible for the benefit. • The benefit can cover home modification, assistive technologies, transportation, homemaker services, and respite care. • Family caregivers are not eligible for compensation.

7. Pretest5. True or False The Independence at Home Act Demonstration Program is modeled on the VA Home Based Primary Care Program.

8. Pretest6. True or False The Independence at Home Act pilot programs must demonstrate a savings of at least 10% annually, compared with the costs of non-participating Medicare chronically ill beneficiaries.

9. Pretest7. Multiple choice Which of the following is not true regarding the Independence at Home Act? • Only veterans are eligible to participate. • Creates teams of health care professionals who manage care. • Each participant receives a comprehensive assessment at least annually. • Each participating program must meet quality performance standards.

10. Pretest Answers true b. false c. true false a.

11. Lack of Needed Home Health Care Services9 After BBA 1997 changed home health care reimbursement, the chronically ill adult and elderly community dwelling population received fewer skilled home health care services. The length of stay in home health care decreased as did overall access to home health care services.

12. Limitations in Existing Home Health Care Programs Medicare limits home health care to acute, episodic, and post-acute care and does not provide comprehensive continuous longitudinal care in the home. Medicare does not provide assistance with personal care needs, activities of daily living and instrumental activities of daily living, apart from concurrent skilled needs. Medicaid fills in some gaps in personal care assistance needs and home health needs for those who qualify, but also has limitations in its programs. PACE and HBPC only serve certain populations in geographical areas where they exist. Unmet home health care needs abound throughout the United States.

13. Programs in the New Health Care Legislation The Patient Protection and Affordable Care Act (PPACA), passed in March 2010, contains two new programs that may improve home health care services. CLASS Act: creates a national voluntary long term care insurance program. Independence at Home Act: creates a pilot program to provide primary care in the home.

14. CLASS Act: Community Living Assistance Servicesand Supports Act24 Creates a national voluntary long term care insurance program for employed people funded by a payroll deduction system. Enrollment in the program is automatic for active workers ages 18 and older, but individuals and employers can voluntarily opt out. The program requires a vesting period in which enrollees pay premiums for a minimum of 60 months before becoming eligible for benefits. Premiums can be based on age but cannot be based on any health conditions of the individual. Benefits have no aggregate or lifetime limit and are payable for as long as an individual remains eligible. The benefits do not replace any Medicaid or other federal, state, or local benefits programs.

15. CLASS Act and Home Health Care24 The CLASS Act will provide benefits to help individuals maintain their independence at home, as well as to provide support to individuals in a variety of settings including at home, in the community, or in an institutional setting. The benefit will be a sliding scale cash benefit averaging $50 per day to purchase home and community based long term care assistance and other non-medical assistance such as personal care assistance. The actual daily amount will depend on an assessment of the functional limitations of the individual. The benefit will include home modification, assistive technologies, transportation, homemaker services, and respite care. Family caregivers are eligible for compensation as caregivers.

16. CLASS Act Specifics24 Eligibility to receive benefits will be based on: the same eligibility criteria used for federal tax qualified long-term care insurance benefits and requires that an individual be unable to do 2-3 activities of daily living or need substantial supervision due to a cognitive impairment that threatens the health and safety of the individual. A health care professional must certify an individual’s need for care which must be expected to last for at least 90 continuous days. The Act does not contain provisions for non-working spouses or other non-working individuals to enroll.

17. Independence at Home Act / Independence at Home Medical Practice Demonstration Program25,26 Creates a pilot program which: brings primary care medical services to the homes of Medicare beneficiaries with multiple chronic medical problems has goals of maintaining independence in the home for as long as possible, reducing costs, and improving healthcare and functional outcomes. The program is actually modeled on the VA HPBC program, but extends that program to Medicare beneficiaries who are not veterans.

18. Independence at Home Project25 The Act establishes Medicare pilot demonstration projects in 26 states. Creates teams of health care professionals including physicians, nurses, physicians’ assistants, pharmacists, and other providers to deliver coordinated home health care and to manage complex medical problems of chronically ill, functionally impaired Medicare participants. Team manages all aspects of care. Each participant receives a comprehensive assessment at least annually.

19. Performance Measures25 The Independence at Home demonstration projects must: meet quality performance standards and must demonstrate a savings of at least 5 percent annually compared with the costs of non-participating Medicare chronically ill beneficiaries Savings go toward an incentive payment for the team.

20. Goals of Independence at Home25,26 Provide patients with care that increases independence and decreases costs. Provide comprehensive, coordinated, longitudinal care in the home that will: prevent hospitalizations prevent hospital readmissions reduce emergency room visit rates reduce duplicative care reduce costs of health care services, and improve health outcomes

21. Goals of Both Programs The CLASS Act and the Independence at Home Act both: provide new resources and services for longitudinal home health care have the goals to keep chronically ill, functionally impaired people independent and living in their homes in the community

22. Post-test1. True or False The Medicare funded home health care program does not meet current or future home health care needs of the aging population.

23. Pretest2. Multiple choice Which of the following best describes how the CLASS Act impacts home health care? • It only provides benefits to people living in their homes in the community. • It provides supplemental funds to purchase additional medical assistance in the home. • It only provides benefits to those with cognitive impairment. • It provides a sliding scale cash benefit to purchase home and community based long term care assistance and other non-medical assistance such as personal care assistance.

24. Post-test3. True or False To activate benefits from the CLASS Act program, a health care professional must certify an individual’s need for care which must be expected to last for 90 continuous days.

25. Pretest4. Multiple choice Which of the following is not true regarding the CLASS Act benefit? • The benefit consists of a sliding scale cash benefit averaging $50 per day. • The actual monetary amount of the benefit depends on an assessment of the functional limitations of the covered individual. • Eligibility for the benefit depends on Medicaid eligibility. • The benefit can be given to family members who serve as caregivers.

26. Post-test5. True or False The Independence at Home Act creates a team of providers to bring primary care medical services to the homes of Medicare beneficiaries with multiple chronic medical problems.

27. Pretest6. Multiple choice Which of the following is not a goal of the Independence at Home Act? • Reduce health care costs. • Provide episodic care for brief periods of time only. • Maintain independence in the home for community dwelling Medicare beneficiaries. • Provide care by teams of health care professionals.

28. Post-test7. True or False The mandatory monetary savings to Medicare created by the teams of health care providers in Independence at Home Act programs go toward an incentive payment to the teams.

29. Post-test Answers true d. true c. true b. true

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