New Developments in Home Care Services for the Elderly

Innovations in Policy, Program, and Practice

Lenard W Kaye

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781317837312
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This anthology responds to the recurring call for quality in home care service provision. It presents to agency administrators, managers, supervisors, and front line service providers a set of the most up-to-date policy, program, and practice developments in the field. Each contributor to New Developments in Home Care Services for the Elderly explores issues of client/staff diversity and the challenges associated with working with clients grappling with disabling conditions. Contributors in New Developments in Home Care Services for the Elderly explore issues of client/staff diversity and the challenges associated with working with clients grappling with various disabling conditions. Topics addressed include:

• alternative organizational models in home care
• the importation of high technology services into the home
• legal and ethical issues in home health care
• counseling homebound clients and their families
• clinical assessment tools and packages
• case management and the home care client
• home care entitlements and benefits
• evaluating and monitoring the effectiveness of in-home care
• marketing home health care services
• home care service experiences in other countries New Developments in Home Care Services for the elderly covers a continuum of care ranging from housekeeping services to self-care education, teaching, and training services to nursing and medically related services. Consequently, the information contained within this volume is of immediate relevance to a multidisciplinary audience having both direct (field) and indirect (office) service responsibilities in the home care organization. Social workers, nurses, business administrators, and public health professionals will find this an invaluable guide for providing effective home care services.

Part I:
Policy Innovation

Chapter 1
Trends in Home Care Entitlements and Benefits

Ellen P. Rosenzweig, JD

Home care services are currently funded through a patchwork of entitlement and benefit programs, none of which were initially designed to systematically provide long term care for chronically disabled individuals. Medicare, the largest public payor for home care, was designed primarily as an acute care benefit. Only through a national class action lawsuit, Duggan v. Bowen, was the focus of the Medicare home health benefit changed from acute care to long term care for chronically impaired individuals. Medicaid initially also focused on acute care, and only the skilled home care services are mandated on states. Medicaid does, however, allow states the option of providing the less skilled home care services through optional state plan services and waiver programs (described in detail, see p. 15). Many states have chosen to provide substantial amounts of less skilled home care services through the Medicaid program. The other federal benefits and entitlements for home care services-Social Service Block Grants, Older Americans Act programs and Veterans Administration and Department of Defense programs are underfunded and limited in the scope or duration of benefits they can provide. Finally, states have not been able to devote much of their own limited general revenue dollars to provide the less skilled home care services which are needed by an increasingly older disabled population.

In 1993, Health Care Financing Administration (HCFA) officials expected that an estimated $33 billion, including public and private funds, would be spent on home and community-based long term care for all populations and projected that 32% would be financed from Medicare, 22% from Medicaid and 46% from private sources (Vladek, Miller & Clauser, 1993). The HCFA projection did not give amounts funded by Older Americans Act funds, Social Service Block Grants, Veteran Administration programs, and state general revenue funding, estimated by others to comprise 23% of public funding for home and community-based care for the elderly (Feder, 1991).

A recent Administration on Aging survey of state expenditures on home and community-based care which excludes Medicare-funded home health care and food subsidies from the Department of Agriculture collected data for the first time on funding sources used by states to provide home and community-based care to the elderly (Administration on Aging, 1994). Based on 1992 figures, the survey concludes that $6.4 billion of federal and state funding, exclusive of Medicare was used to pay for home and community-based services for the elderly. The AoA study figures show that nationally, exclusive of Medicare, states’ funding of home care is attributable 69.4% to Medicaid, 10.2% to Social Service Block Grants, 7.8% to Older Americans Act funds, 10.9% to general state revenues and 1.8% to other sources.

These percentages vary dramatically, however, from state to state, as does the amount spent on services per capita of persons age 65 and above. Maine, for example, uses 82.5% from Medicaid, 0% from Social Service Block Grants, 4.2% from Older Americans Act funds and 13.3% of general state revenues to provide $189 of home care services per capita for persons over age 65. California, providing $240 of services per capita for persons age 65 and above, uses 44.5% of Medicaid, 48.35% Social Services Block Grant funds, 6.5% Older Americans Act funds, .5% general state revenues and .2% other funds. New York provides the highest amount of home care services at $1,180 per capita for persons age 65 and above, 96% from Medicaid funds. Mississippi, providing the least amount of home care funding at $29 per capita for persons age 65 and above, uses 15.2% from Medicaid funds, 45.5% from Social Services Block Grant funds, 30.3% from Older Americans Act funds and 0% from state revenues and other sources. These state variations indicate the flexibility which states currently have in using different levels of funding from various federal sources to design their programs but also demonstrate that, without a coherent federal funding stream, states are free to provide extremely limited amounts of home care services in addition to those covered by Medicare.

The figures also demonstrate that exclusive of Medicare, Medicaid is the only federal program providing significant funding of home care services. Oregon, the second highest funder of home care at $369 per capita for persons age 65 and above, uses 89.7% from Medicaid; California, the next highest at $240 per capita for persons age 65 and over, uses 44.5% from Medicaid; and Washington at $212 per capita for persons age 65 and over, uses 62% from Medicaid (Administration on Aging, 1994).

A substantial amount of the cost of home care is still paid out-of-pocket by the elderly. Estimates of average out-of-pocket long term home care spending by both the elderly and the disabled projected by the Brookings Institution over the 1991-1995 period constituted 37.6% of the total projected cost (Weiner, Aston and Hanley, 1994b). Private long term care insurance currently pays for only one percent of total long term care expenses (Weiner et al., 1994b), most of which presumably covers nursing home care rather than home care.

In addition to private spending for home care services, a large but unmeasured amount of the services used by the elderly and disabled at home is provided informally by family and friends. In 1989, only an estimated 29% of the disabled elderly at home were using paid home care services (Weiner et al., 1994b). Approximately 4.2 million spouses and adult children of disabled elderly persons living at home provide assistance with activities of daily living and another three million relatives, friends or neighbors also are actively providing informal care (Stone, 1991). In fact, most elderly and disabled individuals would be unable to remain at home even with paid home care without the supervision and assistance of an informal caregiver. The importance of informal care is now well recognized as is the importance of providing services such as adult day care and respite care to support informal caregivers.

This chapter will discuss each of the public sources of funding available for home care services for the elderly and disabled, describe, briefly, developments in private long term care insurance coverage of home care and present some of the trends in home care financing currently under development.

Medicare

Use of the Medicare home health entitlement has grown substantially since 1980. This increase is attributable to the removal of the three day prior hospitalization requirement and the 100 visit limit in 1980, the adoption in 1983 of the prospective payment system for hospital benefits which reduced the length of stay for hospital visits thus shifting care previously provided in hospital to home settings and the 1989 changes in Medicare home health coverage after the Duggan v. Bowen lawsuit which expanded the home health benefit from an acute care focus to more of a long term care benefit for chronically impaired individuals (Leader, 1991; Bishop and Skwara, 1993). Spending for Medicare home health benefits increased at an annual average rate of 40% between 1988 and 1991 as a result of the Duggan revisions in the coverage guidelines (Bishop, 1993). Predictably, the rapid increase in Medicare home health expenditures has prompted an internal HCFA review to improve, among other things, the efficiency, accountability and fiscal integrity of the program (HCFA, 1994). Whether an attempt to limit the benefit will result remains to be seen.

Medicare covers primarily skilled medical home health services-part-time or intermittent nursing, physical, speech and occupational therapy and home health aide. Private duty nursing is not covered. Personal care services (assistance with activities of daily living) are funded by Medicare only to the extent that they are “incidental” to medical home health services and are not covered as a stand-alone service. Social work services are covered if they are needed to insure the effectiveness of medical treatment.

Medicare coverage is divided into two parts, Part A (hospital insurance) and Part B (medical insurance). Part A covers home health services, but persons enrolled only in Part B are covered for the same home health services under the same eligibility requirements as Part A enrollees.

Medicare home health eligibility rules are set forth in detail in the Medicare Health Insurance Manual (HCFA pub. 11), known as the H.I.M. 11. Note that the kinds and amounts of services covered are not set forth in statute or regulation, but rather are detailed in HCFA prepared manuals. The home health manual provisions were rewritten at the conclusion of the Duggan v. Bowen law suit. The Medicare home health eligibility rules are complicated and consist of three sets of criteria which the individual must meet to receive services: the qualifying criteria, the coverage criteria and the reasonable and necessary criteria.

There are five qualifying criteria, all of which must be met to qualify for Medicare coverage of home health care. First, a physician must certify the need for the services and must draw up and periodically review the treatment plan. Second, the individual must remain under the care of a physician. Third, the care must be intermittent skilled nursing care (defined as either less than 5 days a week but at least once every 60 days or daily for a finite and predictable amount of time) or physical therapy, or speech therapy or continuing occupational therapy after physical therapy has terminated. Fourth, the individual must be “homebound,” defined as unable to leave the home because of illness or injury without the assistance of a person or device and without a considerable and taxing effort (trips from the home for medical reasons or short and infrequent trips for non-medical purposes are acceptable if all of the other requirements of the definition are met). Fifth, the home health agency providing services must be certified by Medicare.

If all five of the above qualifying criteria are met, Medicare will pay for the kinds and amounts of home health services, defined in the coverage criteria, provided the services are medically reasonable and necessary. Combined skilled nursing and home health aide services are covered if they are part-time (defined as seven days a week and less than eight hours per day and up to a maximum of 28 hours [or 35 hours if additional documentation supports the extra hours] per week for an indefinite period of time) or intermittent (defined as either less than seven days a week and up to 28 [or 35 with additional documentation] hours per week for an indefinite period of time or seven days a week, eight hours a day, for a finite and predictable period of time). Note that home health aide services are not covered unless the skilled nursing or therapy qualifying criteria are met. Physical therapy, speech therapy, occupational therapy, medical social work and medical supplies and equipment are also covered. Medicare does not cover full-time nursing care, drugs (except immunosuppressive drugs) or meals delivered to the home. Homemaker, chore services or personal care services are not covered unless incidental to patient care which is being provided by a home health aide.

Finally, even if the qualifying and coverage criteria are met, the services must still be “medically reasonable and necessary.” Prior to the revision of the H.I.M. 11, Medicare denials were often couched in terms of lack of medical necessity. The revised Manual clarified that a finding that services are not medically reasonable and necessary must be based upon information provided in the plan of care and the medical record with respect to the unique medical condition of the individual. In addition, the Manual provides that determinations of whether care is “skilled” must be made without regard to whether the illness or injury is acute, chronic, terminal or expected to extend over a long period of time.

Note that, since 1980, a three day prior hospitalization is not required for Medicare coverage of home health care as it is for Medicare covered nursing home care. Currently, Medicare pays for home health services in full; that is, without a deductible or co-payment. Many of the recent health care reform and budget proposals, however, considered by Congress impose co-payments on Medicare home health.

A Medicare determination of eligibility is initially made by the Medicare certified home health agency. This determination is not appealable by the individual applicant unless the applicant demands that the home health agency submit the claim for services to Medicare despite the agency’s good faith belief that the services will not be covered. If Medicare denies coverage, the applicant will then have to pay privately for the services received, but will also have gained the right to appeal the Medicare coverage denial. Many Medicare home health care denials are reversed on appeal.

Medicare will pay for hospice services from a Medicare-approved hospice once a doctor certifies that the patient has only about six months to live. The hospice philosophy of terminal care requires that patients choose to forego active treatment and receive only palliative care. Those patients who choose hospice receive a combination of home and institutional services, although hospice is primarily a home care program and most hospice patients die at home. Home care services include home health aide and personal care services, at least one weekly visit from a registered nurse, medical equipment and supplies, drugs, support for family members involved in caregiving and occasional respite. Although hospice has generally been used to provide care to terminally ill cancer patients, about 10% of patients have illnesses other than cancer, the most common being cardiac diagnoses and chronic lung disease (Scanlon, 1994). An increased use of the hospice benefit for terminal care can be anticipated as the population reaching advanced old age continues to grow.

Medicaid

Unlike Medicare, which is funded entirely by the federal government, Medicaid is a joint federal and state program, funded half by the federal government and half by the states. In contrast to Medicare, an insurance program which covers most elderly and disabled individuals without regard to their income and resources, Medicaid is designed to cover certain categories of individuals with very low income and resources. Federal legislation and regulation set forth the general requirements which states must follow, making coverage of some categories of individuals and some benefits mandatory and some optional.

The Medicaid categorical and financial eligibility rules are beyond the scope of this discussion, except to state that blind, elderly and disabled recipients of Supplemental Security Income (SSI) cash assistance are required to be covered in all states unless the state opts to use more restrictive definitions of blindness or disability or use more restrictive eligibility stan...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• About the Contributors
• Preface
• Introduction
• PART I: POLICY INNOVATION
• PART II: PROGRAM INNOVATION
• PART III: PRACTICE INNOVATION
• PART IV: INNOVATION FROM ABROAD
• Index