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Home Care Changing with TimesSpring 2000 – Arizona Geriatrics Society Journal
By Judith B. Clinco, R.N,
The US healthcare system has been under extraordinary pressure in recent years. Aging Baby Boomers, HMO mergers and collapses, changes in Medicare payment arrangements, and the drive to cut costs by shifting Medicare recipients to managed care providers all present challenges to the medical profession, especially for senior home care.The challenges also present opportunities. Home health, the current medical model of adult home care is under attack by regulators and HMOs. Standing in the wings is supportive care, a social model. Physicians have a great deal to say about whether the transition takes place.
The adult home care provisions of Medicare were designed to provide homebound patients with skilled, intermittent, short-term care, usually to help the senior patient return home after a stay in the hospital. The services require a doctor’s orders and are provided by a nurse, or medical social worker, or occupational physical therapist, or speech therapist.
Medicare was never intended to provide long-term home care. Though, in practice, it has been used that way. HCFA reimbursement rules, in effect since November 1997, will stop this practice.
Obtaining home health senior services intended by Medicare is becoming difficult as patients exchange their entitlements for HMO memberships. Managed care providers are required by law to provide the same services patients would receive through Medicare. But many HMOs send their members to nursing homes for post-hospital care, even though studies haveshown savings may be possible through the use of home care.
“The focus of supportive care is to assist senior patients in maintaining independence, pro-mote their health and wellness, and support their quality of life.”
One study estimated that in 1994 alone Oregon, Washington, and Colorado collectively saved al-most $140 million in long-term care spending because they established home care programs (Alecxih, Luzky and Corea 1996).Another 1996 study found that many nursing home residents did not need this level of adult care. As a conservative estimate, the study said, “the needs of some 15 percent could be met safely, economically, and humanely at a less intensive level of care (Spector, Reschovsky and Cohen 1996).
Despite HMO foot-dragging, home health senior services are still available. Most private home health insurance policies purchased years ago and never activated, cover home health. Additionally, paying out-of-pocket is a viable option for many patients. And many HMOs will cover the services, albeit unwillingly at times.
A physician can order home health following an office visit; it is usually not necessary for the patient to be hospitalized first. And if HMO policies discourage home health visits, the physician can still urge the patient’s family to advocate when this is the best-care option.
Additionally, the physician can order a home health visit if the patient’s family reports changes in the patient’s health or behavior. After the visit, the nurse can provide the physician with a skilled evaluation as to whether further home visits or hospitalization are indicated.
Going to the doctor can be stressful and upsetting; symptoms may be amplified, distorted or masked during an office visit. While doctors may be limited in the amount of time that can be spent during office visits, a home visit allows the time needed for a nurse to develop a more accurate picture of a patient’s status.
The physician can play the role of counselor. Sometimes home health is not an appropriate choice. If a patient needs to go to a nursing home, adult care home or other assisted living settings, it falls to the doctor to break the news. By referring patients and families to social workers when necessary, and by becoming counselors themselves, doctors can help their patients deal with this unwelcome news. Beyond these steps, which arise from the medical model of health care, physicians can help facilitate the shift to the emerging social model of community-based sup-portive care.
The focus of supportive care is to assist senior patients in maintaining independence, promote their health and wellness and support their quality of life. There are benefits for physicians as well. People who are healthy and happy require fewer senior medical services. That’s a plus, especially in light of capitated payments and 1,500 patient panels.
Supportive care may be paid for by long-term care insurance or by Medicaid (or a state equiva-lent such as ALTC, the Arizona Long-Term Care program). Sometimes services are paid for out-of-pocket by the patient or family. Supportive care is less expensive than home health because it is provided for the most part by paraprofessional home care aides rather than nurses.
In Arizona a home health skilled visit costs about $75 to $100 and usually lasts from 15 minutes to two hours, with most visits lasting less than an hour. Supportive care costs are from $13 to $18 an hour. Senior services are provided as needed, ranging from two hours once or twice a month to 24 hours a day. Adult care is also available on a short-term or respite basis.
The home care aide takes the patient to medical appointments and handles other transportation duties, helps with personal care and hygiene, does housekeeping, provides companionship and reminds the senior patient to take his or her medications.
Nursing care management is included when supportive care is provided through a JCAHO accredited home care agency. The nurse’s duties include communicating with the physician and family, assessing the senior patient’s condition, setting up medication boxes, supporting the paraprofessional in providing quality senior services, ensuring that the client is receiving adequate fluid and nutrition, and verifying that home safety issues have been minimized.
In the medical model, the physician was called upon to be the bearer of bad news when necessary. In supportive senior care, the very important role of counselor or adviser is expanded to include discussing options other than nursing home placement. For many older senior patients whose health is failing, staying at home is the preferred option. But frail people in their 80s still need help to cope adequately with life at home. Home health meets this challenge.
Convincing the senior patient is the second step. Fortunately, older people have a great deal of respect for what the doctor says. Admittedly, it is hard to tell a senior patient, “You need to have help in your home.” It must be done, though, and often the physician has the best chance of overcoming the senior patient’s objections.
If doubt exists as to whether supportive care is indicated, the physician can refer the patient or family to an adult home care agency. Most agencies are glad to conduct lengthy phone interviews to determine whether supportive care is indicated. If it is, a nurse will visit in the home to create an individualized service schedule.
Quite often, patients who need supportive care resist the idea. They don’t want a stranger in their home; they are shocked at the cost; they fear the loss of independence. And underlying the practical concerns are fundamental human issues; being told that you need help is a clear statement that you are failing, and a reminder that one day you will die.
Often, concerns about money are a focal point for a myriad of unexpected fears. Many seniors are reluctant to spend money; they lived through the great Depression and thrift is second nature. The physician needs to help them understand that the rainy day they’ve been saving for is at hand.
“I don’t have that kind of money”is a common complaint. The best way to overcome this is to be prepared with the facts. The physician can point out that the senior patient does have a choice: supportive care or leaving the home. Between the two, supportive care is the more economical choice. Supportive care is available on an as-needed basis, for $13 to $18 an hour, which often equates to a 40-50% per day savings over nursing home fees. The choice is really one of spending resources wisely. Another point in favor of supportive care is the dread with which many seniors view nursing homes. Faced with a choice between the two, most patients will prefer the comfort and independence of staying at home.
State-of-the-art medical equipment for use in the home – and technicians trained to operate that equipment – now make it possible for many seniors who would otherwise be institutionalized to be cared for and live in-dependently in their own homes.
HMOs may in time embrace supportive long-term care, once their cost-benefit studies show that supportive adult care offers big savings by reducing the incidence of poor nutrition, mismanaged medications, accidents, isolation and depression, and unnecessary hospitalizations. When that day comes, supportive adult care will be the preferred protocol for elderly, disabled and chronically ill patients.
In the interim, there is much physicians can do to lead the way. By watching for the warning signs and doing everything they can to arrange appropriate home care, physicians can help their patients avoid unnecessary hospital stays and live healthier, more independent lives at home.