Download Role of the Physician and Benefits of Home Health Care

An Introduction to Home Health Care
in the United States:
Role of the Physician and Benefits
of Home Health Care
Tracy Gutman, MD
Geriatrics Fellow
University of Kansas
OBJECTIVES:
By the end of this module,
the learner will do the following:

Identify the two major roles that physicians play in home
health care.
 List the four general types of physician home visits.
 List the major indications for physician home visits .
 Describe some of the components of a home safety
assessment.
 Explain how multidisciplinary long term provision of home
health care services benefits patients.
 Identify some of the positive outcomes of home health care,
including benefits to patients and cost savings.
Pretest
1. True or False:
Medicare does not require a licensed physician
to order and oversee home health care
services.
Pretest
2. Multiple choice:
Physicians receive reimbursement from Medicare for
care plan oversight for all of the following except:
Communicating with nurses or therapists
b. Talking with patients and families over the
phone
c. Reviewing labs not associated with
physician visits to patients
d. Certifying and recertifying the care plan
a.
Pretest
3. Multiple choice:
Indications for physician home visits include all of the
following except:
a.
b.
c.
d.
Evaluation of suspected elder abuse or neglect
Patient failure to thrive
Caregiver’s convenience
Limited mobility or difficulty transporting the
patient to doctor’s appointments
Pretest
4. True or False:
The Medicare home health care requirements
of homebound status and skilled need apply
to occasional physician home visits.
Pretest
5. Multiple choice:
Which of the following best describes typical
homebound patients?
a.
b.
c.
d.
Homebound patients tend to be frail with
significant functional impairment and multiple
chronic diseases
Homebound patients are usually independent in
their activities of daily living
Homebound patients have much better functioning
than nursing home patients
The population of homebound patients is
decreasing
Pretest
6. Multiple choice:
Which one of the following is not true regarding the
benefits of home health care?
a.
b.
c.
d.
Improves patient and caregiver satisfaction
Improves medication administration
Improves management of chronic diseases
None of the above
Pretest
7. True or False:
Home health care is cost effect in providing
post hospital transitional care.
Pretest Answers
1.
2.
3.
4.
5.
6.
7.
false
b.
c.
false
a.
d.
true
Section One:
The Role of the Physician
in Home Health Care
 Medicare requires a licensed physician to order and
oversee home health care services.3
 Physicians refer homebound patients with skilled care
needs to home health care agencies.1
 Physicians make home visits.
Oversight of Care Plan1,2

The physician ordering home health care services
receives reimbursement for certification and oversight
of the care plan as well as for coordinating care.
 Medicare Part B pays the physician, but patients pay
20% of the cost.
 To receive reimbursement,


the physician must spend a minimum of 30 minutes
per month on home health care related activities,
But the physician does not receive payment for time
spent speaking with patients or family members.
Physician Home Visits10,11,12


Evaluate the patient in the home environment.
Identify new problems, assess functioning in the
home, and provide comprehensive assessment.
 Provide new interventions, assess medication
compliance, and recommend environmental
modifications.
 Examine patients, conduct diagnostic tests, prescribe
medications, and educate patients, families, and
caregivers about management of chronic diseases.
 Perform some procedures in the home as well as refer
patients for other testing and services.
Specific Types of Home Visits11

Acute and chronic illness
 Hospice/end of life care
 Comprehensive home assessment
 Hospitalization follow-up
Indications for Home Visits11







Physical impairment and limited mobility or limited
transportation to doctor appointments
Assessment of caregiver burden
Suspected elder abuse or neglect
Failure to thrive
Falls
Psychiatric illness and behavior problems
Evaluation of need for nursing home placement
Home Safety Assessments11

Physicians can conduct safety assessments, although
more typically occupational therapists perform them.
 Look at housekeeping, cleanliness, crowding, and
emergency exits.
 Assess patient’s nutritional situation by examining
refrigerators and cupboards and discussing meals,
smoking, and alcohol.
 Determine a patient’s need for other home health care
services.
Elements of
a Home Safety Assessment11






Check the appliances in the kitchen, assess cooking
ability
Assess the bathroom for hand-holds, raised toilet seats,
nonslip showers, nonslip floors,
Assess stairs for handrails, secure carpet, and proper
lighting
Assess maintenance of utilities, including heating and air
conditioning
Check for smoke detectors, fire extinguishers, appropriate
lighting and night lights
Check for safe hallways and walkways, free of loose
carpet and throw rugs
Reimbursement
for Physician Home Visits





The Medicare home health care requirements of
homebound status and skilled need do not apply to
occasional physician home visits.2
Reimbursement rates have varied over time.
In 1998, Medicare instituted new billing codes that
increased reimbursement for home visits by 50%.7
However, reimbursement decreased by almost 20%
between 2005 and 2008.7
Reimbursement depends in part on physician billing,
which focuses on documentation, including evaluation of
a patient’s functioning, caregiver issues, and discussion of
the plan of care.10
Physicians
and Home Technology7

Use of mobile medical technology,


such as lab testing and diagnostics in the home
Participation in telehealth:

telecommunication with patients using interactive video,
telephone, and/or Internet to aid in diagnosis and treatment as
well as health care maintenance and disease prevention
Few Physicians
Actually Provide Home Visits

Patients receiving home health care services typically
do not receive physician home visits as part of their
care.
 Overall, primary care physicians in the United States
do not incorporate home visits into their practices.
 Physicians in England


make 10 times the number of home visits per 1,000 patients per
year compared with U.S. physicians7 and
make 100 times as many home visits to patients older than 85
years.7
Section Two:
Benefits of Home Health Care

Home health care has the potential to benefit a large
number of chronically ill adults, especially older
adults, living in the community.
 Approximately 1 million individuals aged 65 and
older are permanently homebound.13,8
 An estimated 5.8 million community-dwelling older
adults meet the Medicare definition of homebound
either permanently or temporarily due to illness or
injury.13,8
Needs of Homebound Patients

Homebound patients tend to be frail, with significant
functional impairment and many chronic diseases.13
 More than 5.4 million community dwelling adults
have limitations in at least 1 activity of daily living;
about 3 times that number have limitations in
instrumental activities of daily living.5
 Many homebound community dwelling older adults
have enough functional impairment to be eligible for
a nursing home level of care.13
 By 2020, 2 million older adults will be chronically
homebound due to functional impairment.13
Benefits of Home Health Care1,8

Improved





Decreased

hospitalization rates
ER visits

functional decline


health outcomes, functionality, and quality of care
patient and caregiver satisfaction and improved medication
administration
management of chronic care conditions
transitions to home from hospitals, rehabilitation facilities, and
nursing homes
Reduced

social isolation

institutionalization and nursing home use
Benefits of Multidisciplinary Continuous
Long Term Home Health Care
Comprehensive home health care services with
medical, psychosocial, functional, and
environmental components and continuous
long term follow up visits have been shown to
improve functional stability and decrease
nursing home admissions.
Benefits of Multidisciplinary Continuous
Long Term Home Health Care (cont.)
Studies of home health care programs that
provided comprehensive assessment and
follow up visits with a minimum of 9 or more
home visits demonstrated a 24% reduction in
functional decline; a 34% reduction in nursing
home admissions; decreased rates of
hospitalization, number of ER visits, and
mortality; and increased satisfaction with
care.8,7
Home Health Care Cost Savings1

Studies of older adults with specific chronic diseases
have shown that home health care can substantially
decrease costs.
 In patients with heart failure, costs declined by 50%.
 Home health care has also been cost effective in
patients who need short term post hospital post acute
transitional care where it has successfully prevented
readmissions and shortened hospital stays.
Benefits of Home Occupational
Therapy and Physical Therapy4
 Improves
activities of daily living.
 Decreases falls.
 Increases social participation.
 Improves subjective quality of life.
 Reduces caregiver burden.
 Improves health status.
Benefits of Home Health Nursing4
 Improves
activities of daily living.
 Improves health status.
 Decreases mortality rates.
 Decreases use of hospitals.
 Delays nursing home admission.
Home Health Care
Mental Health Benefits
 Social
assistance through home social
workers4


reduces symptoms of depression and anxiety
and
increases social integration.
 Intensive
psychiatric home care by home care
teams is cost-effective and successful.1
Post-test
1. True or False:
Physicians do not usually actively participate in
the development and implementation of the
home health care plan other than certifying
and recertifying it.
Post-test
Multiple choice:
2.
Physician home visits typically include all of the
following except:
a.
b.
c.
d.
Assessment of caregiver burden
Medication review
Comprehensive and complete home safety
assessments
Direct observation of activities of daily living
Post-test
3. True or False:
Overall, primary care physicians in the United
States do not incorporate home visits into
their practices.
Post-test
4. Multiple choice:
What is the minimum number of home visits that has
been shown to provide the most benefit in home
health care programs that provide comprehensive,
continuous care?
a.
b.
c.
d.
3
5
7
9
Post-test
5. True or False:
Home health care is cost effective for both long
term care and short term post acute care.
Post-test
6. Multiple choice:
Benefits of home physical and occupational therapy
include all of the following except:
c.
Decreased use of assistive devices
Improved subjective quality of life
Reduced caregiver burden
d.
Decreased falls
a.
b.
Post-test
7. True or False:
Telehealth is telecommunication with patients
using interactive video, telephone, and/or
Internet to aid in diagnosis and treatment.
Post-test Answers
1.
2.
3.
4.
5.
6.
7.
true
c.
true
d.
true
a.
true