Download CommunityBasedCare.GNRS5

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COMMUNITY-BASED
CARE
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OBJECTIVES
Know and understand:
• What constitutes a home care organization
• How home care is financed and which patients
qualify for home care services
• The primary provider’s role in home care services
• Options for community-based care that do not
require a change of residence and those that do
• How community-based care is financed
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TO P I C S C O V E R E D
• Home Care
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Primary Provider’s Role in Home Care
Patient Assessment
Limitations of Home Care
Liability & Legal Issues
Ethics and Decisions about Institutionalization
• Community-based Services
 Not Requiring a Change of Residence
 Requiring a Change of Residence
I N T R O D U C T I O N TO H O M E C A R E
(1 of 3)
• Home Care Organizations include:
• Home Health Care Agencies
• Home Care Aide Organizations
• Hospices
• Organizations can bill Medicare for
reimbursement only if the organization is
Medicare certified
• Home Care has the potential to improve
patient’s quality of life and avoid
unnecessary hospitalization or
institutionalization
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I N T R O D U C T I O N TO H O M E C A R E
(2 of 3)
• In 1997, a Prospective Payment System (PPS) for
home services was developed.
• By the end of 2001, the number of Medicarecertified home care agencies had declined by
30.4%, many as a result of financial pressures.
However, with implementation of a PPS, the
financial stability has allowed growth of Medicarecertified agencies to well over 10,000 agencies
nationally.
• In 2009, nearly 12 million people received home
care at a cost of $72 billion
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I N T R O D U C T I O N TO H O M E C A R E
(3 of 3)
• For Medicare to reimburse for home health services,
patients are required to be homebound and have a need
for a skilled service provided by a licensed nurse or
rehabilitation professional
• To be considered homebound, a patient’s condition
makes leaving home a “considerable and taxing effort”
• Patients may still be able to leave their home for
nonmedical reasons as long as these occurrences are
“infrequent and short in duration” such as for attending a
religious service or special family event
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OASIS
• The Outcome and Assessment Information
Set is a tool for setting fees for home
health–related groups (HHRGs)
• Completed by the home-health agency
• Tracks domains of functional status and
medical needs:
 Severity of the patient’s illness
 Disabilities
 Nursing needs
 Geographic location
P R I M A RY P R O V I D E R ’ S R O L E I N
HOME CARE (1 of 3)
• Although a member of an interdisciplinary
team, the primary health care provider is the
person legally responsible for the patient’s
care plan
• Duties:
 Determine the patient’s health care needs
 Develop, certify, and recertify the care plan
 Confer regularly with team members to address
patient care issues and handle documentation
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P R I M A RY P R O V I D E R ’ S R O L E I N
HOME CARE (2 of 3)
• House calls can add an important dimension
to the health care provider’s knowledge of
the patient’s circumstances and
environment
• Home evaluation can identify additional
problems not readily apparent in officebased assessment
• House calls have the additional benefit of
reducing the burden of transportation for
patients who have difficulty getting outside
of the home
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P R I M A RY P R O V I D E R ’ S R O L E I N
HOME CARE (3 of 3)
• Current regulations allow house calls to be provided
by physicians, nurse practitioners, and physician
assistants. Their services are often delivered as
part of those of an interdisciplinary team.
• Thorough documentation is key to receiving
reimbursement
– No specific restrictions on the number of visits, as
long as sufficient justification for evaluation,
management, and medical necessity is included in
the progress notes
– Evaluations of the patient’s function, caregiver
issues, and the medical plan of care are also critical
elements of the documentation
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PAT I E N T A S S E S S M E N T
• Determine whether the home is safe and
supportive, given the patient’s abilities
• Directly observe the environment for performing
ADLs
• Recommend environmental modifications to
improve function
• Identify and address the caregiver’s needs for
counseling, training, support, and education
C O N D I T I O N S T H AT M A K E
HOME CARE INADVISABLE
• Caregiver not available who can adequately
address patient’s needs
• Patient requires frequent laboratory testing,
respiratory interventions, or IV medications
• Caregiver stress or burnout
• Unsafe home environment
• Prohibitive expense
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LIABILITY & LEGAL ISSUES
IN HOME CARE
• Malpractice suits related to home care are
relatively uncommon, but clinicians are
potentially liable for adverse outcomes
• Review certificates of medical necessity before
signing—inaccuracies could lead to charges of
Medicare fraud
• Health care providers are prohibited from
benefiting financially from referrals to a homecare provider
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ETHICS & DECISIONS ABOUT
I N S T I T U T I O N A L I Z AT I O N
• Balance between patient autonomy and safety
 Conflict arises when a patient desires to stay
at home but medical care cannot safely be
maintained there
 In cases when the outcome is likely to be
terminal, hospice referral may be indicated
• If neglect or abuse is clearly occurring, the
Adult Protective Services should be contacted
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O V E RV I E W O F
C O M M U N I T Y- B A S E D S E RV I C E S
No change of residence
• Adult day care
• Day hospitals
• Program of All-inclusive
Care for the Elderly
• Managed Long-Term
Care Programs
• Home hospital
• In-Home Technology
• Telemedicine
Change of residence
• Senior Villages and
Senior Cohousing
• Assisted living
• Group homes
• Adult foster care
• Sheltered housing
• Continuing-care
retirement
communities
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A D U LT D AY C A R E
• Community-based option that provides a wide range of
social and support services in a congregate setting
• May offer a variety of services, ranging from simple
nonskilled custodial care to more advanced skilled
services
• Used commonly for:
 Patients with dementia who need supervision and
assistance with their ADLs while the primary caregiver is
at work or tending to other responsibilities
 As a form of respite for the primary caregiver
• In general, adult day care is not covered by Medicare,
although some costs may be covered by Medicaid or
other insurers
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D AY H O S P I TA L S
• Most are housed in chronic care hospitals or
rehabilitation centers
• Broad range of skilled nursing care services:
 Parenteral antibiotics
 Chemotherapy
 Intensive rehabilitation
• Services are covered by Medicare; requirements
are similar to those for home-health care
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PROGRAM OF ALL-INCLUSIVE CARE
F O R T H E E L D E R LY ( PA C E )
• Pools Medicare and Medicaid funds to provide acute
and long-term care to low-income, frail older people
• Participants must meet state-defined requirements
regarding need for a nursing-home level of care
• Goal is to keep participants in the community for as
long as feasible
• Care by an interdisciplinary team provides
 All inpatient, outpatient, and long-term care services to
frail older adults
 Assistance with complex social needs
MANAGED LONG-TERM CARE
PROGRAMS (MTLC)
• Aim to provide safe and cost-effective care
• States partnering with home care, nursing homes,
hospitals to enable older adults to avoid nursing
home placement and decrease hospital utilization
• Include dually eligible patients (Medicare and
Medicaid) with chronic conditions that impair ability
to live independently
• Some referred to as “PACE without walls”
• Provide financing through various capitated
payments per member, per month
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H O M E H O S P I TA L
• Provides more complex care at home to
older people who would have been
hospitalized for acute care
• Patients have access to nurses and
physicians on a regular basis and to episodic
care through an on-call system
• Studies conducted outside the US suggest
that quality of care is comparable to that of
home care for selected patients, and that
patient satisfaction is high
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IN-HOME TECHNOLOGY
• A wide array of technologies have been developed that
can assist patients with ADLs and provide valuable
information to caregivers
 Personal emergency response systems
 Devices that can aid with administering and tracking
medications, monitoring and transmitting vital signs, and
connecting patients to care providers through audio and visual
telemedicine screens
 Fully automated systems to adjust heating and lighting, to allow
doors to be opened and closed with remote devices and to
monitor activity throughout the home
 Home robotics are under development that assist in ADLs or
IADLs
 Computers and smartphones can also be used to connect
patients through social networks to combat isolation and
loneliness
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TELEMEDICINE
• Rapidly growing modality of providing in-home health
care services that can improve access to medical
services that may not be readily available otherwise
• Commonly used technologies include:
 Videoconferencing connections, allowing a clinician to
speak with and observe a patient to conduct a “virtual
home visit”
 High resolution cameras with trained technicians on-site
with a patient and incorporate additional equipment (eg,
stethoscope and otoscope attachments), while the off-site
clinician can conduct a clinical assessment remotely
• These services have varying levels of regulations across
states, insurance coverage, copayment, and out-ofpocket costs to patients
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SENIOR VILLAGES AND COHOUSING
• Intentional communities where residents tend to
be more independent, healthy, and active than in
other forms of senior housing
• Typically not associated with provision of
medical supervision or health care services
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A S S I S T E D - L I V I N G FA C I L I T I E S
• Characterized by coordination or provision of
personal-care services, social activities, healthrelated services, and supervision in a home-like
atmosphere
• Services vary considerably
• Caring for an increasing number of frail people with
significant medical needs
• Care is typically transitional: Average length of
residency is ~2 years
• Most common reason for discharge is need for nursing
home care
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FINANCING ASSISTED LIVING
• Cost varies greatly ($800‒$4000 per month)
• Covered in a growing number of long-term-care
insurance policies
• Not covered by Medicare
• Certain services are paid under SSI and Social
Services Block Grant programs
• Some states reimburse or plan to reimburse for
assisted-living services under Medicaid
• States have the option to include assisted-living
services in Medicaid or petition HHS for a waiver
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GROUP HOMES
• Houses or apartments in which 2 or more
unrelated people live together
• Many serve patients with chronic mental
illness or dementia
• Advantages:
 Lower cost than other community-based care
 Socialization with peers
• Most are for-profit; licensing not required in
all states
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A D U LT F O S T E R C A R E
• Generally provide room, board, and some assistance
with ADLs by the sponsoring family or paid caregivers,
who customarily live on the premises
• Advantage: maintaining frail older people in a homelike environment
• Regulations vary by state; not all states require
licensing
• Covered by Medicaid in some states
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S H E LT E R E D H O U S I N G
• Subsidized housing funded through the Older Americans
Act, through Section 8 HUD programs
• Available to seniors and people with disabilities
• Cost is based on a sliding scale, up to 30% of income
• Often includes:
 Personal care assistance
 Housekeeping services
 Meals
• May be supplemented by social worker services and
activities coordinators
CONTINUING-CARE
RETIREMENT COMMUNITIES
• Options range from independent living apartments
or condominiums to assisted living, skilled nursing,
and home care
• Most require entry fee plus variable monthly fee
• 3 common financial models:
 All-inclusive—total health care coverage
 Fee for service—payments match the level of care
 Modified coverage—covers long-term care to
predetermined level
• Funding is largely private
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S U M M A RY
• Home Care has the potential to improve patient’s
quality of life and avoid unnecessary
hospitalization or institutionalization
• House calls can add an important dimension to
the physician’s knowledge of the patient’s
circumstances and environment
• The availability of community-based services not
requiring a change of residence strongly depends
on financial reimbursement
• Inpatient community-based care is regulated at the
state level and varies considerably in availability,
cost, and services provided
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QUESTION 1 (1 of 4)
• A 79-year-old woman with osteoarthritis is brought in by her son,
who is concerned about a decline in her health.
• Until recently, his mother moved around their apartment
independently and fixed simple meals for herself.
• One month ago, she had symptoms of a cold, with runny nose,
cough, and decreased appetite.
 The runny nose improved, but the cough has persisted.
 She now has dyspnea, her appetite has declined markedly, and she
is increasingly weak.
 She fell several times in the past 2 weeks.
 Her arthritis pain has worsened.
• The son works full-time and is the sole caregiver for his mother.
 He has missed work over the last few days because his mother is
less able to care for herself.
 He cannot afford to hire caregivers to be present while he is at work.
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QUESTION 1 (2 of 4)
• Examination
 The patient appears well cared for, and she is alert and oriented.
 Blood pressure 124/56 mmHg, heart rate 112 bpm, respiratory rate
24 bpm, temperature 37.3°C (99°F)
 O2 saturation 86% on room air
 Weight is 2.7 kg (6 lb) lower than at her last visit.
 Normal heart and abdominal findings
 Decreased breath sounds at the right base and bilateral scattered
crackles and rhonchi
 No focal neurologic deficits
 She is unable to get up from her chair without assistance.
 She is unsteady and walks slowly, with a shuffling gait.
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QUESTION 1 (3 of 4)
Which one of the following is the most appropriate next
step in caring for this patient?
A. Admit directly to a skilled-nursing facility for
rehabilitation.
B. Admit to hospital to determine cause of decline and to
evaluate functional status.
C. Contact Adult Protective Services about possible
neglect and inadequate care.
D. Refer to home-care agency for evaluation, home
safety assessment, and rehabilitation.
E. Recommend move to an assisted-living facility.
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QUESTION 1 (4 of 4)
Which one of the following is the most appropriate next
step in caring for this patient?
A. Admit directly to a skilled-nursing facility for
rehabilitation.
B. Admit to hospital to determine cause of decline and to
evaluate functional status.
C. Contact Adult Protective Services about possible
neglect and inadequate care.
D. Refer to home-care agency for evaluation, home
safety assessment, and rehabilitation.
E. Recommend move to an assisted-living facility.
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QUESTION 2 (1 of 3)
An 89-year-old man comes to the office with his daughter to
establish care.
 His wife died 10 months ago, and he recently moved in with his daughter, a working
single mother with 2 teenaged children.
History: heart failure, Alzheimer disease
 He was hospitalized with heart failure before moving in with her, and he remains weak
and unsteady since hospital discharge.
His daughter has several concerns.
 When he is home alone, he mostly sits on the couch. He cannot use the microwave
oven to reheat meals, and he often forgets to take his medications.
 He is more engaged when his grandchildren are home, but she worries that he is
increasingly withdrawn, isolated, and depressed.
 It is difficult for her to take time from work to bring him to the office.
 He is adamant that he does not want to live in an institutional setting.
The patient receives Social Security income and Medicare and
Medicaid benefits.
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QUESTION 2 (2 of 3)
Which one of the following is the most appropriate
referral for this patient?
A. Psychiatry consultation for treatment of depression
B. Community senior center for socialization
C. Long-term care nursing home
D. Program for All-inclusive Care for the Elderly (PACE)
E. Home hospice care
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QUESTION 2 (3 of 3)
Which one of the following is the most appropriate
referral for this patient?
A. Psychiatry consultation for treatment of depression
B. Community senior center for socialization
C. Long-term care nursing home
D. Program for All-inclusive Care for the Elderly (PACE)
E. Home hospice care
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GNRS5 Teaching Slides Editor:
Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF
GNRS5 Teaching Slides modified from GRS9 Teaching Slides
based on chapter by
Kristin Thornton, MD, FAAFP, AGSF, CWSP and
Thomas V. Caprio, MD, MPH, MSHPE, FACP, CMD, HMDS, AGSF
and questions by Helen Kao, MD
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2016 American Geriatrics Society