Download Medicaid and Alternative Home Health Care Programs

An Introduction to Home Health Care
in the United States:
Medicaid and
Alternative Home Health Care Programs
Tracy Gutman, MD
Geriatrics Fellow
University of Kansas
OBJECTIVES
By the end of this module,
the learner will do the following:
Define personal assistance services and explain when
these are covered by Medicare.
Differentiate the three main Medicaid programs that
provide home and community-based services.
Compare and contrast the Program of All Inclusive
Care for the Elderly (PACE) and the Veterans
Administration Home Based Primary Care (HBPC)
Program.
Describe the characteristics of typical participants in
both PACE and HBPC.
List some of the benefits of PACE and HBPC.
Rate as valuable the use of home health care to
provide comprehensive, multidisciplinary, long term
care to frail, chronically ill, and functionally impaired
adults and elders.
Pretest 1: True or False
Personal assistance services are considered
non-skilled services.
Pretest 2: Multiple choice
Medicare will pay for personal assistance
services under the following circumstances:
a.
b.
c.
d.
If the patient is homebound and has a
concurrent skilled need.
If the patient is homebound.
If the patient meets financial criteria.
If the patient needs continuous care.
Pretest 3: True or False
The majority of community dwelling
functionally impaired adults and older
adults in need of personal care receive
such care from informal and unpaid
sources such as family members, friends,
and neighbors.
Pretest 4: Multiple choice
Which of the following is not correct regarding
the Medicaid Home and Community Based
Services Waiver Program?
a.
b.
c.
d.
States establish target groups for the
waivers.
States vary in the types and amount of
services offered.
Usually includes benefits not typically
covered by Medicaid.
State expenditures on waiver recipients can
exceed expenditures on nursing home
residents.
Pretest 5: Multiple choice
Which of the following is true regarding the
Program of All Inclusive Care for the Elderly
but not true regarding the VA Home Based
Primary Care Program?
a.
b.
c.
d.
The overarching goal involves helping
people live independently in the community.
The focus is on providing care in an adult
day health center.
Participants must be 55 years or older and
need a nursing home level of care
Both b. and c.
Pretest 6: Multiple choice
Which of the following is not true regarding the
VA Home Based Primary Care Program?
a.
b.
c.
d.
Provides services by an interdisciplinary
team.
Requires that participants demonstrate
improvement to continue receiving services.
Targets patients with chronic medical
problems and functional limitations.
Aims to promote functional independence,
reduce emergency room use, reduce
hospitalizations, and reduce
institutionalization.
Pretest 7: Multiple choice
Which of the following best describes the VA
Home Based Primary Care Program?
a.
b.
c.
d.
Provides short term skilled care.
Discharges patients when goals are met or
improvement has been maximized.
Provides in-home long term primary care
services by an interdisciplinary team to
chronically ill, functionally impaired veterans
throughout the remainder of their lives if
needed.
Has strict age and functional criteria.
Pretest Answers
1.
2.
3.
4.
5.
6.
7.
true
a.
true
d.
d.
b.
c.
Section One: Medicaid and
Personal Assistance Services
Personal assistance services include5:
general help with activities of daily living and
instrumental activities of daily living needed by
functionally impaired elders and adults in the
community.
These services are considered nonskilled
assistance and do not require supervision by a
health care professional or other licensed
provider.5
Section One: Medicaid and
Personal Assistance Services
(cont.)
Medicare will only pay for2:
personal assistance services such as a
home health aid for personal care, if a
homebound person has a concurrent
skilled need, and then,
only short periods of time such as a few
hours per day and only for the duration
of the skilled need.
Sources of
Personal Care Assistance
Unpaid, informal caregivers provide more than
80% of personal assistance services while
only 25% of people receive services from 1
or more paid workers.5
Sources of
Personal Care Assistance (cont.)
Paid, formal personal care aides can be
funded by5,1:
out of pocket resources of
recipients/families
public payer programs including
Medicaid, Medicaid waivers,
state block grants,
Title II Older Americans Act funds,
state and local government general funds,
Department of Veterans Affairs Aides
programs,
and sometimes by private insurance
Medicaid is the Major Program
Medicaid serves as the major public program
for paid personal assistance services including
home attendants and private aides.5
Medicaid is a joint federal and state program
managed by the states that serves as the
primary payer for long term care services for
people with low incomes and assets.14
Three Main Medicaid Programs
Medicaid provides home and community-based
services (HCBS) through three main
programs15:
waiver programs
state plan personal care services and
general home health care.
Three Main Medicaid Programs
(cont.)
These Medicaid programs typically provide services
through home health care or personal attendant
agencies, but states are permitted to allow
independent provider service options under their
waiver and personal care services programs.15
The Medicaid HCBS Waiver Program
Established in the Omnibus Budget
Reconciliation Act of 19815,16:
permits states to provide long term care
services in the community to individuals who
would otherwise require nursing home
placement.
1915(c) waiver program under the Social
Security Act15,14:
allows states to waive Medicaid requirements
in order to provide home and community based
services to targeted specific population groups.
The Medicaid HCBS Waiver Program (cont.)
Limits services to community dwellers eligible
for institutional care.5
Data from 2006 shows that 90 % of waiver
participants are either aged, or both aged and
disabled, or are individuals with mental
retardation/developmental disabilities.14
HCBS Waiver Program Services
Personal care assistance, home health services,
and other benefits not usually authorized by
Medicaid such as home modifications.15
HCBS waiver programs may include personal
care assistance services, case management,
homemaker services, adult day care, respite,
personal emergency response systems,
environmental adaptations, home delivered
meals, nursing care, medical equipment, and
transportation.5,16
HCBS Waiver Limitations
HCBS waivers have cost limitations.
Federal guidelines require that the average
expenditures for HCBS waiver recipients do not
exceed those of nursing home residents.16
Generally, long term care payments account for 1/3 of
states’ Medicaid budgets, but overall expenditures for
HCBS recipients are significantly lower than those for
nursing home residents.16
In 2006, home and community services spending per
participant was about $13,300, compared with an
average of about $33,000 for institutionalized
participants.14
States can limit the number of participant slots, set
cost caps, limit types of services, limit services to
specified regions, and put people on protracted waiting
lists.15
Medicaid State Plan
Personal Care Services17,14,15
Since 1975, states have had the option of offering
personal care services as a Medicaid benefit, and each
state can define the amount and scope of services.
Programs usually provide nonmedical assistance with
activities of daily living with limited other benefits.
To participate in these programs,
individuals do not need to meet the institutional
need criteria, but
they do need to meet a functional need
requirement set by the states and assessed by
a professional.
Medicaid Home Health Care17,15
Medicaid waiver and personal care services programs
are optional.
States are mandated to provide Medicaid home health
care services for those eligible for institutional care.
States can vary the amount, scope, and duration of
home health care benefits.
To participate in home health care,
individuals must have a professionally authorized
skilled nursing facility level of care need and a
categorical financial need, but
states can also opt to include the medically needy.
Medicaid home health care provides skilled nursing
care by licensed or certified home health care agencies.
Section Two: Alternative
Home Health Care Programs
Two specific examples of programs designed to provide
long term continuous home health care to chronically
ill, functionally impaired adults and elderly in the
community:
PACE: Program of All-Inclusive Care for the Elderly
HBPC: The Veterans Administration Home Based
Primary Care Program
These programs provide continuous, longitudinal
medical care administered by an interdisciplinary team
to elders and chronically ill adults living in their homes
in the community
The team becomes the primary care provider.
PACE and HBPC Benefits
Improve access to healthcare, improve health
care coordination and continuity of care,
improve quality of care, prevent functional
decline, decrease rates of institutionalization,
decrease caregiver burden, and increase patient
satisfaction.19
Demonstrate that home health care services can
be expanded in a cost effective way to enable
chronically ill, functionally impaired elders and
adults to remain in the community and to avoid
institutionalization.
PACE:
Program of All-Inclusive Care for the
Elderly19,20
Program of All-Inclusive Care for the Elderly
(PACE):
capitated program that combines funds from both
Medicare and Medicaid
provides all care including acute and long term care to
frail, older people living in the community and
has the goal of keeping them living independently for
as long as possible
To enroll, older adults must need a nursing home level
of care as defined by state requirements, must reside in
the community within the geographic area served by
the program, and must be 55 years or older.
Typical PACE patients
Participants in the program overall are very
similar to the typical nursing home resident.
They are on average 80 years old, have 9.7
medical conditions, are limited in 3 activities of
daily living, and 49% have been diagnosed
with dementia.19
Most of the enrollees are eligible for both
Medicare and Medicaid.20
On Lok Senior Health Services18
The Program of All-Inclusive Care for the
Elderly began as one initial program called On
Lok Senior Health Services in San Francisco’s
Chinatown in 1971.
To join the On Lok program, an older adult was
required to:
be certified as eligible to enter a nursing home,
give up the use of Medicare and Medicaid
funds for services outside of the program, and
leave his or her private physician for provision
of care by an On Lok physician.
On Lok: First PACE18
“On Lok” in Cantonese means “peaceful, happy abode.
Program centered on an adult day health center.
Older adults brought to day center and attended daily social
activities and received care including meals, medication,
blood pressure/blood sugar checks, and bathing.
They also participated in exercises and recreational
activities.
They had monthly physician visits and periodic visits from a
dentist, optometrist, and podiatrist.
Every three months, each participant received a complete
health assessment by an interdisciplinary team.
At the end of the day, participants received transportation
back to their homes where they had home health aides help
with dinner and other personal care services.
Growth of PACE
In 1983, the program obtained Medicare and
Medicaid waivers to receive pooled capitated
financing.18
In 1986, the Robert Wood Johnson Foundation and
the federal government provided funding to create
community programs all over the country based on
the On Lok model.18
PACE was designated as a permanent Medicare
program under the Balanced Budget Act of 1997.20
As of 2009, according to the National PACE
Association, 72 PACE programs exist in 30
states.21
PACE Programs Today
PACE programs all have as their overarching
goal keeping older adults, who would
otherwise need nursing home placement, in the
community.10
Programs continue to operate very similarly to
the On Lok program.
A multidisciplinary team serves as the primary
care provider and manages the care of patients
with a focus on prevention, rehabilitation, and
early interventions.19
PACE Interdisciplinary Team20
The PACE care team includes:
primary care physician
nurse
social worker
physical and occupational therapists
recreation therapist
health aides
pharmacist (when available)
nutritionist or dietician, psychiatrist (when available)
transportation coordinator,
all contribute to the care plan
Adult Day Health Center19
PACE programs continue to provide services
based on an adult day health center.
Day center services include:
a geriatric outpatient clinic,
social services and personal care services,
opportunities for social and recreational
activities and therapies.
Other PACE Services
• Home care including meals, personal
care, skilled nursing, and chore
services.19
• Transportation, medication, hearing
aids, and eyeglasses.10
• Acute care, hospitalization,
rehabilitation, medical specialty care,
alternate living situations, respite
care, nursing home care if
needed.10,20
PACE Success19,20
Decreased hospital use (both admissions and
length of stays).
Reduced institutionalization.
Increased use of outpatient medical care.
Integration of acute and long term care:
to maintain older adults in the community and
to provide care at lower costs compared with
traditional fee for services rates.
Improved patient satisfaction with care.
Improved overall health status of participants.
HBPC: The Veterans Administration
Home-Based Primary Care Program
Provides in home long term primary care services
by an interdisciplinary team to chronically ill,
functionally impaired veterans throughout the
remainder of their lives, if needed.22,23,6
Targets individuals with chronic medical problems
and functional limitations with the goal of
providing comprehensive longitudinal long term
home care to increase functional independence,
reduce emergency room utilization,
hospitalizations, and institutionalization, and
maintain quality of life.23,22
History of HBPC Program
Modeled after a hospital based home care program
developed by Dr. E.M. Bluestone at the Montefiore
Hospital in New York City in 1947.6
Began as a pilot program demonstration project known
as the Hospital Based Home Care (HBHC) program at
6 VA locations in 1970.20,6,22
Became an established program in 1972.20,6,22
In 1995, the VA changed the name of the program to
Home Based Primary Care (HBPC).23
HBPC has grown to a total of 116 programs across the
nation caring for an average of more than 12,500
veterans per year.6
Offers services that are not available under other
federal or state programs such as Medicare or
Medicaid.6
HBPC Program Specifics23
The mean age of participants is 76.5 years: 96% are men
and 47% are dependent in 2 or more activities of daily
living.
The program:
Is not restricted by age.
Does not make restrictions such as those required by
Medicare home health care.
Has no strict homebound requirement.
Does not require a skilled care need.
Does not require improvement.
On average, most participants continue in the program for
more than 315 days and receive about 3 visits per month
from various team members.
The program is usually limited in coverage area to 30-70
miles from a VA facility.
Participants can still get Medicare home health services.
HBPC Targets Frail Population
The program targets a frail, chronically ill
population22,6:
Patients with complex medical, social, and behavioral
problems
Patients with impaired mobility, who require assistance
of a device or person to travel to a clinic
Patients who make frequent visits to the ER or have
frequent hospitalizations.
The typical HBPC patient has an average of 19.36
active diagnoses and takes an average of 15
medications.6
More than 60% have mild to severe cognitive
impairment.6
Members of the HBPC Care Team22
The HBPC care team can include:












nurses
physicians
social workers
physician medical director
nurse practitioners
physical and occupational therapists
dietician
pharmacist
pastoral care provider
mental health provider
program director
administrative and clerical support personnel
Members of the HBPC Care Team23
Mid level providers provide primary medical
management in cooperation with a supervising
physician.
Nurses provide home nursing care and assess patients’
needs.
Social workers assess resources and support systems
and help maximize social services.
Physical and occupational therapists assess functional
status, perform home safety assessments and
recommend modifications, determine needs for home
medical equipment, and develop home therapy to
maximize functional independence.
Pharmacists assess medications, educate patients and
caregivers, and offer recommendations about
medication management to the team.
Interdisciplinary HBPC Care Team
Members do home visits on a regular basis.22
The team also has weekly interdisciplinary care
plan meetings to develop and modify the
treatment plan.22
The team initially develops a care plan within
30 days of a patient’s admission to HBPC and
then reviews it every 3 months.6
Patients can continue to receive care from
HBPC as long as the team considers that they
are benefiting, and the most common reason
for discharge is death.6
HBPC Successes
Reduced hospitalizations, nursing home
placement, and ER visits for participants.22
Reduced number of inpatient days and reduced
total cost of care.23
98% patient satisfaction rate.6
HBPC Successes
(cont.)
2002 data23:
hospital bed days of care were reduced by 62%
nursing home bed days of care decreased by 88%
all home care visits increased by 264%
mean total VA cost of care dropped 24%
2006 data23,10:
69% reduction in inpatient days of care
2007 data23:
59% reduction in hospital bed days of care
89% reduction in nursing home bed days of care
78% combined reduction of total inpatient days of
care
21% reduction in 30 day hospital readmission rates
Post-test 1: Multiple choice
Personal assistance services include the
following:
a.
b.
c.
d.
help with activities of daily living
wound care
physical therapy
physician home visits
Pretest 2: Multiple choice
Which of the following is not true regarding
Medicaid?
a.
b.
c.
d.
It is a joint federal and state program.
It serves as the major public program
for paid personal assistance services.
It is the primary payer for long term
care services for individuals with low
incomes and assets.
It is managed by the federal
government.
Pretest 3: Multiple choice
Which of the following Medicaid programs
is/are limited to community dwellers eligible
for institutional care?
a.
b.
c.
d.
Medicaid home and community based
services waiver program
Medicaid State Plan Personal Care
Services
Medicaid home health care
a. and c.
Pretest 4: Multiple choice
The Program of All Inclusive Care for the
Elderly receives funding from:
a.
b.
c.
d.
Medicare only
Medicaid only
Medicare and Medicaid
none of the above
Pretest 5: Multiple choice
The Program of All Inclusive Care for the
Elderly includes all of the following except:
a.
b.
c.
d.
care provided by an interdisciplinary
team
care provided primarily at an adult day
health center
24 hour supervision of participants
acute care hospitalizations
Pretest 6: Multiple choice
Which of the following is not true regarding the
interdisciplinary team in the VA Home Based
Primary Care Program?
a.
b.
c.
d.
A transportation coordinator is part of the
team.
Team members conduct home visits on a
regular basis.
The team has weekly interdisciplinary care
plan meetings.
The team provides comprehensive,
multidisciplinary, longitudinal on-going
health care in the home for veterans.
Pretest 7: Multiple choice
The VA Home Based Primary Care Program
includes all of the following services except:
a.
b.
c.
d.
physician home visits
nurse in-home assessments
personal care assistance
pharmacist assessment of
medications
Post-test Answers
1.
2.
3.
4.
5.
6.
7.
a.
d.
d.
c.
c.
a.
c.