New Federal Rules for Home Health Agencies

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Man and CaretakerHome health agencies will be required to become more responsive to patients and their caregivers under the first major overhaul of rules governing these organizations in almost 30 years. 

The federal regulations, published in January 2017, specify the conditions under which 12,600 home health agencies can participate in Medicare and Medicaid, serving more than 5 million seniors and younger adults with disabilities through these government programs.

They strengthen patients’ rights considerably and call for caregivers to be informed and engaged in plans for patients’ care. These are “real improvements,” said Rhonda Richards, a senior legislative representative at AARP.

Home health agencies also will be expected to coordinate all the services that patients receive and ensure that treatment regimens are explained clearly and in a timely fashion.

The new rules are set to go into effect in July 2017, but they may be delayed as President Donald Trump’s administration reviews regulations that have been drafted or finalized but not yet implemented. The estimated cost of implementation, which home health agencies will shoulder: $293 million the first year and $234 million a year thereafter.

While industry lobbying could derail the regulations or send them back to the drawing board, that is not expected to happen, given substantial consensus with regard to their contents. More likely is a delay in the implementation date, which several industry groups plan to request.

“There are a lot of good things in these regulations, but if it takes agencies another six or 12 months to prepare let’s do that, because we all want to get this right,” said William Dombi, vice president for law at the National Association for Home Care & Hospice (NAHC).

Home health services under Medicare are available to seniors or younger adults with disabilities who are confined to home and have a need, certified by a physician, for intermittent skilled nursing services or therapy, often after a hip replacement, heart attack or a stroke.

Patients qualify when they have a need to improve functioning (such as regaining the strength to walk across a room) or maintain abilities (such as retaining the capacity to get up from a chair), even when improvement is not possible. These services are not for patients who need full-time care because they are seriously ill or people who are dying.

Several changes laid forth in the new regulations have significant implications for older adults and their caregivers:

Patient-Centered Care

In the past, patients have been recipients of whatever services home health agencies deemed necessary, based on their staffs’ evaluations and input from physicians. It was a prescriptive “this is what you need and what we’ll give you” approach.

Now, patients will be asked what they feel comfortable doing and what they want to achieve, and care plans will be devised by agencies with their individual circumstances in mind.

“It’s much more of a ‘help me help you’ mentality,” said Diana Kornetti, an industry consultant and president of the home health section of the American Physical Therapy Association.

While some agencies have already adopted this approach, it’s going to be a “sea change” for many organizations, said Mary Carr, NAHC’s vice president for regulatory affairs.

Patient Rights

For the first time, home health agencies will be obligated to inform patients of their rights — both verbally and in writing. And the explanations must be communicated clearly, in language that patients can understand.

Several new rights are included in the regulations. Notably, patients now have a right to receive all the services deemed necessary in their plans of care. These plans are devised by agencies to address specific needs approved by a doctor, such as speech therapy or occupational therapy, and usually delivered over the course of a few months, though sometimes they last much longer. Also, patients must be informed about the agency’s initial comprehensive assessment of the patient’s needs and goals, as well as all subsequent assessments.

A patient’s rights to lodge complaints about treatment and be free from abuse, which had already been in place, are described in more detail in the new regulations. The government surveys home health agencies every three years to make sure that its rules are being followed.

NAHC officials said they planned to develop a “notice of rights” for home health care agencies, bringing greater standardization to what has sometimes been an ad hoc notification process.

Caregiver Involvement

For the first time, agencies will be required to assess family caregivers’ willingness and ability to provide assistance to patients when developing a plan of care. Also, caregivers’ other obligations — for instance, their work schedules — will need to be taken into account.

Previously, agencies had to work with patients’ legal representatives, but not “personal representatives” such as family caregivers.

“These new regulations stress throughout that it’s important for agencies to look at caregivers as potential partners in optimizing positive outcomes,” said Peter Notarstefano, director of home and community-based services for LeadingAge, a trade group for home health agencies, hospices and other organizations.

Plans Of Care

Now, any time significant changes are made to a patient’s plan of care, an agency must inform the patient, the caregiver and the physician directing the patient’s care.

“A lot of patients tell us ‘I’ve never seen my plan of care; I don’t know what’s going on; the agency talks to my doctor but not to me,’” said Kathleen Holt, an attorney and associate director of the Center for Medicare Advocacy. The new rules give “patients and the family a lot more opportunity to have input,” she added.

In another notable change, efforts must be made to coordinate all the services provided by therapists, nurses and physicians involved with the patient’s care, replacing a “siloed” approach to care that has been common until now, Notarstefano said.

Discharge Protections

Allowable reasons for discharging a patient are laid out clearly in the new rules and new safeguards are instituted. For instance, an agency cannot discontinue services merely because it does not have enough staff.

The government’s position is that agencies “have the responsibility to staff adequately,” Carr of NAHC said. In the event a patient worsens and needs a higher level of services, an agency is responsible for arranging a safe and appropriate transfer.

“Agencies in the past have had the ability to just throw up their hands and say ‘We can’t care for you or we think we’ve done all we can for you and we need to discharge you,’” Holt said. Now a physician has to agree to any plan to discharge or transfer a patient, and “that will offer another layer of protection.”

Boomerang Seniors and Aging Parents

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SENIORBOOMERANG7

Like many peers in their 70’s, Lois and Richard Jones of Media, Pa., sold their home and downsized, opting for an apartment in a nearby senior living community they had come to know well. For 13 years, they have visited Lois’ mother, Madge Wertzberger, there.

Wertzberger, 95, is in assisted living at Granite Farms Estates. Lois, 73, and Richard, 76, who have been married 56 years, moved into an adjoining building in October 2016.

“It doesn’t take me more than three minutes to walk to where my mother is,” said Lois. “I don’t have to drive anywhere to help her or to meet with her [medical] team. I’m right here.”

The Joneses are great-grandparents. Yet they’re among a growing group of seniors with a living parent, which means these 21st-century post-retirement years might well include parental care. Expectations are altered amid the new reality of longer life expectancy and growing numbers of aged Americans.

“I pop in when I need to take something to her or discuss things. We see each other minimally once a week, and it can be more,” Jones said. “My youngest sister normally takes her to the doctor, but I do some sharing on that. Just because I’m here doesn’t mean I have to take her to her doctor’s appointments.”

Caregiving for an older family member is not what it was when first studied and coined as the “sandwich generation,” those people squeezed between aging parents and young children, said Amy Horowitz, a professor of social work at Fordham University in New York City.

“Now it’s the children who are on the verge of retirement or who have retired and are still having the responsibility of older parents,” she said. “In New York City, I know someone whose almost-90-year-old mother is living in the same apartment building. It becomes, how do you balance your own life?”

Kathrin Boerner, an associate professor of gerontology at the University of Massachusetts, Boston, discovered a recurring theme in her research on centenarians and their adult children — that is, very old parents and their elderly children. Even if their children are not direct caregivers, they still must monitor their parents’ welfare.

“With the demographics we’re looking at, I refer to it as ‘aging together,’ — the parent-child constellation will be a lot more frequent,” Boerner said.

“For a lot of people, that is the time — if you’re in good enough health — you hope for a time of greater freedom. You’re past all the other caregiving tasks and, for most people, they can dedicate to their own needs,” Boerner said. “But for those with very old parents, it just doesn’t happen.”

“The very old are the fastest-growing segment of the population in most developed countries, with an expected increase of 51% of elders age 80+ between 2010 and 2030.” And, two-thirds of these very old have advanced-aged children, who typically serve as their primary caregiver.

“We heard things from someone like an 80-year-old — ‘I don’t have a life.’ Imagine that. You’re 80 years old, and ‘I don’t have a life because I’m caring for my mother,’” Boerner said.

Sometimes, it’s the older adult child with more health issues than the parent.

Carol Pali, 71, moved into Fort Washington Estates in Fort Washington, Pa., in October 2014, prompted by a blood disease diagnosis, around the same time she retired from full-time teaching.

“It got to a point where I was in and out of the hospital all the time,” she said. “I just decided I might as well move in here, too. It’s better than having to take care of the house.”

Pali had lived in a townhouse around the corner from the community, where her mother, Peg Henrys, who recently turned 97, had moved three years earlier.

“My mom moved from New Jersey to be closer to me,” she said.

“We get to see each other every day at dinner time, but she’s got her life here and I’ve got mine. We’re not with each other all the time,” Pali said.

“She’s in better shape than I am except that she can’t hear very well,” Pali said. 

 

Jones said she and her two sisters (one lives 10 minutes away; the other, 40 minutes away) have a weekly knitting date with their mother.

“We all knit and spend a good portion of the day with her,” Jones said of the Thursday sessions.

She also stays busy with Bible study, church services and programs featuring professors from local colleges — all on-site.

“We have joined in so many of the activities here,” she said. “We have a whole new social group. There are a lot of activities we participate in here at Granite Farms, but we haven’t given up our outside friends or activities.”

Jones said she and her husband sought to escape from the worries associated with a larger home and assume control over their future while they could. Living near her mother lets them blend caregiving with a relatively carefree lifestyle.

“We were looking to exchange responsibility for fun,” she said.

Dentistry Advocates Aim for Medicare Benefits

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Dentist Photo

Carolyn Thompson’s tight-lipped smile hides a health care problem the 81-year-old retired nurse cannot afford to correct and that Medicare will not cover.

She needs dentures. Her missing bottom teeth make chewing difficult, so she avoids most of the fresh fruits and foods that provide valuable nutrients. Thompson has not seen a dentist for many years.

“While working I always took care of my teeth, but in the last couple of years have found it difficult to pay for care,” said Thompson.

Thompson’s predicament is common. About 1 in 5 people 65 and older have untreated dental problems. But Medicare rarely covers dental care and fewer than half of elderly Americans see a dentist even once a year — often because they cannot afford to — according to a Johns Hopkins University study published in Health Affairs last year. Just 12 percent of Americans over 65 have dental insurance, that study reported.

Dental benefits were not recognized as a priority when Medicare was enacted in 1965. Back then, nearly half of Americans ages 65-74 had lost their natural teeth; today, 87 percent in that age group still have some or all of their teeth, according to the American Dental Association.

Research shows that untreated dental problems can exacerbate health problems such as diabetes and heart disease, leading to costlier bills for Medicare. That’s why a nonprofit think tank devoted to improving oral health is working toward an audacious goal: Medicare-paid dental care for America’s seniors.

The Santa Fe Group’s objective looks daunting in post-election Washington, where repealing the Affordable Care Act and cutting federal health spending are priorities for both the Trump administration and Congress’ Republican leadership.

Moreover, the costs of expansion would be significant. Such a benefit would likely be heavily used in an aging America whose 65-and-older population is projected to grow at least 30 percent by 2030. Also, while dentures were (and are) relatively inexpensive, newer techniques to preserve natural teeth, such as dental implants, are costly.

The Santa Fe Group’s members include academics, dental industry executives and former government officials. Among the sponsors are Colgate-Palmolive, DentaQuest and Henry Schein.

Santa Fe understands the uphill climb for coverage, but its sights are set on on its strategy to start building public demand for a Medicare dental benefit spearheaded by Dr. Claude Earl Fox, a former senior health official in the Clinton administration.

“We have a long road to go, but we think it’s doable and there will be a growing audience for this,” said Fox, who worked as a professor at both Johns Hopkins and University of Miami medical schools after his career in federal government.

The Johns Hopkins study estimated a dental benefit could cost from $4.4 billion to $16.2 billion a year, depending on what is covered, how much seniors pay out-of-pocket and the level of premium subsidies provided to low-income beneficiaries.

“Most of the talk in Medicare reform is how do we reduce cost rather than expand costs, and adding a dental benefit can make people [on Capitol Hill] very nervous,” said Amber Willink, the study’s lead author and assistant scientist at the Johns Hopkins Bloomberg School of Public Health.

Prescription drugs were the last major benefit Congress added to Medicare. That was in 2006 after more than a decade of pleading from advocates.

Without Medicare to help, seniors have few options to get comprehensive coverage. Private coverage is typically too expensive for many seniors.

Medicare Advantage, private plans that cover about one-third of seniors, sometimes offer a limited dental benefit for additional costs but typically only for a small network of dentists.

“It is important to show a benefit can be structured to save money for Medicare,” Fox said.

Supporting evidence from large studies is limited, however. It is uncertain whether the Congressional Budget Office — the official scorekeeper on federal legislation — would agree with the dental industry’s savings estimates from a Medicare benefit.

Politics aside, some advocates point to firsthand experiences to show that older adults’ health improves with regular dental care.

A retirement community in Alabama, which includes a nursing home and an assisted-living facility, added a dental clinic in 2012. Pneumonia rates dropped soon after, said Lillian Mitchell, a dentist who oversees the office and is the director of geriatric dentistry at the University of Alabama, Birmingham. Mitchell and other faculty oversee dental students who treat patients at the clinic.

“Taking care of oral health affects their overall health by reducing inflammation that has been linked to heart disease, diabetes and other chronic conditions common to the elderly,” Mitchell said.

The clinic’s services cost about half the price of private dentists.

Patients say easy access to the clinic in the building where they live makes a big difference. “This is such a comfort knowing we can go to the dentist without having to leave the facility,” said Peggy Batcheler, 87, a former nursing professor. “We feel so fortunate.”

The Santa Fe Group hopes to draw the American Dental Association, AARP and other seniors’ groups into its campaign for a Medicare dental benefit.

“It is not our No. 1 issue, but it is on top of our conversation list,” said Joseph Crowley, a Cincinnati dentist and president-elect of the American Dental Association. He is very optimistic.