CHAPTER 17—COMMUNITY-BASED CARE
COMMUNITY-BASED SERVICES NOT REQUIRING A CHANGE IN RESIDENCE
COMMUNITY-BASED SERVICES REQUIRING A CHANGE OF RESIDENCE
The 2000 U.S. census data revealed that almost 10 million older adults living in the community require help with activities of daily living (ADLs). For a large number of these people, home care has the potential to improve their quality of life and avoid unnecessary institutionalization.
Under a cost-based reimbursement system, home care grew rapidly in the 1980s and 1990s. This growth coincided with the initiation of the prospective payment system (diagnostic related groups or DRGs) for hospitals that resulted in patients’ being discharged sooner from hospitals, which increased the need for home services. New technologies created the possibility of providing therapies in the home that were previously available only in hospitals or nursing homes. Because of an explosive increase in costs, Congress placed limits on Medicare spending as mandated in the 1997 Balanced Budget Act, which led to the development of a prospective payment system (PPS) for home-care services. Since enactment of the PPS, there has been more than a 20% decline in the number of recipients of home-care services and the number of visits for patients receiving home care. Many home-care agencies have adjusted to these changes and developed more efficient, targeted home care, but hundreds have closed because of the financial pressures. Rural agencies have closed at a higher rate than urban ones. The Outcome and Assessment Information Set (OASIS) is a tool meant to set fees for Home Health Related Groups (HHRGs). The OASIS instrument is completed by the home-health agency and tracks several domains of patients’ functional status and medical needs. Like the DRGs, the HHRGs provide the basis for reimbursement to the agencies and are based on severity of the patient’s illness, disabilities, and nursing needs; they include an adjustment for location in the United States. The instrument is also intended to provide a uniform means of measuring quality of care across all home-care agencies.
Like other sectors of our health care system, home-care agencies are charged with developing cost-effective high-quality care despite diminishing reimbursement. Another major challenge facing home-care agencies is recruiting and retaining qualified nurses and aides. Developing community-wide systems of care between hospitals, home care, nursing homes, and practitioners’ offices may help meet these challenges and ensure that patients receive timely and appropriate care.
The physician’s role in home care is to serve as a member of an interdisciplinary team that is generally composed of nurses, therapists (speech, physical, occupational, and respiratory), social workers, personal care aides, home medical equipment suppliers, and, most importantly, informal caregivers. The physician is, by law, responsible for the patient’s care plan. Physicians determine the patient’s health care needs; develop, certify, and recertify the plan of care; and confer regularly with team members to address patient care issues and to handle documentation and other administrative matters. The change to a PPS makes it even more important for physicians to be attentive to the development, certification, and recertification of the plan of care. In particular, the PPS requires physicians to certify the level of need for individual therapy services; the amount of therapy services will partly determine the HHRG assignment. Patients requiring more than ten rehabilitation or therapy visits during a 60-day period will be assigned a higher HHRG level. Changes in patient condition within the 60-day episodic payment period will require recertification by the physician. The shift to prospective payment may encourage some home-health agencies to reduce services to lower costs. The advent of prospective payment makes it even more critical for the physician to certify that the patient requires services and to ensure that the appropriate quantity and quality of services are being provided.
Physicians are reimbursed for certification of the home-care plan and for oversight of complex cases in skilled home care and hospice. Table 17.1 lists the billing codes and requirements for these services. The documentation requirements for billing allow activities over multiple days in a month to be combined.
House calls can add an important dimension to the physician’s knowledge of the patient’s circumstances and environment. Home evaluation can identify additional problems not readily apparent in office-based assessment. Barriers to maximum functioning can be identified and addressed. House calls have the additional benefit of reducing the burden of transportation for patients who have difficulty getting outside of the home. Changes in Medicare have increased reimbursement for home visits, making home visits more financially feasible for clinicians.
Homebound patients have significant functional impairment. Comprehensive geriatric assessment is particularly valuable in this setting to establish a baseline, monitor the course of illness, and evaluate effects of intervention. However, assessment in the home has some important differences from office-based assessment.
During a home visit, an assessment of the patient’s actual environment can be performed to determine whether the home is safe and supportive, given the particular patient’s abilities and disabilities. Performance-based functional assessment can focus on the practical aspects of performing ADLs by direct observation of the environment for bathing, dressing, and transferring. Difficulties can be identified, and the assessor can evaluate the caregiver’s abilities to address the patient’s needs. The caregiver’s needs for counseling, training, support, and education can also be identified and addressed.
Environmental modifications can be recommended to improve function. For example, modifications of the bathtub, a hand-held shower, a shower seat, grab-bars, and a bedside commode can improve the patient’s quality of life and functioning. Barriers to wheelchairs and walkers such as door sills can be identified and removed. Chair lifts and outdoor ramps can help patients circumvent stairs. Occupational therapy consultation can be particularly useful in identifying other personal care and assistive devices for performing ADLs and housekeeping chores. A number of home safety checklists are available to help a reviewer assess the home. Additional technological additions to improve home safety, including necklace or wrist radio devices to call for help, can be considered. Some types of emergency response systems require that a person push a button by a specified time each day to avoid triggering an emergency response or telephone call to check on the owner of the device.
Health care providers are finding that home diagnostics, including radiology and electrocardiography, are available in most areas, and hand-held laboratory devices are becoming more common. These home diagnostics allow for a much more comprehensive medical evaluation to take place in the home.
Medical care in the home may be provided as part of an ongoing office-based program, as an extension of hospitalization through a postacute care program, or as a freestanding entity. Regardless of the method chosen, it is important that the organization of the home-care program be well conceived to maximize effectiveness and efficiency and to remain financially viable. Current regulations allow house calls to be provided by physicians, nurse practitioners, and physician assistants. Regardless of the primary care medical provider, appropriate links to other providers of home-based services are necessary to develop an interdisciplinary team. Consistency and familiarity among all members of the interdisciplinary team are essential to a smoothly functioning house-call program.
To qualify for Medicare home-care benefits, a patient must meet two criteria to establish homebound status. First, the patient must be absent from the home for reasons other than obtaining medical treatment infrequently (three times or fewer per month) or for short periods of time. Second, leaving home must require considerable and taxing effort on the part of the patient or the caregiver, or both—for example, if the patient is bedbound or has a severe mobility impairment.
Patients who are likely to be good candidates for house calls are those with mobility impairments that make transportation to the office difficult; those with disruptive behaviors; patients with terminal illnesses; and patients with multiple medical, psychiatric, and social problems. House calls are needed for some patients a limited amount of time, but others require house visits on an ongoing basis. Home visits may be particularly useful for patients who are either not responding to adequate therapy or responding inconsistently. A diagnostic home visit may reveal caregiver burnout, elder mistreatment, or the use of medications from other sources that may be interfering with the expected response. (See also Pharmacotherapy; Elder Mistreatment.)
Table 17.2 lists suggested equipment and drugs for house calls. A small bag with key equipment is particularly useful. A supply of forms needed for common diagnostic tests and orders, educational material for common problems, and community referral information are also useful.
House calls are now more financially feasible for clinicians; documentation remains the key to receiving requested remuneration. There are no specific restrictions on the number of visits as long as there is sufficient justification in the progress notes. As with most documentation, it is necessary that the primary care provider identify historical data, physical examination findings, diagnostic test results, and an assessment that reflects all the active diagnoses. Further, an evaluation of the patient’s functioning, caregiver issues, and documentation of the medical plan of care are important elements to include in the house-call progress note. Physician assistants and nurse practitioners may also bill for home-care services under Medicare regulations adopted in January 1998. Table 17.3 lists codes and reimbursement for home visits. When visits become prolonged, time codes can be used that justify an enhanced reimbursement. Reimbursement can vary in different localities, particularly where health maintenance organizations act as intermediaries for Medicare.
Family caregivers provide most of the care received by patients in the community. In the United States, three out of four caregivers are women, either wives or daughters. Caregiving is often intense, time consuming, and stressful. The caregiver’s physical and emotional health may be affected, resulting in depression and a worsening of his or her own health problems. Attention to caregiver support and issues are essential to help the patients continue to provide care. Caregiver support groups may be particularly helpful (see the resources listed in the Appendix).
For discussions of specific issues concerning caregiving, see Psychosocial Issues, Dementia, Behavioral Problems in Dementia, Elder Mistreatment, and Depression and Other Mood Disorders.
Most elderly persons would prefer to remain in their own home, but certain situations and conditions arise that make institutional care a more appropriate choice than in-home care. For example, caregivers may not be available to adequately address the needs of the patient. Relatively unstable medical situations requiring frequent laboratory testing, respiratory interventions, or intravenous medications may make institutional care a better choice than home care for some patients. Caregiver burnout and caregiver stress may prevent continued safe care for the patient in the home.
Further, the home environment itself may be a barrier to continuing in-home care. Unsafe neighborhoods, ongoing household social disruptions from alcohol or drug use, and inadequate room for equipment or environmental modifications may make in-home care a poor or risky option.
Finally, home care may be prohibitively expensive for the patient. It is not always the least expensive alternative, and out-of-pocket expenses may make on-going home care unaffordable. Insurance coverage is more likely to cover care that is rendered in a nursing facility or other institutional setting.
As elsewhere in the practice of medicine, clinicians offering home care are potentially liable for adverse outcomes; however, malpractice suits related to home care are relatively uncommon. It is important that appropriate documentation be maintained for medical purposes and also to support physician compensation; documentation is also necessary to support the request for payments to other providers of in-home services. In addition, physicians should be aware that inaccurate certificates of medical necessity could lead to charges of Medicare fraud. These forms should be reviewed carefully before they are signed.
It is important to be sensitive to potential conflicts of interest. Federal legislation prohibits physicians from receiving financial benefit, compensation, or rebate for referring a patient to a home-care provider. Further, physicians may not refer patients to home-care companies in which the physician or the physician’s family has a “substantial” financial interest. In certain situations, there are exemptions to protect physicians in hospitals who are involved in “relatively innocuous or even beneficial arrangements.” Seek legal advice if there is any question of a potential conflict of interest.
Two ethical themes arise commonly in home care. The first is the balance between patient autonomy and patient safety. The second involves issues surrounding elder mistreatment and neglect.
Respect for patient autonomy often dictates that the patient remain in the home as a result of the patient’s (or surrogate decision maker’s) choice. Conflict arises when a patient’s medical care or safety cannot be adequately maintained in the home, yet the patient insists on staying at home. It is difficult to balance respect for patient autonomy with the desire to prevent patient neglect. In some situations, the outcome is likely to be terminal, regardless of whether the patient is maintained at home or in an institution. In such situations, a hospice referral may help provide additional services in the home and support for both the patient and family. In situations where there is a clearly neglectful or abusive situation, Adult Protective Services should be contacted (see Elder Mistreatment, and Legal and Ethical Issues).
Adult day care is a community-based option that provides a wide range of social and support services in a congregate setting. Adult day care has become increasingly common. Providers of adult day care may offer a variety of services, ranging from simple nonskilled custodial care to more advanced skilled services. The availability of a registered nurse allows for on-site health services, clinical assessment and monitoring, and assistance with medication management. Adult day care is used commonly for patients with dementia who need supervision and assistance with their ADLs while primary caregivers work. Adult day care may also serve as a form of respite for caregivers. Most adult day care centers are community based, either in churches or community centers. In general, custodial adult day care is not covered by Medicare, though some costs may be covered by Medicaid or other insurers.
Day hospitals provide a broad range of skilled nursing care services, including parenteral antibiotics, chemotherapy, and intensive rehabilitation. The majority of programs are housed in chronic care hospitals or rehabilitation centers. This arrangement allows for the provider to take advantage of in-house professional expertise and resources, while allowing the patient to return to his or her own home or alternative living site after day treatment is complete. Services are covered under Medicare, with similar requirements to those surrounding home-health care.
Day hospitals are most often used for two groups of patients: those needing multidisciplinary rehabilitation and those with psychiatric illnesses. A systematic review of day hospital care found that there are no significant differences between day hospitals and alternative sources of care with respect to death, disability, or use of health services, but that among those receiving care in a day hospital, there is a trend toward less functional decline and less hospital and institutional care.
The Program of All-Inclusive Care for the Elderly (PACE) is a capitated model of care that pools funds from Medicare and Medicaid to provide acute and long-term care to frail older people. (See also Financing, Coverage, and Costs of Health Care.) Participants in the PACE program must meet state-defined requirements regarding their need for a nursing-home level of care. The goal of the program is to keep the participant in the community for as long as it is medically, socially, and financially feasible. The system, designed to be seamless, uses an interdisciplinary team of health care providers who know the patient and caregivers well and who provide care across the spectrum of hospital, home, alternative living situations, and institutional care. Integrated financing allows the program to provide traditional coverage of acute, rehabilitative, home, and institutional care. It also allows for adult day care, respite care, transportation, medication coverage, rehabilitation including maintenance physical and occupational therapy, hearing aids, eyeglasses, and a variety of other benefits. The program, at the discretion of the interdisciplinary team, has the flexibility to pay for nonmedical costs in unusual circumstances (eg, paying a person’s electric or gas bill). Care by the interdisciplinary team provides for the complex social as well as the medical needs of the participant. PACE has been described as one of the few truly integrated systems of care in the United States. Although the effectiveness of PACE has not been directly tested by a randomized controlled trial, research has shown that PACE provides high-quality care, albeit with significant site-to-site variation.
In 1997, legislation was passed that changed the status of PACE from a demonstration program to a permanent provider under Medicare. PACE is an optional program under state Medicaid. As of November 2003, 29 programs in 17 states were operational, and 50 more were in various stages of development. It is anticipated that the program will continue to expand.
Capitated financing for PACE is provided through Medicare and, in participating states, Medicaid. The Medicare rate-setting method for PACE has traditionally been based on the average cost of providing care to Medicare beneficiaries in a given geographic area, which is multiplied by a frailty adjuster. This method is likely to change in the near future. Each state determines the Medicaid rate of capitation.
The first generation Social Health Maintenance Organization (SHMO) project started in the middle 1980s with the intention of developing innovative, integrated, acute, and long-term care for Medicare beneficiaries. The four initial sites offered a variety of services and a system of care that focused on assessment and case management and that offered additional home and community-based services. Unlike the PACE program, the SHMOs serve not only low-income frail seniors but also healthier, more affluent, nondisabled Medicare recipients. The first round of the SHMO demonstration found that outcomes for participants were similar to those for control persons without any clear cost savings. One of the original four sites elected to drop out of the demonstration in 1994; an additional four sites for the second generation (SHMO II) were approved in 1996. It was hoped that SHMO II would provide a greater degree of effectiveness and integration through a variety of modifications to SHMO I, including more emphasis on personnel with geriatrics expertise, geriatric practice guidelines, and education of nongeriatrician practitioners on the essentials of geriatric care. Only one SHMO II, the Health Plan of Nevada, was actually implemented in the second phase of this program. A recent report from the Centers for Medicare and Medicaid Services concluded that there was no consistent evidence that SHMOs improved patient outcomes. There was evidence in a small subset of medically frail patients that hospital utilization was reduced. This begs the question of whether targeting a more frail population would result in the SHMOs’ having a more positive impact on beneficiaries.
The growth of telemedicine in home care has not paralleled the increasing availability and affordability of this type of technology. Although telemedicine has been used successfully in radiology, where it has been reimbursed, it has not been used to a great extent in other areas of medicine. Telemedicine has been used in some capitated health care programs in prisons and mental health centers. There are also a number of demonstration studies utilizing telemedicine in remote areas that include real-time physician-patient encounters and that store and forward recordings of patients which are later reviewed by a physician. Some home-health agencies are beginning to use telemedicine to monitor patients, as the PPS has created financial incentives to limit the number of home visits. Telemedicine may have particular applicability in rural settings and other areas where access to physicians and other health care providers is limited.
Telemedicine involves the transmission of data to the nurse or primary care provider, who can then evaluate and make decisions regarding the patient’s health care. Systems vary considerably. For example, some systems are relatively disease specific. One example is an automated scale, blood-pressure cuff, and heart-rate monitor for patients with heart failure. More elaborate telemedicine systems allow for audio and video two-way communication, distance electrocardiography, distance auscultation through the use of an onsite stethoscope that can transmit breath, heart, and abdominal sounds, and camera lenses that allow for detailed examination of the skin and eyes. System costs vary considerably, ranging from approximately $1500 for simple audio and video systems to $20,000. In the future they are likely to become more affordable and useful, as broadband eliminates the need for expensive lines and allows for quicker transmission of data than do telephone connections. In certain situations telemedicine is Medicare reimbursable in rural areas. Some states are providing coverage through Medicaid.
The home hospital focuses on providing more complex care at home to older people who would have been hospitalized for an acute-care need. Patients receiving home-hospital care have access to nurses and physicians on a regular basis and for episodic care through an on-call system that allows problems to be addressed promptly. The concept may be viewed as an evolution of home care, which it resembles, though it is more intense. Studies conducted outside of the United States suggest that care is comparable for selected patients and that patient satisfaction is high. (See also Hospital Care.)
More than 800,000 people live in assisted-living facilities, and the number is expected to grow rapidly as our population ages. Even though these facilities are based on a social (not medical) model, they are caring for more frail people with significant medical needs. The transitional nature of assisted living is suggested by the average length of residency, about 2 years in 2002. The most common reason for discharge is need for nursing-home care.
Assisted-living residences are characterized by some level of coordination or provision of personal care services, social activities, health-related services, and supervision, services that are provided in a home-like atmosphere that maximizes autonomy and privacy. The services provided under assisted living vary considerably, both within states and between states.
One national survey of assisted-living facilities found a range of privacy options, from private rooms to apartment units; about half would not admit residents with moderate to severe cognitive impairment; about two thirds did not have a registered nurse on staff but did provide 24-hour staff oversight, housekeeping, two meals, and personal assistance with ADLs. One example of the difference between state licensing requirements is in the area of medication administration. Depending on licensing requirements, medication administration and management may be directed by nonskilled, skilled, or fully licensed nursing staff.
In states where regulations do not require skilled care in assisted-living facilities, home-health skilled care is often provided as an external or independent service to the individual patient who happens to be living in an assisted-living facility. In this context, the boundary between assisted-living and skilled nursing facilities often becomes blurred. Since care in assisted living is generally less costly than in a nursing home, there has been a trend to use assisted living as a lower-cost alternative to nursing-home care. Part of the reason assisted-living care is usually less expensive is that there are fewer regulations governing assisted-living facilities. However, as these facilities have come to care for more people with increasing disability and more medical needs, there has been increasing pressure to regulate them.
Costs for assisted-living residences vary greatly and depend on the size of units, services provided, and location. A survey in 2001 found that 48% of residences charge an average between $1,000 and $2,000 in monthly rent and fees. Another 23% charge between $2,000 and $3,000, and 9% charge more than $3,000 each month; 16% of assisted-living facilities charge less than $1,000.
Assisted living is covered in a growing number of long-term-care insurance policies. The Health Insurance Association of America reports that all 11 of the leading insurance companies that sell long-term-care insurance offer assisted-living coverage. However, the majority of people in assisted-living residences or their families pay for care themselves because most elderly Americans do not carry long-term-care insurance.
Assisted living is not covered by Medicare, but certain services are paid under Supplementary Security Income and Social Services Block Grant programs. Thirty-eight states reimburse or plan to reimburse for assisted-living services as a Medicaid service. In addition, states have the option to pay for assisted living under Medicaid by including services in the state’s Medicaid plan or petitioning the U.S. Department of Health and Human Services for a waiver.
See also the American Geriatrics Society position statement on assisted-living facilities in the Appendix.
Group homes (including domiciliary care, single-room occupancy residences, board-and-care homes, and some congregate living situations) are houses or apartments in which two or more unrelated people live together. Group homes vary in types of residents and often serve patients with chronic mental illness or dementia. Residents share a living room, dining room, and kitchen but usually have their own bedrooms. Advantages of this arrangement include a lower cost of living and socialization with peers. Independence and functional status are supported through the interdependence and relationships of the residents. Resident-to-staff ratios may be higher than in other supported-living environments. Opportunities for socialization are increased, reducing social isolation. Most group homes are run as for-profit businesses, and some states require licensing.
Foster care homes generally provide room, board, and some assistance with ADLs by the sponsoring family or by paid caregivers, who customarily live on the premises. Perhaps the longest experience with adult foster care is in the state of Oregon, where it is used as an alternative to long-term care and institutionalization. Adult foster care has the advantages of maintaining frail elderly people in a more home-like environment. Regulations for foster care vary by state, and some states require licensing. Some states provide coverage of adult foster care through their Medicaid programs.
Sheltered housing is funded through the Older Americans Act and is offered as an option for housing subsidized through section 8, Housing and Urban Development programs for seniors and disabled residents. Often these arrangements are sheltered homes offering personal care assistance, housekeeping services, and meals. Programs may be supplemented by social work services and activities coordinators. Charges to clients are based on a sliding scale, which may cost up to 30% of income.
More affluent seniors may choose a continuing-care retirement community (CCRC). CCRCs usually have a variety of living options, ranging from apartments or condominiums, to assisted living, and skilled nursing-home care. Often, residents enter the more independent living areas and progress through assisted living and into skilled care as they age.
Three financial models are common: the all-inclusive model, which provides total health care coverage, including long-term care; the fee-for-service model in which payments match the level of care; and the modified coverage model, which covers long-term care to a predetermined maximum. Most CCRCs require an entry fee, which may or may not be refundable, plus a variable monthly fee to pay for rent and supportive services. Monthly fees vary, depending upon the level of care being provided. Funding is largely private, though some facilities have Medicare- or Medicaid-funded beds for skilled care.
See also Financing, Coverage, and Costs of Health Care.
■ Bodenheimer T. Long-term care for frail elderly people—the On Lok model. N Engl J Med. 1999;341(17):1324–1328.
This article provides a brief overview of On Lok and the Program of All-Inclusive Care for the Elderly (PACE) projects. It is useful for those who would like a summary of the latter. Current issues surrounding the move to full provider status, expansion to other areas, and modifications of the program are discussed.
■ Boult C, Pacala JT. Integrating healthcare for older populations. Am J Manag Care. 1999;5(1):45–52.
This general article provides an overview of PACE and the first and second Social Health Maintenance Organizations (SHMO I and SHMO II). The challenge of changing from a fragmented system of care to integrated systems that address the needs of older adults is discussed. The authors identify the financial issues that have driven the current system to fragmentation and discuss the benefits and limits of integrated financing.
■ Field MJ, Grigsby J. Telemedicine and remote patient monitoring. JAMA. 2002;288(4):423–425.
This is a well-referenced review of the state of telemedicine in 2002. Several examples of the successful use of telemedicine are described, and the authors provide a thoughtful discussion of why this technology has had limited growth.
■ Levine SA, Boal J, Boling PA. Home care. JAMA. 2003;290(9):1203–1207.
This state-of-the-art paper provides an excellent review of home care. It provides up-to-date coding and financial information along with a history of how we got to where we are today in the field. The challenges and prospects of delivering quality home-care services in the present environment are also covered.
■ Murkofsky RL, Phillips RS, McCarthy EP, et al. Length of stay in home care before and after the 1997 balanced budget act. JAMA. 2003;289(21):2841–2848.
This cross-sectional study examines the effects of the prospective payment system (PPS) on the length of stay in home care. After the start of PPS in 1997, the median length of stay decreased by 16 days for all recipients of home care, and the decrease was even greater in for-profit home-care agencies. The probable reasons for these decreases and future ramifications for patients are discussed in detail.
■ National Center for Health Statistics. Health, United States, 2004, With Chartbook on Trends in the Health of Americans. Hyattsville, MD: US Department of Health and Human Services, National Center for Health Statistics; September 2004. DHHS Pub. No. 2004-1232.
This annual report on the health status of the nation is submitted by the Secretary of the Department of Health and Human Services to the President and Congress in compliance with Section 308 of the Public Health Service Act. The report presents national trends in health statistics; in each edition a chartbook focuses on a major health topic. Available at: http://www.cdc.gov/nchs/hus.htm (accessed October 2005).
■ Tinetti ME, Baker D, Gallo WT, et al. Evaluation of restorative care vs usual care for older adults receiving an acute episode of home care. JAMA. 2002;287(16):2098–2105.
This paper tested an innovative way to provide home care that reduces emergency department utilization and increases the likelihood of patients’ remaining in their homes with less reported pain. A restorative care unit was compared with several other home-care offices. The unit reorganized the home-care staff in a way that provided more coordinated services, following the principles of geriatrics, rehabilitation, and nursing. The patient and family were made part of this process to set mutual goals with the health care team. The development and study of innovative models such as this one will be essential as we search for more cost-effective ways of delivering care.
Robert McCann, MD
G. Paul Eleazer, MD