Differences across payors in charges for agency-based home health services: evidence from the National Home and Hospice Care Survey.

OBJECTIVE: To investigate charge and payment differentials for home health services across different payors. DATA SOURCES: The 1992 National Home and Hospice Care Survey, a nationally representative survey of home and hospice care agencies and their patients, collected by the National Center for Health Statistics. STUDY DESIGN: We compare the average charge for a Medicare home health visit to the average charge for patients with other sources of payment. In making such comparisons, we control for differences across payors in service mix and agency characteristics. PRINCIPAL FINDINGS: Agencies charge various payors different amounts for similar services, and Medicare is consistently charged more than other payors. CONCLUSIONS: Findings imply the potential existence of payment differentials across payors for home health services, with Medicare and privately insured patients likely to be paying more than others for similar services. Such conclusions raise the possibility that, as in other segments of the healthcare market, cost-shifting and price discrimination might exist within the home health industry. Future research should explore these issues, along with the question of whether Medicare is paying too much for home health services.     

The impact of a decade of policy on home health care utilization

The Medicare home health care eligibility changes, which occurred during the 1980s, were designed to make home health care more accessible to older adults. Ideally, by the 1990s, older adults in need of home health care services should no longer have encountered barriers to accessing this benefit. Therefore, an individual's need for home health care services should have been the primary determinant of service utilization. This paper examined whether need was predictive of home health care use. Client-level data on the case mix of home health care agencies in San Francisco and Philadelphia, as well as agency administrator interview data, were analyzed to determine which characteristics were the best predictors of home health care use. The regression analyses results revealed that, although client characteristics were important predictors of the amount and type of home health care services received during an episode of care, client characteristics alone did not adequately predict the amount and type of home health care services received by older adults.     

Retention of clients in service under two models of home health care for HIV/AIDS.

OBJECTIVE: To determine if a Transprofessional, care-management approach (experimental group) produces different patterns of retention in home treatment as compared to a Traditional treatment approach (control group). The care-management approach utilizes an interdisciplinary mix of allied health professionals who adhere to a service delivery protocol based on active medical, surgical treatment (curative services) as well as on pain, symptoms, and emotional care (palliative services). Initially, the Transprofessional Model should lead to a greater retention rate in the program as patients bond to blended care managers, but in later stages clients needing hospice should be moved off-services resulting in lower retention rates in the medical-surgical home care venue. DATA SOURCES AND STUDY SETTING: Data were collected from 549 AIDS patients admitted for medical/surgical home-care services to the Visiting Nurse Association of Los Angeles (VNA-LA). Demographic and disease-specific data were collected from admitting records; service-utilization data were collected from the VNA-LA's computerized data system. STUDY DESIGN: Upon admission for home-care services, patients were randomly assigned to an experimental (Transprofessional) or control (Traditional) treatment group. Service levels were comparable. PRIMARY FINDING: In the earliest stages, Transprofessional patients tend to be more likely to stay in treatment, probably due to the greater bonding to the program. After about one year, the Transprofessional patients are more likely to leave the program as they are transitioned into hospice care. CONCLUSIONS: An integrated model of service delivery, which is based on interdisciplinary care-management and blended modalities of service, provides a quality of life enhancing and a cost-effective method in the provision of home-care services for terminally ill AIDS patients.     

Rationing home care resources: how discharged seniors cope

Rationing home care services has become a common strategy used by state/provincial governments to control escalating health care costs, particularly at a time when very little new funding has been re-directed to the home care sector. Across British Columbia, Regional Health Authorities had implemented service reforms that call for the discharge of higher functioning clients from home support service. This paper describes the coping strategies of 137 senior clients who were discharged from home support services and from the Continuing Care Program in the Simon Fraser Health Region located in British Columbia, Canada. Personal interviews were conducted by experienced case managers to gain an understanding of how seniors were coping 19 to 21 months after their discharge. Of the 137 clients, 34.3% are characterized as being "home alone and suffering in silence," 29.2% reported receiving assistance from informal sources or reported paying out-of-pocket for private care, and 28.4% reported that they can do the work better themselves. The remaining 8.0% of participants reported mixed feelings about the impact of their discharge from home support service. The effectiveness of discharge targeted to a senior population is discussed and it is suggested that functional status together with age are important criteria when rationing home care services.     

Concordance between planned and approved visits during initial home care

Based on little prior information and a brief interview, the Medicare home health agency intake case manager must estimate the types and amounts of services a new client will require during the first 60 days of home care. We systematically examined the concordance between types and amounts of planned services with those actually approved and reimbursed during the first 60 days of care for a sample of 2,431 clients during 1986. Overall, the mean number of planned visits during the first 60 days was 24.76, and the mean number of approved visits was 15.95. Approved visits as a percent of planned visits averaged 64.4.     

Effects of the Medicare Alzheimer''s Disease Demonstration on the use of community-based services.

STUDY QUESTION: Did the Medicare Alzheimer''s Disease Demonstration with its case management and community service waivers affect the use of community-based long-term care services among people with dementia and their primary caregivers? DATA SOURCES: Baseline and periodic caregiver interviews. Measures include client and caregiver attributes and self-reported service use. STUDY DESIGN: The demonstration randomly assigned voluntary applicants into treatment and control groups. Treatment group cases were eligible for case management and for up to $699 per month in community care benefits. The actual monthly entitlement varied among the eight demonstration communities due to regional cost and inflation adjustments over time. Analyses are for the year after enrollment. DATA COLLECTION: Analyses are of cases surviving six months or more in the community after enrollment (n = 5,209). Cases received baseline and semi-annual assessments. PRINCIPAL FINDINGS: The intervention of case management and community service reimbursement had a strong, consistent, and positive effect on the likelihood of using home care (including homemaker/chore services, personal care services, companion services) and adult day care. Treatment group clients were at least twice as likely as control group clients to be using any of the four community-based services. A similar, but less pervasive effect was achieved with caregiver training and support group participation. Reimbursement provided by the demonstration''s Medicare waiver was generally not sufficient to exceed the level of control group service acquired through private payment. CONCLUSIONS: Reimbursement levels within the demonstration may have enabled more individuals to purchase some services, but they were not sufficient to increase the average level of use over those in the control group. No consistent differences between demonstration models were found in service use likelihood or average use among users.     

Effects of the Medicare Alzheimer''s Disease Demonstration on nursing home entry.

STUDY QUESTION: Did the Medicare Alzheimer''s Disease Demonstration, with its goal of improving caregiver outcomes through case management and subsidized community services, affect the nursing home entry rate of treatments with dementia compared to controls? DATA SOURCES: Interviews conducted at baseline and six months thereafter. Measures include date of nursing home entry, client and caregiver health, and income. STUDY DESIGN: The demonstration randomly assigned voluntary applicants into treatment and control groups. Treatment group cases were eligible for case management and for an 80 percent discount on community care benefits, up to about $600 per month. DATA COLLECTION: All cases received baseline and semi-annual assessment interviews for up to three years after enrollment. Analyses are among cases that remained in the demonstration for more than 30 days after enrollment (n = 8,095). PRINCIPAL FINDINGS: The intervention of case management and subsidized community service had no effect on nursing home entry rates for treatments overall, compared to those of controls, and few effects on treatment subgroups, with the exception of one site where it may have increased nursing home entry rates. CONCLUSIONS: Providing case management and subsidized community services with the goal of improving caregiver outcomes may have little effect on nursing home entry rates for people with dementia.     

The effects of predetermined payment rates for Medicare home healthcare.

OBJECTIVE: To assess the effects of an alternative method of paying home health agencies for services to Medicare beneficiaries, based on a demonstration program. DATA SOURCES/STUDY SETTING: Primary and secondary data collected on participating home health agencies in five states and their patients during the three-year demonstration period. Primary data included patient surveys at discharge and six months later, and two rounds of interviews with executive staff of the agencies. Secondary data included agencies' Medicare cost reports, quality assurance reviews, Medicare claims data, demonstration claims data, demonstration patient intake forms, and plan of treatment forms. STUDY DESIGN: The 47 agencies volunteering to participate in the demonstration were each randomly assigned to the treatment or control group. Treatment group agencies were paid a predetermined rate based on their inflation-adjusted cost per visit during the year preceding the demonstration; control group agencies were paid under Medicare's conventional cost reimbursement method. Demonstration impacts were estimated by comparing outcomes for the two groups of agencies and their respective patients, using regression models to control for any remaining differences. PRINCIPAL FINDINGS: Agencies paid under prospective rate setting were slightly better at holding per-visit cost increases below inflation than were control group agencies. The change in payment method had no effect on agencies' volume of Medicare visits or quality of care, nor on patients' use of Medicare services or other formal or informal care services. CONCLUSION: Changing from cost-based reimbursement to predetermined payment rates for Medicare home healthcare visits would not lead to large savings for the Medicare program, but would not increase costs to Medicare or adversely affect patients or their caregivers.     

Organizational and environmental factors associated with nursing home participation in managed care

OBJECTIVE: To develop and test a model, based on resource dependence theory, that identifies the organizational and environmental characteristics associated with nursing home participation in managed care. DATA SOURCES AND STUDY SETTING: Data for statistical analysis derived from a survey of Directors of Nursing in a sample of nursing homes in eight states (n = 308). These data were merged with data from the On-line Survey Certification and Reporting System, the Medicare Managed Care State/County Data File, and the 1995 Area Resource File. STUDY DESIGN: Since the dependent variable is dichotomous, the logistic procedure was used to fit the regression. The analysis was weighted using SUDAAN. FINDINGS: Participation in a provider network, higher proportions of resident care covered by Medicare, providing IV therapy, greater availability of RNs and physical therapists, and Medicare HMO market penetration are associated with a greater likelihood of having a managed care contract. CONCLUSION: As more Medicare recipients enroll in HMOs, nursing home involvement in managed care is likely to increase. Interorganizational linkages enhance the likelihood of managed care participation. Nursing homes interested in managed care should consider upgrading staffing and providing at least some subacute services.     

Medicaid-funded home care for the frail elderly and disabled: evaluating the cost savings and outcomes of a service delivery reform.

OBJECTIVES: In response to rising demand and increased costs for home care services for frail elderly and disabled Medicaid clients, New York City implemented cluster care, a shared-aide model of home care. Our objective: to evaluate the effects of cluster care on home care hours and costs, client functioning, depressive symptoms, and satisfaction. DATA SOURCES: Client interviews, conducted prior to implementation and again 16 months later; Medicaid claims records; home attendant payroll files; and vendor agency records. STUDY DESIGN: The study employed a pretest/posttest design, comparing 229 clients at the first seven demonstration sites to 175 clients at four comparison sites before and after cluster care implementation. Regression methods were used to analyze pre and post-intervention data. PRINCIPAL FINDINGS: Cluster care reduced costs by about 10 percent. Most savings occurred among the more vulnerable clients (those with five or more ADL/IADL limitations). Clients at cluster care sites who started out with fewer than five limitations appeared to decline somewhat more slowly than similarly impaired clients at comparison sites, while those with more than five ADL/IADLs tended to decline more rapidly. This difference was small-less than one limitation per year. Cluster care is associated with a significant decline in satisfaction but appears unrelated to depressive symptoms. CONCLUSIONS: Cluster care appears benign for home care clients with fewer limitations. For the more vulnerable, we recommend experimentation with low-cost interventions that might augment service and improve outcomes without reverting to traditional one-on-one care.     

Risks to home care workers: Professional perspectives

Care at home is fundamental to community care policy, but the simultaneous growth of health and safety regulation has implications for home care services because of the duty of employers towards home care workers. This grounded theory study set in Northern Ireland used data from 19 focus groups and nine semi-structured interviews with a range of health and social services professionals and managers to explore perspectives on planning long term care for older people. Home care workers faced a wide range of hazards in the homes of clients, who themselves were faced with adapting their living habits due to their changing health and care needs and ‘risks.’ Creative approaches were used to ensure the health and safety of home care workers and simultaneously to meet the choices of clients. Staff experienced feelings of conflict when they judged it necessary to impose their way of providing home care and thus impose their values on clients to create a safe working environment. There was variation between and within organizations in terms of the staff focus on client needs or on their employer responsibility towards home care workers. The planning of home care services must take account of both the choices of clients and the hazards facing home care staff.     

Agency and market area factors affecting home health agency supply changes

OBJECTIVE: To use the natural experiment created by the Medicare interim payment system (IPS) to study supply change behavior of home health agencies (HHAs) in local market areas. DATA SOURCES: One hundred percent Medicare home health claims for 1996 and 1999, linked with Medicare Provider of Service and Denominator files, and the Area Resource File. STUDY DESIGN: Medicare home health care (HHC) claims data were used to distinguish HHAs that changed the local market supply of Medicare HHC by their market exit or by significant expansion or contraction of their geographic service area between 1996 and 1999 from other HHAs. Multinomial logit models were estimated to analyze how characteristics of agencies and the market areas in which they served were associated with these different agency-level supply changes. PRINCIPAL FINDINGS: Changes in local HHA supply stemming from geographic service area expansions and contractions rivaled those owing to agency closures and market entries. Agencies at greater risk of closure and service area contraction tended to be smaller, newer, freestanding agencies, operating with more visit-intensive practice styles in markets with more competitor agencies. Except for having much less visit-intensive practice styles, similar attributes characterized agencies that increased local supply through service area expansion. CONCLUSIONS: Supply changes by HHAs largely reflected rational market responses by agencies to significant changes in financial incentives associated with the Medicare IPS. Recently certified agencies were among the most dynamic providers. Supply changes were more likely among agencies operating in more competitive market environments.     

Use of covered services in Medicare home health care

Using data on 295 patients entering Medicare home health care at discharge from Medicare hospital stays, we explain receipt of Medicare home health nursing, PT and OT visits, and length of stay. Care reflected need, but other factors also affected service allocation. Medicare program requirements, as well as variation in provider structure and case load, appear to introduce inequities. Critical in light of recurrent proposals to change Medicare coverage and benefits, findings underline the need to reconsider Medicare home health policies that lead to denial of needed services, inequitable allocation of benefits, and premature termination of care.     

Teaching wound care in the home

A survey of Medicare-certified agencies in Alaska, Idaho, Montana, Oregon, and Washington identified wound care and teaching wound care as being among the highest ranked clinical problems related to earlier hospital discharges that have resulted from Medicare Diagnostic Related Groupings (DRGs). Home care nurses are treating increasingly complex wounds and are required to teach complex wound care skills to clients and caregivers. This paper provides guidelines and resources to home care nurses for teaching wound care to their elderly clients and caregivers. The process of developing and implementing a teaching plan is described through the use of the community health nursing process. Following the presentation of the process content, a sample teaching wound care plan and sample teaching handouts are presented with a list of available teaching resources about wound care.     

Language and regional differences in evaluations of Medicare managed care by Hispanics

OBJECTIVES: This study uses the Consumer Assessments of Healthcare Providers and Systems (CAHPS((R))) survey to examine the experiences of Hispanics enrolled in Medicare managed care. Evaluations of care are examined in relationship to primary language (English or Spanish) and region of the country. DATA SOURCES: CAHPS 3.0 Medicare managed care survey data collected in 2002. STUDY DESIGN: The dependent variables consist of five CAHPS multi-item scales measuring timeliness of care, provider communication, office staff helpfulness, getting needed care, and health plan customer service. The main independent variables are Hispanic primary language (English or Spanish) and region (California, Florida, New York/New Jersey, and other states). Ordinary least squares regression is used to model the effect of Hispanic primary language and region on CAHPS scales, controlling for age, gender, education, and self-rated health. DATA COLLECTION/EXTRACTION METHODS: The analytic sample consists of 125,369 respondents (82 percent response rate) enrolled in 181 Medicare managed care plans across the U.S. Of the 125,369 respondents, 8,463 (7 percent) were self-identified as Hispanic. The survey was made available in English and Spanish, and 1,353 Hispanics completed one in Spanish. PRINCIPAL FINDINGS: Hispanic English speakers had less favorable reports of care than whites for all dimensions of care except provider communication. Hispanic Spanish speakers reported more negative experiences than whites with timeliness of care, provider communication, and office staff helpfulness, but better reports of care for getting needed care. Spanish speakers in all regions except Florida had less favorable scores than English-speaking Hispanics for provider communication and office staff helpfulness, but more positive assessments for getting needed care. There were greater regional variations in CAHPS scores among Hispanic Spanish speakers than among Hispanic English speakers. Spanish speakers in Florida had more positive experiences than Spanish speakers in other regions for most dimensions of care. CONCLUSIONS: Hispanics in Medicare managed care face barriers to care; however, their experiences with care vary by language and region. Spanish speakers (except FL) have less favorable experiences with provider communication and office staff helpfulness than their English-speaking counterparts, suggesting language barriers in the clinical encounter. On the other hand, Spanish speakers reported more favorable experiences than their English-speaking counterparts with the managed care aspects of their care (getting needed care and plan customer service). Medicare managed care plans need to address the observed disparities in patient experiences among Hispanics as part of their quality improvement efforts. Plans can work with their network providers to address issues related to timeliness of care and office staff helpfulness. In addition, plans can provide incentives for language services, which have the potential to improve communication with providers and staff among Spanish speakers. Finally, health plans can reduce the access barriers faced by Hispanics, especially among English speakers.     

Contemplating home health PPS: current patterns of Medicare service use

Implementing a per-episode prospective payment system (PPS) for home health services is one option for Medicare policy makers facing rapid increases in service use and expenditures. Analysis of data on recent episodes of Medicare home health care identified systematic differences in service patterns across provider types; these indicate potential differences in the capacity of agencies of different types to adjust to PPS. The second phase of a national demonstration, which is about to be implemented, will provide information on the extent to which the agency practices that generate much of the observed variation (such as the number of visits provided per episode) are susceptible to management decisions; and whether managers can and do respond to the incentives of per-episode prospective payment.     

How do they manage? Disabled elderly persons in the community who are not receiving Medicaid long-term care services

OBJECTIVE: To expand our understanding of how low-income functionally impaired elderly persons are able to remain in the community. DATA SOURCES AND STUDY SETTING: In-person and telephone interviews with 25 elderly individuals who applied for but did not enroll in Connecticut's Home Care Program for Elders (CHCPE). All met the state's nursing home level-of-care criteria. STUDY, DESIGN: In-depth discussions with a small, purposefully selected sample of functionally impaired elderly persons in the community. PRINCIPLE FINDINGS: Many sample members with very high levels of impairment and multiple chronic health conditions remained in the community without CHCPE services because of Medicare home health services combined with extensive levels of informal care. Some sample members, particularly those with more limited informal care networks, did not receive the level of care that they needed. Virtually all were at high risk for medical complications, hospitalizations for acute illnesses, falls, and further loss of functioning. Further, in many cases, informal care networks were overextended, stressed and vulnerable to break down. All but a few of those we interviewed were not receiving services through the waiver program for financial reasons. Most met Medicaid's income criteria but had assets that exceeded Medicaid's $2,000 limit. Several were not participating due to concerns about estate recovery. CONCLUSIONS: Additional formal help is needed to avoid eventual nursing home placement for many sample members. This could be achieved by expanding the availability of case management services and/or relaxing program financial requirements. Further, efforts to reduce Medicare home health expenditures must recognize the heightened vulnerability of many beneficiaries for potentially costly adverse outcomes.     

Characteristics of elderly home health care users: data from the 1996 National Home and Hospice Care Survey

OBJECTIVE: This report presents demographic characteristics, service utilization, and primary admission diagnoses of elderly users of home health care services. Included are home health care services used by both current and discharged clients (called patients). These services are provided by home health care agencies and hospices. The focus of the report is on services used by both current patients and discharges aged 65 years and over. METHODS: The data used for this report are from the National Center for Health Statistics 1996 National Home and Hospice Care Survey's (NHHCS) sample of current patients and discharges. The 1996 NHHCS is the fourth survey of home health care agencies and hospices and their current patients and discharges. RESULTS: The overall results of the survey indicate that, as in previous years, the elderly current patients and discharges were predominantly women, 75-84 years old, white, non-Hispanic, widowed, and most often lived in a private residence with members of their family. For elderly men and women, the most commonly used home health care service was skilled nursing services and the primary admission diagnosis was diseases of the circulatory system, including heart disease.