Home Health Care Management & Practice

A neglected area of discussion in home care is the relationship and dissonance between evidence-based research on effective home and community-based interventions, Medicare home health practice, and the Medicare Home Health Prospective Payment System (PPS). PPS is critical because the literature increasingly indicates that the PPS reimbursement framework drives home health agency and practitioner resource allocation and practice decisions. However, the PPS system does not have an evidence-based evaluation process to evaluate the effectiveness and cost-effectiveness of new, or existing, intervention. The article reviews existing evidence-based research on the effectiveness of home-based environmental skills building, counseling, and support group interventions, which benefit patients, caregivers, home health agencies, and Medicare. The article indicates these interventions have never been evaluated, nor are they covered by Medicare. The article asserts the need for such an evaluation process to evaluate intervention cost-effectiveness and related changes in Medicare coverage, eligibility, reimbursement, and outcomes measurement criteria necessary for their adoption.

With the rate of diabetes increasing in the elderly, home health care agencies must creatively approach disease management in this high-risk population. Specialized training programs, standardized policies and procedures, and strategic staffing patterns support agencies to systematically and effectively manage diabetes in the home. Collaboration with endocrinology providers assists agencies to incorporate and appropriately use national standards in diabetes care. Additionally, home health partnership with endocrinology providers will enhance a disease management program with increased provider participation and oversight, improving patient clinical outcomes and serving as a resource for home health agencies managing patients with diabetes.

As union organizing of home health agencies increases, many agencies will be asked by a union to enter into a “neutrality agreement” with the union. Whether to agree to such an agreement is a very significant decision for an agency. It requires an agency to understand how such an agreement affects the unionization of its employees and the agency's own goals with regard to unionization.

As of summer 2008, health care reform has become an important part of the 2008 presidential election. However, long-term care has been absent in the discussion of health care reform by presidential candidates. This article examines policies that govern the payers of long-term care, specifically home health care (HHC). HHC is the fastest growing industry within long-term care, as there is a growing number of older adults in need of both skilled and unskilled home care. Medicare and Medicaid are the two major payers of HHC; yet these payers do not address the psychological and social needs of the patients. Furthermore, there is a long-term care disconnect between Medicare and Medicaid that creates even larger problems for older adults in need of long-term care.

The practice implications of the Centers for Medicare & Medicaid Services hospital payment policy change are likely to influence the relationships between home health care agencies and their referring/receiving hospitals. Maintaining infection control measures can be difficult in the home environment, which was not designed for health care provision and where family members, friends, and pets are present. In addition to the hospital payment changes, there have been epidemiologic changes, with increasing recognition of multidrug resistant organisms and increasing virulence. The purpose of this article is to identify the scope of the practice changes that might be expected in response to epidemiologic and policy changes and activities that home health care agencies can undertake in response. Increased calls for transparency, accountability, and high-quality care, along with threats of denied reimbursement, will force changes across the entire continuum of care.

Over the past 20 years, state mental health agencies have shifted the bulk of funding for community mental health services to the federal-state Medicaid program. Over this same period, states adapted their Medicaid programs to more comprehensively address the service needs of people with mental illness. Adopting the financing mechanism that primarily funds other health care for low-income people moves mental health more toward the mainstream. But it is a policy with risks. Changes to Medicaid are now outside the purview of those most concerned with mental health issues. In 2006, Congress radically altered Medicaid, making fundamental changes to the law. These were soon followed by further proposed shifts in federal administrative policy. This article describes these federal policy changes and assesses their impact on individuals and on state mental health policy. (It should be noted that most administrative changes have since been halted by the Obama Administration).