How bright of a future should the home care industry expect?

The right spirit will prevail, editorial board member predicts

By Elizabeth E. Hogue, JD

Despite predictions of dire consequences and widespread discussion of devastation in the home care industry wrought by the Balanced Budget Act of 1997, the future of home care is extremely bright. Medicare-certified and private duty home care providers should be mindful of 10 characteristics of the home care industry of the future:

1. The future of home care is assured.

Despite debate and skepticism about the survival of home care, the industry’s future is absolutely assured. The primary basis for this optimistic attitude rests on the fact that home care’s objectives and services are consistent with those policy objectives that receive widespread endorsements by politicians, health policy experts, and the general U.S. population. Specifically, home care generally allows patients to exercise maximum autonomy and independence by remaining at home in the least restrictive, most cost-effective environment possible while still maintaining quality of care. These values, as reflected in the home health model of care, will ultimately prevail.

2. The home care industry must overcome current predictions of gloom and doom.

There is no doubt that the past two years have been rough. The home care industry has been radically changed by the Balanced Budget Act. In all likelihood, these changes are permanent. By the same token, the sometimes pervasive gloom and doom in the industry has taken on considerable life among some providers to the extent that it paralyzes providers and prevents them from taking positive action to respond to new challenges in the industry. This attitude must be resisted.

3. The home health industry of the future will not be dominated by the Medicare program as it has been in the recent past.

The incentives of Medicare reimbursement prior to the Balanced Budget Act rewarded volume, both in terms of the number of patients admitted and the number of visits provided to each patient. Many providers may now regard the period of time when such a system dominated the home health industry as the "good old days." The reality is that those days are likely gone forever.

Providers should no longer view the Medicare home health benefit as the most viable source of reimbursement for their services. Instead they should look to alternative sources such as baby boomers, who likely will have considerable disposable income and be willing to spend it on health care. Agencies must therefore place less emphasis on Medicare reimbursement and focus more specifically on how to meet the needs of aging boomers.

4. Managed care as it has developed in this decade will not survive.

When the process of health care reform failed in 1992, managed care rushed in to fill the void. Although costs were initially reduced, it now appears that the money was simply moved from the pockets of indemnity insurers into the pockets of managed care organizations (MCOs). The growth of the managed care industry in the 1990s did not involve any process of true health care reform, and not surprisingly, many continue to find an unreformed health delivery system dominated by managed care to be less than satisfactory for a variety of reasons. Stemming from this blanket dissatisfaction, state legislatures, Congress, and the courts have begun the long and difficult task of establishing limitations on the ability of MCOs to operate as they have in the past decade.

5. Home care providers must develop new services related to all types of community-based services.

Home health providers must consider new lines of business that are centered on community-based services regardless of whether they are rendered in patients’ homes. Such services may include assisting public schools with meeting their obligations under PL-94-142, the federal statute requiring schools to provide services to disabled students.

Parish nursing services are also a viable niche for home care providers. Ambulatory clinics, which assist patients with treatments for asthma, coronary disease, and diabetes among other diseases, should also be explored and developed by the home health industry.

6. Case management will survive and thrive.

There is general recognition that home care providers are case managers. The role of case mangers as reflected in national standards of care published by the Case Management Society of America (CMSA) will be essential to the future of home care in this country. Case managers, according to standards of CMSA, are generally required to assess, evaluate, plan, advocate, and monitor in order to assure quality and cost-effective outcomes. These skills, already well developed in the home care industry, will be in demand in a variety of settings in the future and, as such, agencies should work to further enhance their skills in this crucial area.

7. Home care providers must take responsibility for the future of the industry.

It does not appear that the Health Care Finan cing Administration (HCFA) has developed a comprehensive plan for the Medicare home care industry. Furthermore, it is unlikely to do so because of the highly politicized environment in which HCFA must operate. It is likely, though, that HCFA will develop new initiatives that may be of assistance to agencies in the future. One such program is tentatively named "Home Care Plus."

Although still in the early stages of development, the program is intended to establish a direct business partnership between home care agencies and HCFA. Participating agencies’ claims still will be processed by intermediaries, but under the plan, HCFA will work together with each agency on an individual basis to develop performance standards that the agency must meet each year. An annual review will assure that these standards are met. Keep in mind that even with the development of such initiatives, the future of home care truly rests with the members of the industry and not government agencies.

8. Continuing education is paramount for a strong home care industry.

It almost sounds cliché at this point, but intense education at all levels is a continuing prerequisite of a strong industry. The pace of clinical, regulatory, and reimbursement change is fierce. Despite the pace of change, there is a tendency to view continuing education as a luxury and not a necessity. Home health agencies must continue their strong commitment to continuing education in order to succeed in the future.

9. Home care providers must develop data that support the quality and cost-effectiveness of the care provided.

In general, the home health industry has been poorly served by the lack of data regarding the quality and cost-effectiveness of the services it provides. This absence has contributed to the political vulnerability of the industry as a whole. Accordingly, this deficit must be remedied so agencies can provide hard numbers to support legitimate concerns about radical changes in regulatory control and reimbursement.

10. This country may be ready to engage in a process of true health care reform in the near future, and home care providers will play a crucial role in a reformed system.

A truly reformed health care delivery system is likely to be characterized by these components:

• Emphasis will be placed on preventive care, including intensive patient teaching.

• Primary care, as opposed to specialty care, will greatly expand.

• Community-based care will be paramount.

• Nonphysician practitioners, including nurses, will play key roles, but only if they can focus on quality, cost-effective care as consistent, mutually compatible goals for each patient. Because the home health model of care already focuses on these aspects, home care has a crucial role to play in truly reformed health care delivery system.

The spirit of home care

In addition, the spirit of home care as embodied in the care provided to patients is essential to a reformed system. The spirit of home care includes a deep commitment to patients and the willingness to go the extra mile over and over again to meet their needs.

A fine example of this spirit comes from an agency in Maine. In the middle of winter in a rural area, a home health aide went to a patient’s home for the first time to give the patient a bath, among other services.

When the aide walked into the patient’s home she noted that the main room was heated by a wood stove and was warm, but the other rooms, including the only bathroom, were closed off. The temperature in those rooms was icy. When the aide entered the bathroom to prepare the bath, she immediately saw that there was a headless bear in the tub. Since she was from the same area of the state, she realized that the bear was part of the family’s food for the winter.

Still, she was puzzled as to how to give the patient a bath in these circumstances. However, she remembered she had a Hoyer lift for the patient, so in short order, she took it into the bathroom, lifted the bear out, put the patient in, and when the bath was completed, reversed the procedure leaving a clean patient and a bear no worse for wear.

There was the true spirit of home care in action, and it’s this spirit that will ensure the long-term success and viability of the industry in a reformed health care delivery system.

(Elizabeth Hogue, JD, is a health care attorney in Burtonsville, MD, and a member of Hospital Home Health’s Editorial Advisory Board.)