The future of home care

By Elizabeth E. Hogue, Esq.


Burtonsville, MD

There is general agreement that enactment of the Balanced Budget Act (BBA) of 1997 resulted in a number of new challenges for Medicare-certified home care providers. Despite predictions of dire consequences and widespread discussion of devastation in the home care industry, however, the fact remains that the future of home care remains extremely bright.

Both private duty and Medicare-certified pro-viders should be mindful of these 10 basic characteristics of the home care industry of the future:

1. The future of home care is assured.

Despite discussion about the survival of the home care industry, its future is absolutely assured because home care is consistent with the policy objectives that receive widespread endorsements by politicians, health policy experts, and the citizenry of our country. Home care generally allows patients to exercise maximum autonomy and independence by remaining in the least restrictive, most cost-effective environment possible while maintaining quality of care. Those values, as reflected in the home health model of care, will ultimately prevail.

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

There is no doubt that the past two years have been rough. The Medicare home care industry has been radically changed by the BBA, and in all likelihood these changes are permanent. Gloom and doom paralyzes providers and prevents them from taking positive action to respond to new challenges in this industry, and it must be resisted.

3. The Medicare program will not dominate the home health industry in the future.

The incentives of Medicare reimbursement prior to the BBA-rewarded volume, in both 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. Providers should no longer view the Medicare home health benefit as the viable source of reimbursement for home health services. In addition, it appears that baby boomers will have considerable disposable income and are 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 these aging boomers.

Filling the void

4. Managed care, as it has developed in the past 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 money was simply moved from the pockets of indemnity insurers into the pockets of managed care organizations. The growth of the managed care industry in the 1990s did not involve any process of true health care reform. Many continue to find an unreformed health delivery system dominated by managed care to be less than satisfactory for a variety of reasons. Thus, state legislatures, state insurance commissions, Congress, and the courts are hard at work establishing limitations on the ability of managed care organizations to operate as they have during 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 whether or not they are rendered in patients’ homes. These may include services to school districts that help them meet their obligations under PL-94-142, the federal statute that requires schools to provide services to disabled students. Parish nursing services are also a viable niche for home care providers. The home health care industry should also explore developing ambulatory clinics to assist patients with asthma, coronary disease, and diabetes.

6. Case management will survive and experience considerable growth.

There is general recognition that home care providers are case managers. The role of case managers as reflected in the national standards of care published by the Case Management Society of America (CMSA) will be essential to the future of health care in this country. According to CSMA standards, case managers are generally required to assess, evaluate, plan, advocate, and monitor in order to assure quality, cost-effective outcomes. Those skills, already well-developed in the home health industry, will be in demand in a variety of settings in the future. Agencies should work to further enhance provider 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 delivery of health care services in this country. Furthermore, it is unlikely to do so because of the highly politicized environment in which HCFA must operate. It is likely that HCFA will develop new initiatives that may assist agencies.

A program tentatively called Home Care Plus is an example of such an initiative. Still under development, the program is intended to develop a direct business partnership between home care agencies and HCFA. Participating agencies’ claims will still be processed by intermediaries; each agency and HCFA will work together to develop performance standards that the agency must meet every year. An annual review will assure that those standards are met. Such initiatives may make the Medicare-certified home health business more attractive to private duty agencies. But the future of home care truly rests with members of the industry, not HCFA.

Make a commitment

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

It almost sounds like a 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 rather than 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 supports the quality and cost-effectiveness of care provided.

The home health industry has been generally ill-served by the lack of data regarding the quality and cost-effectiveness of services provided. The absence of such data has contributed to the political vulnerability of the industry as a whole. This deficit must be remedied so those agencies can provide hard numbers to support legitimate concerns about radical changes in regulatory control and reimbursement.

10. Our 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 the reformed system.

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

• emphasis on preventive care, including intensive patient teaching.

• expanded need for primary care as opposed to specialty care.

• community-based care as paramount.

• nonphysician practitioners — including nurses. They 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 those, home care has a crucial role to play in a truly reformed health care delivery system.

Can you bear it?

In addition, the spirit of home care as embodied in the care provided to patients is essential to a reformed system. This spirit 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 that 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 noticed that the main room was heated by a wood stove and was warm and toasty, 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 for the patient’s bath, she immediately saw that there was a headless bear in the bathtub. Since she was from the same area of Maine, she knew that the bear was a food source for the family for the winter. But she was initially puzzled about how to give the patient a bath under these circumstances. In short order, however, she remembered that she had a Hoyer lift for the patient. So she took the lift into the bathroom, lifted the bear out of the bathtub, put the patient in, took the patient out, put the bear back in and the job was done.

This was the true spirit of home care at work!