Help staff deal with continued fallout from home care changes

Venipuncture elimination hard on both patients and staff

Consider yourself lucky if your agency hasn't been rocked or capsized by the tidal wave of change from the Balanced Budget Act of 1997. Home care agencies across the country have had to cut staff, discharge patients, and make serious financial changes because of the government's change in how Medicare pays for venipuncture services and because of the Interim Payment System (IPS).

"We are seeing departments of health and other agencies unload aides because of IPS and venipuncture," says Eric Sokol, JD, assistant director for government affairs at the National Association for Home Care (NAHC) in Washington, DC. NAHC has lobbied long and hard to convince Congress to repeal some of the changes because of the devastating effect they've had or are predicted to have on consumers and home care agencies. "We just don't want the issue to die because if legislation doesn't get passed this year, then it will be very easy to forget about this," he says.

U.S. Senators John Breaux (D-LA) and Charles Grassley (R-IA) have led the way in vowing to correct the Balanced Budget Act's mistakes, such as IPS, Sokol says. But the outlook is less hopeful for a reversal on the venipuncture change. "I've heard sources say venipuncture will not be addressed," he says.

That change disqualified venipuncture as a home care service under Medicare Part A, which means that patients no longer will qualify for additional services such as home health aides, case management, counseling, and clinical assessment. Instead, Medicare will cover venipuncture only by lab technicians under Medicare Part B, if it's the sole skilled service needed.

Beneficiaries face hardships under new rules

The Visiting Nurse Association of Crawford County Inc. in Meadville, PA, had to discharge 40 of 44 patients receiving venipuncture services when the Feb. 5, 1998, change took place. Fourteen of those patients also had been receiving other services, such as home health aide visits.

The agency conducted a follow-up study in April to find out what happened to the discharged patients. Of the 32 who were contacted, four had hospital admissions, one died of pneumonia, and two were admitted into long-term care, says Julie A. Hovis, RN, MSN, chief executive officer of the hospital-based agency, which covers one county and parts of two others in Northwestern Pennsylvania. The survey doesn't prove a cause-and-effect relationship between the discharge and what happened later to the patients, but it does suggest that at least seven patients had serious problems shortly after discharge from home health services, she says.

The agency's intake coordinator, who conducted the survey, asked patients if they felt their health had improved, declined, or stayed the same since their home care discharge. Ten said their health had declined, while 17 said it was about the same, she says. "The government thought home health agencies were defrauding the system because they were going in and drawing everyone's blood. But that wasn't the case; the patients were homebound and had a physician's orders, and their medical conditions were very fragile."

Hovis says the agency's venipuncture patients were all 80 years old or older and had major limitations in activities of daily living (ADLs). "Some were bedbound in addition to being homebound, and they were on eight or more medications per day," she adds.

Crawford Memorial Home Health Agency in Robinson, IL, also was strongly affected by the venipuncture change. The rural hospital-based agency had to discharge 15 patients in February, says Susie Allred, RN, director for home health services.

The agency retained two patients even though it no longer is reimbursed for their venipuncture services, Allred says. "We feel we cannot discharge them because they actually do not have any help," she says, adding that the agency does not want to be accused of abandoning patients.

Help patients ease into transition

Crawford spent a lot of time helping patients ease into the transition. Before patients were discharged, Crawford employees talked with patients about the change and gave them information about alternative services. Several patients decided to use the agency's private- duty services, while others had family or neighbors who could assist them with their ADLs. The agency also referred patients to a state-funded community program in which low-income elderly residents receive some house - keeping services, meal preparation, and errand-running.

Some home care industry experts fear the venipuncture change might be Medicare's first step in cutting home care benefits. "What we're real concerned about is that this is the first step in whittling down the benefit; first venipuncture, next another skilled service," Sokol says.

The Health Care Financing Administration (HCFA) of the Department of Health and Human Services in Baltimore has done little to ease those fears. HCFA recently issued a memorandum that further defined venipuncture for home care agencies. The definition stated that drawing from a central line to obtain a blood sample is venipuncture and, in some cases, would be paid under Medicare Part B, which would eliminate it as a qualifying skilled home health service under Medicare Part A.

Medicare's IPS also will continue to cause home care agencies headaches and staff cuts, unless it's reversed soon, Sokol predicts. (See story on what IPS entails, p. 104.) NAHC has been pushing Congress to repeal the IPS or at least delay its per-beneficiary limits, as well as to make other changes, including these:

o NAHC wants Congress to change the base year used in calculating the IPS per-beneficiary limits from the 12-month cost reports ending in fiscal year 1994 to the 12-month cost reports ending in calendar year 1995.

o NAHC says Congress should eliminate the mandatory Oct. 1, 1999, 15% reduction in home health reimbursement.

o NAHC asks Congress to extend the authorization for exemptions and exceptions to the perbeneficiary limits.

NAHC also is trying to head off some potentially disastrous changes, such as a proposal to bundle home health payments with payments to other providers. That could cause a major disruption to the health care industry and would be anti-competitive, says Sokol. In addition, NAHC has asked Congress not to impose co-payments for Medicare home health services because that will discourage some poorer patients from using the services, and instead they may have to be admitted to long-term facilities.

The Visiting Nurse Association of Crawford County has been preparing staff for IPS changes since last fall, Hovis says. The IPS will reduce the agency's reimbursements by about 25%, she says. "So we've been working with the staff to find any way we can to cut expenses and increase productivity."

In fact, the agency has spent a great deal of time on staff education, and with the IPS and other changes, it will continue throughout the year. "These changes are the most widespread and far-reaching changes we've ever experienced. But the other side of the coin is we still know how valuable home care is, and this increases our resolve to continue to provide this valuable service."

Lehigh Valley Home Care in Allentown, PA, also has been preparing staff for IPS and other changes. The agency's fiscal year begins July 1, which is the date the IPS will be implemented, says Cynthia M. Runner-Heidt, RN, MSN, director of the hospital-based agency that serves several counties in Eastern Pennsylvania.

"Our plan is to pull together a team of management, clinical, business, and office staff to develop very specific standards on how we're going to manage the per-beneficiary cap," Runner-Heidt says. The agency already has developed a staff education brochure that defines some of the new vocabulary in home health care. (See Lehigh Valley's IPS definitions, below.)