The United States — now with more confirmed cases than all but two countries — has hit a critical juncture in the uphill battle against the coronavirus. But home- and community-based health care providers are still left fighting for more support.
Home Health Care News caught up with National Association for Home Care & Hospice (NAHC) President William A. Dombi for an update on where home health and home care providers currently stand amid the COVID-19 pandemic.
Highlights from the conversation are below, edited for length and clarity.
You can hear the full conversation by subscribing to Disrupt via Apple Podcasts, Google Play Music, SoundCloud or your favorite podcast app. The full conversation is also available at the bottom of this page.
The situation is changing hour by hour. What are your priorities as of today, March 20?
The No.1 priority relates to getting equipment to home health, home care and hospice workers. And that means all forms of equipment, including the high-level personal protection equipment (PPE). [Not having that] has created an absolute issue in delivering home-based care, in terms of providers’ relationships with patients and clients. Another priority is getting authorization to use technology to support staff and reduce the frequency with which in-person visits are needed particularly around nursing services but also therapy services. The Medicare home health benefit is not equipped to deal with that. We’re trying to see if we could at least get a temporary change to allow for telehealth-type visits to substitute for in-person visits when clinically possible. And when defining telehealth, we mean even situations where just a phone call conversation could take place.
CMS lifted some HIPAA requirements, which could help with that, too, right?
There was a change that Congress authorized relative to a Medicare provision that provides payment to physicians and other practitioners to do telehealth services. The home had never been an originating site. That’s now allowed. And CMS expanded its concept of telehealth to include telephonic, but it has to be two-way audio/video. It then waived HIPAA or created some flexibility around that because, you know, the encryption and protections of privacy that HIPAA requires generally are not going to occur between the senior citizen who has got a smartphone in hand talking to a physician. This does not connect into the home health benefit, but it does connect into the home.
Putting telehealth aside for a second, I’d like to circle back to PPE. What do things look like on the ground right now? I know that’s a particular challenge for providers in New York.
The New York situation is a harbinger of what we would expect to see nationally. And in the near term, there’s little indication there’s going to be a sufficient level of supplies to meet all of the demand. Now, we know the CDC is starting to look at flexibility. And there are differences between treating people who are infected, treating people who are suspected-infected and treating patients generally regarding what kind of PPE is needed. But the equipment that’s necessary for any level of service now seems to be decreasing — on the higher level of PPE being the N-95 masks.
We have to keep our health care staff safe. You can’t sacrifice one staff member while taking care of one infected person, because you need to have that staff person care for multiple infected individuals. This is challenging hospitals. It’s challenging nursing homes. It’s challenging physician offices. And it absolutely is challenging home health agencies.
On the Medicaid side, I know a lot of stakeholders are trying to seek 1135 waivers. I think some have already been issued in Florida and, most recently, Washington. What’s going on there?
There’s a lot of flexibility in Medicaid, and CMS is absolutely supporting home- and community-based care with its waivers, its recommendations on waivers and its blanket waivers. CMS realizes that there is a very large Medicaid population receiving care at home and that the home provides a solution [amid this crisis]. So, we’ve been out there working with state associations communicating with Medicaid programs to request appropriate waivers.
One of them that we’d hoped would be a blanket waiver is not a blanket waiver. But I think CMS needs to reconsider it. States have to request this specifically — the home health aide supervision requirement. That should be waived and allow for either technology-based supervision or just skipping supervision entirely.
Medicaid presents a unique challenge, too, because so much of the care is home- and community-based personal care services, separate from the skilled nursing and therapy services under the Medicare benefit. You have issues of equipment with that, but you have issues of competency among the workforce. And you have issues also related to the amount of time someone is spending in the home, since that infection risk increases. But listen, everything that we’re getting is indicating that the entire home care community is stepping up and trying to do anything and everything it can.
But there are so many challenges. Some home care companies have already put workers into isolation or quarantine because they have been exposed. That, you know, is going to diminish the workforce. So that’s another issue. Where will we go for workforce needs? I actually had a conversation with a reporter yesterday who said, “OK. With stores closing down like Macy’s, Bloomingdales and Nordstrom, does that make home care workforce available?” That may make some workforce available down the road. In the meantime, doctors’ offices are also closing, the types of offices that mostly deal with the appointments or procedures being postponed now. So we’re suggesting that home-based care providers turn to such places — or even school nurses.
There’s been a lot of action out of Congress when it comes to emergency relief. One package signed by the president last week included federally mandated paid sick and medical leave. I know there are some questions about where non-medical home care fits into that.
The relief package had a lot of common sense to it. As it was written, it’s pretty extensive. But they did put within it some exemptions. One of the exceptions is for companies that have 50 or fewer employees. They could apply to a number of home care companies. I haven’t seen any specs up yet on that whole application process, but you can expect [officials]. They probably have to end up expediting, in some capacity, maybe via presumptive approvals. The other is an exemption for health care workers. Unfortunately, what Congress did was not define” health care workers” any differently than it was already defined under the Family Leave Act, which had a very narrow definition, focusing on parties like physicians and nurse practitioners. Nurses are not even included in it, let alone home care workers who are providing a home care aide level of service or a personal care assistant level of service.
So, there is an effort underway to get the Department of Labor (DOL) to redefine health care workers. It is a regulatory and not a statutory definition, which means DOL can make the change. The industry is banded together to seek a broader definition that would encompass all of home care from the professional nurses and therapists on through to the skilled home care aide services. There may be some issues once you get past the home health aides on personal care, but we believe that they are also health care workers, even if they’re helping feed somebody or transfer them from the bed to the bathroom.
Among relief efforts, it looks like the government is moving forward with a $50 billion bailout for the airline industry. To me, it seems like policymakers are so worried about fraud, waste and abuse in home health care, but maybe this is a time to also be pumping financial resources into the space. Any thoughts on that? Or if it would ever be a possibility?
I think it’s more than a possibility. For example, in another relief bill being considered in the Senate, it has a suspension of the 2% sequestration, which is 2% away from every provider, every practitioner, everyone in the health care sector within the Medicare program. In this Senate bill, that would be suspended for the rest of the year. That wouldn’t be a major infusion of dollars, but it would be a starting point.
(Editor’s note: The bill referenced above — a roughly $1.4 trillion stimulus package — was headed toward a Sunday vote, but delayed as of 5:30 p.m. CT.)
Do you think a silver lining to this crisis is that home health providers will be able to prove their mettle?
Without a doubt. And I think what I’ve seen so far is that home health care has really shined in terms of what all providers are doing in their relationships with hospitals and physicians, their focus on solutions. We’ve seen indications coming from Congress and from CMS that home health care is being recognized for its value. Many people may have seen one of the early press conferences from the White House. Standing right behind the president was a representative of home health, an individual who works for LHC Group (Nasdaq: LHCG).
There is a very solid chance that once we get through this crisis, the experiences and solutions that home health is bringing into the health care world will be remembered and embraced.
What general message do you have for home health, home care and hospice providers — and their workers — right now?
First off, they need to stay strong. This is a very pressure-filled time for everyone. And everything I’ve seen indicates that they are staying strong. But the pressure is going to increase. So they have to keep up that resolve to care for people.
I think they need to keep their staff fully informed. They have to do whatever they can to keep their staff safe, not just for the sake of keeping their workers, but for everybody out there. So the top things they need to be focusing on is awareness, training and support, plus the equipment side of it.
And lastly, we have a campaign that’s up on our website. We have our lobbying efforts set to go out on Tuesday. To help get our message out, providers just need to go to NAHC.org. They can sign on to a quick message about home care and technology’s value. We’ll get that in front of Congress. We have to have our voices out there as loud and clear as possible.