As Older Adults Are Increasingly Isolated, Advocates Call for Medicare Home Care Benefit

The COVID-19 virus has driven much discussion over the best ways to revamp home-based care moving forward.

Suggestions as to how to do that have ranged from small tweaks to seismic shifts, from fine-tuning documentation requirements to allowing for direct telehealth reimbursement. While seemingly endless, all of the ideas are valuable, CareAcademy CMO and co-founder Madhuri Reddy told Home Health Care News.

CareAcademy provides education for in-home care providers and caregivers.

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In addition to her role at CareAcademy, Reddy is an instructor in medicine at Harvard Medical School and also serves as a geriatrician for the nonprofit Hebrew SeniorLife. She recently teamed up with two academics from the University of Toronto — Nathan Stall and Paula Rochon — to offer 10 recommendations of her own that would impact the current public health crisis through home-based care.

Perhaps the most noteworthy of Reddy’s recommendations: the inclusion of personal care under the Home Health Benefit.

Expanding the definition of ‘home health’

The idea that the U.S. Centers for Medicare & Medicaid Services (CMS) should expand the definition of “home health care” to include personal care — or non-medical home care services focused on activities of daily living (ADLs) and social determinants of health (SDoH) — is an ambitious one.

But it increasingly seems more logical during the COVID-19 outbreak.

“Traditional Medicare pays for ‘skilled services,’ but it really may be time to move on beyond that limited definition of home care for Medicare,” Reddy said. “I think a couple of the issues we’re facing now blur the lines of what requires ‘skilled care’ versus ‘non-skilled care.’”

Including personal care under the Home Health Benefit — or something else entirely — has additionally made more sense as the needs of aging populations become more complex and home-based care providers evolve, she noted.

More than 3 million people received the Medicare home health benefit in 2018, according to the Medicare Payment Advisory Commission (MedPAC).

The idea of carving home care into Medicare is not new. Even before the coronavirus, home care advocates touted the concept as a way to reduce social isolation among the senior population and provide more comprehensive care to individuals with functional impairments.

But COVID-19 has altered the definition of the at-risk senior population, creating a larger group of people who would benefit from home-based care. To avoid exposure, even healthy older adults are avoiding public places and confined to their homes, for example.

“Personal care plays a large part in helping seniors maintain independence at home,” Reddy said. “What is preventative care, and what is treatment? About 70% of older adults living in the community need personal assistance at some point, and that was pre-COVID-19.”

Broadly, about 20% of older adults have difficulty getting out of their own homes and require personal assistance to do so, she added.

“I think the whole idea of expanding the definition of [home health] is really quite important,” Reddy said.

A revolutionary change

In theory, expanding the parameters of home health helps out Medicare beneficiaries and providers alike, especially those just dealing in home care.

But it would be a drastic change from the current norm, William A. Dombi, president of the National Association for Home Care & Hospice (NAHC), told HHCN.

“It would be a revolutionary change — a welcome one, but a revolutionary change,” Dombi said.

“We’ve long recognized that personal care services often make the difference between an individual staying home or needing an institutional care setting. So it would be quite valuable.”

Still, there are significant roadblocks. After all, the need for medical care has been a prerequisite to qualify for the home health benefit since 1965.

And changing the qualifications would have serious monetary consequences.

“The concern is fully budgetary,” Dombi said. “The number of people in the Medicare enrollment who would need personal care at home, who do not need skilled care at home, probably would expand the spending on the Medicare home health benefit exponentially. The Congressional Budget Office (CBO) hasn’t been brought into the mix on the public health emergency waivers. If they were to be brought in [for this], they would say that this would be a massive expenditure.”

That’s why — for now — NAHC and other home-based care advocacy groups have stuck to more manageable advocacy efforts by comparison, like telehealth reimbursement and expanding the homebound requirement, for instance.

“As necessary as we might think it is, we’d have to face the consequences that it would be a high cost to the Medicare program to get there,” Dombi said.

How workers fit in

Apart from expanding Medicare definitions, any suggestions for improving home-based care amid the coronavirus should consider in-home clinicians and caregivers, according to Reddy.

Firstly, ensuring workers have access to personal protective equipment (PPE) and COVID-19 testing supplies should continue to be a priority, Reddy said. Federal funding for hazard pay and paid sick leave also needs to be secured, because most agencies can’t cover such costs alone.

Additionally, community health workers should be compensated during the public health emergency, she said.

That’s another idea that has gained traction before, but remains ambitious.

“Medically vulnerable, older adults are facing social isolation and the mental health challenges that come with that,” Reddy said. “I think home care workers, as well as community health workers, are particularly well-suited to attend to these social needs, including helping patients or people in the community adhere to their medical treatment. It is important for these workers to be reimbursed and the importance of this work to be realized.”

New home care workers are also being recruited from other industries that have experienced significant layoffs over the last few months.

This provides an opportunity to close the gap on the caregiver shortage, but extensive training programs need to be put in place in order to ensure that these new workers are equipped to take COVID-19 and other challenges head on, Reddy urged.

Many of these workforce issues are already on the forefront of providers’ minds.

“I feel there’s still missed opportunities here to maintain the health and well- being of older Americans,” Reddy said. “And I think it’s important to include home care workers’ voices in these discussions.”

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