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Home health stakeholders often talk about the need to modernize the Medicare home health benefit.
What they are often getting at is the need to make it easier for providers to deliver crucial care, while, in turn, creating better access to care.
“We constantly need to be thinking about what’s ahead, how to improve this benefit, how to make it more available, how to expand what you can receive in the home … because home is the preferred setting,” Joanne Cunningham, CEO of the Partnership for Quality Home Healthcare, told Home Health Care News.
HHCN recently caught up with home health industry advocates who suggested key changes that they believe would update and enhance the Medicare home health benefit.
Greater flexibility around homebound status
Under Medicare, a patient is considered homebound if they need supportive devices such as crutches, canes, wheelchairs and walkers due to illness or injury, or if they need the assistance of another individual to leave their home.
To be considered homebound, leaving the home must require “a considerable and taxing effort.”
While eliminating homebound status entirely could present a number of challenges, broadening the definition is worthwhile, according to Bill Dombi, president of the National Association for Home Care & Hospice (NAHC).
Plus, there is some precedence behind this idea. Congress has introduced flexibility around homebound status in the past.
“Congress at one point added to the homebound standard the ability to leave the home for religious services,” Dombi told HHCN. “Prior to that time, people were being denied coverage because they would go to religious services on occasion and then being told ‘Well, sorry, you left your home.’”
This isn’t the first time NAHC has called for more flexibility around homebound status. Back in March 2020, the organization submitted a letter to the U.S. Centers for Medicare & Medicaid Services (CMS) asking for accommodations that would enable providers to be more effective amid the COVID-19 emergency.
At the time, NAHC asked CMS to expand the existing “homebound” requirement so that providers could treat individuals dealing with COVID-19.
Sen. Susan Collins (R-Maine) — a longtime home-based care advocate — pointed out that the requirement is “extremely strict.”
As of now, changing the homebound status would take an act of Congress.
“The barrier more than anything else is the need to change the law,” Dombi said.
Aside from homebound status, Dombi also noted the need for more flexibility around the eligibility requirements needed to qualify for home health.
Telehealth is not a reimbursed service under home health care.
Yet this hasn’t stopped providers from embracing telehealth, virtual care and remote patient monitoring — especially during the pandemic.
“I think it’s being used effectively as an additional resource gap filler that provides a high level of additional service for patients in the home who are being monitored by a home health provider,” Cunningham said. “I think policy needs to seriously examine how you further take that to the next level.”
Taking things to the next level means paying providers when they utilize these services, according to Cunningham.
On its end, CMS has recognized the value of telehealth by allowing its costs to be recorded in the cost report.
“That’s a good step, but the [public health emergency] has shown that telehealth has become such a linchpin for the delivery of care to patients in the home,” Cunningham said. “We need to think long and hard about policy change that incentivizes and standardizes the use of appropriate telehealth. I think the way to do that is to reimburse for it.”
Over the years, the legislative efforts around home health telehealth have largely been stalled and unsuccessful.
Cunningham believes that educating policymakers about home health care may push the needle forward.
“I think the more up close and personal an understanding policymakers have of the home health benefit — its capacity and the kind of patients that are being cared for in the home — the better off we’re all going to be,” she said. “Policymakers will see a service delivery model that in the past five years has advanced, certainly in the past 15 years.”
Recognition of providers’ role in educating family caregivers
The ability to receive care in the home is often dependent on informal or family caregivers.
Broadly, informal caregivers are spouses, partners, friends or family members who assist with activities of daily living (ADLs) and possibly even medical tasks, according to the San Francisco-based nonprofit Family Caregiver Alliance.
Providers play an important role in the education of informal caregivers, according to Mollie Gurian, vice president of home-based and HCBS policy at LeadingAge.
“They do a lot of caregiver education – teaching family caregivers how to do the exercises or how to clean a wound or helping them figure out how to support a dementia patient while they’re going through their skilled care episode,” she told HHCN. “If caregiver education and support are lifted up, and paid for appropriately, it would be a more holistic benefit.”
Gurian noted that this would help improve home health episodes for everyone.
Plus, it would compensate providers for the work that they are already doing.
“It takes a lot of time to educate the caregiver on the complex tasks that come within a home health benefit, so it’s recognizing the actual time that is spent by nurses, therapists or other people on the team to educate those families,” Gurian said. “[Currently], it’s part of the bundle, it’s part of the expectations, but it’s not reimbursed at a level that allows them to focus on it as much as it might need to be focused on.”
Looking ahead, Gurian believes that this is a period of change for the health care system.
“CMS has focused on an equity strategy about the different kinds of things that we can pay for that will help with outcomes,” she said.
Ultimately, she believes paying for that informal caregiver education is a way to do just that.