Friday, December 2, 1:45 PM Health and Wellness Moderator: Heather Boger, MUSC Center on Aging Panelists: Teresa Lee, Alliance for Home Health Quality and Innovation Sheena Janse, Care for Life NAIPC 2016 ANNUAL MEETING & ROAD SHOW PLANNING A BETTER LATTER LIFE
ACT III: Health and Wellness Affordable Care Act Overview Heather A. Boger, PhD Asst. Professor, Dept. of Neuroscience Interim Director, Center on Aging MUSC
How Does the ACA Improve Health Care? Provides health insurance to those that were once considered uninsurable with pre-exiting health conditions. Provides for certain protections and rights to make your coverage fairer and easier to understand. Provides for a health care Marketplace for an easier shopping experience. Holds insurance companies accountable for rate increases. Makes it illegal for health insurance companies to arbitrarily cancel your health insurance. Covers young adults under 26. Provides free preventive care. Ends lifetime and years dollar limits. Guarantees your right to appeal.
What Will the ACA Policy Cover? All private health insurance plans offered in the Marketplace will offer the same set of essential health benefits. These are services all plans must cover. The essential health benefits include at least the following items and services: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services
How the Affordable Care Act Helps Seniors Lower-cost prescription drugs Preventive services and annual wellness visit Lower Medicare Part B premiums Improvements for Medicare Advantage Plan Members Prevent Medicare Fraud, Waste, and Abuse Establishment of the Center for Medicare and Medicaid Innovation
Shared Responsibility Individuals -Report coverage, -Claim an exemption from the coverage requirement, or -Make a shared responsibility payment Government -Expand Medicaid (at state option), -Make available premium tax credits, -Build Marketplace(s) Employers -Large employers: provide coverage Small employers: Incentives to provide coverage
Panelists Teresa Lee, Alliance for Home Health Quality and Innovation, Trident Area Agency on Aging Sheena Janse, Vice-President, COO, Care for life
What will the new policy cover? All private health insurance plans offered in the Marketplace will offer the same set of essential health benefits. These are services all plans must cover. The essential health benefits include at least the following items and services: Ambulatory patient services (outpatient care you get without being admitted to a hospital) Emergency services Hospitalization (such as surgery) Maternity and newborn care (care before and after your baby is born) Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy) Prescription drugs Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills) Laboratory services Preventive and wellness services and chronic disease management Pediatric services
Home Health Care: Value Today and for the Future Teresa Lee, JD, MPH Executive Director
Overview About the Alliance What is Home Health Care? The Future of Home Health Care
The Alliance 501(c)(3) non-profit research and education foundation Mission: To lead and support research and education on the value home health care can offer to patients and the U.S. health care system. Working with researchers, key experts and thought leaders, and providers across the spectrum of care, we strive to foster solutions that will improve health care in America. www.ahhqi.org
Diverse Membership
What is Home Health Care?
Care at Home: The Spectrum IOM (Institute of Medicine) and NRC (National Research Council). 2015. The future of home health care: Workshop Summary. Washington, DC: The National Academies Press, at 5.
Medicare Home Health Benefit Limited Benefit for homebound, needing skilled care, and under MD plan of care Payment: Part A or B; 60-day episode HHRGs (OASIS assessment) Interdisciplinary team: nurses, therapists (PT, OT, SLP), medical social workers, home health aides.
Challenges Siloes in traditional Medicare program Barriers: homebound, face-to-face documentation, practice level restrictions Inadequate infrastructure for aging in place (e.g., caregiving, transport, housing, meals)
Post-Acute Care Market Overview Chart 3.1: Total Medicare Post-acute Care Expenditures, Billions of Dollars, 2001-2013 $70 Billions of Dollars $60 $50 $40 $30 $20 $29.3 $32.9 $34.8 $39.1 $43.0 $45.6 $48.8 $52.5 $56.0 $58.7 $61.4 $58.5 $59.4 $10 $0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Source: Medicare Payment Advisory Commission. A Data Book: Health Care Spending and the Medicare Program, June 2015.
Post-Acute Care Market Overview Chart 3.2: Initial Patient Destinations Following an Inpatient Hospital Stay for Medicare Beneficiaries, 2013 Death 340,298 (3%) Other 335,107 (3%) Community 5,593,090 (56%) Formal Post-Acute Care Settings 3,805,858 (38%) SNF 1,979,243 (20%) HHA 1,392,251 (14%) LTACH 116,063 (1%) IRF 318,301 (3%) Source: Avalere Health, LLC analysis of Medicare Standard Analytic Files, 2013. Hospital: Short-Term Acute Care Hospital (STACH). Community: Discharges to the community without skilled home health care; includes individuals living at home, assisted living facilities, and retirement communities. Formal Post-Acute Care Settings: Settings designated as post-acute care by Medicare. Includes skilled nursing facilities (SNF), home health agencies (HHA), inpatient rehabilitation facilities (IRF), and long-term acute care hospitals (LTACH). Other: Hospice, a different Inpatient Hospital, or other Inpatient Hospitals such as Inpatient Psychiatric Facilities. 35
Discharges Post-Inpatient Stay, South Carolina Initial Patient Destinations Following an Inpatient Hospital Stay for Medicare Beneficiaries, 2013 Death 6,468 (4%) Other 7,057 (4%) Community 106,343 (59%) Formal Post- Acute Care Settings 61,143 (34%) SNF 29,612 (16%) HHA 22,704 (13%) IRF 7,464 (4%) LTACH 1,363 (<1%) Source: Avalere Health, LLC analysis of Medicare Standard Analytic Files, 2013 Hospital: Short-Term Acute Care Hospital (STACH). Community: Discharges to the community without skilled home health care; includes individuals living at home, assisted living facilities, and retirement communities. Formal Post-Acute Care Settings: Settings designated as post-acute care by Medicare. Includes skilled nursing facilities (SNF), home health agencies (HHA), inpatient rehabilitation facilities (IRF), and long-term acute care hospitals (LTACH). Other: Hospice, a different Inpatient Hospital, or other Inpatient Hospitals such as Inpatient Psychiatric Facilities Percentages may not sum to 100 percent or to total due to rounding 42
Analysis on Post-Acute Care Clinically Appropriate and Cost-Effective Care (CACEP) Project The Alliance commissioned Dobson DaVanzo & Associates to complete an analysis of Medicare data to determine how home health has been used in the U.S. health care system. Data suggest that clinically appropriate and cost effective placement of patients in post-acute care settings could save Medicare $100 billion over 10 years if coupled with structural changes.
CACEP Post-Acute Care Episodes Index Short Term Acute Care Hospital (STACH) Stay Post-acute care following an Index STACH stay 60 days after Index STACH discharge Post-acute care episodes (including Index STACH) = ~50% of FFS Spending Post-acute care (HHA, SNF, IRF, LTCH) during episodes = ~20% of FFS Spending
MS-DRGs Ranked by Medicare Episode Payment MS-DRGs Ranked by Medicare Episode Payment Show Considerable Overlap by First Setting Show Considerable Overlap by First Setting Overall Top 9 MS-DRGs Ranked by Medicare Episode Payment for Post-Acute Care Episodes by Select First Setting (2007-2009) MS-DRG Med/Surg Overall HHA SNF IRF LTCH 470: Major joint replacement or reattachment of lower extremity w/o MCC Surgical 1 1 1 1 34 871: Septicemia or severe sepsis w/o MV 96+ hours w MCC Medical 2 6 3 20 3 291: Heart failure & shock w MCC Medical 3 2 7 29 9 003: ECMO or trach w MV 96+ hrs or PDX exc face, mouth & neck w maj O.R. Surgical 4 91 31 10 1 194: Simple pneumonia & pleurisy w CC Medical 5 9 5 65 22 481: Hip & femur procedures except major joint w CC Surgical 6 73 2 3 53 292: Heart failure & shock w CC Medical 7 3 14 63 37 065: Intracranial hemorrhage or cerebral infarction w CC Medical 8 29 6 2 30 392: Esophagitis, gastroent & misc digest disorders w/o MCC Medical 9 20 35 125 80 Source: Dobson DaVanzo analysis of research-identifiable 5% SAF for all sites of service, 2007-2009, wage index adjusted by setting and geographic region, and standardized to 2009 dollars. Medicare Episode Payment includes care from all facility-based and ambulatory care settings and excludes beneficiary co-payments, DME, and Part D payments.
First Setting Selection has a Material Impact on Medicare Program Expenditures Example: MS-DRG 470 Medicare Episode Payment for MS-DRG 470 (major joint replacement w/o MCC) for Post-Acute Care Episodes by Select First Setting (2007-2009) First Setting Number of Episodes Average Medicare Episode Payment Difference from Overall Payment HHA 366,140 $18,068 $5,411 SNF 430,240 $26,861 ($3,382) IRF 128,680 $33,538 ($10,059) LTCH 1,080 $57,896 ($34,417) STACH 2,580 $30,302 ($6,823) Community 134,240 $17,340 $6,140 Overall 1,062,960 $23,479 $0 Source: Dobson DaVanzo analysis of research-identifiable 5% SAF for all sites of service, 2007-2009, wage index adjusted by setting and geographic region, and standardized to 2009 dollars. All episodes have been extrapolated to reflect the universe of Medicare beneficiaries. Medicare Episode Payment includes care from all facility-based and ambulatory care settings and excludes beneficiary co-payments, DME, and Part D payments. Note: ER, OP, OP Therapy, Hospice and Other IP first setting episodes are not included in the overall.
Which patients are responsible for vast majority of Medicare spend? 5% 5% 15% 25% 50% Medicare Beneficiaries 43.1% 18.4% 23.5% 11.2% 3.8% Expenditures Congressional Budget Office Data analysis of Medicare Data (2001)
Demographics of Home Health Users Table 1.7: Selected Characteristics of Medicare Home Health Users and All Medicare Beneficiaries, 2013 All Medicare Home Health Users All Medicare Beneficiaries Age 85+ 24.0% 12.0% Live alone 36.7% 28.8% Have 3 or more chronic conditions 85.1% 62.5% Have 2 or more ADL limitations * 31.9% 12.0% Report fair or poor health 48.7% 27.2% Are in somewhat or much worse health than last year 41.9% 22.2% Have incomes at or under 200% of the Federal 67.2% 52.1% Poverty Level (FPL) ** Have incomes under 100% of the Federal Poverty 31.2% 21.3% Level (FPL) ** Source: Avalere analysis of the Medicare Current Beneficiary Survey, Access to Care file, 2013. *ADL = Activities of daily living, such as eating, dressing, and bathing. Limitations with at least 2 ADLs is considered a measure of moderate to severe disability and is often the eligibility threshold for a nursing home level of care. **In 2013, 100 percent of FPL for a household of 1 was $11,490, a household of 2 was $15,510, a household of 3 was $19,530, and household of 4 was $23,550. 200 percent of FPL was double each amount. 10
Demographics of Home Health Users Chart 1.6: Percentage of All Medicare Beneficiaries and Home Health Users by Number of Chronic Conditions (CCs), 2013 Home Health Users All Medicare Beneficiaries 51.2% 14.9% 15.3% 24.9% 37.5% 18.5% 17.2% 20.5% 0-2 CCs 3 CCs 4 CCs 5 or more CCs Source: Avalere analysis of the Medicare Current Beneficiary Survey, Access to Care file, 2013. Totals may not sum to 100 percent due to rounding. 9
Demographics of Home Health Users Chart 1.1: Age Distribution of Home Health Users and All Medicare Beneficiaries, 2013 50% 45% 44.8% 40% 35% 33.3% 30% 25% 27.7% 26.4% 24.0% 20% 15% 16.8% 15.0% 12.0% 10% 5% 0% Age <65 Age 65-74 Age 75-84 Age 85+ All Medicare beneficiaries Home health users Source: Avalere analysis of the Medicare Current Beneficiary Survey, Access to Care file, 2013. 4
Demographics of Home Health Users Chart 1.5: Income Distribution of Home Health Users, Skilled Nursing Facility Users, and All Medicare Beneficiaries, 2013 70% 60% 59.1% 52.7% 55.1% 50% 40% 44.9% 40.9% 47.3% 30% 20% 10% 0% Under $25,000 Per Year $25,000 Per Year Or More All Medicare beneficiaries Home health users Skilled Nursing Facility users Source: Avalere analysis of the Medicare Current Beneficiary Survey, Access to Care file, 2013. 8
The Future of Home Health Care
Eyes on the Future Advance understanding of value of home health care today and in the future Strategic framework for Future of Home Health Care Partnered with Avalere Health and drew from literature review, interviews with policy leaders, innovators, IOM workshop summary Focused on Home Health, but acknowledges broad spectrum of home-based care Twitter: #FutureofHH
The Spectrum of Home-Based Care A WIDE RANGE OF SERVICES CAN BE PROVIDED AT HOME Low Acuity & Medical Involvement High Care Coordination and Management Family Caregiving (Informal Personal Care Services) Private Duty Home Care (Formal Personal Care Services) Skilled Home Health Care Home- Based Primary Care (MD/NP) Hospital At Home Hospice Routine & Palliative Care Care coordination and management performed by home healthcare professionals is an evolving area of service 15
Shifting to a Community and Home-Based Model KEY STRATEGY FOR HEALTH CARE INNOVATION 1 Eric Dishman, Intel Corporation (presented October 1, 2014, IOM-NRC Workshop on The Future of Home Health Care). 16
Key Takeaways from Policy and Thought Leader Interviews Payment and Delivery Reform Future of Home Health 1 Payment and delivery reform is here to stay 1 Home health as the big winner in payment and delivery reforms 2 No dominant model is emergingcontinued heterogeneity across markets expected 2 Varying perspectives around how to modify the HH benefit 3 Greater momentum around bundling and Medicare Advantage than ACOs 3 No single model identified for managing patients 4 Locus of control physician versus hospital unclear 4 Opportunity for innovation in benefits for community-referred beneficiaries 5 Payment and delivery will continue to rely on FFS systems with retrospective reconciliation 5 Home health agencies must adapt to the changes to Medicare payment and delivery 6 Flexibility is greater when shared risk but limitations on innovation within existing FFS structure 6 Caregiver burden is a crisis necessitating a long-term care solution 17
Four Key Characteristics of the HHA of the Future Patient and Person-Centered Seamlessly Connected and Coordinated High Quality Technology-Enabled 19
Capabilities Needed to Fulfill these Key Roles Homebased medical care HIT Primary to acute hospital level care Remote monitoring & Telehealth Palliative care Care transitions support Source: Avalere Health, 2016 21
Framework for the Future of Home Health Care Risk Quality and Spending Targets Regulatory and Financial Flexibility Ambulatory Care Palliative Care & Hospice High-Quality Technology- Enabled Outpatient Care Post- Acute Care Acute Care 24
Questions/ Discussion Thank you! tlee@ahhqi.org 571-527-1530
Bridging the Gap Caregivers & Aging in Place Sheena Janse, CRCFA
Aging In Place Statistics show the vast majority of Americans want to stay in their homes as they age. However, due to physical and/or cognitive changes related to aging many will require assistance to do so. That assistance is provided by a caregiver.
Instrumental Activities of Daily Living Paying Bills Medication Management Meal preparation Transportation Housework/Laundry Shopping Telephone
Activities of Daily Living 1-Ambulation 2- Bathing 3-Grooming 4-Dressing 5-Eating 6- Toileting
Common Issues Seniors encounter which require a caregiver 1- Nutrition 2- Medication 3- Home safety 4- Hygiene-Personal & home 5- Unaddressed medical problems
Caregiver A caregiver is an unpaid or paid person who helps another individual with an impairment with his or her activities of daily living. Any person with a health impairment might use caregiving services to address their difficulties. Caregiving is most commonly used to address impairments related to old age, disability, a disease, or a mental disorder.en.wikipedia.org
Many family caregivers experience positive feelings in providing care for a loved one.
Family Caregivers More than 44 million Americans are providing unpaid caregiving for an adult family member 52 % of caregivers are adult children 61% of those caregivers are working 13% percent of households are caring for both children and aging parents the so-called "sandwich generation".
Impact of the Sandwich Generation in the workplace Cost of being a caregiver often impacts the caregiver professionally Absenteeism due to caregiving responsibilities poor work performance presentism when employees are physically at work but mentally distracted by issues at home.
Cost of caregiving Loss of income Job changes to accommodate caregiving responsibilities Absence from work FMLA Decreased hours Early retirement Loss of retirement savings
Personal Cost of Caregiving 43% of Family Caregivers report negative effects Personal well being Health related issues Depression Increased levels of stress 55% don t feel qualified to provide physical care Genworth
Care Services available in the home Care Management Non- Medical Home Care Home Health Care Hospice Palliative Care
Aging Life Care Management Once referred to as Geriatric Care Management- Professional who is specially trained to provide solutions to improve the safety, quality and independence of their older client. Advises, advocates and assists the aging person and their loved one navigate the challenges that arise through the aging process..
Aging Life Care Manager. Coordination of health care & other services- Home care, Activities of daily living, Socialization, Housing recommendations, Referrals to local resources Legal planning Education & Advocacy Caregiver coaching
Aging Life Care Managers Complete assessment with interaction with the client and family members creation of a written care plan provide referrals and resources ongoing monitoring of care
Non-Medical Home Care Transportation Errands Companionship Supervision Assistance with ADL s Medication reminders Meal preparation Light Housekeeping
***Palliative Care - Supportive care for all patients with serious illness to manage symptoms and illness burden for both patient and family from the time of diagnosis onward, thus improving quality of life. Specialized care is provided by a team of healthcare providers in collaboration with your current care team. Insurance is billed just like any doctor visit. Services in the home Home Health Services Non-medical In-Home Care Services Hospice Skilled Services Non- Medical Services up to 24/7 care Skilled End of Life Care Nursing- weekly visits Geriatric Care Management RN Case manager - 1-3 weekly visits Physical Therapy 3 visits weekly Transition Care Management CNA - 3-7 days/week for 1-2 hours Occupational Therapy 2 visits weekly In-home comprehensive assessment Social Worker - 1-2 visits monthly Speech Therapy Medication Reminders/ Reconciliation Chaplain- 1-2 visits monthly Infusion Training for Family Initiate referrals for Home Health, DME Skilled visits are approximately 1 hour in duration Payment source Payment source Payment source Medicare Private Funds Medicare Some insurance plans Long Term Care Insurance Medicaid Grants & VA benefits Some Private Insurance Plans Requirements Requirements Requirements Doctor s Order to initiate services Services provide benefit to and Doctors order based upon life Must demonstrate Progress enhance quality of life of clients expectancy of 6 months or less