Case Management in the Home Care Setting
Elizabeth Alvarado
Edward Sunderland
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be able to:
Discuss the different services available in the home care setting.
Describe reimbursement and insurance issues in relation to the home care setting.
Explain the importance of collaboration within the interdisciplinary team including durable medical equipment agencies and other representatives.
Explain the role of the case manager in the home care setting.
IMPORTANT TERMS AND CONCEPTS
Advance Request Payment
Certified Home Healthcare Agency (CHHA)
Custodial Care
Home Care
Home Health Aide
Home Health Resource Groups (HHRGs)
Homebound
Intermittent or Part-Time Care
Long-Term Care
Low Utilization Payment
Nonskilled Services
Occupational Therapy
Outcome and Assessment Information Set (OASIS)
Outlier Payment
Partial Episode Payment
Physical Therapy
Reasonable Care/Services
Significant Change in Condition Payment
Skilled Services
Speech Therapy
▪ INTRODUCTION
A. Throughout history, medical care was provided in the home by family members, with some guidance from outpatient or home visiting professionals.
B. During the second half of the twentieth century, medical practice shifted from this home-based model of care to the hospital-based care model, which allowed medical practice to expand its knowledge and improve individual outcomes and dramatically increase life expectancy.
C. Unfortunately, however, medical care costs also dramatically increased. These increases have brought about the necessity of controlling costs.
In the private sector, insurance companies sought to control costs through utilization review/management and health maintenance organizations (HMOs).
In the public sector, the Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration, have sought to control costs through the adoption of diagnosis related groups (DRGs) and the prospective payment system (PPS).
The development of DRGs, HMOs, and the practice of utilization review has led to increased pressure on hospitals to control costs by limiting the number of days each patient spends in the hospital—that is, to reduce length of stay (LOS).
The current pressure on hospitals has increased the need for home care services and therefore, case management.
D. Hospitals have found that utilizing interdisciplinary teams to develop post-hospital discharge plans can safely reduce length of stay without compromising patient safety. These teams are best facilitated by case managers to produce the most effective outcomes.
E. Home care, when appropriate, serves two vital functions in reducing costs by limiting length of stay in institutional settings.
First, home care serves as a less expensive extension to hospital-based care.
The average home care visit cost is significantly less than the cost of a day in the hospital. The visit can provide vital information to the physician that can confirm the plan of care or indicate the need for change.
The assessment of a medical professional in the home can provide reassurance to patients and their families that the plan of care or health regimen is appropriate as well as provide important information to the interdisciplinary team about conditions in the home.
Second, home care serves as a less expensive and more satisfying alternative to other types of institutional care.
The average cost of a home care visit is significantly less than the cost of a day in a skilled nursing care facility; and most, but by no means all, families would prefer to provide care in the home setting.
As an alternative to a hospital or skilled nursing facility, home care shifts the burden of round-the-clock institutional care from the insurer to the family. Therefore, across an effective continuum of care, one should expect to see increasing home care costs, not as a result of overutilization of home care services, but as a result of shifting utilization away from more costly settings into home care.
F. Case management in the home care setting is designed with similar goals in mind as those of case management in the acute care setting. These may include the following:
Optimization of the delivery of care across the continuum
Caring for patients in less costly care settings
Employing a proactive approach to patient care delivery by implementing strategies to keep patients out of acute care settings
Monitoring patients’ conditions and preventing deterioration
Reducing patients’ risks and need for acute care services
Improving quality of care and services
Maintaining patients’ safety
Improving patients’ quality of life
G. Patients who are eligible for home care services include those who were hospitalized in an acute care/hospital setting, those with chronic illnesses, or those with seriously complex medical conditions.
H. The demand for home care case management services has increased lately since the implementation of the federal home care PPS, the increase in managed care and capitation, the popularity of demand management programs, and the growth of integrated delivery systems.
▪ KEY DEFINITIONS
A. Advance request payment—A home care services claim submitted at the completion of the initial assessment of the patient, upon admission into home care services, and at the completion of an initial OASIS score. This claim includes a partial payment amount that does not exceed 60% of the specific HHRG-designated reimbursement.
B. Certified home healthcare agency (CHHA)—A company that meets all the eligibility criteria required by CMS before it is permitted to provide home care services for Medicare beneficiaries.
C. Custodial care—Care provided primarily to assist a patient in meeting the activities of daily living, but not requiring the services of a licensed professional, such as bathing and eating.
D. Home care—Health care services that are provided to patients while in their own homes. These services may include professional (i.e., skilled) and paraprofessional (i.e., supportive) services.
E. Home health resource group (HHRG)—Groupings for prospective reimbursement under Medicare for home health agencies. Placement into an HHRG is based on the OASIS score. Reimbursement rates correspond to the level of home health services provided.
F. Homebound—Being confined to the home setting all (or almost all) the time. A patient who is considered homebound is only able to leave the home very infrequently and for short periods of time. Leaving the home requires aconsiderable or taxing effort with or without help. An example is a patient who experiences an unbearable and extreme effort to leave the home just for aclinic visit or to receive some sort of medical treatment.
G. Intermittent services—Care that is provided on a part-time basis; that is, for a portion of hours in a day and for few days of the week; for example, home care services provided by a nurse for 2 hours per day and 3 days per week.
H. Nonskilled services—Health care services that are provided by a paraprofessional or an unlicensed person. Examples of these services may include close observation, bathing, feeding, and transferring from bed to chair.
I. Outcome and Assessment Information Set (OASIS)—A uniform and standardized set of home care services-related outcomes data used by the CMS to examine the quality of home care services received by Medicare beneficiaries. The set includes clinical, financial, and administrative outcome indicators and is used by home health agencies for quality improvement.
J. Reasonable services—Services provided based on a patient’s medical condition; acuity and severity of the disease, and the course of treatment meets what is described in national guidelines or standards.
K. Skilled services—Health care services that require delivery by a licensed professional such as a registered nurse; social worker; and physical, occupational, or speech therapists. Examples of these services may include wound care, vital signs assessment and monitoring, patient and family education, Foley catheter care, psychosocial counseling, physical rehabilitation, and intravenous medications administration.
▪ THE ROLE OF THE HOSPITAL-BASED INTERDISCIPLINARY TEAM
A. The primary care physician, in cooperation with consulting physicians, has responsibility for discharging a patient. All those involved in the patient’s treatment plan, including the nursing staff, the case manager, and the home care agency employees, share in the responsibility and liability for providing appropriate post-hospital discharge care (Mullahy and Jensen, 2004).
B. Hospital-based interdisciplinary teams include physicians, nurses, social workers, care coordinators, physical therapists, occupational therapists, chaplains, nutritionists, and others.
C. Daily interdisciplinary care rounds provide a forum to discuss the medical, financial, spiritual, and psychosocial issues that will impact the post-hospital discharge plan.
D. The role of the hospital-based case managers, whether they are called discharge planners or care coordinators, is to assess patient and family resources for post-hospital discharge planning and to assist with linkage to the appropriate community-based providers who can provide services determined to be necessary by the interdisciplinary team.
E. Before considering home care services, the interdisciplinary team must know that the patient and family would appreciate and agree to a home care referral. The case manager can facilitate such discussion and follow up on the referral with the patient, family, and one or more home care agencies.
Many people are reluctant to allow strangers into their homes and some homes may be too small to accommodate patients, families, and home care professionals.
Other families may not be willing, or able, to participate in a plan of care which includes home care.
F. The case manager, in collaboration with members of the health care team, conducts an assessment of needs. This should include, in addition to the clinical/medical condition of the patient, an evaluation of insurance benefits and restrictions placed by the patient’s health plan on the number of hours of care to be provided per day, number of visits per week, the types of services, and which vendors have contracts with particular payers for provision of home care services.
For example, to be eligible for Medicare reimbursement of home care services, the patient must:
Be homebound;
Require intermittent or part time care;
Require skilled care/services;
Be under the supervision of a physician;
Receive services that are reasonable and necessary; and
In addition, the agency to provide the services must be a CHHA.
G. In addition to the assessment of needs, the case manager must use the findings of the clinical evaluation of the patient to determine the type of services needed such as nursing, both at the professional and paraprofessional levels, rehabilitation therapies, and social work/services such as counseling. The case manager makes such decisions by applying knowledge of the operations of home care services, its related rules and regulations, and policies and procedures. The case manager also works closely with the interdisciplinary team on these assessments and in decision making about what is best for the patient and family.
H. Patients who are eligible for home care services and are known to benefit from these services may include:
Those who may be recovering from a stroke, orthopedic or cardiac surgeries, or injuries; or those learning to live with other neurological or cardiac disorders, diabetes, and other chronic health problems
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
