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HHABNs Are Gone! Introducing The Supposed More Simplistic HHCCN!

As Elizabeth Hogue, our esteemed colleague and well-known health care attorney explains in this article, The Centers for Medicare and Medicaid Services (CMS) has announced that the Home Health Change of Care Notice (HHCCN) has replaced two notice formats of the Home Health Advance Beneficiary Notice of Noncoverage (HHABN). And the HHABN will be discontinued. Providers using HHABNs understand they have three different notice formats, called “Option Boxes,” given to patients under certain circumstances. The HHCCN will replace Option Box 2 and Option Box 3 formats of the HHABN. The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 will replace the HHABN Option Box 1 format.HHABN

Home health agencies should begin using the HHCCN as soon as possible. There will, however, be a transition period during which agencies can use either the HHCCN or the HHABN. The date for mandatory, exclusive use of the HHCCN will be posted on the CMS website at some unspecified time in the future.

When Is a HHCCN Required?

Reductions or termination of care are triggering events for requirements to provide HHCCNs.

HHCCN’s should be issued to beneficiaries or their representatives for notification of changes in plans of care (POCs). Specifically, agencies must provide HHCCN’s whenever they reduce or terminate beneficiaries’ home health services due to orders from physicians and other providers or limitations of the agency to provide specific services for both covered and non-covered services listed in POCs.

An example of triggering events due to orders from physicians/providers includes: “The POC includes wound care every day. The physician writes a new order to decrease wound care to every other day.”

An example of triggering events due to agencies’ inability to provide specific services includes: “Physical therapy (PT) services are ordered four times per week in the POC. The Agency has an unexpected staffing shortage and can only provide PT services two times per week.”

If termination of services involves the end of all Medicare-covered care and no further care is being delivered, the only notice agencies must issue is the Notice of Medicare Non-coverage (NOMNC), Form CMS-10123.

What Instructions Are Available for HHCCN Completion?

CMS has also provided general instructions for the completion of HHCCNs. Among the instructions are the following:

  • Electronic issuance of HHCCNs is permitted. If agencies elect to issue HHCCNs viewed on electronic screens before signing, beneficiaries must be given the option to receive paper copies. Whether the notice is presented to beneficiaries electronically or on paper, beneficiaries must be given copies of signed HHCCN’s for their records.
  • Agencies may reproduce HHCCNs using a variety of methods, but the HHCCN cannot exceed one page in length.
  • Agencies can customize HHCCNs, including pre-printing agency-specific information to promote efficiency and to help ensure clarity for beneficiaries. Guidelines for customization are included in the instructions for use of the form.
  • When there are changes in care that require HHCCNs, agencies must list changes in the area under “Items/services” on the form and must indicate whether the item/service is being reduced or terminated in language understandable to beneficiaries. Examples are: “On December 17, 2016, we will stop all of your occupational therapy services.” or “On December 17, 2016, the frequency of your wound care will decrease to three days per week.”
  • In the blank area under “Reason for change” on the form, agencies must insert the specific reasons changes in care occur. An example related to changes in physicians’ orders is: “Your doctor has changed your order for this care.” An example related to agency related changes is: “Your dog has repeatedly threatened our staff, so we are unable to safely enter your home.”
  • HHCCNs must be signed by patients or their representatives. When patients’ representatives sign instead of patients this fact must be noted on the form next to representatives’ signatures. If beneficiaries refuse to sign, agencies must note this on HHCCNs and provide copies of annotated HHCCNs to beneficiaries.
  • When delivering HHCCNs, agencies are required to explain the entire notice and its contents and to answer all of beneficiaries’ questions. Delivery of the form in-person is not required.


Detailed information about this change can be found in the Medicare Claims Processing Manual, Chapter 30, Section 60.

Here we go again! Something new that is supposed to make providing care easier, but, at least initially, seems to be just the opposite!

For more information about this or other legal issues in homecare, contact Elizabeth as outlined below.

Elizabeth E. Hogue, Esq.

Office: (877) 871-4062

Twitter: @HogueHomecare

©2016 Elizabeth E. Hogue, Esq. All rights reserved.


Spotlight: What You Need To Know Regarding The New RACs And New Rules!

As Elizabeth Hogue, our esteemed colleague and well-known health care attorney explains in this article, the Centers for Medicare and Medicaid Services (CMS) recently selected five new recovery audit contractors (RACs) and established new rules. RAC audits will undoubtedly resume soon. Performant and Cotiviti were awarded contracts, along with HMS Federal Solutions. A previous RAC auditor, CGI Group, did not bid in the latest round of contracts for RACs. Performant will focus on auditing home medical equipment (HME), home health agency (HHA) and hospice claims.RACs

Contingency Fees and Timing for Overpayments

CMS will continue to pay RAC auditors a contingency fee when identifying overpayments. Providers frequently point out that RACs receive incentives to find erroneous overpayments. These errors have resulted in a multi-year backlog of claims pending appeal, especially before administrative law judges (ALJs). Nonetheless, CMS announced that RAC auditors have recouped $8 billion for the federal government since the audits began in 2009.

Under previous rules, RACs received payments for overpayments they identified in less than forty-five days. Under new rules, RACs will now receive payments for overpayments they identify only after providers have an opportunity to appeal through the second level of an appeal process that provides five stages of appeals. As a result of this change, contingency rates for payments to RACs will likely increase substantially, from the current 9.5% to 12%.

Also under previous rules, RACs could review claims that were up to three years old. Under new rules, claims reviewed by RACs cannot be more than six months old.

Audits by RACs, More of the Same

Audits by RACs have been on “pause” while developing new rules and disputes about the contracting process resolved. When RAC audits resume, providers can expect more of the same, i.e., a focus on vague eligibility criteria, such as home bound status and terminal illness, which are open to broad interpretation.

RAC auditors are also likely to continue their focus on whether care that was provided was reasonable and necessary. Unfortunately, RAC reviewers often seem to evaluate this issue very differently than providers who are “on the ground,” so to speak. It seems reasonable to require RACs to cite national standards of care to support their conclusions that care provided was not reasonable and necessary. Without such support, what constitutes reasonable and necessary care seems to be “in the eye of the beholder.” This pattern makes such determinations extremely difficult for providers to address on appeal.

Name of the Game for all Audits Including RACs

CMS’ initial meeting with new RACs is in November. Audits will begin soon thereafter.

As always, the “name of the game” for providers with regard to all types of audits, including RAC audits, is documentation, documentation and more documentation! Although it is an age-old “story” and most clinicians certainly know how to provide appropriate documentation, consistently excellent documentation appears to remain elusive.

Kenyon HomeCare Consulting is here to help! Are you struggling with overpayments discovered by RAC audits and need assistance with improving your clinical documentation? Contact us to schedule an appointment or call us today at 206-721-5091.

For more information about this or other legal issues in homecare, contact Elizabeth as outlined below.

Elizabeth E. Hogue, Esq.

Office: (877) 871-4062

Twitter: @HogueHomecare

©2016 Elizabeth E. Hogue, Esq. All rights reserved.

CMS Emergency Preparedness Final Rule: What You Need To Know!

As Elizabeth Houge, our esteemed colleague and well-known health care attorney explains in this article, The Centers for Medicare and Medicaid Services (CMS) issued final rules regarding emergency preparedness. The final rule published in the Federal Register on September 16, 2016, will be effective on November 15, 2016. Providers are not, however, required to comply until November 15, 2017 but best to get started on these changes now!Emergency Preparedness

Emergency Preparedness Rule: Four Core Provider Elements

The four core elements of all providers’ emergency preparedness programs that must focus on continuity of operations, not recovery of operations, must include the following:

Risk Assessment and Emergency Planning

Providers are required to perform a risk assessment that uses an “all-hazards” approach prior to developing and implementing emergency plans. An all-hazards approach is an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters. Also, the risk assessment must be used to identify essential components of emergency plans specific to providers’ and suppliers’ geographic locations. Examples include:

  • Equipment and power failures
  • Interruptions in communications, including cyber attacks
  • Interruptions in the normal supply of essentials, such as water and food

Policies and Procedures

Providers and suppliers must develop and implement policies and procedures that support the successful execution of emergency plans and that address risks identified in risk assessments.

Communication Plans

Providers and suppliers must development and maintain emergency preparedness communication plans that comply with federal and state laws. And these communication plans must include systems to contact appropriate staff, patients’ treating physicians and other necessary persons in a timely manner. Therefore ensuring continuation of patient care in a safe and effective manner.

Training and Testing

Providers and suppliers must also develop and maintain an emergency preparedness training and testing program. At a minimum, training and testing programs must include training for new and existing staff in emergency preparedness procedures as well as annual refresher training. Staff must demonstrate knowledge of emergency procedures during annual training sessions. Providers and suppliers must also conduct drills and exercises to test emergency plans in order to identify gaps and areas for improvement.

Emergency Preparedness Rule: Conclusion

These requirements will be mandated for suppliers through Conditions of Participation (CoPs) and conditions for coverage (CfCs), if applicable. CMS will also issue interpretive guidelines to assist providers to comply.

Here we go again! Yet another set of new regulations with which providers and suppliers must comply. Although compliance is not required for more than a year, now is surely the time to get started.

For more information about this or other legal issues in homecare, contact Elizabeth as outlined below.

Elizabeth E. Hogue, Esq.

Office: (877) 871-4062

Twitter: @HogueHomecare

©2016 Elizabeth E. Hogue, Esq. All rights reserved.

What You Need To Know: Final Regulations Prohibiting Discrimination

OCR Implements Section of the ACA Prohibiting Discrimination

As Elizabeth Houge, our esteemed colleague and well-known health care attorney explains in this article, the Office of Civil Rights (OCR) of the U.S. Department of Health and Human Services published final regulations in the Federal Register on May 18, 2016. This final regulation implements Section 1557 of the Affordable Care Act (ACA). These regulations generally prohibit discrimination based on race, color, national origin, sex, age or disability.discrimination

Complying With New Discrimination Regulations Now

Here is what home health agencies, hospices, HME suppliers and private duty agencies need to know about these final regulations, which were effective on July 18, 2016:

  1. The regulations make it clear that discrimination based on sex is prohibited, including, but not limited to, discrimination based on individuals’ sex, including pregnancy, related medical conditions, termination of pregnancy, gender identify and sex stereotypes
  2. All providers who receive Federal financial assistance (FFA) are subject to the regulations, including providers that receive reimbursement from Medicaid and Medicaid waiver programs. This means that many private duty agencies must comply with these regulations
  3. The regulations clarify that providers may use adult family members or friends to interpret for patients with limited English proficiency (LEP) only if family members or friends agree to interpret, providers’ reliance on companions is appropriate under the circumstances, and there are no competency or confidentiality concerns
  4. Providers with more than fifteen employees must designate at least one employee to coordinate efforts to comply with Section 1557 of the ACA, including investigation of any grievances alleging noncompliance
  5. Providers with more than fifteen employees must adopt grievance procedures that incorporate appropriate due process standards and that provide for prompt, equitable resolution of grievances alleging violations of Section 1557
  6. All providers must take appropriate initial and continuing steps to notify beneficiaries, applicants, members of the public, etc. that they:
  • Do not discriminate on the basis of race, color, national origin, sex, age or disability in their health programs and activities
  • Provide appropriate auxiliary aids and services to individuals with disabilities and information about how to obtain them
  • Provide language assistance services, including translated documents and oral interpretation free of charge in a timely manner when such services are necessary to provide meaningful access to individuals with LEP
  • Make available information about the identity of the employee responsible for compliance with Section 1557, including contact information
  • Provide a grievance procedure and information about how to file a grievance
  • Provide information about how to file a complaint with OCR

Discrimination Regulations In Effect On 10-16-16

7. Providers are also required to do the following by October 16, 2016:

  • Post a notice that includes the information described above
  • Display a nondiscrimination statement
  • Post taglines in the top languages spoken by individuals with LEP of the relevant state or states. An example of a tagline is: “Attention: If you speak _________ language, language assistance services are available free of charge to you. Call _________, TTY _____________.”
  • Include notices and taglines in significant publications and communications targeted to beneficiaries, applicants and members of the public in conspicuous physical locations where providers interact with the public and on providers’ websites accessible from the home page of providers’ websites
  1. Employers who are subject to the requirements of Section 1557 and provide health benefit programs to their employees are generally liable for discrimination in the employee health benefit programs they offer employees

Compliance with the above provisions related to non-discrimination is yet another hurdle for providers to get over!

For more information about this or other legal issues in homecare, contact Elizabeth as outlined below.

Elizabeth E. Hogue, Esq.

Office: (877) 871-4062

Twitter: @HogueHomecare

©2016 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.

The Dream For The Future of Home Health Care

Recently I have the privilege of presenting at the annual conference for Kinnser Software. My presentation topic was “Surviving and Thriving in the Midst of a Paradigm Shift.” The evidence is clear – we are in the midst of something never experienced in the health care industry. As I watch our sector, home health care, many are hunkering down and just trying to weather the storm. Procrastinating will not work this time!home health care

Study Proves Home Health Care Is The Future

CMS has made it clear they are moving to home and community based services. Costs are out of control and something must be done to break the current cycle. Undoubtedly the finger is pointing towards home health care. Our time has come, but only if we are willing to change into the organizations of the future.

Using the results of the John Hopkins’s ‘Hospital at Home’ study, the evidence substantiated acute care can be delivered in the home. The outcomes show there is as a much better way to provide services, with quicker results while allowing for major savings to Medicare. Additionally, several chronic care studies are also pointing in the direction of homecare. Although there has been much little change in actual practice, this is the beginning of our future. So let me share my dream for the future of home health care.

Home Health Care Acute Team

All clients admitted to a home health care agency are assigned a Geriatric Care Manager. This manager follows the patient for the current care episode, for all health care readmissions and if the patient’s condition becomes chronic. Potentially this patient gains a case manager for the remainder of life. For this model to work, multiple teams will work from and under the direction of the home health agency.

This acute care team consists of nurses, therapists, physicians, nurse practitioners, and pharmacists. The equipment used in an acute environment is also provided. Nurses work one on one until the home patient stabilizes and ready for the sub-acute team to take over. Physicians, pharmacists, and other allied services are on call and available 24/7 during this acute illness phase.

Sub-acute Home Health Care Team

The sub-acute team, those supposedly providing home health care in 2016, will assume responsibility from the acute team. A hand off to the sub-acute team leader occurs and nurses, therapists and home health aides are scheduled based on patient needs. Unlike how many agencies practice today, staff will no longer set their schedules. The sub-acute team visits daily until the patient stabilizes and is able to manage with less assistance. Aides are assigned 8 to 12 hour in home shifts reducing hours over time based on the patient’s progress.

Patients diagnosed with chronic diseases or conditions not being managed well at home resulting in exacerbations, will be assigned to the chronic care team.  A nurse case manager provides skilled care and the home health aide provides the ADL and IADL support needed for the patient to remain stable at home. However, the chronic care team’s focus will be not only be to provide immediate care. Care will include behavior changes supporting a better quality of life and outcomes resulting in reduced costs.  We know from adult learning and behavior change studies, it takes one to two years to make these new behaviors permanent. Changing the behavior of patients with chronic disease to prevent frequent exacerbations is a long term home health care project.

The Home Health Care Dream

Given this picture of the future, the home health care agency will be the care hub. Contracts will be needed with hospitals, organizations offering acute neuro and orthopedic rehab, transitional care organizations, pharmacies and other allied services. Consequently, with the current bundled payment direction, most likely all organizations involved will be working under a shared risk contract.

Finally, in the future home health aides will be full members of the team. As such, they need advanced education to meet the increased demands placed on them. At a minimum, aides will be require certification in all major chronic diseases. Aides will then have the knowledge required to recognize and report changes in condition early enough to prevent emergency room visits and acute care team interventions.

Contact Kenyon HomeCare Consulting today to learn how we can help you prepare for the home health care future. Ready to provide your homecare aides the in-depth knowledge necessary to provide five-star patient care? Chronic Disease University increases the value of your aides and reduces overall health care costs for your patients.

The future has great opportunities for home health care, but only if we are brave enough to step into the unknown and change.  Are you brave enough to dream?

Hospital Preferred Provider Agreements: Expert Advice For Home Care

As Elizabeth Houge, our esteemed colleague and well-known health care attorney explains in this article, hospital Preferred Provider Agreements continue to be misunderstood. But, many hospitals refer patients on a regular basis to post-acute providers. These include home health agencies, private duty home care agencies, hospices, and home medical equipment (HME) companies. Relationships with post-acute providers assist hospitals to control costs and avoid penalties, an essential component of financial viability. Consequently, positive relationships with post-acute providers are increasingly important to the success of hospitals.

Preferred Provider Agreements

Hospital Use of Preferred Provider Agreements

Hospitals may wish to use Preferred Provider Agreements in order to enhance their relationships with post-acute providers. That is, hospitals may agree to make referrals exclusively or on a preferential basis to specified post-acute providers in order to help ensure quality of care. Hospitals may be eager to sign Preferred Provider Agreements for a number of reasons.

Hospitals may decide, for example, to limit the number of post-acute providers to which they are willing to refer on the basis that dealing with many post-acute providers may compromise their ability to implement appropriate plans of care effectively. From the point of view of hospitals, referrals to a number of post-acute providers may complicate communications, which may have the potential to compromise implementation of appropriate discharge plans.

Preferred Provider Agreements may obligate hospitals to refer patients to specified post-acute providers. These agreements should not, however, include a specific number of patients that hospitals are expected or required to refer. In fact, they should explicitly indicate that hospitals make no promises about the number or types of patients who will be referred.

Preferred Provider Agreements and Patient Choice

Preferred Provider Agreements must also take into account requirements related to patients’ right to freedom of choice of providers. Both the Balanced Budget Act of 1997 and Conditions of Participation (COP’s) for hospitals, among other sources, guarantee patients the right to freedom of choice.

Many patients, however, do not yet know enough about post-acute services and providers to be able to make choices. When attending physicians indicate that they prefer certain post-acute providers and patients do not wish to choose other providers instead, physicians’ preferences/orders must be honored. Unless patients or physicians choose post-acute providers, it is permissible for discharge planners/case managers to make suggestions. Then patients may wish to choose post-acute providers with which hospitals have preferred provider relationships.

Hospitals are not required to survey post-acute providers in their geographic area to find every entity that provides care of a quality that is satisfactory to them. Consequently, when patients cannot choose and their attending physicians have not indicated preferences for particular post-acute providers, discharge planners/case managers may wish to encourage patients to choose preferred providers.

CMS Stand on Preferred Provider Agreements

Hospitals certainly cannot restrict patient choice. In the final rule on the Comprehensive Care for Joint Replacement (CJR) Payment Model for Acute Care Hospitals; published in the Federal Register on November 24, 2015; however, the Centers for Medicare and Medicaid Services (CMS) stated at follows:

Hospitals, if desired, may recommend ‘preferred providers,’ that is, high quality PAC (post-acute) providers/suppliers with whom they have relationships (either financial and/or clinical) for the purpose of improving quality, efficiency, or continuity of care.

Based upon this language, it seems clear that Preferred Provider Agreements are acceptable so long as the requirements described above are met.


For more information about this or other legal issues in homecare, contact Elizabeth as outlined below.

Elizabeth E. Hogue, Esq.

Office: (877) 871-4062

Twitter: @HogueHomecare

©2016 Elizabeth E. Hogue, Esq.  All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.


The Inevitable Demise Of The Certified Home Health Agency

For those of you who read the Ankota blog, you know that we’re very excited about the future of the home care industry.  That hasn’t changed one bit, but the industry as we know it today will change dramatically over the coming years. The certified home health agency as we know it today, won’t be a thing for much longer.

Here’s what’s going to happen instead.

The Home Care Payer Will Shift from Medicare to the Hospital

  • This is starting already. Here are two examples.  With the ACO (Accountable Care Organization) model, a health system (combining payer and provider) receives a fixed dollar amount for each patient and they become the payer for all of that patient’s care including post-acute care. In the bundled payment model, which went into effect for knee and hip replacements in almost 800 hospitals on 4/1/2016, the hospital receives a fixed fee for the treatment and recovery (and are also financially responsible if there’s a readmission)

More Hospital Discharges Will Go to the Home

home health agency

  • In 2015 roughly 40% of joint replacement discharges went to skilled nursing facilities (SNFs). With Medicare paying the bills, the hospital would determine whether the patient seemed ready to go home after the surgery.  If not, the hospital sends them to a SNF or other facility.  Now that they’re paying out of their own pocket, more and more patients are going home.  This is good for home care because they’ll get more referrals, but read on…

Successful Care at Home Will Require More that Healthcare

  •  A certified home health agency provides nursing, medication oversight and physical, as well as occupational and speech therapy.  These are all important but cost between $80 and $125 per visit.  Since many of the patients would have previously been sent to a nursing home, the medical services won’t be sufficient to meet all patient needs. Winning agencies will provide the aforementioned skilled care services.  Plus offer non-medical care (at $20 per hour), call center support at $5/call, and automated check-ins (such as friendly “robocalls” at 75 cents per call).

Value-Based Purchasing is Coming to Your Home Health Agency

  •  To make matters worse, the value-based purchasing program is moving to home health.  We offer a free eBook on the Home Health Value Based Purchasing program. In short, Medicare will rate each agency and the best-scoring agencies will eventually be paid 17% more than the lowest scoring agencies.  This program will drive a significant number of home health agencies out of business.

How to Win

Despite the ominous and inevitable changes described above, this story has a very happy ending. But only for the agencies that embrace the future and start preparing for it now.  The key will be to optimize around the new models (ACOs and Bundles) even though today they only represent a minority of the cases.

Will Your Home Health Agency be Blockbuster or Netflix?

In a recent conference presentation, Bob Fazzi from the firm Fazzi Associates, made an analogy between Blockbuster Video and the present state of the home care industry.  As we all know, Blockbuster was a highly successful company. We all had memberships and rented our videos, and now it’s gone.  But we still rent videos.  For a while we got them in the mail from Netflix.  Now for the most part we stream our rental movies and look for original programming in shows like “House of Cards” and “Orange is the New Black.”

The point here is that Netflix saw the inevitable changes in the way that consumers would want to rent videos.  Then they changed their model numerous times to continuously adapt.  Home care agency owners have the historic opportunity to do the same.  Those that don’t act, will perish.  Those that do act will transform themselves into a new kind of organization. They optimize a combination of automation, call centers, non medical care and skilled care in a way that keeps patients/clients at home and minimizes cost.

How Can Ankota Help?

Ankota can help in numerous ways.  If you’re a home health agency delivering nursing, PT, OT and Speech Therapy, we can give you tools.  These tools manage aides and call center personnel and the scheduling capability to optimize across disciplines.  We also offer our Foresight Care service.  Using automated phone calls, you check in with patients so that you can get early warning signs of preventable hospitalizations.  Download, Ankota’s newest e-book,Winning with the Home Health Value-Based Purchasing Program that offers further insight on the discussion. Please contact us if you would like to learn more.

Today’s guest post is by Ken Accardi, who is sometimes referred to as the “Home Care Software Geek.”  Ken founded Ankota LLC to improve the efficiency and coordination of care outside of the hospital.  Ankota provides software to improve the delivery of care, focusing on efficiency and care coordination. Ankota’s primary focus is on Care Transitions for Readmission avoidance and on management of Private Duty non-medical home care.

This article first appeared as “The Inevitable Demise of the Certified Home Health Agency” on June 23, 2016 via the Ankota blog.

Will New Models Reduce Health Care Costs For The Sickest?

Today’s guest post is by Ken Accardi, who is sometimes referred to as the “Home Care Software Geek.”  Ken founded Ankota LLC to improve the efficiency and coordination of care outside of the hospital. Enjoy his always valuable insights!

My wife Tracy has been a health care technology executive on the medical device side for a long time.  She’s presently in charge of technology for Hologic, a leader in breast cancer detection.  At one point Tracy went to a leadership conference in Asia, and met with the Minister of Health of Taiwan. (honestly I might have the country wrong, but I’m pretty sure it’s right)

At the time, this minister put a program in place where the most expensive patients in the country would receive a personal visit from a member of the minister’s office. That team member would make a plan to reduce their health care costs.  In some cases they found that some expensive patients were frequently visiting the nursing room because of loneliness.  They solved the problem by having people call the patient each day and talk to care costs

Pilot Program to Reduce Health Care Costs?

A recent Wall Street Journal article reminded me of this story.  It described a new pilot program authorized by congress where a very high risk patients are authorized for “extreme home care.”  The article profiled Luberta who had a stroke, was paralyzed on one side, had emphysema, diabetes, was on oxygen and had a torn rotator cuff.  The program provides in home care, nursing and physician care in the home.

If the providers are successful in reducing health care costs by 5% over two years, they receive a bonus.  The article goes on to explain that by providing this high level of care with the primary goal of eliminating hospitalizations, that the savings are significant.

Unfortunately, the main message of the article was that the pilot program was capped at 10,000 patients and is no longer funded.

Why is This Important?

Given that the program is no longer funded, you might be thinking that it was a waste of your time to read about it.  Here’s why it’s relevant.  There’s an emerging model of care called Accountable Care Organizations (ACOs).  These organizations are paid a fixed fee for each patient in their census to cover healthcare costs.  There’s a very likely chance that these organizations would love to partner with providers who can provide healthcare at home and avoid hospitalizations.

ACOs and Bundled Payments are Changing Health Care Costs Rules

In addition to the ACO model described above, there is also a new model of reimbursement called “bundled payments.” The convener (generally a hospital) is given a fee to cover an entire acute episode (such as a knee replacement and all of the associated post-acute care).  The good news about this is that the hospitals will be more likely to discharge to home than to the skilled nursing.  The bad news is that the patients will be sicker. They need a combination of healthcare (like med management, wound care and PT) and home care (assistance with activities of daily living).  This will cause the historically strong lines between home health and home care to blur.  Agencies of the future will provide both types of care. And perhaps more and different kinds of care such as telehealth and call centers.

The Conundrum of Reimbursements vs. Health Care Costs Management

As we move from fee-for-service to value-based-care, demands to provide great outcomes with lower health care costs will increase.  In the WSJ example above, the patient received 6 hours a day of non-medical care. The article says that this is more care than they would receive in a nursing home.  When a hospital or ACO is paying the bill, they are likely to want to pay for fewer hours. The way to afford this is to look for other ways to deliver care such as call centers and automation (such as Ankota’s Foresight Care).  Click on Foresight Care to learn more.

Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota’s primary focus is on Care Transitions for Readmission avoidance and on management of Private Duty non-medical home care.

This article first appeared as “A New Home Care Model for the Sickest Patients” on June 13, 2016 via the Ankota blog.


Bundled Payments are NOW! Time for Home Care to Act!

Today’s guest post is by Ken Accardi. Ken, who is sometimes referred to as the “Home Care Software Geek,” founded Ankota LLC to improve the efficiency and coordination of care outside of the hospital. Enjoy his post and feel free to comment below.

We’ve done several very popular articles about bundled payments.  If you’d like to get caught up, please read this article How Will Bundled Payments Effect Home Care?” and this articleWhat’s A Bundled Payment? Will It Influence Home Care?”  The difference between those articles and today’s offering are that the prior articles were written in future tense.  This one is talking about NOW.

Bundled Payments for Join Replacements went into effect 4/1/16

The Wall Street Journal published an article on April 1st entitled Hospitals Brace for new Medicare Payment Rules.  The article mostly focuses on payment reform at a high level with the joint replacement bundle as an example.  Note that the joint replacement bundle is now in effect for 800 US hospitals. This picture (below) from the article is a great representation of what’s going on.


How Do I Interpret These Bundled Payments?

Here’s how to understand it.  Until very recently, hospitals billed for knee and hip replacements and then discharged patients mostly to skilled nursing facilities (SNFs) and home healthcare agencies (HHAs). The SNF or HHA would then bill Medicare separately for their services.  If there was a readmission, the hospital would bill Medicare for the readmission (but might pay a penalty of around $250).bundled payments

With the bundle, the hospital gets a fixed fee of around $28,000 and needs to pay for everything.  So, referring to the diagram above, if they send the patient to a SNF they’ll lose money and if the send the patient to home health they’re likely to be profitable.  You might be thinking that since you’re home health, you’re all set and in fact you’re likely to get even more referrals. But wait, if the hospital discharges a patient who used to go to a nursing home to home health, it’s very likely that the patient is going to need help with meals, toileting, and more. Sending a nurse for 30 minutes a week and a PT for 2 hours a week won’t get it done.  Plus, the hospital doesn’t need to pay the OASIS rate, they’re going to shop for the best provider at the lowest cost, and since they’re losing money on SNF discharges, they’re going to be looking to make it up on their discharges to home.

This Post-Acute Care Picture Paints 1,000 Words

The diagram below, courtesy of Dr. Josh Luke, sums it up.  The hospital (meaning a readmission) is the last resort because the hospital won’t be reimbursed for the readmission and will likely lose $8,000.  SNFs are the second to last resort because they’re a guaranteed loss for the hospital.  Home Health is viable but CMS is trying to reduce the number of home health agencies (read our ebook on Home Health Value Based Payments).


 What Do Bundled Payments Mean for Home Care?

Seeing the glass half-full, this represents a great opportunity for non-medical home care providers to participate in the reimbursed continuum of care.  Our expectation at Ankota is that the historical divide between home health and non-medical home care will break down and that organizations will merge.  The real leaders will also use call centers to drive patient adherence and behavior change and will use automation like our product Foresight Care to get early warnings to prevent hospitalizations.

Here’s Your Homework:

If you read this article and smiled because this is the direction your agency is moving in, then I applaud you.  For the rest of you, here’s what to do:

One of Ankota’s recent whitepapers, entitled “Selling Care Transition Services to Hospitals” is available for download and we think you’ll find it useful.

Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota’s primary focus is on Care Transitions for Readmission avoidance and on management of Private Duty non-medical home care.

This article first appeared as “Bundled Payments are NOW – Time for Home Care to Act” on May 26, 2016 via the Ankota blog.

A New Dream For The Home Health Care Plan

For years I have dreamed of a day when home health nurses and therapists would be in charge of their own services. Doctors would be a part of the team but not the “directors” of the care plan. To me, it has never made sense that a physician who knows little about home health services is required to sign off on all orders.

I agree physicians or nurse practitioners must confirm the working diagnosis and the medications. But in home health the professional clinician completes the assessment, defines problems in terms of their discipline and establishes the care plan, not the physician. A physician directing the home health plan of care makes as much sense as asking a plumber to sign off on and be in charge of the electrician, the sheet rocker, and the roofer when building a house. Physicians have repeatedly objected to this requirement and now with the addition of face to face documentation, their objections are even more plan

Current Care Plan Paradigm

So how did we get here? When and why is there a paradigm that the physician directs the care plan for other providers? Therapists have individual practices not requiring physician oversight, but not nurses. The origins of physician control over nursing practice started in the early part of the last century. It was determined that the independent practice of nurses was the single biggest threat to the financial future of physicians. As a result, the American Medical Association succeed in getting congress to pass legislation requiring nurses to work under the direction of a physician. Unfortunately for nurses, doctors, consumers and payers, this has not always been the best practice.

Many physicians signing the care plan developed by clinicians tell us the plans make little sense to them. They sign what is required so patients can get the care they need. Is it any wonder the plans make no sense to them? They aren’t medical plans of care, but nursing and therapy plans written in the language of each discipline. Is it time for a change? My idea is for physicians to continue to sign the medical components – the diagnosis, medications, and required diagnostic tests – while disciplines write specific plans which are signed by individual disciplines.

Think of the money spent trying to support this false paradigm! Think of all the hours spent by home health staff gathering a physician signature on the 485 and verbal orders. Think of the patients denied services because physician didn’t want to be deal with the paperwork burden required for home health services.

Future Care Plan Paradigm

So what could the future look like?  I dream of a home health future where physicians are part of the team and work with other disciplines to achieve desired patient identified goals. Each discipline is responsible for their part of the care plan and nursing is responsible for coordinating the overall plan. Long ago, Medicare recognized home health nurses as the patient coordinator or case manager negating a change in current practice.

The physician confirms the working diagnosis and medications electronically and each discipline signs and dates their plans. Compliance with the home health conditions of participation would continue to be the home health clinician’s responsibility. In my new world, the requirement that the physician certify home bound status will go away.

Homebound Rules Need to Change 

If the intent of physicians certifying homebound status was to prevent fraud, it has not been successful. The clinician in the home doing the assessment is the best person to determine homebound status. However there is second serious issue with the homebound rule. It interferes with the ability to provide the care needed to return clients to full capacity and independence.

Much of home health’s role is assisting patients to make lifestyle changes, stabilize their condition and prevent further exacerbations which may lead to more expensive care. To achieve these goals, particularly for those with chronic diseases and co-morbidities, time is needed beyond a 60 day episode. But, because of the homebound requirement, the patient is just beginning their needed changes when they are discharged. Evidence and experience proves it takes as long as 6 months to successfully integrate a lifestyle change. We are finally seeing a glimmer of hope as CMS begins to recognize that those with chronic diseases need longer periods of care and support beyond the current homebound phase.

Also, the 485 must be revised to reflect these new changes. Numerous physicians have complained for years that the 485 makes no sense and provides little useful information. Physicians are asking for patient progress information, response to provided services and any identified medical issues that need their attention. These are not unreasonable requests and as team members are our responsibility to provide. However, this will require a paradigm shift for home health clinicians.

A New Care Plan Dream

I believe returning to an individualized plan of care structured in care plan format is the goal to strive for. Not only will this help the team plan better, but will help those new to home health better understand the care planning process. The current system does not support critical thinking skills and the entire process has become an exercise in checking off boxes.

The system is starting to change from rules of enforcement to becoming outcome focused. This change must emphasize the importance of patients achieving desired goals and outcomes as well as care cost reductions. I believe with these changes, costs will decrease and outcomes improve as well as physician, clinician and patient satisfaction.

It’s time to dream a new dream! These are just a few ideas I see the home health industry needing to achieve true patient centered care. This will allow each team member to fully use their skill set to assist patients in goal achievement. What are your dreams for the future of home health?  Contact Ginny Kenyon at Kenyon HomeCare Consulting to discuss or leave a comment below. Together we make a difference!