An Introduction to Home Health Care in the United States: Medicaid and Alternative Home Health Care Programs Tracy Gutman, MD Geriatrics Fellow University of Kansas

OBJECTIVES By the end of this module, the learner will do the following: Define personal assistance services and explain when these are covered by Medicare. Differentiate the three main Medicaid programs that provide home and community-based services. Compare and contrast the Program of All Inclusive Care for the Elderly (PACE) and the Veterans Administration Home Based Primary Care (HBPC) Program. Describe the characteristics of typical participants in both PACE and HBPC. List some of the benefits of PACE and HBPC. Rate as valuable the use of home health care to provide comprehensive, multidisciplinary, long term care to frail, chronically ill, and functionally impaired adults and elders.

Pretest 1: True or False Personal assistance services are considered non-skilled services.

Pretest 2: Multiple choice a. If the patient is homebound and has a concurrent skilled need. b. If the patient is homebound. c. If the patient meets financial criteria. d. If the patient needs continuous care. Medicare will pay for personal assistance services under the following circumstances:

Pretest 3: True or False The majority of community dwelling functionally impaired adults and older adults in need of personal care receive such care from informal and unpaid sources such as family members, friends, and neighbors.

Pretest 4: Multiple choice a. States establish target groups for the waivers. b. States vary in the types and amount of services offered. c. Usually includes benefits not typically covered by Medicaid. d. State expenditures on waiver recipients can exceed expenditures on nursing home residents. Which of the following is not correct regarding the Medicaid Home and Community Based Services Waiver Program?

Pretest 5: Multiple choice a. The overarching goal involves helping people live independently in the community. b. The focus is on providing care in an adult day health center. c. Participants must be 55 years or older and need a nursing home level of care d. Both b. and c. Which of the following is true regarding the Program of All Inclusive Care for the Elderly but not true regarding the VA Home Based Primary Care Program?

Pretest 6: Multiple choice a. Provides services by an interdisciplinary team. b. Requires that participants demonstrate improvement to continue receiving services. c. Targets patients with chronic medical problems and functional limitations. d. Aims to promote functional independence, reduce emergency room use, reduce hospitalizations, and reduce institutionalization. Which of the following is not true regarding the VA Home Based Primary Care Program?

Pretest 7: Multiple choice a. Provides short term skilled care. b. Discharges patients when goals are met or improvement has been maximized. c. Provides in-home long term primary care services by an interdisciplinary team to chronically ill, functionally impaired veterans throughout the remainder of their lives if needed. d. Has strict age and functional criteria. Which of the following best describes the VA Home Based Primary Care Program?

Pretest Answers 1. true 2. a. 3. true 4. d. 5. d. 6. b. 7. c.

Section One: Medicaid and Personal Assistance Services Personal assistance services include 5 : general help with activities of daily living and instrumental activities of daily living needed by functionally impaired elders and adults in the community. These services are considered nonskilled assistance and do not require supervision by a health care professional or other licensed provider. 5

Section One: Medicaid and Personal Assistance Services (cont.) Medicare will only pay for 2 : personal assistance services such as a home health aid for personal care, if a homebound person has a concurrent skilled need, and then, only short periods of time such as a few hours per day and only for the duration of the skilled need.

Sources of Personal Care Assistance Unpaid, informal caregivers provide more than 80% of personal assistance services while only 25% of people receive services from 1 or more paid workers. 5

Sources of Personal Care Assistance (cont.) Paid, formal personal care aides can be funded by 5,1 : out of pocket resources of recipients/families public payer programs including Medicaid, Medicaid waivers, state block grants, Title II Older Americans Act funds, state and local government general funds, Department of Veterans Affairs Aides programs, and sometimes by private insurance

Medicaid is the Major Program Medicaid serves as the major public program for paid personal assistance services including home attendants and private aides. 5 Medicaid is a joint federal and state program managed by the states that serves as the primary payer for long term care services for people with low incomes and assets. 14

Three Main Medicaid Programs Medicaid provides home and community-based services (HCBS) through three main programs 15 : waiver programs state plan personal care services and general home health care.

Three Main Medicaid Programs (cont.) These Medicaid programs typically provide services through home health care or personal attendant agencies, but states are permitted to allow independent provider service options under their waiver and personal care services programs. 15

The Medicaid HCBS Waiver Program Established in the Omnibus Budget Reconciliation Act of ,16 : permits states to provide long term care services in the community to individuals who would otherwise require nursing home placement. 1915(c) waiver program under the Social Security Act 15,14 : allows states to waive Medicaid requirements in order to provide home and community based services to targeted specific population groups.

The Medicaid HCBS Waiver Program (cont.) Limits services to community dwellers eligible for institutional care. 5 Data from 2006 shows that 90 % of waiver participants are either aged, or both aged and disabled, or are individuals with mental retardation/developmental disabilities. 14

HCBS Waiver Program Services Personal care assistance, home health services, and other benefits not usually authorized by Medicaid such as home modifications. 15 HCBS waiver programs may include personal care assistance services, case management, homemaker services, adult day care, respite, personal emergency response systems, environmental adaptations, home delivered meals, nursing care, medical equipment, and transportation. 5,16

HCBS Waiver Limitations HCBS waivers have cost limitations. Federal guidelines require that the average expenditures for HCBS waiver recipients do not exceed those of nursing home residents. 16 Generally, long term care payments account for 1/3 of states’ Medicaid budgets, but overall expenditures for HCBS recipients are significantly lower than those for nursing home residents. 16 In 2006, home and community services spending per participant was about $13,300, compared with an average of about $33,000 for institutionalized participants. 14 States can limit the number of participant slots, set cost caps, limit types of services, limit services to specified regions, and put people on protracted waiting lists. 15

Medicaid State Plan Personal Care Services 17,14,15 Since 1975, states have had the option of offering personal care services as a Medicaid benefit, and each state can define the amount and scope of services. Programs usually provide nonmedical assistance with activities of daily living with limited other benefits. To participate in these programs, individuals do not need to meet the institutional need criteria, but they do need to meet a functional need requirement set by the states and assessed by a professional.

Medicaid Home Health Care 17,15 Medicaid waiver and personal care services programs are optional. States are mandated to provide Medicaid home health care services for those eligible for institutional care. States can vary the amount, scope, and duration of home health care benefits. To participate in home health care, individuals must have a professionally authorized skilled nursing facility level of care need and a categorical financial need, but states can also opt to include the medically needy. Medicaid home health care provides skilled nursing care by licensed or certified home health care agencies.

Section Two: Alternative Home Health Care Programs Two specific examples of programs designed to provide long term continuous home health care to chronically ill, functionally impaired adults and elderly in the community: PACE: Program of All-Inclusive Care for the Elderly HBPC: The Veterans Administration Home Based Primary Care Program These programs provide continuous, longitudinal medical care administered by an interdisciplinary team to elders and chronically ill adults living in their homes in the community The team becomes the primary care provider.

PACE and HBPC Benefits Improve access to healthcare, improve health care coordination and continuity of care, improve quality of care, prevent functional decline, decrease rates of institutionalization, decrease caregiver burden, and increase patient satisfaction. 19 Demonstrate that home health care services can be expanded in a cost effective way to enable chronically ill, functionally impaired elders and adults to remain in the community and to avoid institutionalization.

PACE: Program of All-Inclusive Care for the Elderly 19,20 Program of All-Inclusive Care for the Elderly (PACE): capitated program that combines funds from both Medicare and Medicaid provides all care including acute and long term care to frail, older people living in the community and has the goal of keeping them living independently for as long as possible To enroll, older adults must need a nursing home level of care as defined by state requirements, must reside in the community within the geographic area served by the program, and must be 55 years or older.

Typical PACE patients Participants in the program overall are very similar to the typical nursing home resident. They are on average 80 years old, have 9.7 medical conditions, are limited in 3 activities of daily living, and 49% have been diagnosed with dementia. 19 Most of the enrollees are eligible for both Medicare and Medicaid. 20

On Lok Senior Health Services 18 The Program of All-Inclusive Care for the Elderly began as one initial program called On Lok Senior Health Services in San Francisco’s Chinatown in To join the On Lok program, an older adult was required to: be certified as eligible to enter a nursing home, give up the use of Medicare and Medicaid funds for services outside of the program, and leave his or her private physician for provision of care by an On Lok physician.

On Lok: First PACE 18 “On Lok” in Cantonese means “peaceful, happy abode. Program centered on an adult day health center. Older adults brought to day center and attended daily social activities and received care including meals, medication, blood pressure/blood sugar checks, and bathing. They also participated in exercises and recreational activities. They had monthly physician visits and periodic visits from a dentist, optometrist, and podiatrist. Every three months, each participant received a complete health assessment by an interdisciplinary team. At the end of the day, participants received transportation back to their homes where they had home health aides help with dinner and other personal care services.

Growth of PACE In 1983, the program obtained Medicare and Medicaid waivers to receive pooled capitated financing. 18 In 1986, the Robert Wood Johnson Foundation and the federal government provided funding to create community programs all over the country based on the On Lok model. 18 PACE was designated as a permanent Medicare program under the Balanced Budget Act of As of 2009, according to the National PACE Association, 72 PACE programs exist in 30 states. 21

PACE Programs Today PACE programs all have as their overarching goal keeping older adults, who would otherwise need nursing home placement, in the community. 10 Programs continue to operate very similarly to the On Lok program. A multidisciplinary team serves as the primary care provider and manages the care of patients with a focus on prevention, rehabilitation, and early interventions. 19

PACE Interdisciplinary Team 20 The PACE care team includes: primary care physician nurse social worker physical and occupational therapists recreation therapist health aides pharmacist (when available) nutritionist or dietician, psychiatrist (when available) transportation coordinator, all contribute to the care plan

Adult Day Health Center 19 PACE programs continue to provide services based on an adult day health center. Day center services include: a geriatric outpatient clinic, social services and personal care services, opportunities for social and recreational activities and therapies.

Other PACE Services Home care including meals, personal care, skilled nursing, and chore services. 19 Transportation, medication, hearing aids, and eyeglasses. 10 Acute care, hospitalization, rehabilitation, medical specialty care, alternate living situations, respite care, nursing home care if needed. 10,20

PACE Success 19,20 Decreased hospital use (both admissions and length of stays). Reduced institutionalization. Increased use of outpatient medical care. Integration of acute and long term care: to maintain older adults in the community and to provide care at lower costs compared with traditional fee for services rates. Improved patient satisfaction with care. Improved overall health status of participants.

HBPC: The Veterans Administration Home-Based Primary Care Program Provides in home long term primary care services by an interdisciplinary team to chronically ill, functionally impaired veterans throughout the remainder of their lives, if needed. 22,23,6 Targets individuals with chronic medical problems and functional limitations with the goal of providing comprehensive longitudinal long term home care to increase functional independence, reduce emergency room utilization, hospitalizations, and institutionalization, and maintain quality of life. 23,22

History of HBPC Program Modeled after a hospital based home care program developed by Dr. E.M. Bluestone at the Montefiore Hospital in New York City in Began as a pilot program demonstration project known as the Hospital Based Home Care (HBHC) program at 6 VA locations in ,6,22 Became an established program in ,6,22 In 1995, the VA changed the name of the program to Home Based Primary Care (HBPC). 23 HBPC has grown to a total of 116 programs across the nation caring for an average of more than 12,500 veterans per year. 6 Offers services that are not available under other federal or state programs such as Medicare or Medicaid. 6

HBPC Program Specifics 23 The mean age of participants is 76.5 years: 96% are men and 47% are dependent in 2 or more activities of daily living. The program: Is not restricted by age. Does not make restrictions such as those required by Medicare home health care. Has no strict homebound requirement. Does not require a skilled care need. Does not require improvement. On average, most participants continue in the program for more than 315 days and receive about 3 visits per month from various team members. The program is usually limited in coverage area to miles from a VA facility. Participants can still get Medicare home health services.

HBPC Targets Frail Population The program targets a frail, chronically ill population 22,6 : Patients with complex medical, social, and behavioral problems Patients with impaired mobility, who require assistance of a device or person to travel to a clinic Patients who make frequent visits to the ER or have frequent hospitalizations. The typical HBPC patient has an average of active diagnoses and takes an average of 15 medications. 6 More than 60% have mild to severe cognitive impairment. 6

Members of the HBPC Care Team 22 The HBPC care team can include: nurses physicians social workers physician medical director nurse practitioners physical and occupational therapists dietician pharmacist pastoral care provider mental health provider program director administrative and clerical support personnel

Members of the HBPC Care Team 23 Mid level providers provide primary medical management in cooperation with a supervising physician. Nurses provide home nursing care and assess patients’ needs. Social workers assess resources and support systems and help maximize social services. Physical and occupational therapists assess functional status, perform home safety assessments and recommend modifications, determine needs for home medical equipment, and develop home therapy to maximize functional independence. Pharmacists assess medications, educate patients and caregivers, and offer recommendations about medication management to the team.

Interdisciplinary HBPC Care Team Members do home visits on a regular basis. 22 The team also has weekly interdisciplinary care plan meetings to develop and modify the treatment plan. 22 The team initially develops a care plan within 30 days of a patient’s admission to HBPC and then reviews it every 3 months. 6 Patients can continue to receive care from HBPC as long as the team considers that they are benefiting, and the most common reason for discharge is death. 6

HBPC Successes Reduced hospitalizations, nursing home placement, and ER visits for participants. 22 Reduced number of inpatient days and reduced total cost of care % patient satisfaction rate. 6

HBPC Successes (cont.) 2002 data 23 : hospital bed days of care were reduced by 62% nursing home bed days of care decreased by 88% all home care visits increased by 264% mean total VA cost of care dropped 24% 2006 data 23,10 : 69% reduction in inpatient days of care 2007 data 23 : 59% reduction in hospital bed days of care 89% reduction in nursing home bed days of care 78% combined reduction of total inpatient days of care 21% reduction in 30 day hospital readmission rates

Post-test 1: Multiple choice Personal assistance services include the following: a. help with activities of daily living b. wound care c. physical therapy d. physician home visits

Pretest 2: Multiple choice a. It is a joint federal and state program. b. It serves as the major public program for paid personal assistance services. c. It is the primary payer for long term care services for individuals with low incomes and assets. d. It is managed by the federal government. Which of the following is not true regarding Medicaid?

Pretest 3: Multiple choice a. Medicaid home and community based services waiver program b. Medicaid State Plan Personal Care Services c. Medicaid home health care d. a. and c. Which of the following Medicaid programs is/are limited to community dwellers eligible for institutional care?

Pretest 4: Multiple choice a. Medicare only b. Medicaid only c. Medicare and Medicaid d. none of the above The Program of All Inclusive Care for the Elderly receives funding from:

Pretest 5: Multiple choice a. care provided by an interdisciplinary team b. care provided primarily at an adult day health center c. 24 hour supervision of participants d. acute care hospitalizations The Program of All Inclusive Care for the Elderly includes all of the following except:

Pretest 6: Multiple choice a. A transportation coordinator is part of the team. b. Team members conduct home visits on a regular basis. c. The team has weekly interdisciplinary care plan meetings. d. The team provides comprehensive, multidisciplinary, longitudinal on-going health care in the home for veterans. Which of the following is not true regarding the interdisciplinary team in the VA Home Based Primary Care Program?

Pretest 7: Multiple choice a. physician home visits b. nurse in-home assessments c. personal care assistance d. pharmacist assessment of medications The VA Home Based Primary Care Program includes all of the following services except:

Post-test Answers 1. a. 2. d. 3. d. 4. c. 5. c. 6. a. 7. c.