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JAMA Viewpoint on Home Health Strikes a Chord

Posted 10/2/2013 Categories: healthcare reform, primary care, EMR, research, chronic care

A highly regarded colleague of mine, Dr. Steven Landers, who is the Visiting Nurse Association Health Group President & CEO, published a piece in the Journal of the American Medical Association (JAMA) last week that struck a chord with me, and I need to address three key points he made that I believe are critical to improving the healthcare system in America.

  1. The quantity and quality of research regarding Medicare’s home health program are limited.
  2. To further improve coordination, health information technology policy should address integration of home health records with medical records.
  3. Advanced practice nurses and physician assistants have made important contributions to primary care, and these professionals should be permitted to certify and oversee home health.

First, while it is true that research regarding Medicare’s home health program are limited, I don’t believe we should wait for CMS to conduct it. The leaders in our industry, Amedisys included, must begin to support objective research into the program’s efficacy and areas for improvement. Only then will we be able to prove the value of the skilled care we provide to millions of Americans each day. The Alliance for Home Health Quality and Innovation’s research initiatives are a positive step in that direction – we must continue to build a body of research that is valid and constructive.

Second, Dr. Landers could not be more right -- the lack of integration between EMRs and home health records poses a significant challenge. Our hospital partners are looking to us to help them transition their patients safely home after receiving acute care, but without a clean way to exchange information in real-time, improvements will lag behind. There must be a clear roadmap for how to do it and an incentive to make it work.

Last, but not least, as a physician who has practiced medicine for more than 30 years, I believe strongly that well-trained and qualified advanced practice nurses and physicians assistants are needed now, more than ever to join us in the care for the chronically ill at home. There is a shortage of primary care physicians that care for these elderly patients with chronic diseases. Working alongside these physicians, advanced practice nurses and physician assistants can help improve the communication, quality of care and outcomes of our shared patients if they were allowed to play a more meaningful role.

The time to prove the value of home healthcare is now. The time to make sure we’re a connected healthcare system that can exchange real-time information throughout the continuum is now. The time for collaboration across the spectrum of clinicians to make a difference in caring for our chronically ill population is now.

Well said, Dr. Landers. Thank you for your leadership on these issues. We hope your perspectives also hit home with the key regulators and policy makers we need on board to press forward.

About the Author

Michael Fleming, MD, FAAFP is the Chief Medical Officer for Amedisys, and Past President of the American Academy of Family Physicians and the Louisiana Academy of Family Physicians. Dr. Fleming has served as Speaker of the Congress of Delegates of the AAFP and as Board Chair of the AAFP Board of Directors. He serves as an assistant clinical professor in the Department of Family Medicine at the LSU Health Science Center and in the Department of Family and Community Medicine at Tulane University Medical School.
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New CMS Guidance on Face-to-Face Encounter Documentation

Posted 8/21/2013 Categories: home health, face-to-face, homebound, CMS

CMS recently released additional guidance related to required documentation for face-to-face encounters and further clarified certain statements that, used alone, are considered insufficient documentation.

Acceptable face-to-face documentation does not have to be lengthy or overly detailed. However, the documentation must include:

  1. Date of the encounter
  2. Patient’s name
  3. A brief narrative that explains the reason skilled service is need to treat patient’s illness or injury, based on the physician’s clinical findings during the face-to-face encounter
  4. Specific statements explaining why the patient is homebound
  5. Signature of the certifying physician
  6. Date of the certifying physician’s signature

Forms are not required if your office visit note or discharge summary include the information listed above.

Below are examples of inadequate documentation:

  • Diagnosis alone, such as osteoarthritis
  • Recent procedures alone, such as total knee replacement
  • Recent injuries alone, such as hip fracture
  • Statement, 'taxing effort to leave home' without specific clinical findings to indicate what makes the beneficiary homebound
  • 'Gait abnormality' without specific clinical findings
  • 'Weakness' without specific clinical findings

Face-to-Face Quick Reference KitWe've put together some practical resources on face-to-face documentation to help make this CMS requirement quick and easy.

Download your free Face-to-Face Quick Reference Kit now.


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Updates to CMS Hospice Eligibility Guidelines – What Health Care Providers Need to Know

Posted 8/2/2013 Categories: dementia, hospice, alzheimer's

A pivotal requirement for hospice eligibility is a prognosis of six months or less (following the normal course of a disease). CMS has provided a number of clinical guidelines to help identify when a patient with terminal illness is clinically eligible for hospice. These guidelines are very useful when looking at disease processes that are known and when disease trajectory is more predictable.

However, oftentimes we recognize that elderly patients undergo what is indiscriminately referred to as “the slow dwindles”. In many cases a combination of a number of chronic illnesses is the culprit and the progressive functional and clinical decline associated with these illnesses is indicative of poor prognosis in and of itself. A common practice in these instances has been to consider the use of Debility or Adult Failure to Thrive (FTT) as a primary hospice diagnosis.

Over concerns that Debility and Adult FTT have become “catch all” diagnoses that do not accurately reflect a terminal illness, CMS has recently provided clarification on the use of these two particular diagnoses.

Effective immediately, hospices are no longer allowed to use Debility or Adult FFT as a primary diagnosis.

Instead, hospices are advised to determine the cause of the debility or Adult FFT that they are witnessing. In effect, hospices must now provide a specific diagnosis that has resulted in the debility or FTT, using these two diagnoses in question as a secondary diagnosis further describing the clinical picture that has resulted in the determination of six month prognosis.

For example, consider a patient recently hospitalized for pneumonia who has underlying COPD, Alzheimer’s disease, and renal disease. Clearly all of these diagnoses combined contribute to a poorer prognosis than would one condition by itself. Prior to hospitalization this patient was experiencing symptoms suggestive of adult FTT as evidenced by progressive functional decline, incontinence, weight loss and spending much of the day in bed. The determination must be made which of the underlying diagnoses (e.g., COPD, Alzheimer’s, renal disease) has primarily resulted in the failure to thrive. In this instance, Adult FTT will become a secondary condition.

CMS is also reviewing the use of “dementia” as a primary diagnosis. To be clear, CMS will likely be looking for greater definition related to the specific type of dementia identified as the primary hospice diagnosis. As we all know, there a numerous types of dementia, each with its own disease trajectory and clinical presentation. Although there is no specific requirement issued by CMS at this time, hospices would be well advised to avoid the non-specific diagnoses such as “dementia with behaviors” or “dementia without behaviors” as a primary diagnosis.

Amedisys will be moving forward in a proactive manner, working closely with physicians and medical directors to identify the specific type of dementia that will be listed as the primary diagnosis. The most common forms of dementia seen in hospice today include: Alzheimer’s disease, Vascular dementia, Lewy Body dementia, Parkinson’s Disease dementia, and Frontotemporal dementia.

Hospice Eligibility Kit

Determining prognosis indicative of hospice eligibility is not always easy. If you’d like more details, download our Hospice Eligibility Kit. It includes eligibility criteria for common conditions (like Alzheimer’s, cardiopulmonary disease and liver disease) and guidance on how to have the hospice conversation with a patient, an important part of helping patients receive the right care at the right time.

About the Author

Corrine Connors is a Family Nurse Practitioner and Certified Hospice Administrator with 13 years of experience in hospice and palliative care. Corrine currently works for Amedisys as Chronic Care Program Manager focusing on the development of disease specific programs, trainings and educational materials in support of hospice.
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Health Care Reform Isn't Perfect... and That's Ok

Posted 7/24/2013 Categories: healthcare reform, bundles

The New England Journal of Medicine published an article “Bundle with Care – Rethinking Medicare Incentives for Post-acute Care Services” that warns us that while bundles promote efficiency; the model also potentially promotes skimping on care or avoidance of costly patients.

Then last week, news broke that the CMS Pioneer ACO program is losing nine participants – seven moving to Medicare Shared Savings Program model and two leaving accountable care entirely.

Headlines such as The Wall Street Journal’s “Mixed Results in Health Pilot Plan” about the ACO news, makes one suspect that health care reform efforts aren’t working – but they are, they’re just not perfect and that’s ok.

Our country is faced with a significant challenge – overhaul our nation’s inefficient and unsustainable health care system while continuing to improve the quality of care delivered.

The bottom line is we can’t maintain the status quo.

There isn’t an off-the-shelf, perfect health care system out there – so we’re trying different ways of collaborating, improving care delivery and sharing incentives. That’s good.

The Bundled Payment for Care Improvement Initiative is in fact focused on creating cost efficiencies in our system, but the CMS is not allowing us to sacrifice quality for cost savings. There are specific quality goals participants need to achieve in order to receive any shared savings incentives and monitoring programs to protect against these unintended consequences. The fact that the Bundles Initiative is bringing providers together to say “how can we deliver care better together?” is a huge step forward.

The fact that the Pioneer ACO program generated a gross savings of $87.6 million in 2012 and saved nearly $33 million to the Medicare Trust Funds is also a good result.

On top of that, 25 of 32 Pioneer ACOs generated lower readmission rates than the benchmark rate for all Medicare fee-for-service beneficiaries – another positive step toward progress.

The ACO initiative shows us that health care providers joining forces and sharing a goal can generate positive results.

The Bundles Initiative is in the same category, as is the CMS hospital readmission penalty, which makes hospitals financially accountable for what happens to their patients after they leave the hospital. Neither is a perfect model, but Amedisys’ participation in the Bundles Initiative has given us the opportunity to collaborate like never before with health care partners in the communities we serve on behalf of our patients. We’re leading Model 3 (post-acute care) bundles in five regions and partnering with other providers leading bundles and ACOs across the country.

Over the last year, we have been rebuilding our care delivery networks internally and with our partners. During this time we have had more meaningful conversations with hospitals and physician groups and generated better ideas about post-acute care management than ever before.

And that’s a really good thing.

Amedisys is taking a risk by participating in the Bundles Initiative because we understand that change is imperative. Like the Pioneer ACO participants – both those that stayed and those that left – we understand that our nation and our patients are depending on us to design and deliver a better health care system. If healthcare providers aren’t willing to test new models, we won’t move forward.

Change will be incremental, step-by-step; current health care reforms are not perfect nor will they be the final answer. Those of us taking the risks as a part of the ACO and Bundles Initiatives want to help find which parts of reform will work. We want to uncover the formula for delivering the best care outcomes for a cost that is sustainable for our country.

We must protect patients, put the appropriate quality measures in place, and closely monitor these new initiatives, but we can’t be paralyzed in the face of change.

We’re on the path and won’t give up until we find a better way.

About the Authors

Michael Fleming, MD, is Amedisys' Chief Medical Officer and has more than 29 years of medical field experience. Dr. Fleming is past president of the American Academy of Family Physicians and the Louisiana Academy of Family Physicians, and was founding president of the Louisiana Health Care Quality Forum.

Julie L. Lewis is the vice president of research and development at Amedisys. She assists the continued development of a patient-centered, value-driven agenda for effective chronic disease management and end-of-life care that focuses on the quality and sustainability of the U.S. health care system.

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Why Health Care Should Bring Back the House Call

Posted 6/4/2013 Categories: home health, chronic care

Recently, Dr. Michael Fleming, CMO, discussed the need for a return to home-based health care as a solution to the challenges facing the health care system in the Harvard Business Review.

Years ago, as a family physician in Louisiana, I made house calls. Certain patients were too sick or too hurt to get to my office. Sometimes a condition or injury had worsened, requiring my evaluation bedside. I would visit patients at home for the simplest of reasons: home was where they needed care.

By the mid-1980s, the pressures of time and money prevented most physicians from making house calls anymore. But I kept seeing patients at home until I retired from my practice after 29 years. Home visits enabled me to better detect, diagnose and treat most health conditions. Many of the patients I saw might otherwise have wound up in an emergency room and eventually been admitted to a hospital.

If we hope to rein in health care costs and improve quality, we need, in effect, to bring back the house call.

Dr. Fleming goes on to describe five key steps for the health care community to embrace home care and truly reform the health care system.

  • Define the discipline better.
  • Get in sync.
  • Physician, educate thyself.
  • Adopt new technologies.
  • Remove policy obstacles.

Read the full article, Why Health Care Should Bring Back the House Call, on the Harvard Business Review blog.

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