Home health care
Home health care can include many different services. While the services maydiffer, they all have in common the fact that they are delivered to the patient at his or her home. The patient may be recovering from recent surgery or illness and need medical checkups or wound care, or may be a disabled patientwho received physical or occupational therapy at home. In general, the care needed is more skilled than can be provided by the family or friends of the patient, and the patient prefers to stay home rather than enter a nursing facility.
Home care suppliers vary depending on the kind of services they provide.
Home health agencies provide skilled care from physicians, nurses and trainedtherapists. For instance, a home health agency nurse might visit a woman whohas just given birth and her new baby to do a well-baby check and answer anyof the mother's questions. A physical therapist working for a home health agency might visit an accident victim who is trying to regain the use of his leg. Because they often provide more than just one medical specialty, a home health agency can meet the varying needs of the same patient.
Sometimes home health agencies will also provide hospice care (which can alsobe provided by independent hospice care organizations). Hospice care professionals (such as nurses) and volunteers provide not only medical care but alsoemotional and psychological care to people who are terminally ill. Hospice care workers also help support the family in caring for the patient and dealing with their own emotional health. They also help keep the patient as comfortable and pain-free as possible.
A homemaker or home care aide agency supplies trained personnel who can assist clients with housekeeping, bathing, dressing and preparing meals. These personnel are sometimes called "companions."
Some home care agencies assist patients not by delivering medical care but byproviding essential equipment and supplies. Suppliers of durable medical equipment (equipment that can be used and reused after it is thoroughly decontaminated and cleaned) can provide, deliver and set up a variety of medical equipment and teach patients their proper use. Examples of durable medical equipment include wheelchairs, breast pumps, and walkers. These firms may also provide home oxygen services, delivering and maintaining an oxygen tank in the patient's home if such an arrangement is necessary.
Similarly, other companies can provide in-home delivery of medication and equipment for patients who need intravenous drug delivery or tube feeding.
Other health care professionals that can provide their services in the home health care setting include social workers, occupational therapists, speech-language pathologists, and dietitians.
Home health care can be paid for directly by the patient. However, many services (if provided by a qualified individual or agency) will be paid for underthe federal Medicare program (which covers most people over age 65), Medicaid(which is joint federal-state funded program), the Veterans Administration (available only to veterans who are at least 50% disabled by a service-relatedinjury), and the Older Americans Act.
Commercial insurance carriers and managed care companies will also sometimespay for home health care services. Paying for home care can actually be a bargain for an insurer, because treating a patient at home with home health carecan cost thousands of dollars less than treating the patient in the hospital.
Like hospitals and nursing homes, home care providers must meet strict standards for the quality of services and the delivery of care. Meeting these standards results in a provider being accredited, a sign of quality that persons seeking home care should look for, The major accrediting organizations for home care include the National Committee for Quality Assurance (NCQA) (202-955-3510), the Joint Commission on Accreditation of Healthcare Organization (JCAHO) (630-792-5600), the Community Health Accreditation Council (212-989-9393) and the National Home Caring Council (202-547-6586).
The federal Balanced Budget Act of 1997 drastically reduced Medicare reimbursement for home health care. In Texas, the home health care industry lost about 11% of its staff, a loss of 15,000 jobs. The cuts in Medicare reimbursementfor home health care have had particular impact on women, who make up two-thirds of the users of home health services. Women Medicare beneficiaries livelonger than men in every age group.
In the wake of these budget cuts, the Health Care Financing Administration (HCFA), the agency that oversees Medicare, has instructed home health agenciesthat they must provide patients with advance notice of home care that will bereduced, stopped or not covered by Medicare. HCFA's memorandum, issued in August of 1999, gives patients a chance to make other arrangements if Medicaredenies coverage for home health care. An additional 15% cut in federal reimbursements is anticipated in October 2000. In preparation for a reduction in the amount of time home health workers will be able to spend with patients, some home health agencies are teaching family members to assist with nonspecialized tasks. Some industry observers predict that the next cost-cutting trend will be to limit home health care to patients who have just been discharged from the hospital.
Even though reduced Medicare coverage has cut into payments for home health care, many studies show that home health care is highly cost effective, especially when compared to the cost of keeping a patient in a hospital or nursinghome. With advances in technology, it is now possible for patients to receivedialysis, chemotherapy and wound care at home. It is anticipated that biomedical engineers will develop monitoring devices, diagnostic agents and other self-care tools to assist growing numbers of users of home care services. Sometrials have shown the usefulness of scheduling proactive telephone calls orelectronic mail (e-mail) messages to remind patients of steps they need to take in their treatment. Video teleconferencing, where doctor and patient can see and speak with each other on a computer screen, offers the closest alternative to the physician house call. However, the use of computerized home careequipment has been delayed primarily because of cost. In 1999 dollars, it costs about $5,000 for a patient to have in-home interactive videoconferencing along with an electronic stethoscope to monitor heart and breathing sounds. The companion central monitoring station costs approximately $7,500. All of these technological measures, from phone calls to videoconferencing, are looselygrouped under the heading telemedicine. A 1997 study showed that patients receiving home care that included telemedicine visits were very satisfied, andthe overall costs were 33% to 50% lower than for more traditional methods ofdelivering home health care. However, the start-up costs of equipping homes for telemedicine are prohibitive for many health care providers. Many relatedquestions of documenting and reimbursing telemedical care are still unresolved, along with questions about the confidentiality of long distance record-keeping and the potential for legal dilemmas.
Some family physicians are advocating a hybrid system of home care that wouldcombine the best features of older and newer models of home care. In the most common home care model of the late twentieth century, the physician is in asupervisory role with a nurse or home health aide providing direct care to the patient. Advocates for a hybrid system would like to use telemedicine to bring the physician into closer contact with the patient. Ideally, the patientwould still have a lot of direct contact with home health care providers, with telemedicine giving the health care team a much clearer picture of the patient's progress and needs.
Home health providers have used a hybrid system to reduce readmission of patients with congestive health failure (CHF), a group that is at special risk for disability and death. In one trial of telemedicine, recently discharged CHFpatients were equipped with automated pagers that dispensed educational information and reminded them to take medicines on schedule.
Two-thirds of the overall expenses of caring for patients with chronic CHF fall under hospital admissions. Records show that almost half of all CHF patients are readmitted to the hospital within three months of being discharged. Thus, health care providers are very interested in what can be done to improvethe medical management of CHF patients. In one study, a control group of CHFpatients received standard home care while a comparable group received an intervention style of home care. All of the patients were under the care of a cardiologist and received treatment according to current guidelines. However, the intervention group received more extensive monitoring by a home care cardiac nurse. The theory was that a specially trained nurse would be able to assess the patient's physical condition and the effectiveness of the prescribed medicines, along with offering emotional support to the patient and other family members. The home health cardiac nurse was also best situated to note deterioration in the patient's condition and to seek intervention before hospitalcare was needed. Under the intervention program, patients required markedlyfewer hospital readmissions and there were monetary savings as well.
There were a few drawbacks to this preliminary study. Originally the cardiacnurse's home visits were started one to two weeks after discharge, but by that time, almost 10% of the intervention group had either died or been readmitted to the hospital. Thus, the timing of the home health visits is crucial. The participants in this study were all elderly and frail and many had severalchronic diseases, so other diseases affected the overall health of the CHF patients and in some cases limited the effectiveness of the medicines prescribed for cardiac problems. Even though the intervention method of home health care resulted in an expenditure of time and money when the patient was receiving care at home, there were significant medical and financial benefits to homecare. When the intervention group was compared to the standard care group, the costs of repeated readmissions of the patients in the standard group far exceeded the costs of cardiac home health nursing for patients in the intervention group.
Several countries are reviewing the costs and allocation of home health care.The above-mentioned CHF study of home health intervention was conducted in Australia. The United Kingdom (England, Wales, Scotland and the Republic of Ireland) started with a national system of institutional care and changed it into a system of block grants provided to local governments. This had the effect of changing home care from a service appropriated at the national level toa service controlled by the local community. Under the old national system, there was an institutional bias, because patients were entitled to unlimited residential care but not to unlimited home care. The change in the United Kingdom was modeled on 1989-1994 reforms of the United States system. The commongoals of the United States and United Kingdom reforms were to control publicspending for long-term care, to give local government more accountability, toimprove consumer choice by making it possible for providers to compete, andto enable disabled people to live at home.
In the United Kingdom, medical care, including home health care, is publiclyfunded. If patients meet disability criteria, they are offered a choice of services, a lower amount of cash, or a combination of the two. Under the DirectCare Act of 1996, the United Kingdom is trying variations on this formula. Before the old system was reformed, there were concerns that some patients were receiving home health care services to do things that they could do for themselves. Under the new system, informal caregivers can receive special training and pension benefits to provide home health care. Caregivers who are relatives of disabled patients are eligible to receive up to four weeks of annualvacation. While the caregiver relative is on vacation, a sickness fund pays for a professional home care service to take care of the patient. Local authorities used to think of themselves as providers of care, with decisions made at the national level. Under the reform system, local authorities decide whatservices people should receive, and local authorities purchase private nonprofit and for-profit services. The Recognition and Services Act of 1995 gives informal caregivers the option of calling for an independent assessment of thepatient's needs. Both in the United States and in the United Kingdom, a large portion of home health care is provided by informal caregivers at no publiccost, with professional home care seen as a last resort.
In contrast with the experience in the United Kingdom, Germany provided few home care services to the elderly before the reforms of the late 1980s. Beforethe reforms, German health care providers were often charitable, nonprofit,religious organizations. Families were legally responsible for their elderlyor disabled relatives, although there was little enforcement of this requirement. One main goal of reform was to give priority to home care over institutional care. Germans eligible for home care now have an insurance plan that offers a choice of home health services, a cash settlement that is worth about half the cost of services, or some combination of the two. Researchers suspectthat many people who choose the cash option do not actually use the cash topurchase professional health services. However, between the people using thecash to purchase services and the people opting directly for services, therehas been enough of a demand to trigger a growth in health service providers.The number of home care providers increased from 4,000 in 1992 to nearly 11,700 in 1997.
In Germany, there is little case management of home health care patients because there are no agencies in place to carry out an impartial review. Decisions about services and cash payments are made without consideration of whetherfamily members are available to provide home care. Under the German system, the focus is on giving every patient with comparable physical disability the same level of benefits.
The United States, the United Kingdom and Germany approached some issues of medical care and home health care from a common perspective in the late 1980s,when decisions for reform were being made. Each country has tailored home care benefits to the social, economic and medical forces in play, but the threesystems of reform have yielded some common conclusions. A government on a limited or fixed budget can help shift funds from institutional care to home care, but this in itself will not solve everything. One method of controlling costs is to break the link between needing the services and receiving the services. Both the United Kingdom and Germany have brought this about by providing universal care. However, the lack of a review of who needs the services themost means that all patients are vulnerable to budget cuts. All three countries have had trouble defining the boundary between acute care and long-term care, because patients have a variety of needs that do not fit into neat categories. The United States and the United Kingdom, which do allow for some flexibility in deciding who will receive care, find it easier than Germany to develop care plans based on individual needs.
Japan has traditionally depended on government agencies to provide health care, but when a new insurance program developed by the Ministry of Health and Welfare takes effect in April of 2000, senior citizens will have new options.The new insurance will help pay the costs of "home helpers" who care for seniors who need assistance with meals, eating, basic care and housekeeping. TheJapanese government is urging private-sector companies to enter the home caremarket to increase competition to provide home services needed by seniors. The cost of nursing the elderly is expected to reach an all-time high of $80 billion in 2000, up 40% from 1993. One insurance research group estimates costs will rise to $106 billion by 2010.
For more information about home health care, contact the National Associationfor Home Care, 228 Seventh St. SE, Washington, DC, 20003 (202-547-7424).