CHOOSE HOMEA Program to Allow America’s Seniors to Come Home

Safely After a Hospitalization During and After a Public Health Emergency

What Challenges Will CHOOSE HOME Address?

■ Home care has long been a safe and effective alternative to care in an institutional setting.

■ Reform of Medicare is overdue to provide viable, extended care services at home for patients who otherwise have only one choice, the Skilled Nursing Facility (SNF) benefit. The COVID-19 pandemic has vividly shown the limitations and risks of SNFs.

■ To remedy this problem, we propose a cost-effective and patient preferred home health benefit allowing patients to leave the hospital and recover faster at home with a mix of skilled, personal care and tele-health services

■ Under this program, eligible patients can choose to recover at home in a safe home environment with appropriate and sufficient care tailored to meet their individual needs with no coinsurance and reduced spending for the Medicare program.

Both the Bundled Payments for Care Improvement and Comprehensive Care for Joint Replacement Evaluation Reports demonstrate home healthcare can effectively substitute for some SNF-based care, thereby reducing the

overall cost of care while maintaining quality of care.

“Traditional home health care payment will not be sufficient given these individuals will require a mix of both skilled home health care services and also home care assistance with activities of daily living,” David Grabowski, a professor on the

department of health care policy at Harvard Medical School. “This model will have to

recognize these enhanced service needs”Home Health Care News Aug. 20, 2020

Source: Lewin Group. CMS Bundled Payments for Care Improvement Initiative Models 2-4: Year 6 Evaluation and Monitoring Annual Report. June 2020. https://innovation.cms.gov/data-and-reports/2020/bpci-models2-4-yr6evalrpt

Lewin Group. CMS Comprehensive Care for Joint Replacement Model: Performance Year 2 Evaluation Report Second Annual Report. June 2019. https://innovation.cms.gov/files/reports/cjr-secondannrpt.pdf

Source: Emily Smith and Alan Stevens. Predictors of Hospital Discharges to a Nursing Home in a Hospital-Based Cohort. JAMDA 2009

Why Patients Go to SNFs

§ Today, about 20% of Medicare hospitalizations result in SNF placement

§ Significant predictors of being discharged to a nursing home include:― Longer hospitalizations;― Not understanding one’s illness;― Being female (more likely to be

older and a widow);― Living alone;― Not having a caregiver;― Needing assistance with dressing;

and ― Having a fall risk.

■ Frequent hospital discharges resulting in SNF placement― Sepsis― Joint replacement― Hip procedures― Kidney and UTI― COPD― Renal failure― Pneumonia

Enhance the Medicare Home Health Option

HH Benefit

•Homebound requirement•Patient resides at home•Services - receive part-time or

intermittent skilled nursing care, therapy, medical social services and home health aide services

•Average number of visits for complex patient range from 11 to 16 in person nursing visits and approximately 32 remote patient interactions

•Cost for first 30 days of home health episode for complex patients $2,300 (rate based on number of visits and clinical complexity of patients)

•No cost sharing

SNF Benefit

•Requires 3-day stay in hospital•Patient resides in Skilled Nursing

Facility•The patient needs inpatient care

at a SNF•Services - receive daily skilled

nursing care, therapy, medical social services, meals, medications, and ambulance transport

•Average length of stay 25.1 days•Cost for stay $18,120 (paid per

diem rate based on clinical complexity of patients)

•Beginning day 21 of SNF stay, patient has a co-payment

Enhanced HH Option

•Patient meets SNF benefit eligibility

•Patient resides at home•Receive expanded HH benefit and

home based extended care services with use of approved discharge planning tool

•Payment combines home health amount and fixed add-on for expanded services

•Savings assured with payment not to exceed 80% of SNF 30 day payment amount, with savings as much as $11,800 per patient; minimum savings of $5080 as compared to a SNF stay

An enhanced option of the home health benefit for patients leaving the hospital,

that would otherwise end up in a Skilled Nursing Facility (SNF)

Promoting a safer, faster recovery, increasing patient and family satisfaction, and greatly reducing exposure to COVID-19, will produce significant cost

savings to the Medicare program compared to Skilled Nursing Facility costs.

CHOOSE HOME Program Design§ Studies have shown, approximately 34% of patients that go to SNFs have identical frailty indexes as

those that go home with home health services.

§ Choose Home targets those who are clinically appropriate for home health, but do not have a regular source of 24/7 caregiving in the home (spouse, adult children, very involved neighbor).

§ Eligibility― The program would be made available to Medicare patients being discharged from an acute

care stay in a hospital― Patient would meet the SNF admission and enhanced home health criteria― Eligible patients would be screened pre-discharge from the hospital by the hospital and

participating HHA for eligibility using a patient assessment tool― Patient chooses to receive home-based extended care services rather than SNF placement― Discharge planning requires consideration of individual’s care preferences, goals of care and

caregiver concerns

§ Mechanics― Patient would then get referred to a Home Health provider that offers the Choose Home

benefit― Program starts from hospital discharge with discharge planning and evaluation. The Choose

Home services are covered for 30 days, and home health services continue beyond the initial 30 days as clinically indicated

Source: Joseph E Gaugler 1, Sue Duval, Keith A Anderson, Robert L Kane Predicting nursing home admission in the U.S: a meta-analysis.

Program Financing:A 30-Day Fixed Episodic PaymentShared–risk financing constructed using the following expectations:§ Daily skilled nursing or therapy services as needed through in-person visits or telehealth

§ Primary care practitioner services fully integrated in care planning and management

§ Home-Based Extended Care Add-On for Personal Care Services – Fixed Amount in addition to HH payment based on 4 case mix classifications of number of hours of personal care services: 60 or less, 61-120, 121-240, 241-360 hours. - $28 per hour (approximate – would vary by geography) per hour:― Fixed payment amount based on assessed patient needs related to time and tasks: $2010/

$4,020/$7,360/$10,720

§ Continuous remote patient monitoring – one-month comprehensive services - $140

§ Respite care

§ Meals – 30 meals to be distributed across 30 days. Estimated cost per meal - $11. Pattern may be, three meals a day for first five days, then two meals a day for the next 7 days, with one additional meal another time

§ Home Adaptations and Equipment Supports - $210 ($70) (estimated, one in three patients would need home modifications ($210 x .33). Most common items include bedside commode, bath bench and wheeled walker

§ Non-emergent transportation – five segments - $24 per segment:– From hospital to home (1 segment);– Round trip to primary care provider (2 segments); and– Round trip to specialist (2 segments).

Patient Example

A Medicare beneficiary declined the physician referral to a Skilled Nursing Facility and was instead cared for at home post hospitalization with home health and wraparound non-skilled services as proposed in our model.

In 2019, a 76-year-old retired and married female Medicare beneficiary suffered a fall in the home with multiple arm and shoulder fractures and soft tissue injury with the fractures requiring immediate surgery. Four days post-operatively the beneficiary’s physician proposed at least one week and up to three weeks of inpatient therapy and services in a Skilled Nursing Facility. The patient forcefully declined inpatient services and through her husband, who at 68 worked part time but had limited ability to provide caregiver services, contacted a Medicare certified skilled home health agency inquiring as to whether it could provide skilled and non-skilled services in the home as opposed to facility-based care.

The next day the agency, through a senior registered nurse and a home health aide, assessed the patient who had a history of juvenile viral cardiac infections, leg weakness, treated high blood pressure and coronary bypass surgery at age 65. Assessment indicated the patient temporarily was unable to toilet herself, to make a meal and had limited mobility and uncertain transportation resources for follow up physician appointments.

Through a combination of skilled nursing services including daily and initially twice daily physical therapy sessions, wound care at the points of incision and non-skilled services including transportation services for follow-up care, assistance with toileting and meal preparation, the patient successfully recovered functionality and was discharged from service after 28 days of in-home care. Approximate cost of the care on a private pay basis was $4,200 as opposed to about $18,000 for comparable inpatient services under the Medicare program.