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American Geriatrics Society (AGS) Position Statement
HOME CARE AND RELATED MEDICAL SERVICES

*Last Updated in 2003*

BACKGROUND

Home Care has undergone major changes since legislation encompassed in the 1997 Balanced Budget Act initiated a prospective payment system and restored the focus of home-based services to their original charge: to provide post-acute care and rehabilitation. Home health care takes advantage of the security and comfort of familiar environs, keeps the patient's family and social relationships intact and is the preferred alternative to (or a continuation of) institutional care. To qualify for Medicare home health, a patient must be homebound and in need of skilled, intermittent, part-time services provided under a physician's written direction and plan of care. The complexity of care requires that the skilled professional, who provide services in the home, work in close coordination with the medical team and community-based services. Therefore, physicians, particularly geriatric care physicians, have an increasing obligation to become knowledgeable about and involved in the management of home care. In view of the increasing importance of home care in the overall medical care of the elderly and the necessity for increased physician involvement, the American Geriatrics Society has adopted the following position on home care and related services in the home.

POSITIONS

1. Home health care benefits under Medicare, Medicaid and private long-term care insurance should be restructured to recognize both the short-term convalescent needs of some and the long-term care needs of most elderly patients.
   
   Rationale: Medicare and health insurance supplements have primarily paid for acute illness in the elderly, while Medicaid has funded the health and long-term care needs of impoverished older persons. However, chronic illness has become the overwhelming concern of our society. In fact, most acute care services for the elderly are expended for evaluation and treatment of acute exacerbations of an underlying chronic condition, and most of these episodes could have been prevented given timely access to appropriate out-patient services.
   
   Therefore, health benefits for the elderly should be reconstructed to provide comprehensive, coordinated and continuous care without compromise of quality or the dignity of the individual. Home care is an important part of the full spectrum of geriatric care, improving quality of care and helping to contain costs. Public and private insurance mechanisms should be redesigned to optimize these benefits in the care of the elderly.
   
   
2. Health care payers should avoid all disincentives to the provision of care in the home.
   
   Rationale: Because of restrictive criteria for reimbursement through the prospective payment system under Medicare, many providers are cautious about accepting Medicare beneficiaries with complex conditions and advanced disease. The change in payment structure has had its greatest affect on the availability of the services of home health aids and homemakers. This has forced many elderly who live alone into institutions during their convalescence, thus further impoverishing the most vulnerable and shifting the costs to Medicaid.
   
   Other attempts at cost shifting must also be avoided. Co-payments for home care services will only serve to cause those near poverty to forego a justified benefit, and will surely result in increasing use of much higher cost (but covered) services, such as emergency departments, hospitals and nursing homes. Medical services must be reimbursed through appropriate fee-for-service mechanisms or through contracts based on the ability to provide necessary services, rather than through competitive bidding.
   
   
3. Physicians share responsibility for the outcomes of care in the home and must be actively involved in the leadership and direction of home care. Home care services that the physician determines to be critical to medical care should be allowed, unless disallowed by careful, expert review.
   
   Rationale: With the evolution of sophisticated capabilities in home care and the tendency to use the home setting as an alternative to institutional care, there is an increasing demand for direct physician supervision and involvement. Although non-physician members of the home care team can accomplish much of the actual delivery of care, the physician must provide medical supervision and direction of that team in the management of care. The language of Medicare's conditions for participation for home health agencies should specifically require active and continuous engagement of physicians in the process of care planning and care coordination.
   
   With the advent of prospective payment for home care and the inherent pressure to reduce services, it will be vital for physicians to assist in determining the need for services and to serve as patient advocates. This will require that physicians be familiar with the circumstances of the cases referred and understand the implications for the home care agency.
   
   In certain situations, medical judgment must supersede bureaucratic regulations. The disallowance of a key element of a home care plan may result in a medically, ethically, or legally compromised situation, and ironically, the physician and family may be forced to consider institutionalizing the patient. Specific physician input should be included and considered in the determination of coverage on appeal when a Medicare intermediary has issued a denial of payment.
   
   
4. Home visits by physicians should be encouraged. Reimbursement should be commensurate with the professional's time and skills.
   
   Rationale: Continued development of sophisticated care in the home will require increased physicians involvement and leadership. In general, physician involvement in home care still results in personal financial losses. Health planners and funders must seek to redress these inequities to create a fiscal incentive for the type of physician involvement that is clearly needed.
   
   The fee schedule for home visits (house calls) has been revised effective January 1, 1998 and though work values now much more accurately reflect physician effort and time, practice expense and particularly travel time have not been addressed. This is true for both rural and urban areas. It is especially critical in rural areas where the distances and time commitments can be longer. Physicians and their non-physician provider associates should be appropriately compensated for work involved in the management of complex home care.
   
   Rationale: Physician reimbursement for professional time spent planning, reviewing, and directing others in the provision of home care is important. This recognizes the fact that a critical element in the provision of home care is the communication with and coordination of work by non-physician members of multidisciplinary teams and community-based services.
   
   Medicare physician reimbursement is now available through the Care Plan Oversight billing code for work involved in the oversight of certain complex home care and hospice cases. This was a positive development. However, two significant problems remain with this provision. First, the considerable time physicians spend working with family caregivers is not "countable" toward billing. Second, There is widespread variability in the documentation requirements and the way Medicare intermediaries reimburse for Care Plan Oversight. This has led to confusion and a reluctance among physicians to either avail themselves of a legitimate payment or to avoid involvement in home care services altogether.
   
   
5. Physicians who engage in home care activities often perform domiciliary visits. Compensation for these services must be commensurate with the physician skill and effort required to provide them.
   
   Rationale: Residents of domiciliary facilities now have the least access to high quality physician services due primarily to inadequate payment for the services required. Medical oversight of care in these facilities is therefore limited, despite the critical need for on-site physician participation in care and to promote quality of care leadership. Every effort should be made to rectify these markedly undervalued services in the Medicare fee schedule.
   
   
6. Home care agencies should have mandatory medical direction.
   
   Rationale: This would make home health care similar to all other health care settings and would promote high quality care in times of increasing pressure to limit services. Home health agency medical directors can serve as an additional means of oversight for home care utilization and can serve as a liaison to educate community physicians about proper use of the Medicare home care benefit. A body of knowledge for home care medical directors and a certification process have been developed.
   
   
7. Quality assurance practices, the use of clinical practice guidelines and disease management protocols, as well as processes for accreditation and certification of home care agency providers, must be developed that will optimize patient care yet allow for flexibility and tailoring services to the individual.
   
   Rationale: The home care industry has dramatically increased the capacity and breadth of services offered in the home. Home care must meet the standards of quality assurance that have been developed in other areas of health care. For example, it is important that agencies develop protocols that conform to nationally accepted evidence-based guidelines and that they incorporate the principles of disease management for common conditions. Mandatory use of the Outcomes and Assessment Information Set (OASIS) and participation in Outcomes-Based Quality Improvement (OBQI) are vital to demonstrating the clinical and cost effectiveness of care in the home.
   
   Training and certification of personnel and accreditation of home care agencies are also important to insure professional quality in the delivery of services. Home care personnel need special assessment skills in order to function independently in the less structured environment of the home; they need to develop attitudes and personality traits that facilitate working with the family and other informal caregivers; and they must be able to work with a broad array of physicians with variable training and experience in caring for the diversity of problems such patients present.
   
   Accreditation of home care agencies by nationally recognized organizations is strongly encouraged. Quality review requires inclusion of clinical outcomes and satisfaction survey data from clients and families. Disclosure is a powerful safeguard against the perception (or reality) of conflict of interest.
   
   
8. There is a great need for medical education and clinical research in home care.
   
   Rationale: Physicians, particularly those who care for the elderly, should be the leading advocates of home care. Thus, there is a pressing need to educate practicing physicians in the concepts and technology of home care, since it has immediate application in management of their patients. Home care should be introduced at the undergraduate level. At the graduate level, involvement of residents in the home-care team and home-visiting experiences should be part of the core content of appropriate residency programs.
   
   There is also a pressing need for medical research in home care. For sub-acute and post acute care, research should include the evaluation of home-based procedures and technologies which may obviate the need for more expensive services, the adequacy of rehabilitation in the home, system of coordination with community-based care, caregiver syndromes, and specific indications for selected home care interventions. As a setting for chronic care management of the frail and disabled elderly in the community, areas of investigation should include innovations in health services organization, fiscal impact of changes in the delivery system and patient, caregiver and provider satisfaction. Such studies are needed to inform the public policy debate and discussions concerning appropriate reimbursement and incentives, which will lead to more responsible and responsive legislation and regulatory reform.
   
   

Developed by the AGS Public Policy Committee and approved November 1988 by the AGS Board of Directors. Journal of the American Geriatrics Society 37:1065-1066, 1989. Revised November 1990. Reviewed April 1993. Revised May 1999. Revised November 2003. AGS, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118.