NLRB Targets Non-Compete Agreements

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by Elizabeth E. Hogue, Esq.

The National Labor Relations Board (NLRB) has now joined the Federal Trade Commission (FTC) and some state legislatures to target non-compete agreements. The general counsel for the NLRB argued in a recent memo that non-compete agreements violate the National Labor Relations Act because they interfere with employees’ right to engage in protected concerted activity. Two recent actions by the Board provide more information about efforts of the NLRB to limit use of non-compete agreements.

Juvly Aesthetics Non-Compete Agreement Settlement

In February of 2024, the regional office of the Board in Cincinnati approved a settlement agreement between Juvly Aesthetics and three former employees. The Board claimed that Juvly, an operator of medical clinics, violated the rights of employees through the use of confidentiality, non-disparagement, non-competition, non-solicitation and requirements to repay training expenses under certain conditions. 

According to the NLRB, Juvly prohibited employees from discussing their rates of pay. The Company also required some employees to sign a non-compete agreement that was in effect for a period of twenty-four months for any competing medical practice within twenty miles of any location of the Company.

Juvly agreed to a settlement agreement that required:

  • Payment of back pay to some employees
  • Termination of unlawful policies and procedures
  • Release of employees from unlawful agreements
  • Posting of all of requirements of the settlement agreements for review by employees
Non-compete agreements juvly aesthetics<br />

NLRB Division of Advice

non-compete agreements

In December, the NLRB Division of Advice issued guidance that evaluated the legality of these issues:

  • Customer non-solicitation provisions do not violate the Act because they only prevent employees from soliciting existing customers for one year so that employees are likely not barred from other employment opportunities for more than one year.
  • Confidentiality agreements do not violate the Act because they prohibit only disclosure of trade secrets, marketing plans, customer lists, and other proprietary information, as opposed to information that could involve employee activity regulated by the Act, such as wage information. 
  • Provisions requiring the return of company property do not violate the Act.

Providers are now clearly operating in an environment that prohibits employers from restricting employee activities that were fair game in the past. The specifics of efforts to limit the actions of employers remain unclear, but will likely be “fleshed out” in enforcement actions.

©2024 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article appeared in Healthcare at Home: The Rowan Report. Reproduction by permission only.

editor@therowanreport.com

The Future of NAHC: An Interview with Bill Dombi

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by Kristin Rowan, Editor

NAHC President Bill Dombi announced at last week’s CAHSAH annual meeting and expo that he would end his tenure at NAHC and retire at the end of 2024. We reached had an interview with Dombi on Thursday, May 23rd. He said he was not prepared to speak yet about his upcoming retirement, but we should hear more about that soon.

In the meantime, he provided additional details from his session at CAHSAH. We also discussed updates on the lawsuit against CMS and the status of the merger between NAHC and NHPCO. Tim’s article from last week talks about Dombi’s progress with Senator Wyland.

Ongoing Litigation

When we last spoke with Bill, he told us about the lawsuits filed against CMS. The suit claims that the budget-neutral calculations were based on faulty data and outdated software. These calculations determined the reimbursement rate reductions. Dombi explained the process for those lawsuits.

“The first round of the battle is around whether the court has the power to hear the case either at all or at that point in time. The courts are littered with litigation that have been dismissed on jurisdictional grounds,” Dombi offered. The court dismissed the lawsuit and the case is now closed. The Department of Justice (DoJ) attacked jurisdiction to get the case dismissed. Most concerning, according to Dombi, was the DoJ’s question of whether the statute passed by Congress precluded any litigation. If the courts had found in their favor, they would have dismissed the lawsuit no further suits could be filed. Luckily, that argument didn’t hold. The second attack was whether NAHC had expedited administrative review, which is the argument that caused the dismissal. Now, they have to establish that it would be futile to get CMS to agree to expedited judicial review.

Next Steps

In light of the dismissal, NAHC had to decide whether to appeal the ruling, exhaust the expedited review step with CMS, or both. Ultimately, they decided not to appeal and is pursing the review with CMS. This process could take up to 6 months, according to Dombi. Although they are pursuing the review, CMS has already stated that their final position is that the budget neutrality has been calculated within the law. Dombi feels the review is futile because CMS is not going to change their position. Now, they just have to prove the futility.

Two-Step Approach

Advocacy from NAHC, NHPCO, and other individuals and organizations was always intended to be a two-pronged effort: Litigation and Congress. The two do not interfere with each other. Even though the court dismissed the litigation suit in favor of judicial review, the approach in Congress continues. Of Senator Wyland, Dombi said, “A year ago at this time, his view was that home health agencies needed no relief. Now, he’s indicated a willingness to find a way to help home health agencies and recognizes that the cuts have been harmful to home health agencies and others that provide care.” According to Dombi, it was the personal stories and individual provider information that was crucial in swaying Wyland. The organizations continue to meet with other members of Congress to persuade them in the same way.

Dombi Provides Merger Update

Last year, NAHC and NHPCO announced they would join forces and merge into a new, as yet to be named, organization. That merger is still moving forward, but there are a lot of odds and ends to tie up. Dombi told us, “Nothing is final, final, but I don’t see anything but tailwinds moving forward.” The two organizations are still hoping for a July 1, 2024 launch of the organization. There is an active, open search for a new CEO to actively run both organizations as one. According to Dombi, no one has been slated for that position yet, so they may end up launching before there is a CEO in place.

The two organizations have already started integrating. They have lobbied together and they have worked on policy together. Additionally, they are integrating the association management system and building a website. “We feel confident enough that it’s going to reach the finish line that we’re investing time and money in these elements,” Dombi said. The two organizations can continue to operate together without a CEO, but there are a lot of decisions that need to be made that won’t be made until after there is a CEO.

After the Merger

Once the merger is complete and the two organizations operate under a new name with a new CEO, Dombi and his counterpart Bill Marcantonio of NHPCO will stay on for some time. Dombi will take the title President Emeritus and Council to the organization and Marcantonio will become the Chief Integration Officer. The new name of the organization has not been announced. Dombi says a lot of things are tied together, from an action standpoint, and it’s better to announce all of those details together along with the new name.

Reflections From Bill Dombi

When asked what was next for him after the merger is completed and he moves to retirement, Dombi reflected on his career:

 

“I’m proud of what I’ve accomplished in my life, but I’m more proud of what the people I work with I have accomplished. It’s not the first time we’ve tried to merge the two organizations, but this time, we had all the right ingredients and I’m proud of that. I live with the confidence that my constituency is up to the challenge. Every time they get kicked back, they’re right back at it.

To see where we are today compared to the 70s, we are so many light years ahead of where we were then. I mean, we’re talking about a hospital level of care at home. That was part of the dream. The fore-runners of healthcare at home truly believed those things were possible. The problems that caused the workforce shortage are multi-faceted, so the solutions are multi-pronged.”

Bill Dombi Spring Tour
We will continue following the story of both the lawsuits and the merger and update you as soon as there is more information.
Kristin Rowan, Editor
Kristin Rowan, Editor
Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only.
editor@therowanreport.com

Use of Preferred Provider Agreements

Clinical

by Elizabeth E. Hogue, Esq.

Preferred Provider Agreements as Referral Source

In a highly competitive marketplace, home care providers of all types, including home health agencies, hospices, private duty/home care companies and home medical equipment (HME) suppliers are looking for a “leg up,” especially for patients with certain types of payors. Providers may be able to cement important referral sources using Preferred Provider Agreements. For example, a provider may wish to approach an assisted living facility (ALF) to see if it is interested in a preferred provider relationship. If so, then management of the ALF may want to sign a Preferred Provider Agreement in order to further a relationship with this provider.

Problems with Preferred Provider Agreements

The anti-kickback statute may apply if providers involved in referral arrangements receive any type of federal or state funds, including, but not limited to, payments for services provided from Medicaid waiver programs, managed Medicaid programs, the Tri-Care Program, the VA, or any other state or federal programs. The anti-kickback statute generally says that anyone who either offers to give or actually gives anyone anything in order to induce referrals has engaged in criminal conduct. There are, however, several exceptions to this statute that may be applicable.

How to Assess Your Preferred Provider Agreements

Providers should ask two crucial questions about the application of the anti-kickback statute to referral arrangements:

  1. Is there a kickback or rebate?
  2. If so, is there an exception or “safe harbor” that permits the arrangement even though it would otherwise violate the statute?

 kickback or rebate occurs when a provider receives referrals from another provider and something flows back to the referral source from the provider who received referrals. If there is a kickback or rebate, providers must automatically ask the second question listed above. If they fail to utilize applicable exceptions, they may miss out on useful marketing strategies that are likely to result in numerous referrals.

With regard to Preferred Provider Agreements, however, it is important to note that they can be structured so that no money or anything of value changes hands between providers and the other party involved. If so, there is no kickback or rebate.

Patient Choice

The parties to Preferred Provider Agreements must also make certain that they honor patients’ choices of providers. There are a number of sources of patients’ right to freedom of choice of providers applicable to preferred provider arrangements, including:

  • Court decisions or the common law says that all patients – regardless of payor source, type of care rendered, or types of providers involved – have the right to control the care they receive and who provides it.
  • A federal statute that guarantees all Medicare and Medicaid patients the right to freedom of choice of providers. This statute may be applicable if either party receives reimbursement from the Medicare or Medicaid Programs.

When patients express preferences for certain providers, however, their choices must be honored despite the existence of Preferred Provider Agreements. The agreement of the parties to honor patients’ choices should be included in Preferred Provider Agreements.

Final Thoughts

The market to provide services to patients in their homes is expanding, but the competition for referrals among providers seems to be extremely fierce. Providers are well advised to utilize Preferred Provider Agreements to help them to increase and/or maintain referrals in order to help ensure profitability.

©2024 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.

Bill Dombi Spring Tour has two Major Announcements

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by Tim Rowan, Editor Emeritus

Bill Dombi Spring Tour

For the last time, NAHC President Bill Dombi is spending another Spring on airplanes. It is state association meeting season, and the Bill Dombi Spring Tour has been bringing his regular Capitol Hill update from coast to coast, this time adding the announcement that he will retire at the end of the year.

After 40 years with NAHC, the lengthy standing ovation Californians gave him at the end of his Tuesday speech was well-deserved.

Advocacy and Change

Bill’s core message has not changed, though the details of his ongoing battle to force CMS to take HHAs and Hospices more seriously has its 2024-2025 nuances. “Letting Congress know that you are an important healthcare sector, and clearly the most popular sector, is not NAHC’s job alone. Every one of you has power. Use it. Make your voices heard.”

Meetings with the Senate Finance Committee

To illustrate the point, he related a story about his recent visit to Portland to meet with the Chair of the Senate Finance Committee, Ron Wyland (D-OR).

“Senator Wyden has been one of the major roadblocks to Medicare agencies getting fair payment rates. I went to see him with a group of agency owners and workers to describe the hardships the current and planned pay rate cuts will impose, and to explain the exact problems with the dumb formula CMS is using to calculate those pay rates.

“The Senator said, ‘But MedPAC says you make too much money and rates should be cut. Were they wrong? Or has something changed?’

Reaching Agreement…Almost

“Both, the group and I harmonized. One by one, each agency representative told him about the growing demand of an aging population, the difficulty hiring staff with the salaries our low pay rates allow them to pay, and a full litany of all the problems with Medicare Advantage.

“By the end of our meeting, we hadn’t turned him 180 degrees, but I could see he was beginning to turn.”Later, Dombi added, he met with Senator Debbie Stabenow (D-MI), who is not only a member of the same Finance Committee but the fourth in line in the Senate pecking order. She offered to have a conversation with her colleague, and that turned Senator Wyden the rest of the way toward changing his position 180 degrees.

You Can Make a Difference

“If you think you as an individual owner have no power in Sacramento, Congress, or the White House,” Dombi concluded, “think again.”

See sidebar for the complete list of Finance Committee members. Everyone has power, but if you are a voter in one of their states, you have an even more powerful voice.

The Bill Dombi Spring Tour will continue throughout the year until his retirement. Join Dombi at the 2024 Financial Management Conference & Expo in Las Vegas, July 21-23 and at the 2024 Home Care and Hospice Conference and Expo in Tampa, October 20-22.

Bill Dombi Senator Wyden

Senator Ron Wyland (D-OR)

SENATE FINANCE COMMITTEE MEMBERS

Chair: Ron Wyland (D-OR)
Ranking Member: Mike Crapo (R-ID)
Debbie Stabenow (D-MI)
Chuck Grassley (R-IA)
Maria Cantwell (D-WA)
John Cornyn (R-TX)
Robert Menendez (D-NJ)
John Thune (R-SD)
Thomas Carper (D-DE)D-
Tim Scott (R-SC)
Benjamin Cardin (D-MD)
Bill Cassidy (R-LA)
Sherrod Brown (D-OH)
James Lankford (R-OK)
Michael Bennet (D-CO)
Steve Daines (R-MT)
Bob Casey (D-PA)
Todd Young (R-IN)
Mark Warner (D-VA)
John Barrasso (R-WY)
Sheldon Whitehouse (D-RI)
Ron Johnson (R-WI)
Maggie Hassan (D-NH)
Thom Tillis (R-NC)
Catherine Cortez Masto (D-NV)
Marsha Blackburn (R-TN)
Elizabeth Warren (D-MA)

# # #

Tim Rowan, Editor Emeritus

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

The Wrong Way to Use AI in Healthcare

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by Tim Rowan, Editor Emeritus

Lawsuits are beginning to pile up against insurance companies participating in the Medicare Advantage program. The complaint? The wrong way to use AI in healthcare is with faulty algorithms to approve or deny claims. While AI can be extremely helpful in streamlining administrative tasks — comparing physician notes with Home Health assessments and nursing notes or reading hospital discharge documents — it seems not to be any good at deciding whether to approve or deny care.

The Wrong Way to Use AI in Healthcare Example 1

The Minnesota case, November, 2023, UnitedHealth Group:

    • An elderly couple’s doctor deemed extended care medically necessary
    • UnitedHealth’s MA arm denied that care
    • Following their deaths, the couple’s family sued UnitedHealth, alleging:
      • Straight Medicare would have approved the extended care
      • United uses an AI model developed by NaviHealth called nH Predict to make coverage decisions
      • UnitedHealth Group acquired NaviHealth in 2020 and assigned it to its Optum division
      • nH Predict is known to be so inaccurate, 90% of its denials are overturned when appealed to the ALJ level
      • UnitedHealth Group announced in October, 2023 that its division that deploys nH Predict will longer use the NaviHealth brand name but will refer to that Optum division as “Home & Community Care.”

The family’s complaint stated, “The elderly are prematurely kicked out of care facilities nationwide or forced to deplete family savings to continue receiving necessary medical care, all because [UnitedHealth’s] AI model ‘disagrees’ with their real live doctors’ determinations.”

The Wrong Way to Use AI in Healthcare Example 2

The Class-Action case, December 2023, Humana:

    • A lawsuit was filed on December 12, 2023 in the U.S, District Court for the Western District of Kentucky
    • It was filed by the same Los Angeles law firm that filed the Minnesota case the previous month, Clarkson
    • The suit notes that Louisville-based Humana also uses nH Predict from NaviHealth
    • The plaintiffs claim, “Humana knows that the nH Predict AI Model predictions are highly inaccurate and are not based on patients’ medical needs but continues to use this system to deny patients’ coverage.”
    • The suit says Medicare Advantage patients who are hospitalized for three days usually are eligible to spend as many as 100 days getting follow-up care in a nursing home, but that Humana customers are rarely allowed to stay as long as 14 days.
    • A Humana representative said Humana their own employed physicians see AI recommendations but make final coverage decisions.

What Makes This Possible

According to experts we speak with, there are many ways to use data analytics. The insurance companies named in the lawsuits use predictive decision making. This way of analyzing data compares a patient to millions of others and deduces what treatment plan might be suitable for one patient, based on what was effective for most previous patients. Opponents of this method have called it “data supported guessing.”

A superior analysis method experts are coming to understand  is prescriptive decision making. This is taking all of the available historical and current data surrounding a patient and making a clinical decision specifically designed to that patient’s age, gender, co-morbidities, doctor recommendations, and treatment records.The Power of AI with SmartCare

Until recently, predictive analysis was the preferred method because of its resource efficiency. Examining the data of every individual patient used to be prohibitively labor-intensive, requiring hours of reading hospital records, physician notes, and claims. Today, however, AI tools are able to do that work in seconds, making prescriptive analytics and customized plans of care possible.

Fix May Be in the Works

In a February 6, 2024 memo to all Medicare Advantage Organizations and Medicare-Medicaid Plans, CMS explained the difference between predictive and prescriptive analytics. The memo said these plans may not make coverage determinations based on aggregated data but must look at each individual:

“For Medicare basic benefits, MA organizations must make medical necessity determinations in accordance with all medical necessity determination requirements, outlined at § 422.101(c)1 ; based on the circumstances of each specific individual, including the patient’s medical history, physician recommendations, and clinical notes; and in line with all fully established Traditional Medicare coverage criteria.”

In response to a request for clarification, the CMS memo laid out its rule in specific language:Wrong AI in Healthcare Prescriptive Analytics

An algorithm or software tool can be used to assist MA plans in making coverage determinations, but it is the responsibility of the MA organization to ensure that the algorithm or artificial intelligence complies with all applicable rules for how coverage determinations by MA organizations are made. For example, compliance is required with all of the rules at § 422.101(c) for making a determination of medical necessity, including that the MA organization base the decision on the individual patient’s circumstances, so an algorithm that determines coverage based on a larger data set instead of the individual patient’s medical history, the physician’s recommendations, or clinical notes would not be compliant with § 422.101(c).
(emphasis added)

“Therefore, the algorithm or software tool should only be used to ensure fidelity with the posted internal coverage criteria which has been made public under § 422.101(b)(6)(ii).”

In further responses to questions in the same memo, CMS made it clear MA plans must make the same coverage decision original Medicare would make. The only allowable exception is that plans may use their own criteria when Medicare Parts A and B coverage criteria “are not fully established.”

Knowledge of this CMS directive may give Home Health agencies one more arrow in their quiver when going to battle with powerful, profit-oriented insurance companies over harmful, illogical AI algorithm decisions.

For information on the right way to use AI in healthcare, see our complimentary article in this week’s issue.

 

Tim Rowan, Editor EmeritusTim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

 ©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

Navigating the Home Care Revolution

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by Kristin Rowan, Editor

I was honored to have been a guest on Health Futures – Taking Stock in You Radio Show on Money Radio 1510 AM discussing navigating the home care revolution. Health Futures is hosted by HomeCare expert Bob Roth, owner of Cypress HomeCare Solutions. Cypress just celebrate its 30th anniversary last week and is the recipient of a Grant to Innovate within Medicaid in partnership with PocketRN and is the 2013 & 2018 winner of the BBB Torch Awards for Ethics. You can listen to the full radio show here. Below is the blog based on the show, written by the CEO of Strait Talk PR, Lauren Strait.

 

Home Care Revolution bob roth kristin rowan
Home Care Revolution bob roth kristin rowan

by Lauren Strait, CEO Strait Talk PR

The Aging Population Tsunami

By 2050, the 85-year-old population in the United States is expected to quadruple. As this massive demographic shift unfolds, the already strained home care industry will face unprecedented challenges in meeting the escalating demand for quality care services.

Bob Roth, Managing Partner of Cypress HomeCare Solutions, recently had Kristin Rowan, of The Rowan Report on the radio show and podcast to discuss this trend and everything a consumer needs to know about the homecare industry and how it will affect them.

A Trusted Voice Amid Industry Upheaval

In the latest episode of “Health Futures, Taking Stock in You” hosted by Bob Roth of Cypress Homecare Solutions, Kristin Rowan, Owner and Editor of The Rowan Report, offered insights into how her publication is guiding the industry through this seismic transition.

The Rowan Report’s Unbiased Expertise

What began as a print magazine reviewing home health technology has evolved into a comprehensive digital hub covering regulatory updates, workforce solutions, marketing strategies, and groundbreaking innovations. Rowan emphasized the publication’s commitment to neutrality when evaluating new products and services.

“We do our best to remain as neutral as possible…that’s one of the things that Tim [her father and the founder] established early on in his relationships with tech providers.”

Empowering a Strained Workforce

With a redesigned website offering robust search capabilities, The Rowan Report curates resources to help agencies streamline operations and alleviate administrative burdens on overstretched staff. “The solution is not more people because they’re just not there,” Rowan stated. “But the solution is collaboration to better utilize the people that you have.”

The publication explores leveraging AI, voice technologies, automated claims processing, and outsourcing to reduce paperwork and maximize efficiency, enabling care professionals to concentrate on frontline patient care.

Preparing for the Age Wave

As the population ages, The Rowan Report recognizes the need to educate professionals and families on navigating the complexities of long-term care. By convening experts, the publication covers crucial topics like choosing providers, understanding Medicare/Medicaid, and planning for future care needs.

An Indispensable Industry Guide

With over 25 years of experience, The Rowan Report stands as an indispensable guide for the home care industry as it braces for the challenges and opportunities of an aging America. Access their insights at www.therowanreport.com.

# # # 

Bob Roth is Managing Partner of Cypress HomeCare Solutions. He assisted in creating Cypress HomeCare Solutions with his family in 1994. Bob brings the depth and breadth of his nearly 36 years of consumer products, health care and technology experience to the home care trade. Over the years, Bob has received a number of awards. These include the January 2014 CEO of the Month and finalist for the 2015 Phoenix Business Journal’s Healthcare Heroes award. Cypress won the Better Business Bureau’s Business Ethics award in 2013 and 2018.

In March 2017, Arizona Governor Bob Ducey appointed Bob to the Governor’s Advisory Council on Aging. This was the first time in the Council’s 40 years that a home care/home health care agency owner/manager has served on the Council. Nationally, Bob serves on the Board of Directors for the Home Care Association of America (HCAOA). Locally, he serves on the Board of Directors for DUET Partners in Aging. Additionally, he is on the ambassador committee for Aging 2.0 – Phoenix Chapter. On September 11, 2019 Bob won the Home Health Care News Future Leader Award. The award recognizes up-and-coming leaders elevating the home health industry. When he’s not working, Bob enjoys spending time with his wife Susie, their three daughters, and playing golf, tennis, hiking and walking with Ruby and Lacey, our pet therapy dogs.

Bob Roth
Bob Roth

Bob Roth is Managing Partner of Cypress HomeCare Solutions. He assisted in creating Cypress HomeCare Solutions with his family in 1994. Bob brings the depth and breadth of his nearly 36 years of consumer products, health care and technology experience to the home care trade. Over the years, Bob has received a number of awards. These include the January 2014 CEO of the Month and finalist for the 2015 Phoenix Business Journal’s Healthcare Heroes award. Cypress won the Better Business Bureau’s Business Ethics award in 2013 and 2018.

In March 2017, Arizona Governor Bob Ducey appointed Bob to the Governor’s Advisory Council on Aging. This was the first time in the Council’s 40 years that a home care/home health care agency owner/manager has served on the Council. Nationally, Bob serves on the Board of Directors for the Home Care Association of America (HCAOA). Locally, he serves on the Board of Directors for DUET Partners in Aging. Additionally, he is on the ambassador committee for Aging 2.0 – Phoenix Chapter. On September 11, 2019 Bob won the Home Health Care News Future Leader Award. The award recognizes up-and-coming leaders elevating the home health industry. When he’s not working, Bob enjoys spending time with his wife Susie, their three daughters, and playing golf, tennis, hiking and walking with Ruby and Lacey, our pet therapy dogs.

Kristin Rowan, Editor
Kristin Rowan, Editor
Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Connecticut Senate and House Pass Home Care Worker Safety Bill

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by Kristin Rowan, Editor

Last week, we reported on the proposed Bill in the Connecticut Senate and House to provide additional precautions for home care worker safety. In wake of the Elara Caring at Fault Joyce Grayson Home Care Worker Safety Joyce Grayson murder during a home health visit, leadership in Connecticut aimed to safeguard home health and home health aide workers and collect risk assessment data on the same.

On May 6, 2024, CT legislature passed bills in both the Senate and House of Representatives. Instead of the proposed bills that we reported on previously, both branches added amendments to previous bills. The bills include provisions for cyberattack readiness, child safety, and other items not related to care in the home.

First Stage of Home Care Worker Safety

Some of the provisions in the final bill are effective July 1, 2024. As we previously reported, hospice agencies are currently exempt from these provisions and the CT legislature will address hospice agencies in their next session.

On and after July 1, 2024

The Commissioner shall increase the fee payable to a home health care or home health aide agency that provides escorts for safety purposes to staff conducting a home visit to cover the costs of providing such escorts.

The Commission of Public Health will establish and administer a home care staff safety grant program to provide grants to home health and home health aide agencies for staff safety technology, including, but not limited to :

  1. A mobile application for staff to access safety information about a client
  2. A method for staff to communicate with either local police or other staff in the event of an emergency
  3. A global positioning system-enabled, wearable device that allows staff to contact local police
Effective July 1, 2024

The sum of one million dollars is appropriated to the Department of Public Health for the the fiscal year ending June 30, 2025, to establish and administer the aforementioned grant program.

The Commissioner of Public Health and the Commission on Community Gun Violence Intervention and Prevention, will develop or find educational material about gun safety practices and provide such to primary care providers to give to patients who are 18 years of age or older.

Second Stage of Home Care Worker Safety

Some of the provisions in the final bill are effective October 1, 2024. Home health and home health aide agencies have five months to comply with these measures.

Effective October 1, 2024, home health and home health aide agency must collect and provide to assigned workers information about:

The client, including as applicable;

  1. psychiatric history
  2. history of violence
  3. history of substance use
  4. history of domestic abuse
  5. current infections, if any, and treatment received
  6. whether diagnoses or symptoms have remained stable over time
Home Care Worker Safety
Other persons present or anticipated to be present at the location of care including, if known to the agency:

  1. name and relationship to client
  2. psychiatric history
  3. history of violence or domestic abuse
  4. criminal record
  5. history of substance use

Location where employee will provide services including, if know to the agency:

  1. the crime rate for the municipality in which employee will provide services
  2. the presence of any hazardous materials, including, but not limited to used syringes
  3. the presence of firearms or other weapons
  4. the status and of the fire alarm system
  5. the presence of any safety hazards, including, but not limited to, electrical hazards
By October 1, 2024, each home health and home health aide agency must:

Provide staff training consistent with the health and safety training curriculum for home care workers, including but not limited to:

  1. Training to recognize hazards commonly encountered in home care workplaces
  2. Applying practical solutions to manage risks and improve safety

Conduct monthly safety assessments with each staff member and

Provide staff with a mechanism to perform safety checks, which may include, but need not be limited to:

  1. A mobile application that allows staff to access safety information about the client
  2. A means of communicating with local police or other staff in the event of an emergency
  3. A global positioning system-enabled, wearable device that allows staff to contact local police by pressing a button or through another mechanism
Effective October 1, 2024

Each home health and home health aide agency shall, in a manner prescribed by the Commissioner of Public Health:

  1. Report each instance of verbal abuse that is perceived as a threat or danger to the staff
  2. Report each instance of physical, sexual, or any other abuse by a client against a staff member

Third Stage of Home Care Worker Safety

No later than January 1, 2025

Beginning January 1, 2025 and annually therafter, the commissioner shall report to the joint standing committee:

  1. The number of reports of violence and abuse received
  2. The actions taken to ensure the safety of the staff member about whom the report was made
Effective January 1, 2025

Each individual health insurance policy shall provide coverage for escorts for the safety of home health care agency or home health aide agency staff

The joint standing committee of the General Assembly will convene a working group to study staff safety issues affecting home health and home health aide agencies, including but not limited to the following members:

  1. Three employees of a home health care or home health aide agency
  2. Two representatives of a home health care or home health aide agency
  3. One representative of a collective bargaining unit representing home health care or home health aide agency employees
  4. One representative of a mobile crisis response services provider
  5. One representative of an assertive community treatment team
  6. One representative of a police department; and
  7. One representative of an association of hospitals in the state

Implications

As we mentioned before, these regulations will become mandates across the country soon. OSHA has found the home care agency in Connecticut at fault for failing to implement safety procedures and precautions in the death of Joyce Grayson. The nurse’s family is suing the home health agency for wrongful death. Connecticut has established a protocol for safety measures, committees, reporting, and grant programs to implement immediate safety procedures across home health and home health aide agencies in the state. Before these provisions are passed on a national level, and before you have to tell the family of one of your staff that they aren’t coming home…

 

We urge you to:
  1. Create a safety committee within your agency
  2. Invest in training on de-escalation, workplace violence prevention, and self-defense
  3. Research and invest in a GPS-enabled emergency alert system for your staff. We recommend POM Safe and Katana Safety
  4. Insist on background information on all clients and others living in the home upon intake and BEFORE the first home visit
  5. Create a safe and comfortable way for your staff to report verbal abuse, violence, or uneasiness from any in-home visit
  6. Invest in escort and/or paired visits for high-risk clients, first-time clients, or any other situation that warrants it

We will continue to follow this story and provide updates as we receive them.

# # #

Kristin Rowan, Editor
Kristin Rowan, Editor

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

BREAKING NEWS: Home Care Agency Faulted in Death of Joyce Grayson

Clinical

by Kristin Rowan, Editor

Home health agency failed to protect Joyce Grayson

History

We’ve been following the story of Joyce Grayson since her death in October of 2023. The news was first published in The Rowan Report here on November 8th, 2023.On April 14th, we reported on the pending Senate Bill in Connecticut that would require home health agencies to provide additional information and safety precautions prior to a home visit. The safety  of solo workers is now even more important to home health and hospice agencies with the most recent update.

Elara Caring at Fault Joyce Grayson

Today

May 1, 2024, the U.S. Department of Labor (DOL) posted a news release on their investigation into the death of Joyce Grayson, a home health nurse in Connecticut. According to the Department of Labor, OSHA has determined that Elara Caring exposed their employees to workplace violence from patients who were known to pose a risk to others. Jordan Health Care Inc. and New England Home Care Inc., both doing business as Elara Caring, have been cited for willful violation of the agency’s general duty clause. OSHA cited them for not developing and implementing safety measures to protect employees from workplace violence. They also cited the agency for failure to report work-related injury and illness records within four business hours.

Repercussions

OSHA has proposed more than $163,000 in penalties against Elara Caring. Elara Caring has 15 days from receipt of the citations to respond, request a hearing, or contest the findings. 

“Elara Caring failed its legal duty to protect employees from workplace injury by not having effective measures in place to protect employees against a known hazard and it cost a worker her life,” said OSHA Area Director Charles D. McGrevy in Hartford, Connecticut. “For its employees’ well-being, Elara must develop, implement and maintain required safeguards such as a comprehensive workplace violence prevention program. Workplace safety is not a privilege; it is every worker’s right.”

OSHA found that Elara Caring could have reduced the potential for workplace violence by looking at the root causes of violent incidents and “near misses.” They could also have provided clinicians with background information on patients prior to a home visit. Other recommendations from OSHA include providing emergency panic alert buttons and using safety escorts for visits with high-risk patients.

Future Recommendations

The DOL states that employers should have a comprehensive workplace violence program. This program should include both management and employee involvement. Further, the DOL says this plan should have a written program with a committee. Elements of a workplace violence program include:

  • Analysis of a home upon new patient admission
  • Hazard prevention and control
  • Training and Education
  • Resources for Impacted Employees
  • Recordkeeping
  • Employee Feedback
Elara Caring at Fault Stop Workplace Violence

Implications

If Elara Caring is fined for failure to keep their clinicians safe as a result of the investigation into Joyce Grayson’s murder, state and national level regulations are sure to follow. However, even if the laws in your area don’t change, investing now in workplace safety for your clinicians could save you from similar allegations and fines. As we mentioned in last week’s article about the Senate Bill, we have been in touch with several emergency alert companies and will be providing product reviews in the next few weeks. Start a workforce safety committee, develop a written plan for mitigating dangerous situations, and issue emergency response systems to all of your clinicians before it is your agency under investigation. More importantly, take these steps before your team loses one of its own to workplace violence.

# # #

Kristin Rowan, Editor
Kristin Rowan, Editor

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

UnitedHealth Grilled by Congress, Fired by Walmart

Admin

by Tim Rowan, Editor Emeritus

You know the routine. Everyone does. You log into your bank, airline account, or health insurance web portal, enter the correct password, and are directed to look on your smartphone UnitedHealth Grilled MFAfor a code to enter to fully authorize your login. The name for this is Multi-Factor Authentication, or MFA. Lack of MFA procedures leaves your company at risk, which UnitedHealth discovered when it was grilled by Congress about the cyberattack on Change Healthcare.

United Health Grilled by Congress

In his testimony to the House Energy and Commerce Committee Wednesday, UnitedHealth Group CEO Andrew Witty blamed the absence of MFA as the weak link that allowed a ransomware attack to cripple subsidiary Change Healthcare in February. The breach had ripple effects throughout healthcare, given Change’s role as fiscal intermediary for thousands of providers. Healthcare systems on every level were unable to file claims and receive payments.

Asked by the committee why Change Healthcare, which United acquired in late 2022, did not have MFA in place, Witty testified, “Change Healthcare was a relatively older company with older technologies, which we had been working to upgrade since the acquisition. But for some reason, which we continue to investigate, this particular server did not have MFA on it.”

CBS News reported that Change Healthcare processes 15 billion transactions a year. “The scale of the attack,” their report stated, “meant that even patients who weren’t customers of UnitedHealth were potentially affected. Personal information that could cover a ‘substantial portion of people in America’ may have been taken in the attack.” The breach has already cost UnitedHealth Group nearly $900 million, plus the $22 million ransom Witty decided to pay to the hackers.

The Russia-based ransomware gang, ALPHV, or “BlackCat,” claimed responsibility for the attack, bragging that it stole more than six terabytes of data, including “sensitive” medical records. The attack triggered a disruption of payment and claims processing around the country.

We followed up our initial report on the attack with CMS guidance on March 20, 2024 and an update on April 11, 2024, with reports that Change Healthcare was being blackmailed again by another ransomware gang, RansomHub, who claimed to have 4TB of data from Change Healthcare and demanded another ransom payment.

Walmart & Optum, UnitedHealth Trouble Spots?

UnitedHealth Group is also in headline news this week for two other reasons. The company’s Optum division, which owns home care giant CenterWell,UnitedHealth Grilled Optumformerly Kindred at Home, and which is awaiting government approval for its bid to acquire Amedisys, has quietly been executing a reduction in force. Reports are that the bulk of the layoffs are hitting “Optum Virtual Care,” the name given to naviHealth following its $1 billion acquisition in 2020. Following a surge in demand during the pandemic, the company is apparently abandoning telehealth services.

A planned 10-year collaboration between UnitedHealth and Walmart to provide virtual healthcare services ended Tuesday after only one year. On April 30, the retail giant announced that it will close its 51 health centers across five states due to the “challenging reimbursement environment” and rising operating costs, which have resulted in a lack of profitability. Like Optum Virtual Care, the centers were providing virtual services via telehealth.

A sign of the post-pandemic times? Perhaps. We will keep watching.

 

Tim Rowan, Editor EmeritusTim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

  ©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

Understanding Differences in Medicare Policy and Conditions of Participation

Admin

by Johnathan Eaves, Senior Director of Communications, Axxess

Treating Medicare patients comes with a level of nuance that is important to understand to ensure that organizations remain compliant and patients receive appropriate care. Standards for quality care and payment can sometimes be dictated by Medicare’s payment policies and at other times be decided by the Conditions of Participation. There is an important difference between these two governing principles that providers should understand to ensure compliance.

Care at home industry veteran and Axxess Senior Vice President of Clinical Services Arlene Maxim RN, HCS-C, offered insights into the differences between Medicare’s policy and its Conditions of Participation during a recent webinar.

Explaining the DifferenceMedicare Policies

Maxim pointed out that the differences between policy and the conditional requirements comes down to what can be billed and what are the quality standards for the services provided.

“The Conditions of Participation are dealing primarily with quality, whereas Medicare policy is related to payment,” said Maxim. And while there is a difference, that doesn’t mean both aren’t important and must always be followed.

“If Medicare policies are not followed, you are audited and if you do not have documentation to support those policies, you’re not going to get paid,” said Maxim “Oftentimes, with PDGM, staff members are not getting past that first 30 days. They’re not understanding what they need to do to keep that patient who continues to qualify for services on for longer.”

Maxim says that the problem is often that clinicians do not understand Medicare policy. “Every piece of documentation we submit to the Medicare program for review [needs to be] as pristine as we can possibly get it,” she said.

Assessment and Documentation

Proper assessment and documentation is something Maxim feels is critical in ensuring quality care, meeting Medicare requirements, and receiving payment for services.

“Complete and detailed documentation is going to be the key for agency payment by the Medicare program,” Maxim said.

Maxim pointed out certain services covered under Medicare policy may include observation and assessment, management and evaluation of a care plan, maintenance therapy, teaching and training activities, administration of medications, wound care, ostomy care, rehab nursing, venipuncture, skilled nursing visits, and more.

She also cautioned that agencies need to be prudent with the funds they receive from Medicare, viewing them as a potential “short-term, interest-free loan” until undergoing any audit. Until their documentation is reviewed and approved, there are no guarantees.

“Medicare is an insurance and it’s not free,” said Maxim. “Medicare policy provides us with a list of covered items. If experiencing an audit, and if the documentation is not there to cover the covered service, you’re not in compliance with that Medicare policy and you will not be paid for the services.”

Communicating With Physicians

Maxim further emphasized the importance of frequent contact with physicians, adherence to care plans, and ensuring that care plans are simple with individualized plans and goals that are achievable.

“You want to make sure that you have orders that physicians are actually going to read and to determine that they make sense and they’re going to sign off on them,” said Maxim.

“Keep your plan of care simple.”

# # #

Axxess Home Health, a cloud-based home health software, streamlines operations for every department while improving patient outcomes.

© 2024 Axxess. For reprint permission, please contact The Rowan Report: kristin@therowanreport.com

80/20 Finalized Rule

CMS

by Kristin Rowan, Editor

The Centers for Medicare and Medicaid Services (CMS) has finalized the “Ensuring Access to Medicaid Services” rule, more commonly known as the 80/20 rule. The 80/20 finalized rule requires at least 80% of Medicaid payments for home care services goes to caregiver wages. No more than 20% can be spent on administrative or other overhead costs. The White House, citing a study by The Commonwealth Fund, says that higher wages for caregivers will reduce turnover. Facing massive workforce shortages, home health, hospice, and supportive care at home agencies have been struggling to recruit and retain an adequate number of caregivers. The higher wage will also increase the quality of care, according to the study.

Prior to the 80/20 rule, there was no law or rule requiring home care agencies to report how they were spending money from federal medical payments. The rule includes requirements for states to create advisory groups to consult on rates and compensation. This changes the current Medical Care Advisory Committee regulations by increasing the percent of beneficiaries on the committee from 10% to 25% over the next two year. The Home Care Association of America (HCAOA) and the National Association for Home Care & Hospice (NAHC) argued that the rule adds administrative requirements to home care agencies while simultaneously reducing the resources available to fund them. NAHC President Bill Dombi said, “We all agree that more needs to be done to support the direct care workforce; however, this policy will make things worse, not better.” NAHC suggests the policy will force some agencies to close and others will leave the Medicaid program altogether, causing patients to have even more problems accessing care.

Exceptions to the Rule

From the text of the final rule, CMS acknowledges additional comments that the minimum direct payment to caregivers in this rule will create hardships for some agencies. Across the country, there are substantial differences among waiver programs for HCBS that are not accounted for in the rule. There is some flexibility built into the rule to account for these factors, according to CMS. Some of the flexibilities include:

  • Excluding some costs from the calculation
  • Including clinical supervisors in the calculation
  • Allowing states to set a different minimum for small providers
  • Allowing states to develop their own criteria to qualify as a small provider
  • Allowing states to develop criteria to exempt some providers from the rule
80 20 rule finalized
  • Exemption from the minimum payment rule for all Indian Health Service and Tribal health programs

The final rule also changes the timeline for complying with the rule from four years after the date of publication to six.

Objections to the Rule

Other comments included the need to address various reasons for the workforce shortage. In addition to low wages, commenters cited the social valuation of direct care work, lack of governmental support for some workforce pipelines, and immigration policies as deterrents to recruitment. One suggested that CMS start looking at creative strategies for developing an atypical workforce.

There were several submitted comments stating the either HHS or CMS or both does not have the authority under the Affordable Care Act to make specific requirements for minimum payments, but only to ensure that each State is assessing payment regulations and ensuring payments are economical, efficient, and ensure quality of care. A specific section of the Affordable Care Act, section 2402(a)(1) requires the Secretary of the Department of Health and Human Services (HHS) to ensure states implement service systems to allocate resources. The provision does not give HHS the authority to dictate the terms of those service systems, only to ensure the states develop those systems. Not surprisingly, CMS disagreed with those comments.

Many people questioned the 80% as being unrealistic, too high, and not based on quality data. CMS cited data from several states, who have pass-through requirements of 80-95% for all rate increases. This is not a minimum payment from all Medicaid payments, only a requirement for a minimum pass-through to direct care workers of increases in rates. Two states, Minnesota and Illinois, currently have minimum payment requirements set at 72% and 77%, respectively. CMS used these two states as justification for the 80% rule, acknowledging that it is higher than both states while also acknowledging that they did not perform a state-by-state study of the impact the 80% rule will have. CMS states the rate was set higher than those states to “encourage further steps towards improving compensation for workers.” CMS believes that requiring HCB agencies to pay their direct care workers a higher percentage of Medicaid rates than any state currently does will somehow make those agencies want to voluntarily pay even more.

The 80/20 Rule and Technology

Technological advances in telehealth, remote patient monitoring, revenue cycle management, scheduling, employee benefits, assistive technology, EVVs, EMRs, CRMs, and other software solutions can and will lower overhead costs and increase efficiency in your agency. Paperwork automation can reduce the time spent on documentation by a significant percentage. Revenue Cycle Management software can reduce claim denials and decrease reimbursement payment cycles so you can get your money faster. They can also reduce the number of unpaid claims. Employee benefit and training software can reduce responsibilities for HR teams, lessen the requirements for clinical supervisors, and cut training time in half, getting your newly recruited caregivers out in the field faster. Scheduling and onboarding software can increase your intake capabilities. The advances in generative AI allow you to create robust reports almost instantly so you can see your agency’s strengths and weaknesses and create plans for improvement.

Some of these costs will be excluded from the calculations for the 80% rule. Now is the time to invest in technology for your agency. Not only will your agency be more efficient and more effective, but you will be able to care for more patients with the same staff you have now, and the software solutions are as close to cost-neutral as they will ever be. We have a list of technology solutions that we’ve recently discovered and will be writing about in the next few weeks. If you are in immediate need of a software solution, contact us directly for a consultation.

# # #

Kristin Rowan, Editor
Kristin Rowan, Editor

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

HOPE is on the Way: Part 3

CMS

By Beth Noyce, RN, BSJMC, BCHH-C, COQS
CHAP-certified home health & hospice consultant

This is part 3 of the 3 in the series, outlining the discussions and implications in adopting new outcome and process measures for Hospice care. The final segment addresses future process and outcome measures that the board discussed, but did not yet implement. Read Part 1 on Outcome Measures and Part 2 on Process Measures.

The TEP discussed potential future process and outcome measure concepts that Abt Associates presented to the panel as well.

The process measures included:

  • Education for Medication Management
  • Wound Management Addressed in Plan of Care
  • Transfer of Health Information to Subsequent Provider
  • Transfer of Health Information to Patient/Family Caregiver

Hope-based outcome measures were:

  • Patient Preferences Followed throughout Hospice Stay
  • Hospitalization of Persons with Do-Not-Hospitalize Order

Developing education for medication management as a process measure was a popular concept, and the top priority of the recommended measures with the TEP as they “broadly agreed that CMS should develop this measure,” the report says, citing “a significant need for training in medication management for patients and their caregivers.” They recommended that the measure weigh more heavily when care is provided in a home setting than in a facility setting because hospices are unable to control facility training and hiring practices. One panelist commented that including the phrase “during today’s visit” in the measure is important.

Whether CMS should further develop the process measure addressing wound management in the plan of care was less straight-forward, as panelists provided varied feedback. They generally agreed that this measure is important, as having a record of wound management addressed in the plan of care can hold the staff accountable for treating the wounds. But some members recommended measuring wound management with outcome measures rather than process measures. One panelist cited potential problems from patients’ deterioration over time and another noted that the time frame of this measure is important, and encouraged recording the process of getting care in place once a wound is identified.  The panel agreed CMS should carefully define the measure’s specifications.

Because standard practice for most agencies is, when a patient is discharged live, to transfer health information to the subsequent provider and to the patient and family or caregiver, TEP members expressed that the two measures were likely to “top out,” meaning they would almost always be marked “Yes,” making them of no value in differentiating between hospice providers. The group generally discouraged developing these process measures.

The group strongly rejected any merit in developing two outcome measures concerning Patient Preferences Followed Throughout Hospice Stay and Hospitalization of Persons with Do-Not-

Hospitalize Order. The report says “Multiple TEP members described situations in which patients who had preferred not to be hospitalized changed their minds when a crisis occurred. Patients’ preferences and unexpected crises are usually out of the hospice’s control. Although it is still important for hospices to ask patients about their preferences as part of patient-centered care, the TEP did not believe these two items would be practical measures of a hospice’s care quality.”

Dr. McNally expects that Abt. Associates will apply the HQEP TEP’s suggestions to the HOPE tool.

“Oh yeah, they did it,” he says. “Abt would come to a specific meeting with information, data, suggestions, and specific information about how these things would be measured. We’d give feedback. Then they’d come back to the next meeting having incorporated our suggestions,” he explains. “All of us felt very much heard and responded to. It didn’t feel in the least bit perfunctory.”

Whatever specific measures are eventually included in the HOPE tool, Lund Person sees value in its implementation. “Hospice providers have had a woeful lack of outcome measures for hospice patients, which has made the evaluation of quality hospice care based only on process measures and the family’s evaluation of hospice care in the CAHPS® Hospice Survey, she explains. “Implementing HOPE will begin to identify outcome measures that can be compared between providers.”

Lund Person warns of potential challenges as well. “The selection of risk adjustment and stratification must be carefully done to minimize bias and maximize effectiveness of measures,” she says. “In addition, hospice providers have been awaiting the release of the HOPE tool with significant anxiety about content and administrative burden.”

Dr. McNally is confident the HOPE tool will be a healthy change for hospices.

“A lot of my role as a medical director and hospice physician is supporting our nurses,” he says. “They do 95% of the work. I really would like to see this not be burdensome for our hospice nurses. I’m looking forward to seeing what the [HOPE tool] beta testing translates to in our own hospice world.” He added “What I would hope to see is that the tool feels user-friendly to the hospice team, the people who have to use it, and that it also provides useful information to patients and families.”

NAHC’s Wehri says that standardizing processes through the HOPE tool is the key foundational element for the hospice industry. “High quality care is driven by reducing variance through standardized processes, Wehri writes. “Also, CMS will have a better idea of how the type of population a hospice serves impacts some of the clinical care.” This small glimpse into hospice variances that CMS does not currently have could be very helpful in future policy and payment decisions, according to Wehri. “What CMS finds in terms of differences between hospices and their care for patients may be a bit of a surprise to CMS,” she says.  “I hope they are pleasantly surprised with the overall quality of care that is revealed.”

# # #

Beth Noyce provides education, consulting, mentoring, compliance assessments and auditing services to home health and hospice agencies and their clinicians in several states. She also now provides patient and family guidance concerning hospice and home health services. Beth loves teaching and helping others succeed. She also makes available recordings of much of her education for her clients’ convenience.

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Private Duty Home Care in Fraud Enforcers’ Crosshairs

Clinical

by Elizabeth E. Hogue, Esq.

Some owners and managers of private duty home care agencies mistakenly think that fraud and abuse prohibitions apply only to services paid for by the Medicare Program. In fact, fraud and abuse prohibitions apply to providers if they accept any state or federal funds, including, but not limited to, Medicaid, Medicaid waiver, VA, and Tri-Care. Many private insurers have adopted the prohibitions on fraud implemented by state and federal programs.

Private duty home care agencies are increasingly in the crosshairs of fraud enforcers if they receive reimbursement from Medicaid and/or Medicaid Waiver Programs. The reason for enhanced scrutiny is that both the federal government, which partially funds state Medicaid and Medicaid Waiver Programs, and state governments that also fund these programs are alarmed about the high costs of them.

Conventional wisdom says that there are big bucks to be saved if fraud and abuse in the Programs are controlled and ultimately eliminated. Conventional wisdom also says that enforcement actions in Medicaid Programs have just scratched the surface. According to this “wisdom,” there are big bucks to be recouped from “low-hanging fruit!”

A recent report from the Office of Inspector General of the U.S. Department of Health and Human Services seems to support this perception regarding private duty home care agencies based on the following:

  • Patient Fallen From Wheelchair AbuseBetween 2014 and 2023, at least 34% of fraud convictions in some years were based on private duty home care services. In some years, this percentage was as high as 48%.
  • In fiscal year 2023, there were 279 criminal convictions related to private duty home care services compared to 66 for registered nurses and 43 for home health agencies.
  • Recoveries from private duty home care agencies in 2023 totaled $26.4 million.
  • The amount of civil recoveries reached a 4-year high in 2023 and the combined criminal and civil recoveries were $1.2 billion, resulting in a return on investment of $3.35 for every $1 spent.

The return on investment of more than three times the amount spent is perhaps the most important figure of all. With a three to one return, regulators will not hesitate to “beef up” enforcement actions.

THE CONSEQUENCES OF FRAUD AND ABUSE ARE SEVERE WHEN SERVICES ARE PAID FOR BY THE MEDICAID AND OTHER STATE AND FEDERAL PROGRAMS!

Personal care private duty agencies, don’t believe the myth that only services paid for by the Medicare Program are subject to fraud and abuse enforcement. The consequences may be devastating, including the loss of businesses. Heads up!

©2024 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.
©2024 This article appeared in The Rowan Report. All rights reserved.

HOPE is on the Way: Part 2 – Process Measures

Clinical

by Beth Noyce, RN, BSJMC, HCS-C, BCHH-C, COQS
CHAP-certified home health & hospice consultant

Process Measures

The outcome measures being considered look at effectiveness of hospice clinical efforts to decrease pain and other symptoms. The process measures paired with them focus on the hospice’s follow up with the patient after moderate or severe symptoms are found during assessment.

Exhibit 6 (below) shows the numerator and denominator for these.

HOPE-based Process Measures

TEP members determined that these two process measures have high face validity. This means the measure items clearly state, or “look like” they will measure what CMS intends them to measure. This allows consumers to see what hospices are assessing and treating. It can also help hospices track how well they are reducing or treating patients’ symptoms.

Katie Wehri, Director of Home Health & Hospice Regulatory Affairs for the National Association for Home Care & Hospice says the face validity of process items is the most important information the HQRP TEP provided to CMS. “Having HOPE items and subsequent measures that actually measure what is intended is key to success,” she says.

Exclusions from Process Measures Success

Exclusions from calculating a hospice’s process measures’ success need careful consideration. Here is the list of options of which patients to exclude:

  • Patient desired tolerance level for symptoms
  • Patient preferences for symptom management
  • Beth Noyce ConsultingNeuropathic pain
  • Actively Dying (death is imminent)
  • Other conditions

The report says that reassessing a symptom within two days of identifying that symptom as moderate or severe is fundamental. This is true regardless of the beneficiary’s stated tolerance-level for symptoms. It also said that process measure calculations should include patients with no symptom-management preference. Further, exclusion criteria should be the same for pain and non-pain symptoms.

Neuropathic Pain

The TEP’s recommends including neuropathic pain in the HOPE tool’s pain-reassessment process measure. Including rather than excluding patients suffering neuropathic pain prompts nurses to reassess these patients for changes. The report references research that suggests 40% of hospice patients may experience neuropathic pain. Patients who experience neuropathic pain have more severe and more distressing pain symptoms. [Tofthagen, C., Visovsky, C., Dominic, S., & McMillan, S. (2019). Neuropathic symptoms, physical and emotional well-being, and quality of life at the end of life. Supportive Care in Cancer, 27(9), 3357-3364. doi:10.1007/s00520-018-4627-x]

The TEP agrees that patients with neuropathic pain should be part of the process measure. However, they recommend excluding the same patients from the outcome measure addressing the patient’s pain impact. The report cited TEP discussion that such pain is chronic and not likely to be resolved or decreased within two days when the reassessment captures outcome data.

The TEP broadly agreed that a nurse who assesses a patient who is actively dying (life expectancy of 3 days or fewer based on clinicians’ assessment) as suffering moderate or severe pain should attempt to reassess the patient. Such patientsshould not be excluded.

The panelists agreed that process measures should include patients of all ages. Several TEP members noted that all patients experience pain and non-pain symptoms, and therefore the measures should apply to adults and children alike.

Exclusion Due to Inability to Reassess

When a hospice is unable to reassess a patient for a valid reason process measures should exclude those patients.

Identified exclusion reason were:

  • discharge, alive or dead
  • visit refusal
  • inability to access the patient due to an emergency department or hospitalization event
  • the patient traveling outside of the hospice’s service area
  • inability of the hospice to contact the patient or caregiver.

However, the report says, “…hospices should be penalized if reassessment is missing or delayed due to hospice staffing or scheduling issues.”

This article is the second in a series about implementation of HOPE. Next week, Beth Noyce shares details from the panel as it discussed potential future process and outcome measure concepts.

# # #

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Home Care Worker Safety: Aftermath of Home Health Nurse Death

Caring for the Caregiver

by Kristin Rowan, Editor

In October of 2023, nurse Joyce Grayson went to the home (halfway house) of a released convict. She was later found dead in the basement of the house. In addition to adding focus to home care worker safety, the immediate response to this tragic event was an increase in nurses being afraid to do their jobs. Lawmakers in Connecticut vowed to increase protection for visiting nurses to ensure health care worker safety. The nurses requested additional reporting requirements for assaults while lawmakers suggested requiring an escort for high-risk situations.

Elara Caring at Fault Joyce Grayson Home Care Worker Safety

Home Care Worker Safety by Law

Connecticut Senator Saud Anwar recognizes the growing segment of people wanting to age at home. “We want people to be able to get treatment at home,” he said. However, he also recognized the need for more information about potentially dangerous homes. He said at-home health care workers should be aware of what they’re walkin into “if there’s a high-risk situation.” Conn. lawmakers introduced Senate Bill One for Session Year 2024. The bill would require agencies to provide patient information, as applicable, including:

  • Medical History
    • Psychiatric history
    • History of violence
    • History of substance abuse
    • History of domestic abuse,
    • Current infections and treatments
    • Stability of diagnoses or symptoms over time
Joyce Grayson Lone worker safety
  • Housing Information
    • Other persons in the home
    • Name and relationship to patient
    • Psychiatric history
    • History of violence or domestic violence
    • Criminal records
    • History of substance abuse
  • Location of Service
    • Crime rate
    • Presence of hazardous materials
    • Presence of firearms or other weapons
    • Status of location’s fire alarm system
    • Presence of any other safety hazards

The bill also included ongoing safety training, safety assessments, and safety checks including:

  • A mobile app with patient information
  • A GPS enabled wearable device that allows staff to contact law enforcement

The Bill included payment rates to offset the cost of implementing all safety items to ensure cost-neutrality.

Implications for Hospice Agencies

Barbara Pearce, interim CEO of Connecticut Hospice, raised some legitimate concerns over the bill. Pearce warns that the background screenings required are lengthy and would result in many patients not receiving hospice care at all. According to Pearce, Connecticut Hospice “had 300 people die within three days, 200 people within two days, and 100 people within one day of entering home hospice care.” None of these patients would have been cared for if the bill had been in place at the time. Pearce discussed her concerns with Conn. lawmakers, who have since changed their approach.

Senate Bill One "Home Care Worker Safety" Moving Forward

Connecticut lawmakers are opting to exclude hospices from the bill for now. Sen Anwar said they plan to write a hospice-tailored bill “in the future” to ensure safety of hospice workers. Anwar continued, “We will have a plan of action to see what can be done to reduce the risk for hospice care workers too because…we want to make sure they’re safe too.”

The Connecticut 2024 legislative session is scheduled to adjourn on May 8. Senate and House representatives are racing the clock to modify the bill before the session ends.

Implication for Home Health

Few, if any, states have laws for home health worker safety. Alaska and Idaho have strict penalties for violence against health care workers. Wyoming introduced a similar bill in 2013, but it was defeated. Oregon passed a law in 2007 to require hospitals and surgery centers to implement safety strategies. Washington state established a law in 1999 that requires the development and implementation of a work-place violence plan. The law includes home health, hospice, and home care agencies, but does not have the detailed measures included in Connecticut’s bill.

If Senate Bill One passes in Connecticut, it could pave the way for additional state or federal regulations for in-home care safety precautions. Violence in home health, hospice, and home care has increased and steps need to be taken to ensure the safety and well-being of caregivers. Keep an eye out for some upcoming product reviews on mobile apps and hand-held emergency devices that allow home care workers to alert the agency, law enforcement, and/or family members before, during, and after a care visit.

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Kristin Rowan, Editor
Kristin Rowan, Editor

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com