Shorter Hospital Stays? No Problem
by Sherry Netherland (www.ilikefitness.com)

There has been a growing awareness in our country that long hospital stays are a thing of the past.  In the 50’s my mother was in the hospital for two weeks when she had her children by C-section, now it’s a three day stay, or less!  Even though some may feel that drive-through brain surgery is just around the corner, a short hospital stay is not necessarily a bad thing.  It is an accepted truth in the health care industry that patients have better outcomes if brought home early.  Part of the reason for this enhanced recuperation at home is the advent of home health care.

November is National Home Care and Hospice Month.  Statistics gathered by the California Association for health Services at Home reveal that more than 20,000 home care and hospice providers are currently delivering these services in California.  They also report that home health visits were provided to 510,067 patients in California, preventing, postponing and limiting the need for them to be institutionalized to receive these services.

Medicare is the payor source for the majority of these patients.  According to the California Department of Aging, by 2010, 1 in 5 Californians will be age 60 or over.  California is home to the largest aging population in the country.  Even the term elderly is now divided into “elderly” and “oldest old” – those persons over 85 years of age.  The over 85 year-old age group will increase 143% by the year 2020, faster than any other age group.

In October, 2000, Medicare instituted revolutionary changes in reimbursement for the home health care industry.  In the past, payment was cost-based, fee-for-service, retrospective payments.  Now, reimbursement is by a Prospective Payment System (PPS).  With a system similar to the hospital DRGs (Diagnostic Related Groups), the data used to determine how long you need to stay in the hospital according to your diagnosis, home health care reimbursement uses HHRGs (Home Health Related Groups).  Since the payments are prospective, the reimbursement is based upon the patient’s acuity level at the start of care.

The key to HHRG computation is OASIS – Outcome and Assessment Information Set.  This assessment tool is done at the initial patient visit.  It is designed to provide CMS, (the Center for Medicare and Medicaid Services) with case mix data.  The data includes a clinical score (diagnosis), a functional score (how well can a patient perform activities of daily living, ADLs), and a service utilization score, e.g., a need for physical therapy.

The services allowed by Medicare home health benefits include: skilled nursing, physical therapy, occupational therapy, speech/language pathology, medical social worker, and home health aide (bath visits).

The Medicare coverage criteria for home health has not changed.

1. The patient must be homebound.  This is defined as being unable to leave the home ”at will.”  For some patients, home care is provided during that transitional period from hospitalization to the time when they are able to obtain necessary services through outpatient care.
2. The patient must need skilled intervention.  This is defined as care that falls within the scope of practice of a registered nurse, physical therapist, and/or speech/language pathologist.  At least one of those three specialties must be on the case to qualify a patient as having a medical need as defined by their Medicare home health benefit.  Patients require services because of acute illness, long-term health conditions, permanent disability, or terminal illness.  Bath visits may be appropriate during the time skilled intervention is occurring, but once a patient is discharged from those skilled services, the Medicare covered bath visits end.  This skilled need criterion is the number one source of confusion for home care consumers.  If the only service needed is a bath, Medicare will consider that custodial care and not a covered benefit.
3. The services provided must be medically necessary.  Medicare is designed to be restorative or rehabilitative, it is not a maintenance program.  If a patient reaches a plateau with no further improvement, even if they have not achieved pre-illness status, service must be discontinued.

If you are not yet a Medicare recipient, check your private health insurance policy for your home health benefits.  The benefit allowances will differ from policy to policy.  The criteria for coverage will mimic Medicare.

The patient’s physician determines all care necessary.  A home health agency nurse is the eyes and ears of a doctor in the patient’s home.  The home nursing assessment and home care plan is a vital tool for the physician in directing patient care. 

So, if you feel you were discharged from the hospital too soon, it might have been the best thing for your health.