Making the case for Safe Transitions

How safe is the transition from hospital to home if you cannot get the services the person needs at home when they are ready to transition? 

We are experiencing challenges with home health care agencies not being available for our patients that need home care at discharge.  Are you also experiencing this issue? 

The staffing crisis is everywhere, and our home health care partners are not immune to this.  But it isn’t usually the staffing that seems to hinder the agency from taking on patients to care for.  It seems to be the insurance companies and the contracts that they do or do not create for home health care follow up.

Remember that Medicare Advantage (MA) plans can provide more care than Traditional Medicare if they chose, but they must provide at least what Medicare covers.  This would include Skilled Intermittent Home Health Care visits. 

Over the past few years, the MA plans are contracting with less agencies.  We have experienced, time and again, that those agencies decline the referral for our patients because of the agency experience of no reimbursement by the insurance company for which they claim to be contracted.

In the discharge planning rules set forth by the Centers for Medicare & Medicaid Services (CMS), the hospital must have the conversation about goals of care and make sure that the home care agency has the skilled caregivers to provide the visits at home.  They hospital must also offer choice of agency, and document that choice.  We have educated our teams around the way to discuss the next site of care so that this is a comfortable discussion and so we are not just shoving a bunch of agencies at them and asking them to pick one. 

But there is a problem now:

Imagine if you will, a patient with a skilled need that needs home health care.  Not only does the hospital want to have the physician attest to the face-to-face meeting in order to guarantee that the physician agrees that the patient needs home care, but the hospital also has to keep a running list of which home care agency is used by which insurance company. 

They discuss with the patient and family, obtain agreement with them, document in the chart.  But it isn’t over until the agency accepts that referral.  When they send the referral to that agency and the agency declines, we are left with an unsafe discharge plan. Now they must go back to the patient and tell them the outcome and change the agency and change the documentation.  All of this to stay in compliance with the regulations, and to provide a safe transition.

So then, what if you cannot find an agency to take the referral?  What then? 

We have had an experience such as this recently and it seems to be getting worse.

A very recent experience was a patient with a new Tracheostomy and feeding tube.  The Insurance company declined Skilled Care Facility and told the home health care team.  This was a good option since there was motivated family to help and the patient was very independent in walking and taking on the other care she needed.  But the team was unable to find a home health care agency that was contracted with that payer that would take on the patient.  Imagine going home without any skilled home care like that?  After seven more unnecessary days in the hospital, they finally found an agency that would take the patient, but that agency had to sign a Single Case Agreement with the insurance company. 

How complicated can it get? 

What do the hospitals do?  They get creative.  They set up more frequent physician visits to make sure that the patient is cared for.  They reach out to the community Care Managers (who also do not get paid typically by the insurance company either).  There are not many Parish Nurses left in the communities either so they do the best they can by teaching and training the patient’s family/loved ones to provide the care.   This is a huge burden on the family and patient.  But the alternative would be to keep a patient that no longer needs acute hospital care in the hospital.  And that is not a safe plan either. 

CMS changed the DCP rules back in 2019. The hospitals provide all sorts of information about the Home care agencies:  quality scores, readmission rates (part of quality scores).  I wonder if there is a time when the hospital could provide data to the patient about their insurance and the way they do not do what they promise they will do at times.   Shouldn’t CMS hold the MA plans accountable for those post-acute services that they claim they contract with agencies for, yet do not pay for.

If you have experienced this, please make sure your voice is heard.  Reach out the CMS and provide details of this.  We must help advocate for your Home Health Care agencies or there will not be any left, and we need them.