Medicare cuts totaling $10B over next decade constitutes a 'battle for the future of health care at home,' one home health leader says.
Home health leaders are cheering U.S. Senate bipartisan lawmakers for introducing new legislation that prevents a newly proposed 7.69% permanent cut and an additional $2 billion in “clawback” cuts to home health care servicesincluded in the Centers for Medicare & Medicaid Services’ (CMS) Home Health Prospective Payment System (HHPPS) for 2023.
The bill would also block additional cuts of more than $2 billion as soon as 2024 due to an “unjustified clawback” of payments for critical home health care services delivered to seniors and people with disabilities during the pandemic, the press release says.
Estimates show Medicare’s proposed cuts will total $18 billion to providers over the next 10 years.
“We applaud Senators Stabenow and Collins for introducing this legislation, which will protect home health patients and providers from extreme cuts and help ensure continued access to safe, patient-preferred home health care for millions of American seniors and individuals with disabilities,” said Joanne Cunningham, CEO of the Partnership. “While we continue to educate CMS on the overall impacts of their proposed cuts, we commend lawmakers in Congress for proactively offering legislative solutions to these harmful payment adjustments.”
The legislation will make these policy changes:
Prevent CMS from implementing any permanent or temporary adjustment to home health prospective payment rates prior to 2026. This would delay cuts currently proposed by CMS for 2023 and beyond, allowing more time for CMS to refine its proposed approach to determining budget neutrality in home health.
Ensure that any adjustments CMS determines to be necessary to offset increases or decreases in estimated aggregate expenditures are made by 2032, such that no cuts would be delayed beyond the end of the budget window.
The legislation is intended to be self-implementing. It would become effective as of the date of enactment and includes instructions allowing for implementation by program instruction or other means.
Home health leaders have consistently expressed concerns about CMS’ method in proposing these payment adjustments, particularly in light of significant increases in labor and supply costs across the home health community. An August 2021 labor cost survey of home health providers concluded that wages and home health industry expenses have increased dramatically since 2019—a trend that continues to worsen as inflation hits its highest point in decades.
“Home health providers are facing enormous pressures today, including historically high costs of delivering quality home health care, so these severe and unjust cuts could not come at a worse time,” Cunningham said. “We look forward to working with lawmakers in Congress to build support for this legislation to ensure Medicare’s proposed cuts are not implemented as proposed.”
Home health leaders will work with lawmakers to build support for the legislation, they say.
“This is a battle for the future of health care at home,” said William A. Dombi, NAHC president. “We sincerely hope that CMS will support this legislation and recognize the need to work with us to avoid the harm that the current proposal would inflict.”
Bon Secours Mercy Health's Nursing Flex Team gives nurses 'an opportunity to take advantage of the geography, size, and complexity of our health system,' CNO says.
A unique nurse staffing program at Bon Secours Mercy Health (BSMH) serves as an internal travel agency program, of sorts, providing nurses more flexibility and choices about how and where they advance and progress across the health system.
The Nursing Flex Team is divided into three tiers, says Andrea Mazzoccoli, RN, PhD, FAAN, the Cincinnati, Ohio, health system’s chief nurse and quality officer. Tier 1 is the most traditional, where nurses stay within their facility or a single geographic area and flex by either staying within their specialty or learning new specialties.
Tier 2, which was added about 18 months ago, gives nurses more flexibility in region and geography.
“If a nurse is enjoying our Richmond [Virginia] market, they are able to have concentrated and assigned intervals in different kinds of units across all of the facilities within that market,” Mazzoccoli says.
Tier 3, introduced just within the past few months, allows nurses to take assignments across the health system’s 13 markets in five states: Ohio, Virginia, South Carolina, Florida, and Kentucky.
“We’re most excited about our Tier 3 program, because it’s a way that we afford nurses an opportunity to take advantage of the geography, size, and complexity of our health system, Mazzoccoli says. “They now have the opportunity to have assignments across our ministry in any of the markets and in any of the facilities. Those assignments range much like you see in traditional traveler programs, where it goes for eight, 12, and 16 weeks, and where they talk to us about their career pathway progression and choices, where they’d like to have assignments, and what kinds of things they're looking to experience within our ministry.”
BSMH targeted about 100 nurses to start the program and about 75 are currently in the program, she said.
Mazzoccoli spoke with HealthLeaders about how the Nursing Flex Team is working at BSMH.
This transcript has been lightly edited for length and clarity.
HealthLeaders: How does the flex program benefit the nurses?
Andrea Mazzoccoli: It allows our nurses to stay inside our ministry of a faith-based community setting. It also allows the nurses to maintain their compensation, tenure, and service within the ministry.
Nurses have the opportunity to choose whether they want to stay in the unit or department they came from, or travel. They can take a break and say, “Over the next year for 12 weeks, I'd really like to go to Greenville, South Carolina, where we have a bone marrow transplant unit and see what that might be like to work there.”
Our nurses aren't necessarily constrained by what kind of experience they already have, because we help nurses in building their experience. They may try different specialties, or they may stay in their specialty and try different kinds of clinical areas.
Perhaps, for example, we have ED nurses who have never worked in a trauma ED but with the flex program, they can go and experience assignments in Toledo [Ohio] where there's a level-one trauma ED and see how that fits in terms of their career path and progression.
HL: What do the nurses think about the program?
Mazzoccoli: One of the most exciting things is their opportunity to stay within in our ministry and have lots of different kinds of experience based on their choice and their time. At one time, if they wanted to have these kinds of experiences, they would have to choose to leave the ministry to travel. Now they have that opportunity as part of our own portfolio.
The other part is that introduction of external traveling and agency [nurses] is sensitive and sometimes difficult in terms of the acculturation that happens. Nurses see [the flex program] as a way in which they're supported by our own nurses—nurses who come committed to our mission and our vision and our values, who already know what it's like and what it means to be a Bon Secours Mercy Health nurse.
HL: What kind of results are you seeing from the flex staffing program?
Mazzoccoli: We’ve had our external agency nurses opt to join our own internal traveling program. That’s a huge step in and of itself.
We certainly are seeing, thankfully, a downward trend in our resignations and our turnover. There are certainly lots of things that we're working on, so I wouldn't say that this program is necessarily the one single thing, but in our portfolio what we're looking at, particularly for recruitment and retention, are things that afford nurses mobility and flexibility and lots of choice in their own design of their staffing and scheduling.
HL: New nurse turnover is a particular challenge, with newly licensed RN turnover rates reaching 30% their first year and nearly 60% by their second year, according to studies. Is the flex program helping BSMH hold onto its new nurses?
Mazzoccoli: This is one of the ways that we're affording them with opportunities. If some other new nurses can opt to do this, perhaps in a smaller geographic area just to get a taste of different kinds of experiences, either within a facility or market before they make a choice, that will help new nurses get a real-life lived experience before they make the choice.
Often what we hear from the new nurses that choose a unit is, “That’s not really what I thought it was going to be.” It’s not been long enough yet for us to truly say that it’s helping us to hold onto new nurses, but it will continue to be a factor in where nurses choose to work for us and the options they have.
Vivia care model assigns one care team for clients who live in close proximity, enabling more care to more senior citizens.
A new home care model where one caregiver serves a group of clients who live within a close geographic neighborhood is helping to solve staffing challenges while saving money for the client.
The new care model—called Vivia—assigns a client to an assistant and team leader who serve them along with a group of clients who live within close proximity, according to a company press release.
The new model, which has been operating in Hawaii for two years, is now available in Olympia, Washington through a partnership between ABOVE Home Health and Vivia Cares, Inc.
This model enables the client to receive consistent, frequent, and shorter visits—even several times a day—by the same Vivia assistant without having to purchase minimum hours, the company says.
Traditional home care models could not meet community requests for shorter, more frequent visits, said Natalya Rubel, chief executive officer of ABOVE Home Health.
“Now, with Vivia, we are excited to begin offering frequent, shorter visits by a consistent caregiver, which half of our clients have been requesting,” she said.
Vivia clients get a consistent caregiver who helps with various homecare tasks and provides social engagement. There are no minimum hours required and families develop a close working relationship with their neighborhood Vivia assistant, the company says.
The new model is expected to help with Washington’s growing aging population.
The state’s 65+ residents are projected to at least double from 2010 (828,000) to 2040 (1,995,000), with gains of 40,000 per year expected through 2028, according to the most recent Washington State Plan on Aging report.
The available workforce is not able to meet the expected demands under current models, the report says. Introducing the Vivia model to Washington allows ABOVE Home Health to meet the community’s needs by serving many more seniors, as well as offering direct-care workers a new way to work, the company says.
“Vivia’s innovative model not only transforms the experience for seniors,” said Dew-Anne Langcaon, Vivia’s chief executive officer, “but also transforms the job for caregivers by offering higher wages, guaranteed hours, and a company car for transportation to attract Vivia assistants, thus making services much more readily available to many seniors.”
The new advisory council is made up of government officials, educational leaders, and healthcare industry experts throughout Florida and the United States who will collaborate to find solutions to the shortage, according to Keiser University.
Like the rest of the United States, Florida faces a dire nurse staffing shortage that is expected to result in a nursing workforce deficit of 60,000 nurses by 2035, according to a recent report by the Florida Hospital Association.
The new council will seek out and share best practices to develop short- and long-term solutions to the state’s staffing shortage, according to the university.
“We hope to develop at least three or four recommendations that are practical in nature, that can be implemented, that can address head-on, different issues and challenges that will help alleviate the nursing shortage,” said Belinda Keiser, the university’s vice chancellor.
Council members discussed at a press conference some of the barriers they’re already facing to keep pace with the current demand for nurses.
Gino R. Santorio, president and CEO of Mt. Sinai Medical Center, cited the COVID-19 pandemic as a contributing factor to the nursing shortage and shared how Mt. Sinai Medical Center is working on expanding nurse educator programs, is rapidly implementing new technology, and using simulation labs to build new nurses’ confidence.
“Vacancy rates for nursing are double to triple what [they were] pre-pandemic and that’s pretty consistent on a national level,” Santorio said.
Other barriers that exist include burnout, early retirement, higher pay for traveling nurses, a lack of nurse educators, and limitations on clinical availability for advanced nursing students.
“We must salute and applaud Keiser University for convening this nursing advisory council to help tackle the nursing shortage,” Grant said. “Together, we can make a difference.”
Nurses' unique perspective sets them up to be natural healthcare innovators.
Nurses are natural healthcare innovators, and an article in the July issue of Nursing 2022 outlines key actions that nurses can take to turn their ideas into innovations that solve healthcare problems.
Nurses’ understanding of patients, families, and communities provides a unique perspective to the use of technology and other innovative processes to promote health and well-being, prevent disease, and manage acute and chronic conditions.
Innovations can produce new devices or products, but they also may result in new processes or concepts for change, according to the article by Dr. Nelita (Marianela) Iuppa, DNP, MS, BSN, NEA-BC, RN-BC, FHIMSS, Cleveland Clinic’s associate chief nursing officer for informatics.
She referenced a Cleveland Clinic medical-surgical nurse who recognized the need for enhanced assessment skills for pressure injuries for patients with limited mobility.
“She determined that assessments done under the aid of a mirror produced better outcomes with minimal pain and discomfort associated with traditional nursing skin assessment turning techniques,” the article says.
The nurse worked with her manager to purchase handheld mirrors for the nursing staff and created the “Reflect to Inspect” initiative, which has been a resounding success. Since “Reflect to Inspect” was initiated, no pressure injury incidents in the nurse’s unit have been identified in more than three years, the article says.
Still, setting aside dedicated time to identify and engage support resources to bring an idea to fruition is a challenge. The article offers detailed steps that nurses can take to help that happen, including:
"We must promote nurse-led innovation initiatives internally and externally, to amplify the work being done by nurses in education, research, policy, and practice," says Marion Leary, RN, MSN, MPH, FAHA, director of innovation at Penn Nursing.
"If we do this, we will achieve a clear, coherent, and unified message around nurse-innovation,” Leary says, “and further solidify the innovation ecosystem within the profession.”
MDRO transmission is common in skilled nursing facilities, which contributes to substantial resident morbidity and mortality and increased healthcare costs, according to the CDC.
EBPs, however, are an infection control intervention designed to reduce transmission of resistant organisms.
Introduced by the CDC in 2019 as a new approach to the use of personal protective equipment (PPE), EBP employs targeted gown and glove use during high-contact resident care activities, such as dressing, transferring, helping with hygiene, changing linens, assisting with toileting, wound care, and use of devices such as a central line, urinary catheter, feeding tube, or tracheostomy/ventilator.
A summary of the CDC’s updates this week include:
Added additional rationale for the use of EBP in nursing homes, including the high prevalence of MDRO colonization among residents in this setting.
Expanded residents for whom EBP applies to include any resident with an indwelling medical device or wound, regardless of MDRO colonization or infection status.
Expanded MDROs for which EBP applies.
Clarified that, in most situations, EBP are to be continued for the duration of a resident’s admission.
Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care,” according to the CDC.
Standard precautions—a group of infection prevention practices—continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status, the CDC notes.
The CDC notes that many nursing homes implement contact precautions only when residents are infected with an MDRO and on treatment. But focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, who have no symptoms of illness. In fact, MDRO colonization may persist for long periods of time—months, even—which allows the “silent spread” of MDROs, the CDC says.
Newly adopted state budget allocates more than $500M for long-term care and nursing facilities.
Senior care advocacy groups are celebrating Pennsylvania’s “historic” investment in senior care after Gov. Tom Wolf signed into law a state budget that allocates more than $500 million for long-term care and nursing facilities.
The move is a “new chapter in Pennsylvania’s long-term care industry,” said Wolf, who joined senior care advocacy groups and state lawmakers for a joint press conference Monday.
The spending plan allocates $250 million to long-term care, including $131 million in immediate support for nursing facilities using some of Pennsylvania’s remaining America Rescue Plan Act (ARPA) funding.
“It also lays out a major rate increase for nursing facilities with the requirement that 70%—seven-zero percent—of the funds to be spent directly on resident care to ensure that taxpayer dollars are spent as intended and to provide ongoing support for facilities and staff in the years to come,” Wolf said.
“This funding will help stabilize the direct-care workforce and nursing facilities in Pennsylvania,” Wolf said. “It will help ensure that our direct-care workers have the support they need to keep providing high-quality care to [long-term-care] residents.”
The budget also includes a Medicaid raise of $35 per resident per day for nursing homes.
“What an incredible day it is for long-term care in Pennsylvania,” said Zack Shamberg, president & CEO of the Pennsylvania Health Care Association.”
“I stood here a little more than two months ago, and I asked our elected leaders, ‘Who will care? If nursing homes across Pennsylvania continue to close, who will care for our most vulnerable residents?’” he said. “‘And if providers are forced to turn away vulnerable senior citizens simply because they don’t have enough staff, who will care enough here in Harrisburg to step up and do something about it?’”
The Pennsylvania General Assembly’s state budget and spending plan “makes a historic investment for the Commonwealth’s nursing homes, personal are homes and assisted living communities,” Shamberg said. “It is truly an investment that could save senior care in this state.”
The spending plan is “a huge step in the right direction,” said Matt Yarnell, president of SEIU Healthcare Pennsylvania.
It will: lift wages, creating living-wage jobs; allow for safe staffing levels; and provide for the training and education support employees need to make long-term care a career, he said at the press conference.
Preventing sepsis begins with preventing infection, says the chief medical officer of Sepsis Alliance.
In a typical year, more than 350,000 adult Americans die of sepsis—a number that could be lowered with better recognition of signs and symptoms of sepsis by everyone on a care team, says the chief medical officer of Sepsis Alliance, the nation’s first and leading sepsis organization.
“It should be everyone's responsibility,” says Cindy Hou, DO, MA, MBA, CIC, CPHQ, FACOI, FACP, FIDSA, Sepsis Alliance’s chief medical officer. Dr. Hou also is the infection control officer and medical director of research at New Jersey’s Jefferson Health.
“And the reason I say ‘everybody’ is just imagine that physical therapy comes to a person's home or to long-term care and they are doing careful assessments every single day. They may notice [signs of sepsis]. That’s why, in my opinion, everybody should be engaged,” she says.
A 2018 DePaul University study also found a lack of sepsis awareness among healthcare professionals, though it noted that “the nature and ambiguity of sepsis may contribute to the lack of understanding and lack of research.”
That knowledge gap regarding sepsis results in some startling data. According to Sepsis Alliance:
More than 1.7 million people in the U.S. are diagnosed with sepsis each year.
In the United States, sepsis takes a life every two minutes.
Sepsis is the No. 1 cause of hospital readmissions, costing more than $3.5 billion each year.
Nursing home residents are over 6 times more likely to present with sepsis in the emergency room than non-nursing home residents.
More than one-quarter of U.S. adults have NEVER heard of sepsis and just 15% can name the common symptoms.
Elderly most prone to sepsis
Anyone can get sepsis, but those most prone include elderly people with chronic conditions such as diabetes, or kidney, heart, or lung disease, Hou says.
Indeed, more than 70% of sepsis patients are 60 years of age or older and adults age 65+ are 13 times more likely to be hospitalized with sepsis than adults younger than 65, says Sepsis Alliance.
And while sepsis is the leading cause of death in U.S. hospitals, according to Sepsis Alliance, that can be partially attributed to a patient’s condition before they ever entered the hospital, Hou says.
“Often what happens is that people present too late in the game, and the body’s response is very hard to turn off and so people may succumb to their underlying illness,” Hou says. “Most the time when people have sepsis, they really had an infection that was going on well before they came into the hospital.”
But sometimes, she says, sepsis isn’t recognized in time by clinicians.
“Sometimes there is what I call ‘academic disagreement’ about what constitutes a patient who has sepsis versus one who doesn't,” says. “What ends up happening is … lack of recognition of early signs and symptoms. Now sometimes, no matter what we do—they have the patient on the right treatment—sometimes they still succumb to their illness and that's where it hinges not on the treatment that was given but rather on the response of that patient’s body.”
In a home health setting, the subtle signs and symptoms of sepsis may go unnoticed by caregivers and family members, and the patient may be unable to articulate any discomfort, Hou says.
“An elderly person may have bladder pressure but perhaps they had a stroke or they can't express themselves,” Hou says.
Additionally, because the older population is more likely to have chronic conditions, the signs and symptoms of sepsis may not behave in a textbook manner and may present much later, when the danger of septic shock increases, Hou says.
Symptoms of sepsis
It's About TIMETM is Sepsis Alliance’s national initiative to raise awareness of sepsis and the urgent need to seek treatment when symptoms are recognized:
T – Temperature: Higher or lower than normal
I – Infection: May have signs and symptoms of an infection
M – Mental decline: Confused, sleepy, difficult to rouse
E – Extremely ill: Severe pain, discomfort, shortness of breath
“They may have a high temperature or a low temperature, they could be breathing fast, their heart could be fast, and it’s due to infection,” Hou says. “Most of the common causes of sepsis are related to conditions like a urinary tract infection, pneumonia, skin infections, or infections within the abdomen.”
Nurses are the “secret weapon” against sepsis because they’re generally with patients more often than physicians, Hou says.
“A nurse will be most likely to notice that something is off and, depending on their skill level, they may often be able to tell the ordering physician that this is what's going on,” Hou says.
Preventing sepsis
Lowering the numbers on sepsis centers on preventing it, as well as ensuring patients are treated correctly once it is diagnosed, Hou says.
Preventing sepsis begins and ends with infection control, she says.
“At the heart of it, sepsis is due to an overwhelming infection,” Hou says, “so the best way to prevent sepsis is to prevent an infection from occurring in the first place.”
Reliable Home Health Care LLC misclassified employees as independent contractors, denied overtime pay and falsified payroll records, feds say.
A Dayton, Ohio home health care provider who misclassified its employees as independent contractors, denied workers overtime pay, and falsified payroll records to hide the violations must pay $133,661 in back wages to 63 of its employees.
An investigation by the U.S. Department of Labor’s Wage and Hour Division determined that Reliable Home Health Care LLC and its owner Sheikuna Omar misclassified home health aides and office staff as independent contractors. The employer then paid workers straight time for hours over 40 in a workweek, a violation of federal law, according to a press release from the Labor Department.
The division’s investigation disclosed that the company falsified its payroll records in an attempt to hide the violations of the Fair Labor Standards Act.
“Reliable Home Health Care workers provided around-the-clock, daily living assistance and delivered essential care to people in need, yet their employer denied workers their earned overtime wages and then falsified records to create an appearance of compliance with the law,” said Matthew Utley, Wage and Hour Division district director in Columbus, Ohio.
“Misclassification of employees as independent contractors and overtime violations are all too common in the home healthcare industry,” Utley said. “The U.S. Department of Labor will protect the rights of workers who commit themselves to the care of others and ensure they are paid all their legally earned wages so they, in turn, can take care of themselves and their families.”
Reliable Home Health Care provides home health care, skilled nursing care, physical and occupational therapy, and speech therapy services. The company also operates offices in Columbus and Cincinnati.
“For a healthcare employer to succeed in this competitive industry they must recruit and retain qualified workers,” Utley said. “When workers are not paid their full wages, they may look elsewhere for employment.”
The one-day strike is set to demand better wages, safer staffing, and better patient care.
Workers at a 159-bed Bloomfield Hills, Michigan, nursing home will go on a one-day strike July 11, demanding better pay, safer staffing levels, and better care for patients.
SKLD Bloomfield Hills employees voted unanimously to strike, according to a press release issued by SEIU Healthcare Michigan.
“While the owners of nursing homes like SKLD look out for their profits, the workers who go above and beyond to provide quality care struggle to afford our groceries and rent. That’s why the nursing home industry is a revolving door—because employers don’t respect our voices or pay us enough to survive,” said Aulana Harper, a certified nursing assistant (CNA) at the nursing home.
“Now, we are standing together to win a voice on the job. And our ability to use our strength in numbers to negotiate for better pay, safer staffing, and respect, and to solve our issues together so we can provide the quality care our residents deserve and take care of our families is only possible through a union," Harper said.
SKLD Bloomfield Hills is not without embroilments. On the Medicare.gov website, the for-profit nursing home, on a scale of one to five stars, ranks just a “one” for an overall rating. The overall rating is based on a nursing home's performance in three areas: health inspections, staffing, and quality measures, according to Medicare.gov.
Additionally, SKLD Bloomfield Hills has been assessed $335,000 in fines for “deficiencies,” according to ProPublica.
Among those deficiencies are:
Neglect of a patient.
Two instances of failing to ensure residents were treated in a dignified manner. One was when staff referred to a resident as a “feeder” and complained about their job in front of residents. The second was when a sign that discussed positioning needs was observed propped on the front/lap area of a severely cognitively impaired resident in a geri-chair.
Failing to ensure personal privacy for two residents who were unknowingly video recorded by an employee and posted on social media.
Failure to maintain an effective infection control program and follow infection control practices according to Centers for Disease Control (CDC) guidelines and facility policy for COVID-19.
