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Section 202 extends the waiver of liability to denials for home health services when the denial is based on failure to satisfy the homebound or intermittent skilled nursing requirement. The section also extends to home health agencies the favorable presumption of a waiver of liability when the home health agency's denial rate does not exceed 2.5% of claims.

Section 204 requires the Secretary of the Department of Health and Human Services to develop a uniform needs assessment instrument to determine an individual's functional ability and to assess the "need for post-hospital extended care services, home health services and long term care services of a health-related or supportive nature". The Secretary must also advise Congress on the advantages and disadvantages of using the instrument as the basis for determining whether to make payment for home health services. Use of such an assessment instrument could rationalize and make more objective and predictable the determination of eligibility for post-acute care services.

Section 205 requires expedited home health agency claims review by fiscal intermediaries.

Section 207 permits providers to represent beneficiaries on appeals and permits appeals of technical denial of home health agency claims.

Section 208 requires the inclusion in annual reports on PPS information on the quality of post-hospital services and an assessment of problems encountered by beneficiaries on receiving post-hospital services.

6. Senator Bradley (with Glenn and Heinz) has introduced S. 2494, "The Medicare Home Health Care Improvement Act of 1986". The bill proposes: to raise cost limits for home health providers and permits them to aggregate the costs of all provided services.

The bill also includes a proposal to require Medicare certified hospitals, as a condition of participation, to provide discharge planning for all elderly hospital patients as well as those scheduled for ambulatory and inpatient surgery. The bill also requires BCFA to publish for public comment all proposed policies and rules.

While each of the foregoing pieces of legislation attempts to remedy particular problems in Medicare's home health benefit, much work remains to be done. There is no doubt that we are in the midst of a major shift in the focus of health care from the institution to ambulatory settings. But we cannot allow the drive for cost efficiency to override the equally valid goals of quality and access to care by those in need of services. The remedy for the current situation is to keep beneficiaries as our main focus. Only by clearly understanding the needs and experiences of beneficiaries can we design public policies which adequately balance the impetus to contain costs, assure access to services, and provide quality care.

APPENDIX

Definition of Terms in BCFA's Survey of Providers

A deficiency means that the surveyors concluded, based on an on-site visit to the providers and review of their records, that the provider did not meet the following requirements:

"Coordination of Patient Services: All personnel providing services maintain liaison to assure that their efforts effectively complement one another and support the objectives outlined in the plan of treatment.

(1) The clinical record or minutes of case conferences establish that effective interchange, reporting, and coordinated patient evaluation does occur.

(ii) A written summary report for each patient is sent to the attending physician at least every 60 days.

Plan of Treatment: The plan of treatment developed in consultation with the agency staff covers all pertinent diagnosis, including:

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(x)

(xi)

(xii)

medications and treatments,

any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items.

(Examples: laboratory

procedures and any contra-indications or precautions to be be observed.)

If a physician refers a patient under a plan of treatment which cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the origianl plan. Orders for therapy services include the specific procedures and modalities to be used and the amount, frequency, and duration. The therapist and other agency personnel participate in developing the plan of treatment.

Conformance with Physicians Orders: (1) Drugs and treatments are administered by agency staff only as ordered by the physician. (ii) The nurse or therapist immediately records and signs oral orders and obtains the physician's counter-signature. (iii) Agency staff check all medicines a patient may be taking to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, and contra-indicated medication, and reports any problems to the physician.

Clinical Record Review: At least quarterly, appropriate health professionals, representing at least the scope of the program, review a sample of both active and closed clinical records to assure that established policies are followed in providing services (direct as well as services under arrangement). There is a continuing review of clinical records for each 60-day period that a patient receives home health services to determine adequacy of the plan of treatment and appropriateness of continuation of care. " (HCFA, Home Health Agency Survey Report, form HCFA1572).

APPENDIX D

ANALYSIS OF:

STATE OF CALIFORNIA
DEPARTMENT OF SOCIAL SERVICES

"EVALUATION
OF

IN-HOME SUPPORTIVE SERVICES PROGRAM"

MAY, 1983

PROGRAM REVIEW BUREAU

INTRODUCTION

A number of Home Health Agencies in California have been committed to improving the availability and quality of home health care for those with long term health care needs. A significant segment of the home care provided to those with long term health care needs has been done by Homemakers-Home Health Aldes, nurses' aides, family members, relatives and companions.

In recognizing the role of the non-professional in long term care, these agencies have been developing recruitment, training and supervisory standards for non-professional home-health care personnel in order to provide the public with assurances concerning agency quality controls, appropriateness of services and accountability for their long term care patients.

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In-Home

As a part of this activity these agencies have for years been critical of the California Title XX Program Supportive Services. In California, some 96,000 frail elderly, blind and disabled people are receiving in-home supportive services. Of these 96,000 individuals, approximately 60,000 people in 27 counties have access to home care only through "Individual Providers" The term "Individual Provider" (IP)* is a State Department of Social Services coined euphemism describing an unskilled, untrained, unsupervised and unmonitored person who the service recipient allegedly employs to perform home and health care services. For many years, the State Department of Social Services has held that these "Individual Providers" are quasi-private contractors and that the client is the employer. However, the courts have found (United States Court of Appeals, D.C. No. 75-1812-MHP - Eleanor Bonnettte, et al, Plaintiff, United States of America, Intervenor versus California Health and Welfare Agency, et al) that the Independent Provider is actually a co-employee of the State and the County.

The

These concerned agencies have been advocates for quality assurance, appropriateness of service and utilization, and accountability in the use of non-professionals in home care. largest employer of this group of people however, is the State of California which promulgates those very concepts that are abhorrent to those interested in long term home care. The State Report and this Analysis will use the initials "IP" from time to time to refer to "Individual Providers".

The following is an analysis by concerned Home Health Agencies of a service mode study commissioned by the State Department of Social Services. Using these State generated statistics and findings we wish to more thoroughly acquaint the public with the In-Home Supportive Services Program.

Visiting Nurse Association of San Francisco, Inc.
Home Health Services of Lake County

Health Conservation, Inc.

Visiting Nurse Association of Pomona-West End
Visiting Nurse Association of Orange County
Visiting Nurse Association of Los Angeles

The In-Home Supportive Services (IHSS) Study Report states In the introduction that the purpose of the Program Review Bureau Report was to:

1.

2.

Determine if significant cost differences exist among

the different modes of services;

Describe the different methods of each mode;

3. Evaluate the difference in quality, if any, among the different modes and combination of service delivery; and Recommend changes in program direction for

4.

Improvement and cost effectiveness.

The Report is extremely confusing in that the four

objectives, the purpose, of the study were not dealt with in a clear and concise fashion. It appeared that the reporters had reached their conclusions and recommendations prior to the accumulation and study of the data. The results of this study draw the thoughtful and analytic reader to conclusions that make the Report's recommendations less than rational, logical,

efficient or cost effective.

The aforementioned concerned agencies' analysis of the data In the Report will start with the study objectives as stated

above!

PURPOSE 1. Determine if Significant Coat Differences Exist Among the Different Moves of Service"

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The first objective of the study was in the data. The

It is an

numbers are clear. It is shown that "significant cost differences exist among the modes of services". The Report however chose to downplay this result by paying a great deal of attention to the "Disability Index". The "Disability Index" was developed in the IHSS Equity Demonstration Project. assessment guide and functioning scale that has been criticized as inappropriate, simplistic, unscientific and wrong. It was developed under a contract with the School of Social Welfare without the participation of experts in medicine, disability, health rehabilitation, home or community care, nursing or gerontology. In short, the disability Index is not respected by colleagues in the field but continues to be utilized like flawed and incorrect Intelligence tests which do great harm to people

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