Appendix D (continued)
Home Health
Home health agencies (HHAs) provide part-time care to
patients in their homes. In a major disaster, many home health patients are
not able to self-evacuate and require help moving, access to care, and
specialty aids or medical equipment in order to evacuate and travel to a new
location. Benefits of a national system, privacy and confidentiality issues,
existing admission and discharge procedures, and existing information
technology systems for home health agencies were examined through discussions
with HHA directors or administrators in urban and rural areas of Florida and California.
Home Health Typology, Population and Definitions
HHAs
provide skilled nursing care, physical therapy, occupational therapy,
speech-language therapy, home health aide services, medical social services,
and other services to patients in their home. Some patients require services
multiple times per week and others require assistance multiple times per day.
Medicare home health patients are homebound and require skilled nursing or
therapy services.
There are about 7,530 HHAs and 1.4 million home health
care patients in the United States. About 7% of home health patients are
served by a noncertified HHA; the remainder is served by a Medicare and/or
Medicaid certified HHA. Proprietary HHAs serve about 34% of home health
patients; nonprofit agencies serve 57% of patients; and government or other
serve 9% of home health patients in the U.S. Sixty-five percent of patients are
served by an agency that is part of a chain, operated by a hospital, or
operated by a health maintenance organization.64
This discussion of HHA procedures, systems, and evacuation plans only applies
to certified HHAs.
There are 270 Medicare certified HHAs in Miami-Dade County
and 37 in Monroe County, a southern Florida rural county. There are 396
Medicare certified HHAs in Los Angeles County and 12 in San Luis Obispo, a
southern California rural county.65
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Home Health Intake and Discharge Processes
Home health patients are referred to an agency from a
physician, hospital, or other provider and the HHA decides whether they can
provide the services the patient needs. Preliminary information is entered
into their IT system and a nurse is dispatched to the patients' home to do the
initial assessment. A written plan of care is created between the physician
and the HHA staff. This plan of care describes which services will be provided
to the patient. Data elements include:
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Name.
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Date of birth.
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Social Security number.
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Payer/insurance (if any) and insurance policy number.
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Family contacts/next of kin/emergency contact.
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Demographics.
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Physician name.
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Physical capabilities and assistance needed with activities of
daily living.
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Care regimen and duration.
Internet access is generally not available where the
patient is assessed (in the patient's home), but is available where the data
are later entered (at the HHA office).
Medicare home health patients typically receive a 60-day
episode of care. At the end of each episode, the HHA reports back to the
physician and Medicare about the condition of the patient. If the patient is
not better or needs additional care, the patient is discharged (because the
episode is complete) and readmitted. The patient needs to be recertified and
the nurse goes back to the patient's home to reassess the patient and develop a
new plan of care. Most home health patients require care for more than one
60-day episode. If a patient is recertified, they receive the same medical
record number and same identification number, but a different episode number.
When services are no longer needed, the patient is discharged.
In an emergency evacuation, the HHA would not discharge
the patients in the system if patients are being evacuated for a day or two.
If the evacuation is for a longer period of time, the HHA could place the
patients 'on hold' and alert their families.
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Existing Home Health Information Technology Systems with
Population-Level or Client-Level Data
Several systems have population-level or client-level data
on home health patients. Home health agencies have electronic systems for
their billing and some clinical data. These systems use unique identifiers for
each patient, but the identifiers are not the same across systems. There are
several major vendors of these IT systems.
Home Health Client-Level Data. The Outcome
and Assessment Information Set (OASIS) is the core group of data elements that
are collected during a comprehensive assessment for all Medicare or Medicaid
home health patients receiving skilled care. This comprehensive assessment is
completed within 5 days of the start of care. These data elements and
assessments are the basis for the development of the plan of care and ongoing
management of the patient. OASIS data are used to measure changes in a
patient's health status between two or more time points. All home health
agencies must be able to produce or extract a standard set of data for
Medicare/Medicaid patients.
Data elements collected include demographics (gender, age,
race/ethnicity, marital status, informal caregiver assistance) and patient
history, living arrangements, supportive assistance, health status (sensory,
skin, respiratory, neuro/behavioral status), activities of daily living,
medications, and required medical equipment. Patient addresses are not
transmitted with OASIS data; in order for a national system to find the
locations from which home health patients need to be evacuated, the OASIS data
would need to be matched against the Medicare Enrollment Database using patient
identifying information.
HHAs are required to transmit electronically OASIS data
for home health patients receiving Medicare and Medicaid services to State
survey agencies within 30 days of the completion of an assessment. The State
survey agencies are responsible for collecting OASIS data according to Centers for Medicare &
Medicaid Services (CMS)
specifications and preparing the data for a CMS established national
repository.
Home health agencies are able to run internal daily
reports on the number of current home health patients they are serving. The
system allows the agency to run reports by several categories, but these daily
reports are usually sorted by diagnosis or physician name.
Home Health Comparison of Data Systems. In
an emergency, it would not be possible to know exactly how many home health
patients are living in a specified area and what type of help each patient
needs to be evacuated (ambulance, van equipped for wheelchairs, etc.).
Facility-level databases have information on location of home health agencies
and the services they provide, but do not have information on the number of
patients served by each agency. Patient-level data is available through OASIS,
but this data is not current (does not need to be transmitted to the State
agency until 30 days from completion of the comprehensive assessment) and does
not include patient addresses. Since data on the patient's informal caregiver
assistance is collected during the comprehensive assistance, OASIS can identify
those patients who are completely dependent on others for evacuation and do not
have family or another caregiver to help.
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Home Health Evacuation Plans
Some HHAs believe it is their responsibility to help transport
patients in an emergency, but others do not. One HHA administrator said the
HHA does not have its own transportation since nurses and aides travel in their
personal cars to the patient homes. It would not be possible for the HHA to
transport the patients.
Patients with family members in the local area likely will
have help from their family to leave their home, but other patients will need
transportation help. Those agencies that do feel responsible for helping their
patients evacuate may have agreements with local transportation companies and
will work with them to set up transportation for each patient. Evacuation of
patients will be time consuming since each patient starts in a different
location (in their home) and will evacuate to different locations.
In an emergency, HHAs would review each patient's needs
and try to identify a location that can provide care for their individual
needs. The HHA refers patients to shelters and will call to see if there is
space available for the patient. If a patient needs help with wound care or
medications, they will be evacuated to a specialty shelter that can provide
that care. Some shelters allow home health agencies to send their staff with
the patient and then the patient remains in the nurse's care and is not
discharged from the HHA. However, since each nurse tends several patients, and
they would probably not all be evacuated to at the same shelter, many patients
would be sheltered without their nurses.66
One HHA administrator believes that the HHA staff are part of each patient's
family and will do whatever is needed to help each patient; this administrator
said that "It doesn't matter where the nurse has to go to give a patient their
care—she will go."
In Florida, where emergency plans are mostly focused on
hurricanes, HHAs do have detailed plans to care for their patients in a
hurricane. An HHA does not want to endanger the nurses and aides by asking
them to go to the patient's homes, so they ask the staff to go to the patients
homes before the hurricane arrives to make sure they have everything they
need. One HHA gives each patient a disaster recovery plan that details
everything a patient should do in an emergency (what food to have, what to
bring with them if evacuating, where to go, etc.). After the storm, nurses
visit their patients to determine their status and assess any new needs
resulting from the storm. Home health agencies are not as prepared for a
larger or longer mass evacuation.
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Home Health Perceptions: Benefits of Evacuation Tracking
During an evacuation, HHAs want to know what has happened
to their patients. In the weeks immediately following Katrina, New Orleans
HHAs heard from most of their staff, but did not know what had become of the
great majority of their patients—whether they had evacuated, were receiving
appropriate care, etc. Since HHA patients are located in their homes and not at
one physical location, evacuating each patient in an emergency is difficult and
time may be inadequate to evacuate them all following an evacuation order.
Some HHAs believe they are fully responsible for helping their patients
evacuate, while others do not believe they can accept this responsibility.
HHAs need to alert emergency coordinators about where
their patients who cannot self-evacuate reside. A national tracking system
could provide assistance with coordinating transportation, identifying
destination locations, making certain that patients end up in appropriate care
settings, and eventually resettling patients back to their homes. One
administrator is a proponent of a national system because it will help assure
patients that in an emergency, someone is concerned with locating them and
helping with their evacuation and relocation.
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Home Health Privacy and Confidentiality Issues
Under HIPPA, patients must sign a specific authorization
before the provider may release their medical information to an outside
business for purposes not related to their health care. The HHA must ensure
that all patient identifiable information remains confidential as a condition
of participation as a Medicare provider.
It is important that receiving locations have access to as
much information as possible about the patient medical records to provide the
most appropriate care for them. Home health agencies do not have further
company policies about sharing information and believe that it is possible to
share aggregate-level information.
64. Center for Disease Control and Prevention, National Home and Hospice Care data, 2000.
65. Home Health Compare, http://www.medicare.gov/HHCompare/Home.asp
66. In addition, nurses and their families may also be facing evacuation, so planners should not assume that home health patients will be accompanied by their familiar nurses.
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