Report calls for easing access, improving home health for older adults

Older adults have suffered disproportionately from the COVID-19 pandemic, with increased risk of severe illness and death reported across the globe. A new report argues that one policy change made during the pandemic should remain in place after the novel coronavirus virus fades away: better access to home health services through Medicare.

In a new set of recommendations published by the Commonwealth Fund, researchers at Oregon Health & Science University and Duke University argue for regulatory changes to expand the Medicare home health benefit.

"Changes to the benefit could allow more Medicare beneficiaries to receive services in their own homes, rather than institutional settings, so they may reduce their exposure to COVID-19," they write.

The pandemic affords a unique opportunity to consider long-term improvements in health care for seniors, said Walt Dawson, D.Phil., an assistant professor of neurology in the OHSU School of Medicine, who co-authored the report with Courtney Harold Van Houtven, Ph.D., a professor of population health science in the Duke University School of Medicine.

"This is a real opportunity for change in our health care system," Dawson said. "It's an opportunity to rethink and readdress how we provide health care and how we pay for health care services, in particular for older adults."

"Bolstering the Medicare home health benefit could enable older adults to more easily receive care in the setting that most of them prefer—their homes," Van Houtven said. "Innovations could help the older adult with care needs and family caregivers who support them."

The temporary pandemic-era rules are a major benefit to seniors for whom traveling can be an ordeal, including the McCrary family in John Day, Oregon.

Margy McCrary said she and her husband, Eddie, a retired machinist living with a form of aphasia, recently completed an annual neurology checkup with an OHSU clinician by way of an hour-long video exam from the comfort of their own home, saving a five-hour trip into Portland.

"It was a Godsend," she said. "It's more comfortable for him, he's more at ease, the stress level's down. This is just such a relief. If anything good comes out of this COVID thing, doing these video appointments has been perfect."

New Medicare rules approved under the Coronavirus Aid, Relief, and Economic Security, or CARES, Act in March for the first time enabled nurse practitioners, clinical nurse specialists and physician assistants to certify a Medicare beneficiary's eligibility for home health services. Until then, only a physician could certify a patient's need for home health care. In addition, the act provided sweeping expanded access to telehealth services, albeit not for home health visits.

"Strengthening telehealth access could enable critical monitoring of patient status at a time when beneficiaries are not eager to have providers visit their homes," the authors write.

The new Medicare rules are a welcome relief for many patients in the same position as the McCrarys, said Allison Lindauer, Ph.D., N.P., assistant professor of neurology in the OHSU School of Medicine.

As a nurse practitioner, she now can certify home health for patients who need it.

"Advanced practice providers have been very limited in their ability to order home care services," Lindauer said. "I really believe in the value of home-based care and rehabilitation and am relieved I can now order this for my patients."

The report lays out three major policy recommendations:

• Expand opportunities to provide care at home: The report suggests better integrating home health, health care and social care; expanding coverage of telehealth home health visits after discharge from skilled nursing facilities; and paying family caregivers to support COVID-19 patients' recovery at home.
• Bolster the home health workforce: This would make permanent the scope of practice for nurse practitioners, physician assistants and clinical nurse specialties now allowed under the CARES Act. The report also recommends increasing wage and benefits for home health aides, who currently earn less than $12 an hour on average nationwide.
• Enhance quality and oversight: The report recommends expanding regulatory oversight of home health agencies.