Report on the Massachusetts Serious Illness Coalition

The MA Serious Illness Coalition pushes to bring awareness and focus on end-of-life issues.

“It is my goal that every nursing school in MA embrace that a nursing student must see a dying patient with the same fervor that they embrace that every nurse must see a baby being born.”
— Susan Lysaght Hurley, PhD, RN
Director of Research, Care Dimensions, Inc

Last week, the Massachusetts Serious Illness Coalition hosted its annual meeting welcoming more than 100 attendees to the JFK Library in Boston. The message from the Coalition’s leadership – as articulated by Blue Cross Blue Shield MA President and CEO – is that “the momentum is building.” From the Coalition’s beginnings less than five years ago, Dreyfus has focused on a long-term strategy to achieve the Coalition’s six goals. These include the ideas that everyone in Massachusetts 18 years or older has a designated health care decision-maker and that all Massachusetts clinicians have appropriate training to communicate comfortably with patients around advanced care planning and serious illness. Dreyfus has likened the work to that done in years past on smoking and on car seats, where steady force and public messaging achieved near-universal changes in public thinking.

The progress on clinician education – from a provider association perspective – is perhaps the most engaging and encouraging news. Dr Atul Gwande, as eloquent as ever, declared that the work to date has shown that: “People have priorities in life beyond just surviving, but you must ask them. Suffering happens when care doesn’t match our priorities.”

In addition to a public education campaign about engaging in advanced care planning conversations, Dr. Gwande announced that the Coalition is in talks with all four Massachusetts medical schools about a cooperative effort to require training of med students in serious illness communication as a graduation requirement.

But it was Dr, Hurley’s remarks that struck home for the home health and hospice agencies in the Coalition. In addition to the above comment, Dr. Hurley spoke of being a young nurse “totally unprepared as to how to talk to the dying.” Along with her subcommittee co-chair Anne Marie Barron of Simmons College, she is working on recommendations on core competencies for nursing education related to serious illness care. These are to be presented in the near future to the Massachusetts Association of Colleges of Nursing. What a great achievement that would be!

For those following the Coalition’s work, these may also be of interest:

  1. End Games, an Academy Award-nominated short documentary on hospice and palliative care executive produced by Shoshana Ungerleider, MD. It premiered at Sundance Film Festival in 2018 and was acquired by Netflix.

2. The Coalition’s public message research and draft public facing marketing approaches.

Commendable progress!

Return to www.thinkhomecare.org.

Get “Woke” on Sepsis

Several new resources are available to members to help them combat one of the most dangerous health conditions in the Commonwealth: Sepsis.

Massachusetts Sepsis ConsortiumSepsis: A public health challenge of enormous proportions, a top driver of health care costs, and a condition that kills more people each year than cancer. But when recognized and treated swiftly, sepsis can be stopped before it causes significant health damage.

The statistics are sobering: Approximately 42,000 Massachusetts residents are diagnosed with sepsis every year and an estimated 5,000-7,000 of them die from the condition. Sepsis is consistently among the top causes for 30-day hospital re-admissions in all regions of Massachusetts and is the third-leading cause of hospital inpatient deaths in the state. And yet, Massachusetts is only a middling performer on sepsis indicators, ranked 25th in mortality in 2017 and at the national average in providing timely care for patients with sepsis.

Providers and policy makers have come together as the Massachusetts Sepsis Coalition – under the umbrella of the Betsey Lehman Center for Patient Safety – to bring more resources to bear in terms of understanding, identifying, and treating sepsis. The Coalition’s initial task force assessed the current state of sepsis response in hospital emergency departments and just recently released their extensive report, with recommendations.

Because 80% of sepsis cases are thought to originate outside the hospital, the home care community is beginning to examine our own understanding of, and training around, sepsis identification. A year or so ago, the Home Care Association of New York State developed their “Stop Sepsis at Home” campaign and tool kit. The Home Care Alliance of MA presented this to our members on several occasions, including at last year’s annual Spring Conference and Trade show.

On May 14th, 2019, the Alliance will host – along with Healthcentric Advisors – a free Train the Trainer session on Sepsis Awareness in the home setting. All members are encouraged to send someone. Agencies who cannot attend can find sepsis resources below.

Return to www.thinkhomecare.org.

Home Health, EHRs and Data Interoperability

In 2011, the Centers for Medicare and Medicaid Services launched the “Meaningful Use (MU) initiative to incentivize certain sectors in the US health care system to move toward electronic health records (EHR) that would be used in a meaningful manner that allows for the electronic exchange of information to improve continuity and quality of care. Significant financial incentives were provided to “eligible providers” – essentially defined as hospitals and physician practices. More than $20 billion was spent and more that 600,000 eligible providers were enrolled. Home health, behavioral health and skilled nursing facilities were not eligible.

Now, it seems there is some limited acknowledgement that it may be time to rethink that. In a proposed rule relative to interoperability just published in the Federal Register, CMS is including – as a Request for Information – an ask for any feedback as to how to improve data interoperability for providers that have as yet received any incentives for using electronic health records.

“Transitions across care settings have been characterized as common, complicated, costly, and potentially hazardous for individuals with complex health needs. Yet despite the need for functionality to support better care coordination, discharge planning, and timely transfer of essential health information, interoperability by certain health care providers such as long term and PAC, behavioral health, and home and community-based services continues to lag behind acute care providers,” the proposed rule says.

CMS acknowledges that a contributing factor to the lag in Interoperability among post-acute care providers was that they were not eligible for incentives under the program formally known as meaningful use. CMS asks for input on specific ways it could financially help these sectors adopt and use technology.

CMS also asks for feedback on measurement concepts and quality improvement steps that could feasibly be applied to post-acute care, behavioral health and home and community based-services providers. Given that mandate in the IMPACT ACT that certain patient assessment data should be standardized and CMS is interested in feedback as to what parts of that data set — or the whole IMPACT Act data set — would be appropriate to include.

Adding some fuel to what may be an obvious fire (no incentive = limited movement) is a just published study in the Journal of the American Medical Directors Association that examined gaps in communication between hospital and home health care staff, concluding that some could have serious medical consequences.

The authors surveyed nurses and staff at 56 home health agencies throughout Colorado. Participants were sent a 48-question survey covering communication between hospitals and agencies, patient safety, pending tests, medication schedules, clinician contact and other areas. Although almost all (96 percent) respondents indicated that Internet-based access to a patient’s hospital record would be at least somewhat useful, fewer than half reported having access to EHRs for referring hospitals or clinics. No surprise: getting medication doses right due to conflicting information was identified as a major problem.

Their conclusion: Future interventions to improve communication between the hospital and HHC should aim to improve preparation of patients and caregivers to ensure they know what to expect from HHC and to provide access to EHR information for HHC agencies.

Comments to CMS will be due in April. Date not yet announced.

Return to www.thinkhomecare.org.

How CMS Stole Home Care Christmas!

Every person in Home Care liked caring a lot.
But the Grinches south of Baltimore, they surely did not!
The Grinches hated home care, delivered in any which way.
Now, please don’t ask why. No one knows what to say.

It could be CMS didn’t have a mom or a dad.
It could be their jobs were incredibly sad.
But, the most likely reason was this just this my dear,
Their hearts were hijacked by nasty old fear.

They feared the support, the need and the caring.
“It has to stop now,” they said, nostrils flaring!
“I hate all their teamwork! I despise all they do!
I’ll pick them all off, one-by-one, two-by-two!”

With a laugh and snort, they sneered, “I know just what to do!”
And put pen to paper to plot their evil, awful coup.
They threw it all at us, with the usual glee,
COPs, OASIS changes, and even VBP!
“I’ve ruined them now and forever, I swear,
Let’s see how you cope, how you can possibly still care!”

But across the Land of Home Care, they got down to work.
HCA had their back, a membership perk!
Every worker in home care, the small and the tall,
Still kept making visits, swearing once and for all:
“The families, they need us, and we will be there!
No Grinches in DC can stop us with fear.”

And what happened then? Well… in home they say,
Those Grinches’ hearts grew three sizes that day!
The true meaning of home care shined right on through.
They ripped up their papers, stopped pre-claim review.
“Maybe home care,” they said, “isn’t about regs, or rules.
Maybe home care is bigger, a national jewel!”

“Thank you, home care,” they said, now with a smile.
“For once, in your shoes, maybe I’ll walk a mile.
I’ll make a home visit, I’ll assist with a med.
I’ll listen to stories from clients in bed.”

“I’ve a new understanding why you do what you do.
Let’s make a new year that’s bright with a start that’s brand new!”

Return to www.thinkhomecare.org.

OASIS D-Day: Assess Once, Score Twice

In less than three weeks, home health agencies will be transitioning from OASIS-C-2 to the new OASIS D assessment. Given all the regulatory changes this year and with the holiday season upon us, it has really been a sprint to get staff trained.

HCA of MA recently held three training sessions for members and not surprisingly there is concern with staff being ready, especially around the nuanced degrees of functional assessments and specifically related to the new items related to mobility and self-care.  While OASIS-D comes advertised as “dropping 28 previous M-Items” from OASIS-C-2, the additional assessments will require lots of creative patient engagement on the part of the admitting nurse or therapist, according to HCA Director of Regulatory and Clinical Affairs Colleen Bayard.

“OASIS-D is intended to begin to standardize patient assessment and quality measures across all post-acute providers,” said Bayard. “But for us in home care some of the new items ask for very nuanced responses. For example, the mobility item (GG0170) has 17 mobility activities that  the clinician must  ‘code’ with a  6-point scale from independent to dependent or  ‘code’ with 4 possible responses related to ‘activity not attempted.’ he admitting clinician is responsible for assessing a patient’s ability to stair climb, pick up an object from the floor and even make a car transfer.

During the Alliance’s trainings, Bayard warned agencies to expect some productivity issues related to the learning curve,  but stressed that the training message across the industry should be: “assess once, score twice.” In other words, be aware of OASIS M assessment questions which track to newly added  GG assessments and use the same assessment to respond to multiple OASIS items in the same category.  Bayard also recommends close auditing or self-monitoring in the initial months, especially related to the responses “patient refused” or “dash” (not attempted). (Ask:  could the clinician interview a family member as a way to get a response?)

Bayard recommends using the “Expansion of the one Clinician Rule” to your advantage because CMS is encouraging an interdisciplinary team approach with OASIS-D. Bayard’s final advice: “As you focus on your training be aware that your nurses are going to need to have a strong intersection of observational skills with interview skills.”

HCA has several places members can come to share and learn as they move past Jan 1. Our Clinical Directors and Quality Improvement list serves and networking groups will be highly focused on OASIS-D as winter turns to spring.  The Clinical Directors next meet Thursday, January 10 and the QI Managers will next meet on January 9th. Meeting information is here. Our email groups are here.

If you haven’t already studied it – here is a list of more than 100 answers to OASIS questions received by CMS from the industry during recent CMS in-person trainings and webinars.

Return to www.thinkhomecare.org.

Home Care Month 2018: Building a Workforce for the Future

Today marks the start of Home Care Month. This is the first of several blogs post reflecting on the current issues impacting the industry.

Every day in this country, 10,000 baby boomers turns 65. This new generation of “elders” are unlike any other to come before it. Economists suggest that these baby boomers control 70% of all US disposable income, yet a large percentage are not well prepared financially for retirement, with savings far below what they are projected to need to “sustain their quality of life.” Thanks to medical advances, these aging boomers should have a longer life expectancy than even the generation before them. They are more educated. They are accustomed to speaking up about their health care needs and they are technologically savvy. And without a doubt, they will be looking for a long-term care delivery system that meets their needs, allows them to age in place with some degree of financial security and with little dependence on their children (whom many boomers are still supporting!).

In short, they will want a high-quality, cost-effective, technologically-advanced home care delivery system. As we celebrate home health care month in Massachusetts and around the country, let’s look at some of what we need to do to make sure we have that in place.

Starting with Workforce Issues

This chart from a recent report from global health care consulting firm, Mercer, depicts what many have written about: There is a huge gap between the availability of a home health aide/personal care workforce and patient need. Massachusetts is among the states expected to feel it the most, and the graphic speaks to how much has to be done in this area.

Home health agencies – dependent on heavily regulated Medicare and Medicaid funding for most of their services – are increasingly unable to offer wage and benefit packages that allow them to compete within the health-care or service-delivery sectors. Added business costs such as the state’s EMAC assessment and mandated paid sick leave make it harder for private home care companies to keep costs affordable and attract workers. Already, many report more demand than they have the workforce to meet.

To ensure an available, productive, and healthy workforce we support:

  • Repealing the onerous EMAC assessment on agencies whose workers access public insurance (Medicaid);
  • Providing premium assistance or pooled purchasing of health insurance for direct care workers;
  • Adequately adjusting Medicaid reimbursements to cover living wages and benefits; and
  • Investing now in the creation of a meaningful, long-term care workforce training, with nurse and aide training funds.

Looking at Technology

There are many who think some of the workforce demand can be offset with the new technologies emerging to support aging at home. These include sensor devices that can detect a multiplicity of conditions and situations including missed meals or medications, a problematic change in weight or blood pressure, or a fall. According to a recent report by the MA state Auditor’s office:

The potential for technological change to impact the labor requirements for home health/direct care workers is considerable. As low cost technologically-based products become available it is likely that these emerging products and services will serve as both substitutes for and complements to home health/direct care occupations.

Most of these technological devices require a receiver to get and act on the collected data. While in some cases this may be a family member, it should also be noted that home care agencies are appropriately poised to be the monitor of remotely transmitted systems, sending a nurse or aide to visit only as indicated. As workforce issues intensify, we would like to see and support:

  • More insurance coverage, including Medicare and Medicaid for remote monitoring devices
  • More modeling of partnerships between private home care companies and technology vendors to test the market for, and price, care extender technologies as part of a private home care plan of care.

Home Care Month is a time to honor the contributions of home health workers who are the lifeline to health care for some many home-bound elders, for isolated and struggling families and for the disabled. Let’s also use this opportunity to listen to and respond to their needs.

Return to www.thinkhomecare.org.

Podcast – Are You Listening?

Yesterday, on this blog we announced our latest podcast, featuring a conversation with Barbra Citarella on Emergency Preparedness in our industry. See post below for the links to listen and find the referenced resources. Today, I thought it fun to stray a bit from the home care topics normally covered here to reflect a bit on the whole notion of podcasting. Hope you enjoy. — Pat Kelleher

In 1978, a little known and now little remembered musical group the Buggles put out the song “Video Killed the Radio Star,” a self-explanatory lyric that about the perceived loss of imagination inherent in the move to turn music into pictures (i.e., videos). The song — for all you trivia buffs — was the first video aired on August 1, 1981 at 12:01 on a little upstart channel known as MTV.

Well, in 2018, audio is back and in a big way. The phenomenon known as “podcasting” is exploding, with walkers, long-distance travelers, and insomniacs finding there’s a lot out there to listen to no matter your taste, politics, or hobbies. Surprisingly, healthcare seems one of the least fertile areas – hard to make regulatory updates engaging!

If you haven’t jumped on the bandwagon, be forewarned: There is a lot of junk out there from so-called subject matter experts who quickly reveal a paucity of knowledge on their chosen topic and aren’t quite as clever as they think they are. If you aren’t yet a “podhead,” to get started, it’s often good to look to some of the “OGs” – the originals that paved the way with content and high-production quality, such as This American Life and the TED Radio Hour. For techie type stuff, Reply All is good fun and, for those who like language and word play, the British import The Allusionist is on many “best of” lists. Note: these links are all websites, but all of these can be found on iTunes or the podcast app on your smart phone.

At HCA of MA, we have just gotten started podcasting, and interesting guests are welcome! If you have a home care story to tell, email me: pkelleher@thinkhomecare.org and we will have you on!

We also welcome hearing in comments what are some of your favorite health care or non-health care podcast series or episodes. Here are links to a few of mine – two are stories that, like all great stories, are of loss and love. One is on technology’s infiltration in our lives. All three are infinitely listenable. They are:

Happy Listening!

Return to www.thinkhomecare.org.