Category: Regulation

Proposed Changes Prep Mass. for Nurse Delegation

The Massachusetts Board of Registration in Nursing (BORN) has released proposed regulations that sets guidelines for, among other activities, delegation by nurses to “unlicensed personnel.” These guidelines are NOT a change in the nursing scope of practice around medication delegation, which requires a law  approved by the legislature and signed by the Governor.

The BORN is merely aiming to establish a nurse delegation framework inclusive of much more specificity in areas such as training, supervision and documentation should nurse delegation practices become allowable in Massachusetts.

The proposed regulations also protect nurses by setting criteria for delegation that includes the following:

  • Ensuring that the delegating nurse would not bear any responsibility for any deviation by the unlicensed personnel from the nursing directive, instruction, or plan of care.
  • Formalizes the nurse’s role in knowing what is within the ability of the unlicensed personnel to carry out and what can be delegated that would not require judgment or assessment by the unlicensed personnel.
  • The final decision to delegate is made by the nurse and not the employing healthcare provider.
  • The employing healthcare provider must have the competencies of the unlicensed personnel documented for each nursing activity along with periodic validation of those abilities.
  • The nurse can determine at any time that an activity can no longer be delegated based on the health status of the patient, the unlicensed personnel’s performance of the activity, or any other reason the nurse believes would jeopardize the health and safety of the patient.

The proposed regulation follows years of discussion and a BORN subcommittee report on the state’s readiness for potential changes to nursing practice.

One of the possible changes is a longstanding policy priority of the Home Care Alliance, which is to allow home health care nurses to delegate certain medication administration tasks to a trained and certified home health aide. The HCA has dubbed the proposed policy as the “Nurse Delegation Bill.”

This bill will not pass in the current legislative session that ends with the New Year in 2017, but the HCA plans to continue pursuing a change that would allow – not mandate – that home health and home care agencies can implement proper training and procedures to maximize the efficiency of their direct care staff.

It should be noted that this bill includes protections, such as the fact that delegation is limited to medications which are NOT controlled substances and are administered in the following methods:

  • Oral
  • Ophthalmic
  • Otic
  • Topical
  • Internasal
  • Transdermal
  • Suppository
  • prefilled auto-injectables designed for self-administration
  • Products which are administered by inhalation.

The legislation states that “delegation of intramuscular, subcutaneous, intradermal, intraosseous or intravenous administration of medication shall not be permitted.”

Although the Alliance has comments and suggestions for the BORN’s proposed regulations, HCA fully supports the move to ensure the state is prepared for laws that promote nurses practicing at the top of their licenses. The Alliance appreciates the BORN’s thoughtful approach that further solidifies the importance of nurses in healthcare delivery.

The BORN will hold a public hearing on October 4th and will accept written comments until October 11th.

Return to www.thinkhomecare.org.

Home Care’s Part in the CMS Bundled Payment Program for Cardiac Care

Though no final announcements on participants have been made, several areas of Massachusetts were declared “eligible” by CMS for random selection of nearly 100 metropolitan statistical areas (MSA) across the country for a new innovation initiative that offers bundled payment for cardiac care.

CMS released the proposed rule on July 25th where the hospital in which a patient is admitted for care for a heart attack, bypass surgery, or surgical hip/femur fracture treatment would be accountable for the cost and quality of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days after discharge.

As with many similar alternative payment programs, established quality metrics would help determine whether the hospital would be required to pay Medicare for poor performance or receive reward payments for higher-quality care. CMS chose July 2017 to March 2018 as the “performance year” and then a gradual increase in the gains and downside risk for hospitals beginning at 5 percent in 2018 and capped at 20 percent in 2020-2021.

CMS is encouraging collaboration with other providers, including home health care and other post-acute providers. Equally important are a list of waivers this program will grant relative to the provision of post-acute care. Some notable highlights are listed below, with explanatory excerpts from the proposed rule, but the full list of waivers can be found in the proposed rule under “Subpart G” on page 885.

  • Waiver of direct supervision requirement for certain post-discharge home visits:
    • “CMS waives the requirement in  § 410.26(b)(5) of this chapter that services and supplies furnished incident to a physician’s service must be furnished under the direct supervision of the physician (or other practitioner) to permit home visits as specified in this section.  The services furnished under this waiver are not considered to be “hospital services,” even when furnished by the clinical staff of the hospital.”
  • Waiver of certain telehealth requirements:
    • “Except for the geographic site requirements for a face – to – face encounter for home health certification, CMS waives the  geographic site requirements of sec tion 1834(m)(4)(C)(i)(I) through (III) of the Act for episodes  being tested in an EPM, but only for services that  (1)  May be furnished via telehealth under existing requirements; and (2)  Are included in the episode in accordance with  § 512.210”
    • The Alliance is researching whether this is restricted to physicians performing telehealth or whether home health agencies would be allowed to engage in remote patient monitoring.
  • Waiver of the SNF 3-day rule
    • Only applies to the AMI (Acute Myocardial Infarction) model.

There is a 60-day public comment period and it is unlikely that the participating MSAs will be revealed before the final rule, but the “eligible” areas in Massachusetts are included below:

  • Barnstable Town, MA
  • Boston-Cambridge-Newton, MA-NH
  • Providence-Warwick, RI-MA

Based on CMS’ selection criteria, the Pittsfield and Springfield Metropolitan Statistical Areas are “excluded” from selection eligibility.

Return to www.thinkhomecare.org.

 

Moratorium on Home Health Agencies Extended by CMS, MassHealth

Both the state and federal governments are extending moratoria on new home health providers.

MassHealth will be extending the six-month moratorium on new home health providers, which will become effective on August 12 for an additional six months, according to MassHealth. The Home Care Alliance has been supportive of the measure and has collaborated with the state Medicaid office on program integrity efforts, but attempts to kick-start a state oversight policy for home care agencies have been unsuccessful.

In a letter requesting the initial stoppage on new providers from Massachusetts Health and Human Services Secretary Marylou Sudders to federal HHS Secretary Sylvia Mathews Burwell, it was noted that home health spending under MassHealth increased 41% from fiscal years 2014 to 2015. The letter continued to explain that 85% of that growth was driven by providers that were new to the MassHealth program since 2013.

Meanwhile, the Centers for Medicare and Medicaid Services (CMS) announced that they will be not only  extending their temporary moratoria on enrollment of specific locations within Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey, but will also be broadening moratorium across each of those states.

Below is an excerpt from the Federal Register with CMS’ reasoning in announcing the extension and expansion:

CMS has determined that the factors initially evaluated to implement the temporary moratoria show that a high risk of fraud, waste, and abuse exists beyond the current moratoria areas, which may suggest that a high risk of fraud, waste, or abuse exists due largely to circumvention of the moratoria by some providers and suppliers.

The primary means of circumvention includes enrolling a new practice location outside of a moratorium area and servicing beneficiaries within the moratorium area. Additionally, CMS has continued to see areas of saturation that exceed the national average in the moratoria states. As a result, CMS, in consultation with the OIG, has determined that it is necessary to expand the temporary moratoria on a statewide basis, by implementing temporary moratoria on all newly enrolling HHAs in the remaining counties in Florida, Illinois, Michigan, and Texas, and on all newly enrolling Part B non-emergency ground ambulance suppliers in the remaining counties in Texas, New Jersey, and Pennsylvania, in order to combat fraud, waste, or abuse in those states.

Return to www.thinkhomecare.org.

Medicare Proposed Home Health Payment Rule

Home Health Payment Update

HCA of MA has posted to its website, a summary of the Home Health Prospective Payment System (HHPPS) changes that are to be effective  on January 1, 2017. The proposed rule implements the last year of the 3.5 percent rebasing adjustments required by the Affordable Care Act; implements the second year of the three year phase-in of a case-mix adjustment; changes the methodology for outlier payments; proposes payment changes for Negative Pressure Wound Therapy (NPWT); discusses monitoring and research regarding the impact of the changes; seeks comments on a potential process for grouping claims centrally during processing; and proposes changes to the Home Health Value-Based Purchasing (HHVBP) Model; and updates the Home Health Quality Reporting Program (HH QRP).  The Alliance has prepared a PPS Rates spreadsheet with all of the HHRG rates in each county in MA.

Comments are due no later than August 26, 2016 no later than 5:00 p.m.

One Care Program Extended Through 2018

MassHealth announced that the One Care Program for individuals dually eligible for Medicare and MassHealth and between the ages of 21 and 64 has been extended through 2018.

Part of this new agreement with the Centers for Medicare and Medicaid Services (CMS) is that MassHealth will be accepting letters of intent (LOI) from entities interested in becoming One Care Plans effective January 1, 2018.

Beginning in 2013, the One Care program included several plans that were whittled down to what is now Commonwealth Care Alliance and Tufts Health Plan, which began participation in the initiative as Network Health. Funding issues were at the center of why other plans could not sustain covering One Care enrollees, although adjustments have been worked out that are intended to help plans better predict costs and assess financial risk. Fallon Total Care was the latest to drop their participation in June 2015.

Out of 103,041 eligible individuals, MassHealth reports that 13,038 are covered by the two One Care Plans. Commonwealth Care Alliance covers the bulk of that total with 10,050 enrollees as of June 1, 2016. According to the latest enrollment report, more than 30,000 individuals have “opted out” of the One Care Program.

Return to www.thinkhomecare.org.

What the Senate’s Economic Development Bill did for Home Care

Late Thursday night, the Senate wrapped up debate on more than 200 amendments to legislation promoting economic and workforce development and the Home Care Alliance was active on several issues.

Senate Bill 2423, “An Act relative to job creation, workforce development and infrastructure investment,” created a a special commission to investigate and report on barriers to meeting labor market demands in the commonwealth. The commission’s report can include a broad range of industries, but according to the legislation, it must consist of cyber-security, high technology and biotechnology, early education and care, home care and home health. Despite this focus, the “labor commission,” as it was labeled, did not have a member that represented the home care industry.

Working together with the Home Care Aide Council, and Senator Patricia D. Jehlen’s office, an amendment was adopted to get a home care agency representative on that commission. If the Senate’s legislation advances and is passed, this commission will be shining a light on home care workforce issues on a level of importance that places it with other industries.

The other amendment, which was of great concern, was an effort that would have created a publicly-available registry with the personal information of home care workers. It was the same provision that showed up in legislation and FY17 budget amendments – all of which were defeated.

In this particular iteration, the result was a redrafted amendment to create a registry of home care workers that does NOT include personal information, but rather certifications and whether that worker has ever committed abuse, mistreatment or neglect of an elderly patient or consumer.

The Alliance thanks the many agencies that weighed in quickly with their state senator by phone and email on both of these matters.

The Senate’s legislation now must pass a conference committee process where differences between S.2423 and the House’s version of the bill must be worked out.

Further updates will be shared when they become available.

Return to www.thinkhome.care.

HCA Breaks Down MassHealth 1115 Waiver Proposal

Months of stakeholder meetings and public engagement by MassHealth has resulted in a long-awaited draft proposal that aims to completely restructure the state’s Medicaid program.

Known as the Section 1115 Waiver, the 90-plus page document outlines a possible multi-year agreement  with the federal Centers for Medicare and Medicaid Services (CMS). The focus of the proposal is a move towards accountable care organizations (ACOs) and alternative payments while better addressing the needs of MassHealth members and putting in place a financially sustainable system of health care and support services.

Before the agreement can be made with CMS, however, there is a public comment period that runs until July 17th. The Home Care Alliance created a breakdown of the proposal so that members and advocates can better understand the key provisions.

MassHealth also provided a more basic fact sheet available on their 1115 Waiver Proposal webpage that also includes the full document and slide decks from previous public meetings.

The proposal attempts to seize an opportunity for new funding streams to support the creation of three types of ACOs that are required to partner with existing providers of behavioral health (BH) and long-term services and supports (LTSS). The state aims to rearrange provider and managed care relationships to set forth a better coordinated and integrated set of networks.

The first “pilot ACOs” are expected by MassHealth to come online later in 2016, while the full roll-out of the three ACO models, enhanced funding, and BH/LTSS integration will take place in October 2017.

The Alliance was appointed to several of the MassHealth stakeholder groups and plans to submit comments on the proposal on behalf of home care.

Return to www.thinkhomecare.org.

 

MassHealth Releases Prior Authorization Presentation

The first in a series of education sessions administered by MassHealth on their newly implemented prior authorization process occurred on March 16th and the slides have been made available.

After a basic overview of home health regulations, the prior authorization portion begins on slide 20 with helpful information and links as well as the contact information for the MassHealth Prior Authorization Unit (PAU). With a limited number of spots for this webinar, the Home Care Alliance is continuing to work with MassHealth on offering additional sessions.

The Alliance continues to take questions from agencies and is actively and constantly in contact with MassHealth to address ongoing issues.

Next week, MassHealth will be offering separate one-hour sessions on utilizing the Provider Online Service Center, or POSC.

During this training, MassHealth will provide step-by-step instruction on how to submit a prior authorization via the POSC, including how to inquire on and view prior authorization decisions, as well as other POSC techniques.

As space is limited, agencies are encouraged to register soon, if they have not already.

The sessions will be held at UMass Medical School (333 South St, Shrewsbury, MA 01545) on the following dates.

  • Wednesday, March 23, 2016  1:00 PM – 2:00 PM
  • Friday, March 25, 2016 10:00 AM – 11:00 AM
  • Friday, March 25, 2016 1:00 PM – 2:00 PM

Register here for POSC Training

The official Public Notice of the regulatory change requiring prior authorization was published last Friday. The notice include an invitation for public comment, with all comments due by April 1, 2016. Agencies are encouraged to submit constructive comments.

Return to www.thinkhomecare.org

MHA, ONL & HCA Publish Latest Quality Measures for Hospitals, Home Health Agencies

The Massachusetts Hospital Association (MHA), Organization of Nurse Leaders of MA, RI, NH & CT (ONL) and Home Care Alliance of Massachusetts have publicly posted the latest available key national care quality performance measures for both hospitals and home healthcare agencies in Massachusetts. Data from Medicare’s Hospital Compare and Home Health Compare are now available on the PatientCareLink website for 77 Bay State hospitals and 89 Bay State home health agencies.Patientcarelink logo

Reported measures for hospitals include best practices for heart attack or chest pain, heart failure, pneumonia care, influenza prevention, surgical care improvement, stroke care and blood clot prevention and treatment. For home care agencies, the reported measures include timely initiation of care, patient/family medication education, depression assessment, and more.

To view the updated reports, visit www.patientcarelink.org and click on the “Healthcare Provider Data” tab and then either the “Hospital Data” or “Home Health Agency Data” link, then “Individual Hospital Performance Measures” or “Select an Agency.”

The home health agency reports now incorporate data for the period June 2014 – July 2015 for all measures, and the hospital reports cover April 2014 – March 2015. In addition to each facility’s individual performance, the PCL pages also provide a comparison to state and U.S. “peer” facility averages.

“Providing high quality, safe patient care is a top priority for Massachusetts hospitals,” said Pat Noga, PhD, RN, Vice President of Clinical Affairs for MHA. “Our hospitals are also committed to publicly posting important quality and staffing information to provide patients and caregivers alike additional confidence in their care.”

Patricia Kelleher, Executive Director of the Home Care Alliance of MA, added that the partnership between hospitals and home health agencies on PCL furthers positive working relationships along the entire continuum of care, which can only improve patient safety and quality overall.

“Choosing in-home services can be a daunting task and that’s why we’re proud that PatientCare Link (PCL) website allows patients and their families to find high-quality care in the home setting that fits their needs,” Kelleher said. “PCL includes Medicare-approved agencies that meet certain federal health and safety requirements, and provides patients, caregivers, and families the tool to easily access home health agency quality data to take control of their care and their health.”

Massachusetts was the first state to voluntarily make hospital staffing and nursing-sensitive quality information public starting in 2006. Home Care Alliance of Massachusetts joined the PCL quality and patient safety transparency effort in 2013. The PatientCareLink website is a great resource and gives patients an open and transparent view of the hospitals providing them care.

Hospitals and home care agencies welcome transparency about their performance when performance measures are grounded in good science and are designed to make fair comparisons across institutions. Publicly reported performance data can offer several benefits, including:

  • Offering useful information for making decisions about where to obtain healthcare
  • Helping healthcare professionals and institutions improve the care they deliver; and
  • Providing extra motivation to improve performance.

Return to www.thinkhomecare.org.

Prior Authorization Demo Proposed by CMS

Piling on top of existing pilots and demonstrations, the Centers for Medicare and Medicaid Services have released another proposed program that would establish Medicare prior authorizations and a fraud measurement pilot.

Massachusetts is one of five states – along with Florida, Texas, Illinois and Michigan – selected for the prior authorization demonstration. There are no details on what the authorizations would entail in the proposed demonstration aside from CMS stating that it would be similar to “Prior Authorization of Power Mobility Device (PMD) Demonstration, which was implemented by CMS in 2012.” The rule continues that “this demonstration would also follow and adopt prior authorization processes that currently exist in other health care programs such as TRICARE, certain state Medicaid programs, and in private insurance.”

CMS’ reasoning for implementing such a program a belief that it will help assist in “developing improved procedures for the identification, investigation, and prosecution of Medicare fraud occurring among HHAs providing services to Medicare beneficiaries.”

According to CMS, Medicare contractors will request the information from home health agency providers submitting claims for payment from the Medicare program in advance to determine appropriate payment.

The second piece of the CMS’ proposal is titled the “Medicare Probable Fraud Measurement Pilot.” The pilot would establish a baseline estimate of probable fraud in Medicare fee-for-service payments for home health care.

CMS purports that this would be accomplished using, at least in part, a summary of the service history of the HHA, the referring provider, and the beneficiary to estimate the percentage of total payments that are associated with probable fraud and the percentage of all claims that are associated with probable fraud for Medicare fee-for-service home health.

HCA is currently working to get more details on this demonstration so as to devise an advocacy strategy.

Comments on the proposed demonstration are due by April 5th and details are available here on the Federal Register.

Return to www.thinkhomecare.org.