On Dec. 17, the U.S. Senate voted 67 to 32 to approve a $915 billion megabus appropriations bill for fiscal year 2012. So, how does this bill affect funding for Older Americans Act programs? Let's take a look.

What we liked

We are pleased that compared to FY 2011 funding, there was no change in funding for:  

• The congregate meal program.
• Home delivered meals.
• The nutrition services incentive program.
• The home and community-based supportive services program (Title IIIB).
• The National Family Caregiver Support Services Program. 

There is also good news that the funding for Social Service Block grants and the Community Service Block grants remain at the 2011 funding level.

What we did not like

• The unfortunate situation is that the final FY 2012 budget for Supportive Services and the National Family Caregiver program that was passed by the Congress is significantly lower than the funding requested by President Obama. The president had requested higher funding for these programs as a part of his Caregiver Initiative. 
  
• The Older Americans Act programs received a decrease of $24 million in funding for 2012 compared to the 2011 budget. Most of the cuts came from the elimination of funding for Program Innovations and decreased funding for the Alzheimer's Disease Supportive Services Program and the Corporation for National and Community Services. 

At the request of Members of Congress and the public, theWage and Hour Division of the U.S. Department of Labor (DOL) has extended by 14 days the comment period for its proposed rule that would lift theso-called companionship exemption for agency-employed, non-medical home careworkers that provide companionship and other services for individuals who,because of age or infirmity, are unable to care for themselves.  

Comments on the proposed rule must be received on or before March 12, 2012.

Why lift the companionship exemption?

On Dec. 12, PHI published Caring in America: A Comprehensive Analysis of the Nation's Fastest-Growing Jobs: Home Health and Personal Care Aides, a new report that offers an analysis of the 2.5 million home care and personal assistance aides who provide long-term services and supports to elders and people living with disabilities in home and community-based settings.

The statistics on wages and health insurance coverage for direct care workers employed by home health agencies in this report highlights our view that we can not afford additional cuts to Medicare and Medicaid.  

According to the report:

• The median wage for a home health aide is $9.89 hour and $11.54 hour for a nurses aide, while the average wage for all U.S. workers is $16.27 hour. 
• 26% of nurses aides have no insurance
• 37% of home health aides have no insurance compared to 18% of U.S. workers with no insurance.
• More than 50% of home health aides are working part-time. 56.2% of home health aides in 2009 relied on Medicaid or food stamps. 

There is significant turnover in home health aides because of low wages, number of hours worked and transportation costs. The report also mentions that 19 states have no licensing for non-medical home care agencies, and that this situation has a negative impact on quality of care.

We are not prepared for the increase in older adults that we will need in home health services. Reductions in Medicaid and Medicare will further deteriorate the direct care workforce.  

The Centers for Medicare and Medicaid Services (CMS) updated the Medicare home health Prospective Payment System (HH PPS) rates effective Jan. 1, 2012. The final rates were published in the Federal Register on Nov. 4, 2011.

The updated rate is reduced by 2.39% on average per episode. 

“Most home health agencies were braced for another 5% reduction in payment rates, given the decline in the market basket from the proposed rates in 2010 to the final rates published for 2011,” explains Gregg Hathorne, a health care principal with LarsonAllen. “However, the reduction of approximately 2.4% was fairly consistent with expectations from the proposed rules issued earlier this year. The case mix creep adjustment was reduced, but could be added back next year.”

In addition, the Federal Register recently released the timelines rule for the updated market basket and case mix system changes.

You can learn more from LarsonAllen about:

• The rates by state and Core-Based Statistical Area.
• How the final 2012 HH PPS rates, market basket amount, and case mix adjustment affected the new rate adjustment.
• The penalty for home health agencies that don’t submit quality reporting data.
   

The Center for Medicare and Medicaid Services (CMS) released the full solicitation for the Independence at Home demonstration.

Under this 3-year demonstration, physician practices will receive payments based on spending targets, as well as performance requirements for at least 3 of 6 quality measures that are tied to payment. 

Why the Independence at Home demonstration program matter to members

We believe that the Independence at Home demonstration could be an opportunity for members that operate Geriatric Clinics and home health agencies. The demonstration will also help elders with chronic diseases age in place. 

LeadingAge applauds the work of Rep. Edward Markey (D-MA) and Sen. Ron Wyden (D-OR) for making Independence At Home a reality and to CMS Administrator Tavenner for her leadership in getting the implementation instructions issued before the statutory deadline.

Section 1866E of the Social Security Act, as added by Section 3024 of the Affordable Care Act (P.L. 111-148), directs CMS to conduct the Independence at Home (IAH) Demonstration to test home-based primary care for Medicare fee-for-service (FFS) beneficiaries with multiple chronic illnesses.  

More about the Independence at Home demonstration program

CMS announced that 16 organizations were approved to participate in the Independence at Home program. The Independence at Home program has the potential to reduce costs under Medicare. Under the Independence at Home Demonstration, eligible participants will work with CMS to provide home-based primary care to targeted chronically ill beneficiaries. 

Participating practices will make in-home visits tailored to an individual patient’s needs and coordinate their care. 

CMS will track the beneficiary’s care experience through quality measures. According to the announcement, the Independence at Home Demonstration will begin June 1, 2012, and run through May 31, 2015. 

Organizations applying as consortiums have until May 4, 2012, to file their applications, and those selections will be made public at a later date. 

There were over 100 organizations that applied to provide home-based primary care to thousands of eligible Medicare beneficiaries that were denied the opportunity to participate in the IAH program.Hpefully, if this program is successful it will become a permanent part of Medicare.

We are especially pleased to congratulate Visiting Nurse Housecall, LLC (Atlanta, Georgia), a LeadingAge and Aging Services of Georgia member for being approved as an Independence at Home provider.

On Dec. 15, 2011, the Medicare Payment Advisory (MedPAC) Commission discussed draft recommendations to Congress that would freeze  home health payment updates for  2013.  For home health agencies, the MedPAC Commission considered proposing the same recommendations the did last year, which includes revising the home health PPS to eliminate financial incentives that encourage more therapy and replace it with a system based on patient characteristics, and rebase the payment levels to equal costs beginning in 2013 (with a 2-year transition).  MedPAC staff expressed concern that the 2010 financial performance of freestanding HHAs continued to be excessive, with margins for for-profits agencies at 20.7% and for non-profit agencies at 15.3%.  The average projected margin for HHAs in 2012 is 13.7%. MedPAC as a whole will have to vote at its next meeting on whether to send these recommendations to Congress. The recommendations will not go into effect unless and until they are legislated by Congress. 

Bloomberg has published an article that describes how enrollment-based incentives have increased the profits of a number of for-profit hospices. According to the article, "Hospice care, once chiefly a charitable cause, has become a growth industry, with $14 billion in revenues, 1,800 for-profit providers and a base of Medicare-covered patients that doubled to 1.1 million from 2000 to 2009." 

Bloomberg adds, "Compensation based on enrollment numbers, pay to nursing- home doctors who double as hospice medical directors, and gifts to the nursing facilities have helped fuel the boom."

The inspector general of the U.S. Department of Health and Human Services (HHS) is probing hospice marketing practices and financial relationships with nursing facilities. 

The Medicare Payment Advisory Commission (MedPAC) had also found hospices “aggressively marketed” to nursing-home patients, and paid incentives to medical directors for “inappropriate” referrals and enrollments. 

The rise of for-profit hospice care since 2000 has helped drive a 60% increase in the average time patients spend in hospice, to 86 days in 2009, according to MedPAC.

The average stay of the 10% of patients who remained in hospice the longest soared 71% to 240 days.  

Earlier this month, the Kaiser Commission on Medicaid released Medicaid Home and Community-Based Services (HCBS) Data Update, a report that presents a summary of the main trends to emerge from the latest expenditures and participant data for the 3 main Medicaid HCBS programs. 

The report states that while the majority of Medicaid long-term care dollars still go toward institutional care, the national percentage of Medicaid spending on HCBS has more than doubled from 19% in 1995 to 43% in 2008. 

In 2010, 39 states reported waiver wait lists totaling 428,571 individuals. This reflects a 17% increase compared to the previous year. 

The strain on state budgets have resulted in many states having to balance cost-control policies on HCBS services with the broader goal of serving more people in the community rather than institutions. 

States used various changes in eligibility and cost control policies on HCBS to reduce state budget deficits. And, 47 states used some form of cost controls above and beyond the federally mandated cost neutrality formula in 2010. 

Another way states can limit eligibility for HCBS waivers is by setting functional eligibility criteria that are stricter than those used for care in a nursing facility. 

The Kaiser Commission on Medicaid and the Uninsured released Money Follows the Person: A 2011 Survey of Transitions, Services and Costs, an issue paper based on an August 2011 survey of states about the current status of their MFP demonstrations.

Key findings

According to the report:  

• Nearly 17,000 individuals have transitioned back to the community.
• 5,700 transitions are currently in progress. 
• 3 states (Ohio, Texas and Washington) transitioned 46% of all individuals who returned to the community from nursing homes. 
• 8.3% were re-institutionalized after being transitioned back into the community through the Money Follows the Person program. 
• The average monthly cost of serving a Money Follows the Person participant in the community was approximately $9400 per person. 
• 18 states said that the Money Follows the Person costs were lower than nursing home services under Medicaid. 
• 2 states reported that the costs were comparable to nursing home costs. 

The Money Follows the Person demonstration program was started 5 years ago and was expanded under the Affordable Care Act.  

Aging in Place: A State Survey of Livability Policies and Practices, a new AARP state survey on aging in place, highlights challenges for seniors wishing to age in place, specifically attributing major problems to: 

• Unsupportive community design.
• Unaffordable and inaccessible housing.
• A lack of access to needed services. 

Unless there are significant changes in how communities are constructed and what services are offered, says the report, many older adults will find it increasingly difficult to live in their communities and may have to consider institutional care.

The report identifies the following land use, transportation, and housing policies as well as promising state practices that enable aging in place.

Land Use

• Integrating land use and transportation planning to reduce reliance on automobile travel. California, Florida, and Washington are among the states with statutes requiring this.
• Implementing transit-oriented development within a quarter- or a half-mile from a transit stop. Statutes in at least 12 states, including California, Massachusetts, New Jersey, and Utah, address this issue.
• Encouraging joint use of community facilities such as a senior center or health clinic in a school. Promising practices include those in California and Wyoming.

Transportation

• Designing “Complete Streets” to enable all users, regardless of age or ability, to get to where they want to go. 25 states plus D.C. and Puerto Rico have complete streets policies, 16 of which state legislatures enacted.
• Ensuring pedestrian safety given the vulnerability of older adults in vehicle and pedestrian fatalities. At least 10 states have considered “vulnerable users” laws within the past 5 years to better protect pedestrians and bicyclists.
• Ensuring access to services in rural areas. States such as Idaho and Montana have policies that address access to services for people who live a significant distance from city centers.
• Improving human service transportation coordination to more efficiently use limited resources. Twenty-eight states have coordinating councils, 14 of which were created by statute and 14 by governor’s executive order or initiative.
• Enacting volunteer driver laws to protect volunteer drivers from civil liability. Only Georgia and Oregon explicitly protect volunteer drivers.

Housing

• Accessing the federal Low-Income Housing Tax Credit program to leverage funds for development of housing near transit and in livable community settings. These states include Connecticut, Florida, Massachusetts, Missouri, Nevada, and New Jersey.
• Encouraging developers to use building standards that promote accessibility. At least 3 states—Minnesota, Pennsylvania, and Texas—have these statutes.
• Promoting aging in place by supporting neighborhoods with large populations of older adults involved in social and community life. Promising practices include models to provide services at home such as Naturally Occurring Retirement Communities and Communities for a Lifetime.

According to the Digital Journal, Lutheran Social Services of Michigan (LSSM) acquired Home Care Assistance of Michigan, a for-profit, leading provider of in-home care senior services throughout the southeastern Michigan.  

The acquisition will further Lutheran Social Services mission to serve individuals with care needs, enabling them to age in the comfort of home. Home Care Assistance currently operates in southeastern Michigan with offices in Birmingham, Troy, Grosse Pointe Woods and Ann Arbor. 

Under Lutheran In-Home Care, services will begin an immediate expansion to other areas of the state beginning with Grand Rapids. With the major increase in the number of older adults remaining in the community, this acquisition will enable LSSM to move forward with their mission to serve their communities.

Lutheran Social Services currently has 70 programs in 44 cities throughout Michigan. Home Care Assistance of Michigan has the highest client satisfaction rating in Michigan, according to Home Care Pulse, an independent research company. 

Many members value LeadingAge listservs as a forum for garnering ideas and polling peers for suggestions on solving problems or implementing innovations. But the number of emails can be daunting, especially as many listserv members weigh in with their experiences on an issue.

We are very pleased to offer a solution. Now, you can log into your My.LeadingAge account and opt for a once daily digest of all messages posted to a listserv.  That will enable you to keep up with the conversation with just one email a day.  

You can still post messages as frequently as you would like and you can always re-subscribe to have messages delivered as they are sent if you need to get an answer fast.  Please note, it takes one business day for our system to apply a change in listserv delivery preferences.

My.LeadingAge is also your tool for signing up for e-newsletters and updating your contact information.  You can also use it to invite a colleague to receive LeadingAge newsletters and join listservs as well.  Anyone affiliated with a LeadingAge member is eligible.

Please let us know what you think of our electronic publications and how you like the daily digest option.  We are always looking for ways to improve members' experiences and do a better job of providing information. 

CMS released an important clarification on the Home Health Face to Face Physician Encounter requirement. CMS has been notified that some CMS contractors are denying payment for patients who use home health services following an acute or post-acute stay when the HHA uses a single form such as the 485 for the plan of care and the certification with a single signature by the community physician.  This physician either assumes the oversight of the patient’s home healthcare and/or cares for the patient in the acute or post-acute setting and has provided and signed the attached documentation for the face-to-face encounter.  

CMS does not require that a specific form be used for the certification or the plan of care. Since April, providers who use the CMS 485 form attach the face-to-face encounter documentation to the CMS-485.  Medicare contractors have been instructed to accept the CMS-485 form signed by the community physician who assumes oversight of the patient’s home healthcare with an addendum containing the face-to-face encounter documentation requirements signed by a physician who cared for the patient in an acute or post-acute setting, to satisfy the certification, face-to-face encounter, and plan of care requirements. Additionally, some contractors are erroneously denying claims for failure of the acute or post-acute physician to identify the community physician who will assume care for the patient.  CMS has not mandated the acute or post-acute physician to follow a specific documentation protocol to hand-off a patient to the community physician.    

On May 7, 2012 CMS released an MLN article designed to provide education on the contents of the home health certification, including homebound criteria and requirements for the face-to-face encounter and documentation. It includes guidance that physicians, non-physician practitioners, physician support personnel, and home health agencies can use to ensure that all certification requirements are understood and met. In addition, on May 4, updated face-to-face encounter Questions & Answers were posted and are available through the CMS Home Health Agency (HHA) spotlight page.

So many books, blogs, articles, studies, reports, surveys…there are countless resources for learning more about seniors. But how do you know what’s most important to read to enhance your professional interactions — and your personal relationships — with older adults? 

GlynnDevins has identified 10 good books and blogs to get you started:

1. The New Old Age Blog: A New York Times blog about aging, health, finances and relationships between parents and the adult children caring for them. It’s written to and about a generation (largely Boomers) who are dealing with wide-ranging issues facing their aging parents, all the while realizing that they’ll very soon face their own “new old age.”
   
    
2. Boomers: A Trip into the Heart of the Baby Boomer Generation: A blog about Boomer consumers, an area that will drive American business for the next two decades. Author Brent Green — himself a Baby Boomer — is a marketing consultant, author, presenter, opinion writer and researcher, whose focus is on the cultural development, psychology and marketing habits of people born between 1946 and 1964. 
   
    
3. ChangingAging Blogstream: This is a fantastic resource for finding many different approaches, opinions, experiences and ideas about the subject of aging. The site’s self-description is: ChangingAging™ is a platform to challenge conventional views on aging. We believe aging is a strength, rich in developmental potential and growth. Join us and begin changing aging today. Log on and you’ll find a network of pro-aging blogs publishing updates into a single stream of content.
   
    
4. Losing My Mind: An Intimate Look at Life with Alzheimer’s by Thomas DeBaggio: Diagnosed at age 57, the author reveals a deeply personal account of his firsthand experience with Alzheimer’s, describing in vivid detail how his progressive degeneration affected both him and those closest to him.
   
    
5. How to Say It to Seniors: Closing the Communication Gap with Our Elders by David Solie: A thoughtful and sensible guide to improving interactions with seniors through sensitive, patient and productive communication. The author presents numerous common scenarios as settings for helping adult children talk to their aging loved ones about their independence, safety and overall well-being.
   
    
6. What Are Old People For? How Elders Will Save the World by William H. Thomas: Geriatrician William H. Thomas, M.D., discusses many subjects, among them the importance of learning to enjoy what aging has to offer, the need to replace today’s nursing homes with positive alternatives, and steps for building a society where aging, longevity and the wisdom of the elderly are used to build an improved life for people of all ages.
   
    
7. Ageless Marketing: Strategies for Reaching the Hearts & Minds of the New Customer Majority by David B. Wolfe with Robert E. Snyder: The authors document the results of a landmark research project on Boomers, encompassing their core values and buying behaviors, and emotional factors that define this segment of consumers. Among other things, you’ll learn that “empathetic connections” drive many of their purchase decisions, why traditional approaches simply aren’t effective, and how to build marketing campaigns that increase brand loyalty and improve customer satisfaction.
   
    
8. Designated Daughter: The Bonus Years with Mom by D.G. Fulford with Phyllis Greene: This is a refreshing and inspiring mother-daughter story about sharing late-life years together. The author tells the story of how, after her father’s death, she moved home to be close to and help her mother — a move that brought her unexpected emotional rewards.
   
    
9. Dot Boom: Marketing to Baby Boomers Through Meaningful Online Engagement by Dave Weigelt and Jonathan Boehman: Boomers are very much attuned to interactive media, making online marketing channels a great way to connect with them. This book shows you how to build meaningful, effective online campaigns, employing emotionally driven, experiential marketing techniques that are most effective with older consumers.
   
    
10. Successful Aging by John W. Rowe, M.D. and Robert L. Kahn, Ph.D.: Results of the 10-year MacArthur Foundation Study, the most extensive, comprehensive study on aging in America, reveal that the way you live — much more so than the genes you were born with — determine your health and vitality. This book deals with three fundamental questions about human aging: What does it mean to age successfully? What can each of us do to be successful at this most important life task? What changes in American society will enable more men and women to age successfully? 

The Office of Inspector General (OIG) of the U.S. Department of Health and HumanServices (HHS) has released several short video and audio presentations on tophealth care compliance topics.

Part of a planned 11-episode series, the videos and audio podcasts are free and cover topics such as exclusion authorities and the effects of exclusion, the Federal Anti-Kickback statute, the False Claims Act and the Physician self-referral law, with new content to be posted at the start of each week through February 2012.

The videos and audio podcasts are part of the OIG’s Health Care Fraud Prevention and Enforcement Action Team (HEAT) Provider Compliance Training initiative.

Feb. 20: How to use the Exclusions Database

This video explains how to easily and effectively use the Exclusions Database to avoid liability by determining whether or not an individual or entity has been excluded before employing or contracting with that individual or entity, and by regularly checking the OIG’s Exclusions Database.

Feb. 14: How to report suspected fraud to OIG

The OIG's podcast for the week of February 13 covers "How to report suspected fraud to OIG."  This video and audio podcast is the tenth in OIG's 11-part series of provider compliance training videos and audio podcasts.

Feb. 6: Self-Disclosure Protocol

For the week of Feb. 6, 2012, the OIG has posted a video and audio podcast concerning self-disclosure protocol.  The video and podcast shows providers how to disclose and resolve potential fraud issues identified by their compliance program by using the OIG's Self-Disclosure Protocol.

Jan. 15: Compliance Program Basics

This week's video describes 6 steps to implement and operate an effective compliance program in a health care entity.These steps cover:

• Culture of compliance.
• Useful policies.
• Appropriate training.
• Effective communication.
• Corrective action plans.
• Regular risk-based auditing.

Jan. 9: Overview of OIG's published guidance

The video for the week of January 30, 2012, features compliance program basics, including how proper medical records documentation helps protect health care providers from fraud and abuse liability.

The latest video and audiopodcast focus on OIG’s Exclusions Database, which is a comprehensive list ofindividuals and entities prohibited from participating as providers in allFederal health care programs, including Medicare and Medicaid.