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Written by: Darlene D'Altorio-Jones (1959-2015) on Thursday, March 15, 2012 Posted in: Outpatient Rehab


The CMS Innovation Center will release multiple opportunities to demonstrate better care, lower costs and managing health outside of traditional brick and mortar establishments.  Just recently they released “Independence at Home Demonstration”, a model program that will surely affect outpatient services and new wave ‘home health’.

On Dec. 21, 2011, CMS released a call for applications for this new project and encouraged medical practices to test effectiveness of delivering primary care services in the home for Medicare beneficiaries with multiple chronic conditions. These comprehensive services are to focus on timely, appropriate care that improves quality of life while lowering costs; preferably by decreasing the need for care at institutional settings.

This project will also test ”whether home-based care can reduce the need for hospitalization, improve patient and caregiver satisfaction and lead to better health and lower costs to Medicare,” per the CMS announcement.

If you look at the number of beneficiaries that referred to ‘home health’ or ‘outpatient services’ upon leaving rehabilitation, you begin to understand the need for coordinated care management beyond discharge.

So who are the candidates for this type of program? Beneficiaries with multiple chronic conditions who require someone’s assistance with two or more activities of daily living; and who have had a hospital admission within the last 12 months that included rehabilitation services. The potential for growth beyond initial participants is quite remarkable.

Will these types of programs be sustainable and how much will they affect services presently provided by outpatient therapy settings and home health services? Will these programs help fill the gaps perceived to occur in the near future with an explosion in covered Medicare lives (whereas multiple caregivers and increased physician visits with increased co-morbidities is not a rare occurrence for people with chronic conditions)?  (The Silver Book: Chronic Disease and Medical Innovations in an Aging Nation; Partnership for Solutions. Chronic Conditions Making the case for ongoing care – September 2004 update.  Baltimore, MD: Johns Hopkins University, 2004.)  Small populations with chronic conditions may be responsible for more than 80 percent of health care cost dollars.

Medicare is asking that the Independence at Home Demonstration include primary care practices and associated multidisciplinary teams of which can include pharmacists, social workers and other ‘supporting staff’.  They must serve no less than 200 beneficiaries with multiple chronic conditions each year of the demonstration. Overall, the demonstration may include up to 10,000 beneficiaries and up to 50 such practices. The application process and instructions for how payments will be made during this 3 year demonstration are included HERE.

Payments will be tied to success in meeting six quality measures compared to a threshold equal to or less than the average utilization in an unmanaged, clinically similar population with case mix and geographic adjustments.

So the question remains, are the complexities for innovation within the capabilities of  standard payment models?  Medicare states providers ”will continue to bill and be paid standard Medicare FFS reimbursement, subject to beneficiary deductibles and coinsurance and balance billing rules.” Additional incentive payments will then be derived from targeted payment levels and the number of quality measures met.  Will providers take those risks?  To what level can ‘supportive staff’ be utilized within a home? Does this create a level of care dependent on extenders of a multidisciplinary team not yet recognized within ‘standard payment’ methodologies? Only time and creativity will tell.

We have been told post-acute care services may look very different from what we have today. Health care reform will take on many faces.  For up to 10,000 beneficiaries, this new face of health care will begin shortly after the deadline for applications in just a couple of months.

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