After seeing the very first homebound patient of the day, gives me such a rewarding feeling of making a difference in someone’s life, no matter how minute. I surmise, the homebound and frail elderly person I just saw in her home, would have ended up in the ER for a preventable concern such as refills of her COPD medications.
I am a nurse practitioner (NP) who provides medical house calls or more formally known as home based primary care (HBPC) for homebound elderly patients.
The Centers for Medicare and Medicaid Services (CMS) statistics from 2015 illustrates that the 15% of Medicare beneficiaries with six or more chronic conditions accounted for 51% of Medicare spending and 77% of hospital readmissions (Wolff-Baker & Ordona, 2019). There is a superimposing chronic condition and functional limitations among our homebound elderly population. The health care system spends a tremendous amount of resources, financial and otherwise, on this population group and the problem may not lie in the fact that they have multiple co-morbidities, per se. The problem, and perhaps one that can be addressed, is mainly the provision of adequate access to care.
HBPC has demonstrated cost-savings for Medicare as exemplified by the Independence at Home demonstration that have shown average of $111 per month per patient savings over three years (CMS, n.d.).
In recent years, NPs have picked up the slack in providing access to care for the homebound elderly population. According to the 2017 Moran data on Medicare billing prepared for the American Academy of Home Care Medicine (AAHCM) and the Home Centered Care Institute (HCCI), NPs are currently the largest segment of health care professionals providing HBPC to seniors. Of the 5,306,500 HBPC visits made in 2016, NPs performed over 2,023,000 of them by providing both Home and Domiciliary visits (Moran, 2019; Wolff-Baker & Ordona, 2019).
HBPC by NPs is not without barriers, though. Due to an antiquated Medicare guideline, NPs are not able to certify, re-certify, or sign orders for Medicare Fee-For-Service Home Health, despite being recognized by Medicare and Medicaid as primary care providers. This restriction originated from 1965 Medicare language stipulating the “physician must sign” for home health orders and has not been changed to reflect current health care delivery or recommendations from the Institute of Medicine, Future of Nursing Report, the Federal Trade Commission, the National Health Care Workforce Commission, and the American Enterprise Institute (Brassard, 2012; Wolff-Baker & Ordona, 2019).
There is a proposed solution. Introduced last January, Senate Bill 296 or the Home Health Care Planning and Improvement Act (2019) would allow advanced practice registered nurses such as NPs to order, certify, and re-certify Home Health. This legislation, if passed will certainly help improve access to care especially for the homebound elderly population. The American Nurses Association and American Association of Nurse Practitioners commissioned Dobson, DaVanzo, and Associates (2014) to update its assessed impact of the Home Health Care Planning Improvement Act on Medicare expenditures and estimated that the Medicare cost savings by relieving this barrier alone would generate $82.5 million savings over five years.
Removing this barrier relieves paperwork burden for our physician colleagues. More importantly, care is delivered to the most vulnerable older adult population, offering them cost-savings, efficiency, and access to honored generations of seniors in homebound communities.
Ron Billano Ordona, DNP, FNP-BC is a family nurse practitioner based in California.
Brassard, A. (2012). Removing barriers to advanced practice registered nurse care: Home health and hospice services. AARP Insights on the Issue, 1-10. https://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/removing-barriers-advanced-practice-registered-nurse-home-health-hospice-insight-july-2012-AARP-ppi-health.pdf
Centers for Medicare & Medicaid. (n.d.). Chronic conditions among Medicare beneficiaries. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Chartbook_Charts.html
Dobson, DaVanzo & Associates. (2014). Updated Report: Impact of Proposed Legislation H.R. 2504/ S. 1332 on Medicare Expenditures [Memorandum]. Retrieved from http://www.nahc.org/assets/1/7/Dobson_DaVanzo_Impact_Memo_Revised_3_25_14.pdf
The Moran Company. (2019). Medicare payment systems. Retrieved from http://www.themorancompany.com/expertise/medicare-payment-systems/
Wolff-Baker, D. & Ordona, R.B. (2019). The Expanding Role of Nurse Practitioners in Home-Based Primary Care: Opportunities and Challenges. Journal of Gerontological Nursing. 2019;45(6):9-14 https://doi.org/10.3928/00989134-20190422-01
Illustration by Yi-Min Chun