Healthcare at Home: The Rowan Report

Caveat: I realize my experience may not be typical. Working in home health for nearly 25 years probably gave me an advantage that most would not have. Still, it occurs to me that it may be a good idea for those in home health to give patients some of the inside information to which I had access. Who knows? Maybe some nurses and therapists will find something here they did not know about the joint replacement patient’s experience. [Rowan provides extensive play-by-play  details about caregiving delivered by his many service providers until he was mobile again.]

— Tim Rowan
Colorado Springs
December, 2017

Toda.rs to me that it may be a good idea for those in home health to give patients some of the inside information to which I had access. Who knows? Maybe some nurses and therapists will find something here they did not know about the joint replacement patient’s experience.[Rowan provides detailed play-by-play accounts of his time preparing for his operation, the surgery itself, dealing with healthcare at home providers and difficult times learning once again to be vertical and mobile.]

– Tim Rowanolorado Springs
December, 2017

October, 2016
I had been acquainted for several years with Ben, a physical therapist and owner of a small home health agency that specializes in physical therapy. His agency has a stellar reputation, a 4.5-star CMS rating, and more 5-star Google reviews than any of the other 43 certified agencies in town. I asked Ben which orthopedic surgeon he would go to if he needed total joint replacement. He did not hesitate with his recommendation and I did not hesitate to make an appointment with Dr. Feign.

X-rays convinced Feign my left knee was fully bone on bone and I was a good candidate for total replacement. “However,” he told me, “payers like to see less invasive, less expensive procedures tried first to be sure surgery is absolutely necessary.” He recommended an injection of hyaluronic acid, a gel that expands into the joint and provides relief for about six months. I was fine with that as I had a health plan that year with a $6,000 deductible but would be signing up with Medicare in five months. He also prescribed some outpatient physical therapy sessions, saying they would be useful both to prepare for surgery and to satisfy my insurance company.

The gel worked remarkably well. It took three to four weeks to take full effect but eliminated most of my pain for a time. It did not, however, increase my range of motion. The old college injury still imposed its limitations. A stationary bike proved doable and effective, as long as I didn’t mind the clicking sound that vibrated up to my shoulder with every pedal revolution.

2013 – 2017
Actually, exercise is an important part of this story. Something about turning 60 flipped a switch in my conscience. With a little encouragement from my adult children (OK, a lot of encouragement), I got into a regular routine with a trainer who emphasized flexibility and core strength rather than building muscle bulk. By the time I was ready to go under the knife, I had developed – and here I get to show off the words most readers already know but I had to learn  – strong quads and hamstrings, and strength and flexibility in both my IT band and anterior tibialis. When I expressed some doubts about surgery, the outpatient PT laughed and said, “Anyone who rolls his IT band on a foam roller as often as you do is going to do fine.” Thank you, Greg the trainer.

Final preparations
Considering the normal recovery time and the active summer of traveling and hiking my wife and I had planned, I wound up not scheduling the surgery the day I received my Medicare card, instead putting up with a little pain as the gel wore off, until after the NAHC Annual Meeting in October. After one last session in the gym with Greg, I checked into the hospital on October 24. First, though, there were four more mandatory preparation activities.

1. A week before Knee-Day, Ben, the agency owner, paid a visit to my house to look over everything from throw rugs to the width of bathroom doorway openings. “Take your shower in this bathroom, where there is a small step into the shower stall,” he advised, “but put your beside commode over the toilet in this other bathroom, where the doorway is wider so you can get your walker through. When you rent the walker, make them attach the wheels inside the frame, not the outside. It will fit through doors better. And get rid of all these rugs!”
2. Following his recommendations, I borrowed or rented an “IceMan” machine, a bedside commode, a walker, a shower bench, and an adjustable aluminum cane. Interesting lesson learned: renting an IceMan machine for the recommended 10 days is not nearly enough; renting it for 30 days costs more than buying it. So I now own one.
3. The hospital insisted on a “fitness for surgery” checkup with my primary care physician, including an EKG, and a pre-op class at the hospital. I had just had an EKG the previous March during my “Welcome to Medicare” checkup but the hospital said I needed another because that one was more than six months old. (The results had not changed.)
4. My surgeon also needed a pre-surgery visit with his assistant. She went over the details of the procedure and prescribed my pain medication, 60 Oxycodone tablets, with an added warning to start taking a laxative the minute I got home from the hospital. (She was right!)

In the hospital
I was fortunate that my surgeon is on the staff of an excellent hospital. Check-in was easy and warmed blankets over a skimpy hospital gown made the lengthy prep interview process tolerable. I had not been warned they were going to shave my knee from mid-thigh to mid-calf. I survived that ordeal but wondered why they did not offer me the anesthesia before handing a razor to that muscular CNA who appeared to be in a big hurry.

My surgeon showed up and asked me what I was there to have done. I knew he knew what he was going to do, and I knew that he knew that I knew it was a test, but I played along.

“You’re going to stick metal and plastic in my knee,” I quipped. “That’s what I thought,” he grinned, “but which knee?” I suggested he should cut into the hairless one with the nicks and razor burns. He agreed, and then signed his name right on the shaved area with a Magic Marker. It is hard to describe my feeling of relief that the odds of a life-changing mistake after I was anesthetized were significantly diminished.

The anesthesiologist appeared and described in great detail exactly how he was going to put me under. (What he did not mention was that he is not in my insurance network, even though the hospital in which he works is. I did not learn that until his super-sized bill arrived weeks later.) Back to the present. The smiling face of an anesthesiologist, viewed over the top of the mask he strapped onto my face, is the last thing I remember.

K-Day, Tuesday afternoon
I am told I was in the operating room less than two hours. I awoke in a private hospital room to find massive bandages encircling my knee and two tubes disappearing into my thigh, one to drip a nerve block, the other for a stronger local anesthetic. I laughed when someone asked if I wanted to order lunch, then went back to sleep. Before long, however, a physical therapist woke me up to say it was time for my walk. “My what?” Yes, she said, up and at ‘em. I made it to the end of the hall and back, then to my room for another nap. That evening, I was able to eat, and watch Game One of the World Series, sitting up in a chair. It would not be exactly accurate to say I felt no pain; “I felt no leg” better describes my first and only night in the hospital.

Wednesday
Apparently, anesthesia drugs take days, not hours, to wear off. Wednesday was a day of attempting to catch up on emails while barely able to focus. Then there was “Walk #2.” This time, I made a 360 degree trip around the entire ward. My PT was impressed; I was relieved when it was over. After a quick lesson in the PT gym on how to ascend and descend stairs, she cleared me to go home and the surgeon agreed. (“How did it go?” I asked Dr. Feign. “I don’t remember; it must have been OK,” he answered, in all seriousness.) They removed the compression machines from my calves and replaced them with the tightest thigh-high stockings I had ever seen. “They prevent blood clots,” I was told, which immediately shut up my complaints about how tight they were.

I have heard a lot over the years about hospital discharge planners who steer patients toward their owned or affiliated home health agencies. I did not have that experience. I had named Ben’s agency from the beginning and the discharge planner, who had my request in her Epic station, offered no argument. All that remained was to figure out how to get clothes on and get to the exit. Fortunately, I had help with both.

World Series Game 2
The company that rents the “IceMan” delivered my unit right to my hospital room. Remembering the advice I had been hearing from every PT, “ice is your best friend,” I had my brother-in-law driver fill it up and plug it in as soon as I negotiated the four steps from garage to kitchen (old knee leads going up, new knee leads going down).

Settled, iced up, and saturated with Oxycodone, I turned on Game Two, Dodgers vs. Astros. Fortunately, I subscribe to my local daily newspaper so I could read the re-cap in the morning. Apparently, Oxy makes one very sleepy. Before I nodded off, Bethany called to set my first in-home PT visit for the next morning.

The Home Health Experience
I know which EMR Ben’s agency uses; I helped him pick it out. So I was on the alert to see how his PT used it for my OASIS assessment. She didn’t. I anticipated being put through the “OASIS walk.” I wasn’t. Bethany did, however, do a professional assessment, even though she did not write anything down. She watched me walk with my rented walker and told me I was doing it correctly. She measured my range of motion. I almost managed 90 degrees, which she explained was pretty good for day three. We walked around the house a bit while she watched me get in and out of bed and in and out of the bathroom. She talked about Oxycodone, especially the importance of taking it as scheduled and the side effects. Following her advice, I consumed large amounts of Miralax…to no avail, it turned out. (Instructions on the bottle say it should be taken once a day. Ignore that!)

Later that same afternoon, Ashli the OT dropped by. She also watched me walk around the house with the walker and said I should shower while she was there, waiting within earshot while I struggled through an activity of daily living that I had done by myself for 60 years. Don’t tell Ashli, but I stared at the shower chair for a minute and decided not to use it. Disobedient, I know, but I didn’t fall, not even close. Eventually, I returned the rented shower chair, unused.

My Slave-Driver PTA
On Friday, the real work began. Bethany assigned me to her physical therapy assistant, Jill. That day, followed by four visits the next week and three the week after, she stretched my range of motion from 90 degrees to 70, taught my daughter how to help me get those awful stockings on, walked me up and down the 13-step stairway to my basement, took me outside for a goal of an 1,100 foot walk through the neighborhood (I managed almost 1,600), and covered my leg with kinesthetic tape. I noticed that she did carry a tablet with her. She used the EMR to check her schedule before arranging each visit, but she took her notes on paper. Bethany joined her for a supervisory visit on my 5^th session.

At the end of Jill’s seven challenging, expert visits, Bethany returned to evaluate me for discharge. Happy with my range of motion and stability, she said she had no doubts I was ready to graduate from in-home to outpatient PT. Still no software, still no obvious OASIS questions. I assume that was all done later; I hope it was all done accurately. Her farewell hug stopped me from asking any pointed questions.

In the middle of my home health episode, it was time for my two-week checkup with my surgeon’s PA. I found it just as difficult to get into the passenger seat of my car as it had been when I was driven home from the hospital 12 days earlier. I was concerned that the swelling and range of motion had not yet significantly improved, but my pain was greatly diminished, enough that I had been able to cross two milestones: from Oxycodone to Ibuprofen and from walker to cane.

I was still determined to walk into that appointment without either assistive device. With a little bit of a swagger, I strode from the waiting room to the exam room carrying the cane rather than leaning on it. The PA replaced my gauze bandage with a half dozen butterfly strips laterally across the incision and looked at me suspiciously when I asked if I could drive myself home. “Is it an automatic?” Yes. “Are you still taking Oxycodone?” No. “OK, since it was your left knee, I guess you can start driving again.” Freedom!

Outpatient PT
With ice still a constant companion, I got set up with twice-weekly outpatient sessions. They turned out to be more similar to my gym workouts with Greg than my exercises and strolls with Jill. Pushing through the pain on a stationary bike until the joint loosened up, kicking in four directions with an elastic band strapped to my ankle, standing on one foot with my eyes closed, and pushing against a heavily-weighted plate left me winded and exhausted, especially as they added weight to the plate every session. The welcome relief of ice for the final 10 minutes made the first 50 quickly fade from memory.

Here is the most important thing I learned. Full flexion, straightening the leg until the back of the knee touches the therapy table while lying on one’s back, is as important as it is difficult. It is so tempting to fall into the comfort of sitting with one’s knee slightly bent, or lie in bed with a pillow underneath, that it becomes a matter of will power to force oneself to practice flexion. The consequence of weak will power, they tell me, is that scar tissue will form in the slightly bent position and you will never be able to straighten your leg completely again.

PT Brad explained this to me as he literally forced my knee down to the table by leaning most of his weight on it. No amount of moaning convinced him to stop. “I’m trying not to fight against you but I’m afraid something bad is going to happen.” He was unmoved. “Nothing bad will happen. This is good for you.” I questioned whether he and I had the same definition of “good.”

Six-week checkup
This time I drove myself to the appointment and did not bring the cane. Dr. Feign took x-rays and proclaimed me another one of his successes. “You should come back again in another six weeks but, if you’re feeling OK, just call a week early and cancel. You’ll be fine.” I reminded him how much prep work I had done, rolling my IT band and strengthening my quads and hamstrings for four years. He agreed to share the bragging rights with me.

Epilogue
Having no clear idea last summer how long it takes to recover from total knee replacement, I took a gamble and accepted an invitation to deliver a speech to the Home Care Alliance of Massachusetts Financial Managers meeting in December, three days after my 6-week checkup. I made it. Even my first TSA encounter was relatively uneventful. I pointed to my knee, they routed me through the full-body x-ray machine, and sent me on my way. There was a little pain after standing and talking for an hour but far less than Brad jamming my knee into the table with all his might. Thanks to careful planning, I spent that night in a hotel with a well-stocked ice machine.

©2017 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

November 29, 2017

Dear Editor:

Thanks for the opportunity to respond to the testimony provided by Joe Russell. We appreciate and respect the role of the Ohio Council for Home Care & Hospice, and we understand their goal to improve the Ohio Department of Medicaid (ODM) EVV program.

We would like to clarify several of the comments included in the testimony provided on November 17 by providing additional details that may not have been available prior to this testimony.

There is an assertion that the Alternative EVV (Alt EVV) specifications are too complicated, that the specifications were created by Sandata, that the specifications were released without input from the community, and that there are no Alt EVV vendors who have completed certification. [Underwood provides a very detailed response in which he rebuts Jim Russell’s contentions about Sandata’s role in designing sprcifications for EVV submissions by vendors].

Following are some of the details regarding the Alt-EVV specification and process for vendors to complete:

• The Alt-EVV specifications were established by ODM, and then documented and published by Sandata.
• There have been numerous communications from ODM regarding the Alt EVV process, including:
  • ODM released the Alt-EVV specifications to a group of providers for input in March, 2017.
  • ODM held an EVV Advisory Board meeting on 4/4/2017. This meeting was focused on Alt-EVV and included a discussion of the approval process, demo of the eTRAC registration and email system, and presentation of the support mechanisms for the process (information on the ODM website, utilizing Customer Care, etc).
  • A letter was sent to Agency providers on 4/28/17 which included links to the business requirements for Alt-EVV systems and the Alt-EVV specifications. It also included the Customer Service toll free number and a link to the eTRAC registration site to start the approval process.
  • An outreach email was sent to Agencies on 5/15/17 with the same content and links as the above letter.
  • ODM held an EVV Advisory Board meeting on 6/20/17. Alternate EVV was an agenda item and there was an open Q&A session regarding Alt-EVV.
  • Sandata presented the approval process at an in-person OCHCH meeting on 8/14/2017.
• To date, 4 vendors have successfully completed the Alt-EVV certification and 11 more are in the process of certification.
  • For those vendors that have completed certification, the average elapsed time from the start of the process to the completion of certification, was 75 days.

There is also an assertion that ODM allowed Sandata to write the policy for Alternative EVV systems that have an adverse impact on providers, for example, requiring alternative systems to mirror the Sandata system such as requiring social security number.

Following are the facts behind the policy, and the use of SSNs for caregivers:

• ODM defined the policy for Alt-EVV systems. The program owner is ODM and Sandata provides the technology to administer the policies defined by the state.
• Like other state Medicaid programs that have implemented EVV, ODM has chosen to require the use of SSNs as a unique identifier for each caregiver. Note that states like New York have required the use of the caregiver SSN for many years.
• The use of the SSN is not a Sandata requirement; rather, it’s an ODM policy decision to ensure that each caregiver can be uniquely identified across providers and programs.

Concern is also expressed regarding the deviation of the current program from the system described in the original RFP.  Specifically it is noted that the MCOs are excluded from the current program, and that schedules and alerting are also not included in the current program that launches in January. Regarding this concern:

• ODM has determined that a phased implementation is best for all constituents. In this manner, certain groups will be included in the initial phase that begins in January, 2018, and other groups and additional requirements will be implemented in the future. The MCOs will be included in a future phase.

Finally, it should be noted that ODM is continuing to enlist input from the provider community and in fact has recently announced a relaxation of the GPS requirements for Alt-EVV solutions. In addition, ODM is participating in an EVV forum being held by OCHCH on December 6, 2017.

I appreciate the opportunity to provide this input. As the first OpenEVV solution in the industry, in our opinion, the ODM program is built on the principles of “Provider Choice” and “Provider Involvement,” and the information provided should support that view.

Regards,

Tom Underwood, CEO

On November 17, Ohio Council for Home Care & Hospice Executive Director Joe Russell testified before the Ohio Department of Medicaid. He represented the association’s position that the method the department has chosen to comply with the 21st Century CURES Act will harm its members. See the reply from the Ohio Department of Medicaid, written by Sandata CEO Tom Underwood, elsewhere in this week’s issue.

Ohio Department of Medicaid Public Hearing 
Proposed Rule 5160-1-40, Electronic Visit Verification (EVV)
Testimony by Joe Russell, Executive Director
November 17, 2017 [Joe Russell provides 6 detailed reasons in this article for opposing passage of EVV in Ohio. including: 1) its noncompliance with federal law; 2) few and complicated alternatives to adopting EVV; and other unacceptable aspects of the EVV rule are noted. A history of Russell’s organization is also provided in this article.]

Hello, my name is Joe Russell and I am the Executive Director at the Ohio Council for Home Care & Hospice (OCHCH). I want to thank the Ohio Department of Medicaid and Director Sears for the time you have spent to create an Electronic Visit Verification (EVV) program in Ohio. I also want to thank you for allow me to provide testimony today on proposed Rule 5160-1-40, Ohio’s EVV rule.

Founded in 1965, OCHCH is a member-driven statewide trade association that represents the interests of home health care and hospice agencies in Ohio. We strive to support our members’ ability to provide quality community services in home care, hospice and palliative care industry through advocacy, education, information and research.  As an association that supports our members’ ability to improve quality, we support initiatives like EVV that can reduce fraud. This is why we supported the federal 21st Century CURES Act that, among other things, created the EVV program for states.

Unfortunately, as written, our members cannot support this rule. The rule does not take into consideration the numerous agencies that have taken the initiative and invested in an EVV program long before a mandate existed. In some ways these agencies are being punished as the rule will be so difficult to comply using their existing EVV systems that they will have to redesign their internal structures and spend more money just to support this mandate. While we had hoped that this was going to be a good policy for Ohio’s Medicaid program, the lack of flexibility will make EVV an expensive burden that will be difficult for agencies to comply with, which could eventually lead to a lack of access to these needed services.

We have heard from our more than 650 member agencies, and they’re asking to fix this rule so that there’s flexibility and a peace of mind that this system will work. Or as one of our members said “…avoid this being just another Medicaid induced headache.” I want to share with you what our members are saying about this rule.

1.  EVV Rule Does Not Comply with Federal Law
a.  SEC. 12006 of the 21 Century CURES Act outlines requirements for EVV, and requires a system by January 2019.
b.  The act requires a state’s EVV system to be (1) “be minimally burdensome” and (2) “take into account existing best practices of the EVV systems already being used in the state.”
c.   Ohio’s proposed EVV system places a massive burden on providers to comply and ignores current best practices including the use of telephony, which a majority of Ohio’s providers using EVV use. As such, Ohio EVV proposal violates federal law.

2.  Alternative EVV System Requirements Are Not Clear & Too Complicated
a.  ODM allowed the EVV contractor, Sandata, to write specifications for alternative Systems, which seems like a major conflict of interest when you consider that the specification impact their competitors. These specifications were released on April 25, 2017 with no input on how they would impact providers.
b.  ODM also allowed Sandata to write policy for alternative EVV systems that have a major impact on providers in an inappropriate way. For example, they require alternative systems to mirror the Sandata system such as requiring social security number, among others.
c.   The burden to comply is completely on the provider despite being excessively difficult to do so. In fact to date, we’re not aware of any alternative EVV systems that have been approved. That should sound alarm bell given the number of agencies already using EVV.

3.  ODM Can Require Recertification of Alternative Systems At Any Time
a.  Section E(4) of the rule allows ODM to require a company to recertify their certified system if ODM changes their data requirements or if a company fails to maintain department requirements. Given the department is also allowed to change the requirements at any time, compliance will be all but impossible.
b.  It’s not clear the process ODM will use to certify alternative EVV systems, so it’s difficult for providers to prepare existing systems for the certification process.
c.    Worst of all, the rule allows ODM to terminate a Medicaid provider agreement for not maintaining data elements that ODM can change at any time. This is inappropriate and unacceptable.

4.  EVV System Does Not Meet ODM RFP Specifications 
a.  Several documents released by ODM, including the RFP, require the system to be used by managed care plans, yet the plans are now carved out of the rule. No explanation has been given why this changed has occurred, or how exactly EVV will work with MCPs. Like MyCare Ohio, there is major concern that claims will unnecessarily be denied.
b.  The RFP requires the system to notify providers when frontline staff are late or missed an appointment; a standard feature of most EVV systems. Yet, the EVV system proposed by the state does not have this capability so there’s no way to ensure quality or timely services. Agencies will have to purchase this feature from Sandata.
c.   The RFP also states that the contractor has the burden to install the system, yet the rule places a huge burden on providers to ensure the system is working for patients, including having to identify their patients who need devices and upload their patients’ data into the system.

5.  The Drafted Rule Exceeds ODM’s Rule Making Authority
a.  The proposed rule violates three of the six JCARR “prongs” including:

i.   The draft rule exceeds ODM’s statutory authority given to it by the feds in the 21 Century CURES Act by requiring GPS, in addition to the other requirements has highlighted earlier;
ii.   ODM ignored most of the Business Impact Analysis comments that we submitted alongside LeadingAge Ohio stating this would be a large unfunded mandate, including the need for each agency to hire one or more people specifically to manage the EVV system due to its design.
iii.   No fiscal analysis was done to determine the cost of the system for providers to use the Sandata system or an alternative system.

6.  System Design Will Reduce Quality And Access
a.  Most EVV systems allow for real time data. For example, if an aide does not show up for a shift a provider will know immediately and send someone to replace them. ODM’s system cannot do that so people will go without care. We are afraid that without this capability someone will get hurt, or worse.
b.  The focus seems to be on money, not quality. Nothing about the EVV system will improve quality of care. In fact, quality is likely to be diminished because the primary focus will be on managing the EVV devices not the patient. The total focus is on preventing fraud and saving money. Shouldn’t we give individual agencies the ability to improve quality and use an EVV system that helps them achieve that goal?
c.   This will place such a huge burden on agencies and could force them to make tough decisions including shifting scarce resources to other non-
Medicaid populations that are “easier” to serve. This is not something an agency would want to do or take lightly, but when faced with a choice between serving Medicare patients and Medicaid patients the choice is easy. Well, it’s not really even a choice.

These are just a few of the many issues that our members are concerned about, and this list doesn’t include concerns over the function of the Sandata system, which we know will have bugs that need to be worked out. As stated before, we support EVV and want to see this work. We just want a system that works for providers.

For these reasons, we cannot support the rule as proposed. I respectfully ask that you make the changes needed to provide flexibility to providers to come into compliance without making this a huge burden or a huge expense. We look forward to the opportunity to sit down with ODM to discuss how we can fix the EVV rule to provide additional flexibility ahead of the JCARR hearing next month.

Thank you again for allowing me to testify today. Thank you again to ODM and Director Sears for taking the time to address our concerns and making EVV a good thing for providers and for the people of this great state. Thank you.

by Audrey Kinsella. Telehealth Reporter for HCTR

“Connected Health for Shaping Health and Wellness for Every Generation,” was the title of the 2017 joint “Personal Connected Health” and Partners Healthcare’s Annual Symposium held in Boston last month. Joe Kvedar, MD, VP of Connected Health at Partners, kicked off this year’s event with a keynote address named after his new book, “The New Mobile Age.”

Dr. Kvedar indicated a range of components that healthcare workers must embrace to ensure that elders in their care are incorporating certain components into their daily lives. These components include such goals as having a sense of purpose in life, perhaps through doing volunteer or other helpful community-oriented activities to help them maintain social connections.

In his address, Kvedar asserted, “New connected health technologies will help us to re-imagine how we think about health as we age, and enable older adults to better maintain their health and wellness, manage chronic conditions and remain vital, engaged,and  independent.” Acknowledging that this is a tall order, the leading technology advocate added, “Caregivers using technologies to help achieve these ends is important but not as a substitute for human contact.”[Additional details about Dr. Kvedar’s new book are provided in this article as are details about the new and burgeoning legions of seniors (and their wants and needs. We’re looking at a “new kind of old” Kinsella says.]

The book Kvedar wrote, with co-authors Carol Colman and Gina Cello, is subtitled “How Technology Will Extend the Healthspan and Optimize the Lifespan.” It suggests caregivers concentrate not only on helping people live longer but also help them enjoy a healthier older age. In other words, the “healthspan” as well as the lifespan. As Kvedar explains in the book’s introduction, “This book is about new connected health technologies that can enable older adults to better maintain their health and wellness.”

Indeed, seniors using connected health technologies to maintain their health and wellness are the focus of the book, but the authors are quick to add that these technologies “will not just improve healthcare for older folks. They will create a better and more responsive healthcare system for everyone.” [p. xxii]

A new kind of old
Generally, the authors say, what elders want today from technology are not low-tech assistive devices such as “chunky, big-number phones or TV remotes or other tech tools dumbed down for ‘old people’ (page 6). Elders today “want what everyone else wants: sleek and attractive-looking devices that don’t scream ‘I’m old.’ They prefer devices that are well-designed for aging adults, devices that are effective, seamless, and requiring little fuss or bother.” (p.6).

Responsibility of patients to manage their own health is key in the new healthcare enterprise as well. Kvedar and his co-authors note in their book that today, healthcare delivery moves from conventional to new care delivery modes. “Patients have to start thinking of the healthcare system as a partner to keep them healthy, not as a place you go when you don’t feel well.” (p.72).

And how should these technologies be used, according to the authors? Simple question. But it requires more than simple answers. The gist of the matter is: we first need to create incentives for consumers to want to improve their own health. Strategies to create such incentives are defined the co-authors as:

1. Creating incentives for doctors to engage in prevention and provide the appropriate training to their patients.
2. Changing our cultural views of healthcare from one where everything is bad luck or an accident to one where some accountability is accepted and encouraged.
3. Combining the push toward value-based reimbursement with investment in public health prevention. (p.72)

Back to the book’s introduction. Kvedar and his co-authors encourage readers to join them “in the journey, as we describe how we’ll get there.” (p.xxii). Which tools work? Good question. Over the 30 years that I have studied advanced health technologies, I have come to the conclusion that the ever-changing plethora of new tools — always seeking to match their capabilities with the multiple needs of patients and providers — remain a veritable work in progress.

__________________________________________

— Kvedar, Joseph; Colman, Carol; Cello, Gina (2017) The New Mobile Age: How Technology Will Extend the Healthspan and Optimize the Lifespan. (Boston: Partners Connected Health)

Audrey Kinsella, MA, MS, is HCTR’s telemedicine reporter. She has written on home telehealthcare and new technologies for home care service delivery for 25 years, in 6 books, multiple web sites, and more than 150 published articles. Audrey can be reached at audreyk3@charter.net or 828-214-9434.

©2017 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

Springfield Mo. — November 14, 2017 — HEALTHCAREfirst announced this week what it is calling a “game changing technology.” CAREpliance for hospice providers, released earlier this year for home health, comes at a time of pronounced regulatory change and increased scrutiny, promising to strengthen clinical documentation and create charts that uniquely describe each patient’s health journey, according to a company news release. [Three senior executives at HEALTHCAREfirst describe the hospice software’s features; and voice great expectations for its successful use in hospice when released between late Nov-early Dec.2017′]

“The thoughtfully designed clinical workflow thinks like a clinician following the standard patient care processes to direct the clinician’s focus to the patient by alleviating documentation burdens. When problems are identified in the assessment, the system suggests interventions and goals for each problem, allowing the clinician to customize the plan of care and build a story for that patient, something surveyors are looking more closely for in today’s site audits. Equipped with the most thorough, evidence based clinical expertise and guidance in the market today, the result is comprehensive, quality patient care and consistent clinical documentation that ensures compliance, minimizing the risks of audits, denials, and take backs.

“We have had an overwhelmingly positive response to our CAREpliance Technology for home health,” said Misty Skinner, EVP of Services at HEALTHCAREfirst. “We’ve been receiving a lot of great feedback from our hospice focus group participants as well, so I know we’re on the right track to deliver something special that hospices desperately need.”

Steve Sablan, CIO of HEALTHCAREfirst said, “Our entire team is very excited about what we are bringing to the market. The regulatory environment always stirs up anxiety, but our team is always working ahead to minimize that for our customers and bring solutions that will enable them to integrate change while staying focused on patient care.”

CAREpliance will be available for firstHOSPICE customers in late Nov-early Dec. For more information, please visit the company’s website at healthcarefirst.com

©2017 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

by Elizabeth Hogue, esq.

New Conditions of Participation (CoPs) of the Medicare Program for home health require agencies to take action to protect patients’ exercise of their rights. The Centers for Medicare and Medicaid Services (CMS) issued draft Interpretive Guidelines for the new CoPs for home health agencies on October 27, 2017. The draft provides information about what surveyors will be looking for when they survey agencies based on the new CoPs for patients’ rights.

With regard to patients’ rights, Section 484.50(c(4) of the draft interpretive guidelines makes it clear that patients have the right to participate in, be informed about and consent to or refuse care in advance of and during treatment, as appropriate,… The author provides and describes in detail 8 “appropriate” instances in which patients might need to exercise their rights in the healthcare at home services provision. ]

These are:

• Completion of all assessments
• Care furnished, based on comprehensive assessments
• Establishment and revisions to plans of care (POCs)
• Disciplines that will furnish care
• Frequency of visits
• Expected outcomes of care, including patient-identified goals and anticipated benefits
• Factors that my impact treatment effectiveness
• Changes in care to be furnished

What must Agency staff members do to obtain informed consent from patients? First, it is important for agencies to understand some of the basics regarding informed consent. In order to obtain valid informed consent, providers must first establish that two prerequisites have been met: capacity, and voluntariness.

Capacity is defined in terms of chronological age and in terms of the ability to understand information. Patients must have attained the age of adulthood before they are generally able to give valid informed consent. The age of adulthood or majority varies from state to state, since it is established by each state legislature through statutes. Many states have determined that patients are adults at 18 years of age. Capacity is also defined in terms of patients’ ability to understand information. This ability is necessary in order to ensure that patients understand the treatment choices available to them.

It is often difficult for providers to determine if patients can understand the information given to them. This difficulty stems in part from the fact that mental capacity may vary from day to day, perhaps even from moment to moment. Staff member evaluations of mental capacity may, therefore, differ tremendously. This difficulty can be partly alleviated through the regular use of so-called mini-mental state examinations. Examples of these brief tests of mental capacity may be found in nursing and medical textbooks on psychiatry.

Staff must also determine that patients’ consent to treatment is voluntary. Specifically, staff must evaluate whether there is any fraud or duress that interferes with patients’ ability to make independent decisions.

When the above two prerequisites are met, staff may then proceed to provide information necessary to patients in order to provide valid informed consent. Patients must first receive a detailed description of proposed treatment. Thus, general consent forms indicating that patients have agreed to any and all treatments rendered are invalid.

This requirement also means that informed consent must be obtained whenever patients’ treatments change. Informed consent is not something that is obtained upon admission and then never addressed again. When patients’ treatments change, informed consent must be obtained again using a specific description of the new treatment(s). This requirement is included in the draft Interpretive Guidelines:

Providers must tell patients about significant risks associated with particular treatments. Practitioners obviously cannot disclose all of the risks associated with specific treatments. Instead, they must tell patients about those risks that they know are statistically significant or are particularly important to individual patients. If, for example, there is a fifty percent chance that a patient will die while undergoing proposed treatments, this risk must be disclosed. Another example is the case of a patient who is a world-famous violinist. Although proposed treatments have a statistically small probability of adverse effects upon the violinist’s hands, this risk must be disclosed, nonetheless, since staff members are aware that this it is particularly important to the patient.

Possible benefits of treatment must also be explained to patients as a part of the routine process of obtaining informed consent. The emphasis must be on the word “possible.” Practitioners have to be careful not to guarantee any particular result to patients. If certain outcomes are promised, some courts have ruled that a contract has been established between patients and providers that practitioners breach when they fail to produce promised results.

In addition, alternative treatments should be explored with patients. According to the draft Interpretive Guidelines, patients should, for example, be able to choose between a bath and a shower, unless there are physical restrictions or medical contraindications.

Finally, patients’ absolute right to refuse treatment must be directly affirmed to patients as a part of the consent process. As Judge Kelleher pointed out in Wilkinson v. Vessy, 295 A. 2d 676, 690 (R.I., October 20, 1972), obtaining valid consent is “good medicine, good humanity, good public relations, and good medico-legal defense.”

(To obtain a copy of Informed Consent, which includes more information about how to obtain valid informed consent from patients, send a check for $25.00 that includes shipping and handling made out to Elizabeth E. Hogue, Esq. to: Fulfillment, 107 Guilford, Summerville, SC 29483.)

©2017 Elizabeth E. Hogue, Esq. All rights reserved. No portion of this material may be reproduced in any form without the advance written permission of the author.

©2017 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

The U.S. House of Representatives on Nov. 7 [2017] passed the Veterans E-Health and Telemedicine Support (VETS) Act of 2017 (H.R. 2123), which will allow Department of Veterans Affairs (VA) health professionals to practice telemedicine more freely nationwide.

The bill, introduced by Reps. Glenn Thompson (R-Pa.) and Julia Brownley (D-Calif.), would do three things. First, it would create a VA state licensure exemption to allow VA-licensed doctors to practice telemedicine across state lines without having to acquire a new license in that state. Second, it would expand the definition of exempt healthcare professionals to include VA doctors. And third, it would remove the location requirement to allow for care regardless of where the VA physician or patient is located. [Also noted in this Act is the provision of services in veterans’ own homes.]

“I am pleased the House passed this bill today to allow our servicemen and women greater access to care–especially those in rural areas,” said Rep. Thompson. He added, “This bill will ensure that our veterans receive timely healthcare no matter where they live.”

House Committee on Veterans’ Affairs Health Subcommittee Ranking Member Brownley said, “The passage of our bill in the House today marks a major step toward our goal of expanding the VA’s ability to provide better, more accessible care to our veterans–including right in their own homes. New technologies provide us with better ways to provide care for veterans and tailor it to their unique needs, and we need to capitalize on that innovation.”

The VETS Act is backed by a number of organizations, including the American Telemedicine Association and American Medical Association.

©2017 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only.editor@homecaretechreport.com