NAHC’s National Council on Medicaid Home Care Examines Health Homes
May 1, 2014 02:31 PM
The health care system is currently undergoing a profound service delivery evolution caused by the Affordable Care Act (ACA) and other reforms. One such patient population particularly affected is the chronically ill. This population stands to greatly benefit from enhanced skilled integration and coordination of care, particularly through the new Medicaid health home model.
While they may have to modify their business models to accommodate such an opportunity, home care agencies are perfectly poised to capitalize on health homes. As explained below, home health agencies can be participating providers should the state choose to include them. Some states have already explicitly adopted home care agencies as partners in their health home models. For those five states, home care agencies currently not participating should advocate for participation. Agencies in the ten other health home states should advocate for express home health agency inclusion, as well as their own participation. Those agencies in the remaining 35 states lacking health homes altogether should push for state adoption of this model, along with agency (and their own) inclusion.
According to a November 2010 State Medicaid Director Letter issued by the Centers for Medicare & Medicaid Services guidance document (the CMS Letter), health homes were created as “a cost-effective, longitudinal ‘home’” with which to integrate services for Medicaid enrollees with chronic conditions, including primary, acute and behavioral health services, and long-term services and supports (LTSS). The health home model builds on previous patient-centered care systems like the medical home by linking to “other community and social supports,” and by improving integration between medical and behavioral health care.
For the evolving definition of a medical home, see page 2-3 of the CMS Letter, here.
While not explicitly mentioning home care companies, the CMS Letter stipulated that the health home model should facilitate “less reliance on long-term care facilities” and “coordinate and provide access to long-term care supports and services.”
In 2010, health homes were established through the ACA, and clarified through the CMS Letter of the same year. Specifically, Section 2703 of the ACA added Section 1945 to the Social Security Act (the SSA), which stipulated how states could establish health homes through negotiating a Medicaid State Plan Amendment (SPA) with the Centers for Medicare and Medicaid Services (CMS). This health home option became effective on January 1, 2011.
By creating this mechanism, the ACA afforded states significant flexibility on how to structure their health homes. Unless otherwise stipulated, below is the framework for health homes from the Section 1945 of the SSA and the CMS Letter.
Health homes are available for Medicaid beneficiaries who either: 1) have two or more chronic conditions; 2) have one chronic condition and are at risk for a second; or 3) have one serious and persistent mental health condition. A “chronic condition” can be: 1) asthma; 2) diabetes; 3) heart disease; 4) a mental health condition; and 5) substance abuse disorder. Additional eligible chronic conditions may be negotiated with CMS, including HIV/AIDS.
States may tailor who is eligible for health home participation geographically, but cannot restrict health home eligibility by dual eligible status (i.e. Medicaid enrollees who are also Medicare beneficiaries).
Services provided by the health home include: care coordination and health promotion; comprehensive care management; comprehensive transitional care, including follow-up, from impatient to other settings; patient and family/authorized representative support; referral to community and social support services, when applicable; and use of health information technology to integrate services, where applicable and feasible.
States may structure their health home in one of three provider structures: 1) a designated provider; 2) a team of health care professionals operating with such a provider (a team of health care professionals); or 3) a health team. While the designated provider and team of health care professionals lists below are not exhaustive and can be negotiated with CMS in the SPA approval process, the health team is defined in Section 3502 of the ACA.
Designated provider. A designated provider may be a clinical group practice, a clinical practice, community health center, community mental health center, home health agency, rural clinic, a physician or an OB/GYN or other provider.
Team of health professionals. A team of health professionals may include: behavioral health professionals, nurse care coordinators, nutritionists, and physicians, and can be free-standing, virtual, or based in a hospital or other clinic or clinical practice.
Health team. A health team must include behavioral health providers, chiropractors, dieticians, medical specialists, nurses, nutritionists, pharmacists, social workers, and licensed complementary and alternative practitioners.
National Adoption of the Model
Overall, fifteen states have so far adopted the health home model through a SPA. These states are: Alabama, Idaho, Iowa, Maine, Maryland, Missouri, New York, North Carolina, Ohio, Oregon, Rhode Island, South Dakota, Vermont, Wisconsin, and Washington State. Of these, only five (Idaho, Iowa, Maine, New York, and Washington State) explicitly mention home care agencies as providers eligible to join the health home. Most of the remaining ten states contain language supporting that the health home should “provide access to long term services and supports” or otherwise providing for LTSS despite not mentioning home care agencies specifically.
For details on each of the 15 states’ health homes, see this chart here.
In order to receive payment, the health home providers must report on “all applicable measures for determining the quality of such services” that are provided “in accordance with such requirements as the Secretary [of Health and Human Services] shall specify.” In the CMS Letter, CMS states that further guidance on quality reporting requirements is forthcoming, and that it plans to develop, with assistance from the States and other groups, a core set of quality measures for health homes. In a January 2013 State Medicaid Director Letter, CMS enumerated eight recommended health home core quality measures, stating that it later intends to finalize these into a rulemaking. CMS did not give an anticipated date for this rulemaking.
For the January 2013 Letter, click here.
States will specify in their SPA how the state will determine payment for health home services. The payment methodology may be “tiered” to properly compensate based on complexity of the chronic condition, as well as the “capabilities” of the provider structure. CMS states that it will consider capitated, fee-for services, or other payment structures, in addition to those that differ from a per member per month (PMPM) methodology.
Quality reporting. The Council supports quality reporting, so long as the requirements mandated by CMS are reasonable. At this time, the Council finds the quality reporting requirements vague and requests that CMS timely release further guidance on the matter as it has stated. As quality reporting is a condition for receiving payment, the Council believes that the final rule stipulating the core quality measures for health homes will be critical for home care providers to fully understand their obligations. In the meantime, the Council advises providers to check their state’s SPA(s) for further specifications.
Health homes provide opportunities for home care companies. If not explicitly mentioned in the SPA, home care companies can still stand to leverage health homes in their states to increase their referral base. The Council advises home care companies to lobby their states to have home care companies explicitly included in the health home design, as is the case currently with five states. Alternatively, home care companies are encouraged to contact their states’ Medicaid programs for further clarification on how they can participate in the health homes.