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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

Health care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton

NAHC Talking Points for Use in Commenting on FY2017 Hospice Proposed Rule

June 14, 2016 08:22 AM

On April 21, the Centers for Medicare & Medicaid Services (CMS) released CMS-1652-P: Medicare Program; FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. The National Association for Home Care & Hospice (NAHC) has sought input on the changes proposed in the rule and developed the following talking points as the foundation for its comments, as well as to assist hospices and other stakeholders in development of their own comments for submission. Comments may be submitted electronically at:!documentDetail;D=CMS-2016-0058-0002 and are due by Monday, June 20, 2016. Please note that NAHC’s comments are still under development so the final comments may include additional or modified perspectives.

Hospice Payment Reform: Research and Analyses

NOTE: As part of the proposed rule CMS did not request comment on the issues addressed in this section of the talking points document so this section does not contain specific points that hospices may want to consider when developing their own comments on the proposed changes. NAHC will, however, be providing comments on the payment reform data along the following lines:

Pre-hospice Spending

CMS discusses recent analysis conducted for the Medicare Payment Advisory Commission (MedPAC) finding that use of hospice appears to modestly raise end-of-life costs across all diagnoses. CMS conducted its own analysis evaluating pre-hospice spending as an initial step in determining whether patients have different resource needs prior to hospice based on the principal diagnosis reported on the hospice claim. CMS found that patients with the longest length of stay (who tend to have neurological conditions and are more difficult to establish a prognosis for) had lower pre-hospice Medicare spending in comparison with patients with shorter hospice lengths of stay. 

NAHC Comment Summary:

The hospice benefit was developed using data related to patients with terminal cancer but patient mix has dramatically changed over 30 years. A patient electing hospice care has access to an array of services as part of the hospice “bundle”; some of these services (hospice aide, homemaker) are not offered generally under Medicare to non-hospice patients so prior to hospice these services would most likely be funded through Medicaid or private pay. MedPAC data (MedPAC, June 2013, Report to Congress: Medicare and the Health Care Delivery System) indicates that patients in nursing facilities (a larger proportion of which have neurological conditions as their principal diagnosis) receive more hospice aide services and fewer nursing services than patients living at home. This variation in patient care needs may, at least in part, explain the variation in the amount of Medicare spending prior to hospice election. CMS indicates that it is monitoring pre-hospice spending to determine whether a case-mix based payment system can and should be developed for hospice. Additional study (MedPAC, 2012, Report to Congress: Medicare Payment Policy) indicates that with long-stay patients, length of stay is a greater driver of hospice costs than terminal diagnosis. This raises concerns relative to pursuit of a case-mixed based system. NAHC believes it is most appropriate for CMS to consider payment refinements that help to incentivize appropriate timing on enrollment for hospice.

Non-hospice Spending

In recent years CMS has tracked spending outside of hospice while patients are on service in an attempt to determine whether “unbundling” of care responsibilities is occurring under the hospice benefit.

NAHC Comment Summary:

Hospice patients retain the right to receive services under Medicare if the services are for treatment of a condition that is not the terminal condition or any conditions related to the terminal illness. This right is guaranteed by law and must be protected. However, spending outside of hospice for the terminal or related conditions is inappropriate and we support efforts to protect against this. We note that in the aggregate CMS data show Medicare spending outside of hospice has declined over recent years, due in large part to reductions in Part D spending for hospice patients (more than $100 million between CY2012 and FY2014). This is a very positive development and is attributable to significant efforts by all stakeholders to support prior authorization of specific categories of drugs. We believe, based on the commitment and efforts of hospice providers and others that this trend will continue on the Part D side.

Elimination of inappropriate spending under Parts A and B is a challenge as many non-hospice providers lack understanding of the interaction of Part A and B services and the hospice benefit. We applaud efforts by some of the Medicare Administrative Contractors (MACs) to educate providers under Parts A and B about coverage rules when a patient is on hospice care.

Submission of the NOE/NOTR through direct data entry (DDE) instead of Electronic Data Interchange (EDI) is slowing the posting of patient hospice status in the Common Working File (CWF). We urge CMS to move swiftly to allow for electronic submission of NOE/NOTR. In the interim, CMS should continue to make changes so as to minimize NOE/NOTR processing challenges and lost revenue.

Live Discharge Rates

CMS continues to track hospice live discharges and notes that between 2006 and 2014, live discharge rates have declined from 20.4% to 17.4%. CMS also has found a relationship between hospices with high live discharge rates, average lengths of stay, and non-hospice spending per beneficiary per day.

NAHC Comment Summary:

Continued analysis of live discharge rates is of value, particularly where it provides data identifying potentially problematic patterns of care. NAHC also supports the expansion of the live discharge target areas that were included in the 2016 Hospice PEPPER report; hospice providers benefit from being able to compare their own patterns of live discharge with those of their peers in the state, MAC jurisdiction, and nationally. We support an even finer breakdown of hospice live discharge data as part of the PEPPER as there are a variety of reasons for live discharge due to different circumstances that may apply. Greater detail on live discharge types as compared with other hospice providers will allow hospices to conduct more meaningful analysis of their live discharge patterns. Finally, because live discharge can be such a complex issue, NAHC continues to have concerns about use of live discharge rates as a publicly-reported measure -- there is significant potential for the public to misunderstand the significance or meaning of a live discharge measure.

Skilled Visits in the Last Days of Life

CMS continues to track visits delivered by hospice providers while patients are in the final days of life. This is considered an important domain relative to palliative and hospice care and is likely to be an important element related to care quality for these patients and families.

NAHC Comment Summary:

Continued tracking of the delivery of skilled visits in the last days of life is of value to hospice providers and consumers. As noted in our comments related to the Visits at the End of Life measure (below), it is important that CMS and hospice providers recognize the importance of honoring the wishes of patients and family members relative to the types and frequencies of visits in the last days of life.

Monitoring for Impacts of Hospice Payment Reform

CMS outlines a lengthy list of factors that it will be monitoring as data related to the payment system changes becomes available.

NAHC Comment Summary:

NAHC fully supports CMS’ planned oversight of the impact of hospice payment reform on hospice providers, patients, and overall patterns of care. We have received anecdotal reports indicating that some hospice providers with a high proportion of short-stay patients are receiving less revenue than was previously the case. We urge CMS to examine this area closely and if it can be determined that these hospices are being negatively impacted by some aspect of the payment changes that swift action be taken to address these concerns.

Proposed Updates to the Hospice Quality Reporting Program (HQRP)

Two New Proposed Measures

The Hospice Visits When Death is Imminent Measure Pair provides some indication of whether a hospice patient and their caregivers’ needs were addressed by the hospice staff during the last days of life. This measure is specified as a set of two measures as follows:

  • Measure 1: assesses the percentage of patients receiving at least 1 visit from registered nurses, physicians, nurse practitioners, or physician assistants in the last 3 days of life and addresses case management and clinical care.
  • Measure 2: assesses the percentage of patients receiving at least 2 visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses, or hospice aides in the last 7 days of life and gives providers the flexibility to provide individualized care that is in line with the patient, family, and caregiver’s preferences and goals for care and contributing to the overall well-being of the individual and others important in their life

CMS indicates this measure will encourage hospices to visit patients and caregivers and provide services that will address their care needs and improve quality of life during the patients’ last days of life. The measure includes visits for the following hospice employed/contracted disciplines made in the last 7 days of life:

  • Physician (or physician assistant or nurse practitioner)
  • Registered nurse
  • Licensed practical nurse
  • Aide
  • Medical social worker
  • Chaplain or spiritual counselo

Points for consideration/potential comment:

  • CMS recognizes the impact of each of these disciplines on hospice quality.
  • Are there other disciplines that should be included?
  • Should any of these disciplines be excluded?
  • Should CMs take into consideration the potential for the patient and/or family to decline visits or request fewer or different services in light of imminent death?

Data for the paired measure would be collected via the existing HIS. CMS proposed that four new items be added to the HIS-Discharge record to collect the necessary data elements for the measure. The expectation is that data collection for this quality measure via the four new HIS items would begin no earlier than April 1, 2017 (providers would begin collecting data for the measure for patient admissions and discharges occurring after April 1, 2017).  

Points for consideration/potential comment:

  • Is this the best time frame for implementation? If not, why not and what is the best time?
  • Does the revised HIS-Discharge include all the necessary instructions for this measure? If not, what is missing/how should the form be revised? (See revised HIS-Discharge below.)


Below is Section O that CMS proposes to add to the HIS-Discharge for the paired measure.



The second of the two proposed measures is the Hospice and Palliative Care Composite Process Measure - assessing the percentage of hospice patients who received care processes consistent with existing guidelines.

This is a process measure.

Points for consideration/potential comment:

  • Is a process measure meaningful to hospice providers? Hospice consumers?
  • What are some of the reasons hospices do not complete all seven of the processes found on the HIS with each and every patient, and should the outcome calculation for this measure be risk-adjusted to accommodate for these situations?

NAHC Comment Summary:

NAHC supports measures that recognize the value of the core interdisciplinary team members, maintain the holistic approach to care that is the essence of hospice care, and that address quality throughout a patient’s hospice stay. NAHC believes that CMS intends to include all visits delivered by the various disciplines included in the Visits in Last Days of Life measure as recognition of the value that each of the disciplines in hospice care contributes. Because there is a specific definition for visits as reported on claims, CMS should provide clear instruction on the definition of a visit for quality purposes and what type of visits should be counted in the HIS-Discharge. For instance, quality visits should include post mortem visits, social worker phone calls, NP visits that are part of nursing services, NP visits that are attending physician visits, and volunteer visits if the volunteer is providing care as a specific hospice discipline.  However, this is not how the measure numerator was defined in the NQF Measures Under Consideration (MUC15-227). Since the measure has not been finalized, CMS must include detailed instructions of what constitutes a visit for each of the disciplines and how the measure outcome(s) will be calculated.  Some hospices report that at the end of life their bereavement staff visit more often for patient/family support, as do volunteers (excluding those already reported as an existing discipline in the current measure), and NAHC encourages CMS to include these disciplines in this measure at some point in the future.; CMS believes the first of the two measures will encourage hospices to visit patients and caregivers and provide services that will address their care needs and improve quality of life during the patients’ last days of life. NAHC concurs but cautions CMS against creating incentives that drive visits for the sake of visits and not quality of care. CMS should remind hospices that visits must be reasonable and necessary for the palliation and management of the patient’s terminal and related conditions.  NAHC also believes the individualization of care for hospice patients must be preserved and encourages CMS to risk adjust any outcome(s) calculated from Measure 1 to reflect the patients’ right to refuse visits or request visits from disciplines not included in the measure.

The outcome calculation of the composite process measure should be risk adjusted to reflect the fact that hospices may not be able to deliver all seven care processes when serving a patient with an extremely short length of stay. Otherwise, an unintended consequence of Measure 2 is that the hospice is incentivized to complete all seven processes as opposed to identifying and addressing the patient’s and caregiver’s immediate needs for short length of stay patients. Patient needs should always be the priority.

The composite process measure is valuable, but consumers likely will not understand the difference between a process measure and an outcome measure and be able to draw conclusions about the experience of hospice care from just the composite process measure. To address this concern, CMS should incorporate CAHPS hospice survey data as soon as possible in public reporting. NAHC also strongly supports the Medicare Payment Advisory commission’s (MedPAC) comments urging timely development of hospice outcomes measures, as well as routine efforts by CMS to eliminate measures that are no longer considered to effectively measure quality.

Comprehensive Patient Assessment Instrument

CMS is considering a comprehensive patient assessment instrument for use by hospices. This would allow CMS to collect data concurrent with care delivery and provide information to be considered by CMS in the hospice quality reporting program and future payment reform. CMS indicates the instrument would replace the HIS but not the current initial and comprehensive assessment requirements.

Points for consideration/potential comment:

  • What assessment and care processes are important to include in a comprehensive patient assessment instrument?
  • CMS proposes two time points for data collection using the instrument – admission and discharge. Are these sufficient or should there be additional time points?
  • What aspects of comprehensive patient assessment instruments in other settings (i.e. OASIS and MDS) are applicable/not applicable for hospice care?
  • What additional costs will use of a comprehensive assessment create for hospice programs?

NAHC Comment Summary:

Any comprehensive assessment patient instrument in hospice should be comprised of a physical, psychosocial, and spiritual component. All core members of the IDG should be able to document within the tool. Any outcomes generated by the tool need to be risk adjusted

  • To reflect the patient’s right to refuse or defer some services from the IDG
  • For short lengths of stay
  • To account for situations where attending physicians refuse to give orders aligned with identified patient needs and patient preferences (i.e. effective use of narcotics for patients with history of substance abuse, use of narcotics with ‘street value’, etc.)

Because hospices do have slightly different processes to follow based on the patient’s site of service, CMS should consider this in development of the instrument, as well as the level of care the patient is receiving, and possibly modify questions based on these factors. Settings include the patient’s home, hospice inpatient unit, nursing home, assisted living facility, and hospital. Given that the assessment will be completed by different staff than are currently completing the HIS Admission and Discharge records and that the assessment will be more lengthy than current HIS, CMS must ensure that its estimate of increased costs to hospice programs are accurately reflected.  The instrument should, of course, be tested and revised as necessary prior to full implementation with input from hospice experts and stakeholders. NAHC stands ready to assist as appropriate.

Public Reporting and Star Rating

CMS plans to publicly report all seven HIS measures on a CMS Hospice Compare Web site. The CMS Hospice Compare Web site is on target to be implemented in spring/summer 2017. As stated above, the proposed Composite Process Measure is valuable, but NAHC believes it is difficult at best for consumers to draw conclusions about the quality of care from only seven process measures from the admission/assessment periods of care only. In addition, it may lead to confusion about the composition of the hospice benefit. We believe that CAHPS Hospice Survey data would be most helpful for consumers in drawing conclusions about the quality of hospice care and the experience that should be expected. Therefore, NAHC encourages CMS to include CAHPS Hospice Survey Data as soon as possible in public reporting.

Star Rating

Provider quality star ratings usually are developed and available for public viewing soon after the provider’s compare website and corresponding quality measures are available for public viewing. For hospice this could mean the implementation of star ratings as soon as summer of 2018.

Points to consider/potential comment:

  • What aspects of public reporting and star ratings from other provider settings (home health, hospital, nursing home, etc.) are applicable/not applicable to hospice?

NAHC Comment Summary:

NAHC encourages CMS to include CAHPS hospice survey measures in any star rating developed for hospices and to ensure that all components of the hospice interdisciplinary team are reflected in publicly reported quality measures. Risk adjusting for individualized care is a must, i.e. very short lengths of stay, patient right to refuse some IDG services, etc.

When developing star ratings for hospice programs, we note that CMS has graded some other provider types along a bell curve rather than on a “grade” rating scale. Use of this type of grading method creates confusion for consumers and may misrepresent the quality of the care that a hospice provides.




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