Changes Are Underway My Last Editorial for You, With a Roadmap and a Call to Action! TINA M. MARRELLI, MSN, MA, RN, FAAN

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his is my last official editorial to you as editor of Home Healthcare Nurse. The past 8 years have flown by and I have enjoyed working with all the authors, readers, subscribers, and reviewers who I have interfaced with on various issues and manuscripts and articles. A special thanks goes to all the HHN Editorial Board members over the years, many of whom I have worked with for decades on various books, journals, and journal articles. Thank you, thank you! And Brittany also says hello and thank you! And for those needing a “CliffsNotes” version of APA, Brittany’s article on that topic, “Writing and Reading With American Psychological Association Style,” can be accessed at http://journals.lww.com/homehealthcarenurseonline/ Fulltext/2013/07000/Writing_and_Reading_With_American_Psychological.1.aspx For those of you seeking to submit an article, that is a very helpful read. That said, please welcome Maureen Anthony as the new editor! There is a great saying attributed to President John F. Kennedy: “Change is the law of life. And those who look only to the past or present are certain to miss the future” (Kennedy, 1963) This issue of Home Healthcare Nurse and the topics included in it reflect the diversity of chronic illness, patient populations, and the focus on safety and quality that are the continuing emphasis in healthcare reform and need for effective and positive change. On the topic of safety, the CE article “Mechanical Lift Algorithms,” by Susan Lowe, is the second part in a series about this important topic. “Integrating a Pharmacist into a Home Healthcare Agency Care Model: Impact on Hospitalizations and Emergency Visits” written by an interdisciplinary team led by Shannon Reidt includes their lessons learned. Chronic and palliative care articles include “Facilitators of Diabetes Self Management among Rural Individuals” and “Palliative Care Hits a Triple Win: Access, Quality and Cost,” the latter of which is another CE article. Infection control is always an important part of efforts toward increasing safety and quality, and “Creating a Meaningful Infection Control Program: One Agency’s Lessons” addresses this topic at length. Peg Terry and Eileen Grande offer an interesting look at the future in “Information Technology and Home Healthcare: The New Frontier in Home Care,” in the VNAA’s Voice column. This issue’s Commentary, “The Cost of Observation” by Julia Steele, is an interesting discussion of the nuances of reimbursement. The following are some of the changes that will impact home care and healthcare. I am starting with “big picture” macro changes that set the foundation for a more rational healthcare system and then move into the home care—specific items that we should be aware of (and, in some cases, very concerned about). Home care will not look the same in 10 years, or even in 5. This is our time to adapt, change, and reconfigure. Some project that the next 2—3 years will look like

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or be like the years before interim payment systems and prospective payment systems. On the positive side, home care will have an important place, but it may be unrecognizable from the historic and perhaps outdated Medicare model. In addition, the American Nurses Association will be releasing the revised, 2014 “Home Health Nursing: Scope and Standards of Practice” this year. Stay tuned. As the patients are changing, so too must the models and Medicare, and we can see it happening. 1. In January, the Centers for Medicare & Medicaid Services (CMS) issued 41 pages of accountable care organization contractors. These were geographically all over the country and that report solidifies what we know is happening and will continue to happen: consolidation as we move toward a more holistic and rational healthcare system and patients are cared for across lines of care, be it a home healthcare agency, a hospital, a skilled nursing facility, or some other provider. As collaboration and communication move to the forefront of healthcare and healthcare transitions, these kinds of partnerships will be the norm, and who better to manage patients and populations with chronic care problems and keep them out of the hospital when possible? It will be home care, although “home care” may look very different. 2. The CMS announced that Maryland will be an “all-payer model.” The CMS is partnering with the state of Maryland to “modernize Maryland’s unique all-payer rare setting system for hospital services that will improve patients’ health and reduce costs”(CMS, 2014a). The goals are to lower costs and improve patient outcomes. When I was the director of a home care and hospice in Maryland, I did not understand how “unique” their system was until I moved to Ohio. Maryland did not have diagnosis-related groups because they had the foresight to address spiraling healthcare costs in the 1980s, so they consistently remained below the national average for healthcare costs. Read more about this innovative new model at http://www.cms. gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2014-Fact-sheetsitems/2014-01-10.html. Maryland may serve as the model for other states seeking to decrease costs and readmission rates. 3. A “final rule” was issued by CMS to “ensure that Medicaid’s home and community-based services programs”provide full access to the benefits of community living and offer services in the most integrated settings”(CMS, 2014b).The final rule is available at the Federal Register at http://ofr.gov/ OFRUpload/OFRData/2014-00487_PI.pdf. Simply put, this will allow an alternative to institutional care—and bring some patients back into the community. 4. The Medicare Payment AdvisoryCommission made some recommendations that will directly impact home care. Not only did they recommend a freeze on payments for home healthcare and hospice (and some other provider types), they also finalized a recommendation to create one common postacute assessment tool. This would be used for home healthcare, skilled nursing facilities, and some other provider types. TheContinuity Assessment Record and Evaluation (CARE) Item Set has been being studied for some years, and you can learn more about it from CMS by visiting http://www. cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PostAcute-Care-Quality-Initiatives/CARE-Item-Set-and-B-CARE.html 5. CMS clarified documentation requirements for face-to-face encounters. The CMS issued a special edition of MLN [Medicare Learning Network] Matters in

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an effort to clarify this confusing regulation. This important clarification reviews coverage criteria for skilled nursing and therapy and the requirements for a patient to be considered homebound. Examples and other important information can be accessed by going to the MLN Matters article at http://www. cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE1405.pdf. 6. There is bill in Congress (House and Senate bills HR 2504/S 1332) to remove unnecessary barriers to home care services and through the use of nurse practitioners to certify, order, or otherwise authorize home care services for Medicare beneficiaries. Your congressperson and senators may be needed to support this legislation. For more information, visit http://beta.congress.gov/ bill/113th/house-bill/2504. As you know, we need to facilitate getting patients into home care and the services they need—not have barriers to care. The patients in home care are too complex and have too many comorbidities, and we know that patients need to be seen sooner rather than later to identify risks (e.g., medications, changes in condition, no scheduled doctor’s appointment) that may lead to an avoidable (re)hospitalization. Given all these changes, and the ones not addressed which include the fact that the administrative law judges are reportedly not going to taking or scheduling any more home care and hospice cases (a discussion for another day!), that the Bureau of Labor Statistics(BLS) projected a 70% increase in home health and personal care aides between 2010 and 2020 (BLS, 2012), and others. I believe that home care has arrived. We, more than any other group, know that patients want to be out of the hospital (e.g., costs, infections, patient rights, quality of life) and that payers (i.e., the government) will move to the lowest cost setting —after they go through much intellectual violence and figure out how to get there, which I believe is finally happening. There is no question that this realignment will be painful. Table 1 presents some action steps I believe will help you through this time of change.

Table 1. A Roadmap for Success: A Call to Action 1. Acknowledge the change and try to work on processing it. 2. Improve your people (collaborative, communication, mentorship), technology, and other skills. 3. Know and apply the Medicare and other rules. In this time of increased scrutiny, we must know what are the skilled nursing services, what is homebound, what does good care planning and care coordination and documentation “look like,” and so on. 4. Use the evidence when making clinical decisions and to support the best care. This includes important areas such as infection control, safety, and quality. 5. Get ready for ICD-10. The Centers for Medicare & Medicaid Services released a video on ICD-10 coding basics, which provides a fundamental introduction. See the video at http:// www.youtube.com/watch?v=kCV6aFlA-Sc&feature=youtu.be. 6. Try to think in terms of patient populations, health promotion, and prevention. 7. Apply the nursing/scientific process for patient care and improvement/management. 8. Read and stay up to date! Consider certification in your area of expertise. (continues)

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Table 1. A Roadmap for Success: A Call to Action, Continued 9. Use your critical thinking skills—and never let anyone tell you that your idea is not good or not needed; it may simply be ahead of its time and the curve. One quick story here: When I first wrote the Handbook of Home Health Standards: Quality, Documentation, and Reimbursement (Marrelli, 2011), it was written for the great home care and hospice team I managed—I remember thinking there “has got to be a better way” to plan care and make sure documentation is clear and coverage is understood. Twenty years and 5 editions later, this book is still used by many thousands of nurse and therapy clinicians. I tell you this because when I first submitted this book to a publisher, I was told there was no market for the book. That was in the late 1980s, when home care was having huge denial rates and such—and not unlike now. (Visithttp://www.marrelli.com to see the red book). The lesson here is believe in your ideas—you know home care! 10. I think you can tell that the U.S. Department of Health and Human Services has made home care a priority. For an interesting read, there is a report entitled “A Vision for Anywhere, Everywhere Healthcare.” This report was released by the Association for the Advancement of Medical Instrumentation, and the stories and information in this 41-page report will broaden your perspective on healthcare and where it is provided, including the home. Visit http://www.aami.org/publications/summits/HomeHealthcare.pdf. 11. Participate in your professional associations and state meetings! Submit abstracts, showcase exemplars that work at your organization, volunteer on their committees, and use theseopportunities to move the industry and patient care forward and to an improved level. Whether the Visiting Nurses Associations of America (http://www.vnaa.org) or the International Home Care Nurses Organization (http://www.IHCNO.org) these are venues to improve care and practices! 12. Take care of yourself! We are the models for the “health” in healthcare and in our communities. Our patients and their families may look to use as role models and mentors, and they should. Remember that “sitting is the new smoking,” and, as such, we should move as much as possible (Ravn, 2013). For more information visit http://consumer .healthday.com/senior-citizen-information-31/misc-aging-news-10/briefs-emb-1-15women-sitting-early-death-ajpm-cornell-release-batch-1101-683906.html

I believe together we collectively have the skills, vision, and desire to make home care better—be it safety, quality, innovations, the use of technology that support care and in other ways. I challenge you to be your best and to embrace what you know— what the best healthcare at home truly looks like. We must be the change we seek.

The author declares no conflicts of interest. DOI:10.1097/NHH.0000000000000052 REFERENCES

Bureau of Labor Statistics. (2012). Occupational employment projections to 2020. Retrieved from http://www.bls.gov/opub/mlr/2012/01/art5full.pdf Centers for Medicare & Medicaid Services. (2014a). Maryland all-payer model to deliver better care and lower costs. Retrieved from http://www.cms.gov/Newsroom/MediaRelease Database/Fact-Sheets/2014-Fact-sheets-items/2014-01-10.html Centers for Medicare & Medicaid Services. (2014b). HHS strengthens community living options for older Americans and people with disabilities. Retrieved from http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2014-Press-releases-items/2014-01-10-2.html Kennedy, J. F. (1963). 266—address in the assembly hall at the Paulskirche in Frankfurt. Retrieved from http://www.presidency.ucsb.edu/ws/?pid=9303 Marrelli, T. (2011). Handbook of Home Health Standards & Documentation Guidelines for Reimbursement (5th ed.). Philadelphia, PA: Mosby. Ravn, K. (2013, May 25). Don’t just sit there. Really. Los Angeles Times. Retrieved from http:// articles.latimes.com/2013/may/25/health/la-he-dont-sit-20130525

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Changes are underway: my last editorial for you, with a roadmap and a call to action!

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