Be a champion for your patients, caregivers

Readers of HME News already know the statistics: The number of people with chronic care needs who wish to age at home will soon exceed the number of caregivers available to help. This has far-reaching implications for HME companies who have labored for years under restrictive Medicare, Medicaid and private insurance coverage determinations.

HME reimbursement has been limited by the priorities of a health system pre-occupied with acute care interventions. “Medical necessity,” an acute care standard, continues to apply even though advocates such as the Center for Medicare Advocacy have long argued for a “chronic care” standard that would focus on maintaining functional abilities or preventing deterioration.

The medical necessity standard has had multiple unintended consequences for those relying on assistive devices to perform activities of daily living such as walking, bathing, toileting, showering, and eating. Consumers seeking a higher quality product, one that helps them function at more than a basic level, or eases the burden on family caregivers, must pay 100% out of pocket. 

Thankfully for chronic care recipients and their family caregivers, CMS is considering “functional status” as part of a proposed standardized dataset across post-acute care settings, including long-term care hospitals, skilled nursing facilities, home health agencies and inpatient rehabilitation facilities. Self-care and mobility are two quality metrics that have been recommended for CMS review.

To that end, Health and Human Services is considering a six-step assessment reflecting the assistance needed for self-care/mobility tasks: (1) Dependent: Helper does all of the effort. Patient does none of the effort to complete the task; (2) Substantial/maximal assistance: Helper does more than half the effort. Helper lifts or holds trunk or limbs, and provides more than half the effort; (3) Partial/moderate assistance: Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort; (4) Supervision or touching assistance: Helper provides verbal cues or touching/ steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently; (5) Setup or clean up assistance: Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity and (6) Independent: Patient completes the activity by him/herself with no assistance from a helper.

In addition, public health professionals have declared the functional independence of an aging population as an important goal. Charging themselves with finding innovative ways to meet the multiple needs of older adults and their caregivers, they are developing national estimates of the current level of independent function from the National Health Aging and Trends Study (NHATS) across multiple activities of daily living.

It will take time for these policy changes to go into effect. In the meantime, hospitals are being charged with formally bringing family caregivers into care plans. Some health systems have gone further, issuing basic mobility aids as part of an expedited discharge protocol. Such products, considered to be commodities, are easy for them to buy cheaply in bulk, then distribute for themselves. This approach continues to assume that patients/caregivers will “make do” with what they get. 

These separate, yet related, trends bring into sharp relief the overlap of interest between HME, care recipients and caregivers. Multiple discussions regarding social supports for family caregivers are occurring in national and state forums. Nonprofit advocacy groups are discussing outcome measures for family caregiver health-related quality of life, functional status and their caregiving experience. 

HME companies have a unique point of view to bring to these conversations. Your products are what enable so many people to accommodate, or even mitigate, their functional decline. While the work around competitive bidding is important, arguments can now be made to replace “Medical Necessity” with a new “Optimize Function” standard for HME. That can unleash a wave of innovative equipment design that supports both restoration/maintenance of self-care/mobility across post-acute settings and well-being of caregivers. HME companies can refer to the safe patient handling and movement literature's evidence connecting equipment design/use to caregiver safety. Public health's data on the number of older adults struggling with functional levels, even with assistance and equipment, demonstrates the residual effect of the now-outdated “medical necessity.”

Get started by creating forums to challenge each other, patients, family caregivers, researchers, clinicians and administrators to include a “wish list” of equipment features that will maximize functional independence and caregiver safety/health. I've started this journey by working with health economist researchers to query the National Health Aging and Trends Study (NHATS) data on toileting caregiving experience for the Medicare 65-plus population and their caregivers, speaking up during family caregiver webinar Q&A sessions, and supporting the work of organizations such as Medicaring. Please join me in working toward this worthy goal.

Peg Graham, MBA, MPH, is semi-retired after many years working in health care advocacy and hospital administration, as well as a decades-long, life-affirming caregiving experience for an aging parent.