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Medicare Complicates Efforts to Age in Place

Last week’s column introduced the concept of frailty and its effect on an individual’s ability to age in place While frailty can be present at any age, it is more common among older adults.  Frailty influences an individual’s ability to respond to physical and emotional stressors and increases the likelihood of negative outcomes such as hospitalization and loss of independence.

Mobility is a significant aspect in the assessment of frailty. Some of the symptoms of impaired mobility include low energy levels, poor endurance, slow movement, weakness, and inactivity.  While the loss of some muscle mass is normal with aging, this loss does not have to result in a decline in function.

There are actions which an older adult can take to prevent or minimize the development of frailty.  These actions will sound very familiar as they are recommendations which apply to adults of all ages.  They include a sensible diet, management of disease processes (as much as is reasonably possible), and regular exercise.  The physical effects of a lack of attention to one or more of these areas are more pronounced for older adults than younger ones.

An upcoming change in Medicare regulations may make services which support exercise, medical monitoring, and the ability to age in place more difficult for older adults.  This change relates to home health services for hospital patients who have been classified under observation status instead of admission.

Already, Medicare denies reimbursement to individuals for rehabilitation in a skilled nursing facility following a hospitalization under observation status.  For individuals who have risk factors for frailty or are already considered to be frail, a temporary stay in a skilled nursing facility following an emergency room evaluation or short observation stay can potentially provide the necessary structure and additional support required to maximize the individual’s recovery and promote a successful transition back to home. 

When an individual is discharged directly to home in a compromised state, some families do not have the knowledge, skills, time, and/or physical/emotional resources to provide optimal support for their loved one despite their best efforts.  Even with additional supportive services, the variables which are present within a home environment can influence the length and outcome of the recovery process. 

A primary supportive service which is available to certain individuals who are at home is Home Health. Home Health agencies provide medical monitoring, health education, and therapy services to individuals who meet the criteria of being considered homebound (it is difficult to leave the home for outpatient services) and have a temporary need which can be met with intermittent services.  Individuals who are homebound are likely to be frail.  A physician’s order is required for home health services, but the order can be obtained after seeing a physician in the office and not necessarily the hospital.

 Beginning in January 2020, the Centers for Medicare and Medicaid Services will be changing the level of reimbursement which is provided to home health agencies.  Reimbursement rates will be lower for individuals who have not had a hospital admission prior to a referral for services (this includes observation status patients). 

This change may cause home health agencies to pursue more hospital referrals in order to maintain enough revenue to remain viable and/or earn a profit.  The Center for Medicare Advocacy estimates that payments to home health agencies may be as much as 25% lower for “community admissions” than for “post-hospital” admissions. 

Thus, a person in the community who experiences an illness or a fall which can be treated at home may have a harder time obtaining home health services to assist in recovery. 

Home health services are a common intervention used to help prevent or reduce the incidence of falls. The U.S. Centers for Disease Control report that every year, 25% of adults age 65+ experience a fall. Falls negatively impact the ability to age in place.  Even without injury, falls directly affect quality of life.  The fear of falling causes some older adults to limit their activities, resulting in depression, isolation, reduced mobility, and frailty.

The use of home health services by older adults to maintain and improve their physical strength, stamina, and overall mobility should be encouraged as a tool to reduce rates of frailty, hospitalization, and institutionalization. Instead, Medicare is making access to this service more difficult.

The lesson here is if you want to age in place in your home, you had better be proactive in taking steps help yourself.  Medicare is NOT on your side.

Karen Kaslow, RN, BSN