On Heels of CDC Vote, Home Health Providers Grapple with COVID-19 Vaccine Mandates

On Tuesday, the CDC’s Advisory Committee on Immunization Practices (ACIP) — in an overwhelming majority — voted to recommend that health care workers, among others, get first priority on a COVID-19 vaccine when one is authorized.

In light of this latest development, the question now becomes: Should home health providers mandate vaccinations for employees?

The news of the federal advisory committee’s vote should come as no surprise, given the significant toll COVID-19 has taken on the health care community, including home health workers.

More than 200,000 U.S. health care workers have now contracted the virus. More than 800 have died from COVID-19, according to the CDC’s latest count.

Vaccinating health care personnel — which the CDC defines as those working in home health, hospitals, long-term care facilities, outpatient clinics, pharmacies, emergency medical services and other settings — supports the principle of maximizing benefits and minimizing harms, Dr. Kathleen Dooling, a medical officer at the CDC, said during a recent ACIP meeting.

“Protection of health care personnel leads to preservation of health care capacity — and better health outcomes for all,” she said. “Vaccinating health care workers promotes justice because health care personnel put themselves at risk and will be essential to carry out the vaccination program.”

If home health providers were to mandate vaccinations for employees, the move would not be unprecedented.

Over the years, many providers have mandated flu vaccinations, but when it comes to COVID-19, some companies have expressed concerns.

“There are a number of home care companies that have mandated flu vaccines, but in talking to some of those companies, they’re hesitant to mandate this vaccine,” National Association for Home Care & Hospice (NAHC) President William A. Dombi told Home Health Care News. “And lawyers could come up with a whole series of reasons to go after a health care provider that mandates a vaccine. I’ve even heard some lawyers talking about various Constitutional rights under the First Amendment.”

Indeed, providers could potentially land in legal hot water if employers don’t navigate this action carefully.

“The research that I’ve done on this one leads me to a position of, there’s no real solid advice, in the absence of specific legislation that lawyers can give, other than to tell people, ‘It’s going to create risk for you.’” Dombi said. “It created risk with the flu vaccine, but this one may create even more risk because of the clinical aspects of this vaccine.”

A major factor for providers: Some employees are still likely to be skeptical despite promising results from Pfizer and Moderna on their COVID-19 vaccine trials.

About 79% of health care workers said they haven’t received enough information about the COVID-19 vaccine, in terms of safety, side effects and administration, according to a recent survey conducted by the American Nurses Foundation.

On the flip side, there are many home health providers that are hopeful about the vaccine and applaud ACIP’s recent vote.

“I’m very pleased that home health care workers are in that conversation … and part of the front-line workers,” Cleamon Moorer Jr., president and CEO of American Advantage Home Care Inc., told HHCN. “Oftentimes, hospitals, of course, are the top priority, and then outpatient clinics. But I’m glad that home health care workers are included on the front end.”

Dearborn, Michigan-based American Advantage Home Care Inc. is a provider of home health care and rehab services, plus specialty care and medical social work. The agency operates across nearly a dozen Michigan counties.

Moorer also believes there are a host of reasons why it may be difficult for providers to mandate vaccinations for employees.

“Some of our home health care workers could be pregnant or planning for a family,” he said. “In that event, we’re often concerned about the impact of vaccines on pregnant women. Secondly, there are some individuals who for religious and/or ethnic purposes find themselves averse to vaccines. We definitely want to be sensitive to this.”

For context, Pfizer and Moderna’s vaccine trials haven’t included people who are pregnant.

Still, for people who don’t fall into the previously mentioned categories, strongly encouraging and incentivizing employees to take the vaccine — rather than mandating — might be the best option for providers.

“[Providers could potentially] offer a monetary incentive, for those that take on a high volume of patients, especially for those that continuously see patients who have been diagnosed with COVID-19,” Moorer said.

In cases where an employee may decide to forgo the COVID-19 vaccine, there are administrative actions that providers can take.

“They could take the staff that’s refusing to be vaccinated and only assign them to patients who are low risk and are not in a position to transfer the virus from patient to provider,” Dombi said.

Typically during flu season — October through March — American Advantage Home Care Inc. makes multiple in-services available to employees. This means providing education around the flu vaccine and presenting the option for workers to receive the shot or decline, as well as keeping documentation of this information.

The company plans to approach the COVID-19 vaccine in a similar manner, once it’s available. Moorer urges providers to lean on educating workers in the coming weeks and months.

“I think that education is of the utmost importance for health care workers,” he said. “It tends to be one of those forks in the road where a person considers what is the lesser of the two burdens, perhaps contracting COVID-19 versus experiencing some unknown side effects of the vaccine. I think many who have seen the death toll, as related to the virus, would perhaps look at the vaccine as the less of two burdensome outcomes.”

Ultimately, the COVID-19 vaccine could serve as another safety tool.

“The best thing that I’ve heard from anybody so far, is the vaccine … becomes another tool, but you don’t drop your guard on everything else that you’re doing in infection control,” Dombi said. “It doesn’t mean you stop wearing the mask. It doesn’t mean you start gathering with large numbers of people or start getting reckless.”

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Perspectives: Home Health Insiders Sound Off on the 2020 Election

The ongoing expansion of Medicare Advantage (MA), a federal minimum-wage hike and additional support for front-line health care workers during the COVID-19 public health emergency.

These are just a few of the industry-shaping topics that home health insiders are following going into Election Day this Tuesday. While each presidential election is important, 2020 will help set the trajectory of U.S. health care policy for years to come.

No matter who wins between President Donald Trump and former Vice President Joe Biden, one thing is clear: In-home care gained a larger role in the overall continuum of care this year — and that momentum isn’t going away.

To get a deeper understanding of the 2020 election and what it means for home-based care operators, Home Health Care News reached out to several stakeholders for their perspective. Their responses are provided below, edited for length and clarity.

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Regardless of who wins, the fundamentals for home health care remain the same. There is a growing need for more care and higher levels of care in the home. The pandemic has only accelerated this trend as family members eschew institutional care settings. Meanwhile, telemedicine and virtual care will play the dual role of supporting quality care in the home — particularly for patients who need fewer services — and blurring the lines of what is considered traditional home care.

As state Medicaid budgets tighten, care for dually eligible individuals who have chronic and long-term care needs will need to be addressed. These individuals account for 20% of Medicare and 15% of Medicaid enrollment, yet account for about a third of spending for each. In-home care and care management can play a critical role in improving outcomes while reducing the overall cost of care. However, the U.S. Centers for Medicare & Medicaid Services (CMS), Congress and state Medicaid programs will need to figure out the right models to integrate this care while figuring out who pays for what and who gets the savings.

Ensuring that home health agencies can fully participate in virtual care initiatives — including reimbursement for such services — and ensuring that dual eligible integrated care efforts fully value the impact of care in the home are two of our top priorities.

Marki Flannery, president & CEO of the Visiting Nurse Service of New York (VNSNY)

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The health care industry experienced unprecedented strains this year, but we also made strides in many areas. At the highest level, we saw bipartisan cooperation in the time of crisis that led to solutions for those acutely impacted by the pandemic, from telehealth coverage to Paycheck Protection Program (PPP) loans.

Regardless of the 2020 election outcome, in 2021, we’re turning our focus to a few key areas based on lessons learned from the public health emergency. Further elevating home health care as a viable care alternative is crucial. Whether it was helping to divert the surge on hospitals or sending patients home to recuperate from the effects of the virus in order to free up ICU beds, home care really rose to the occasion.

While there has been an increased appreciation and awareness of the power of home health care, there is still an opportunity to elevate understanding around the need for better home care reimbursement rates, fueled by an authentic understanding of the tireless value skilled and direct care workers provide. We are also working towards ways to secure and drive more competitive pay so that the home health care industry can more effectively fill the labor demand needed to support Americans who want to heal and thrive safely at home. We are continuing to see how cost-effective and truly preferred the home setting is for seniors who desire to age in place safely and securely. We want to do everything in our power to make this option more accessible.

— Jennifer Sheets, president & CEO, Interim HealthCare

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Regardless of the outcome of the election, the prospects for positive legislation impacting the home health sector in 2021 are promising. The new Congress will be interested in making policy changes to strengthen the Medicare program, examining the needs of the Medicare population and building off of lessons learned because of COVID-19. One of these lessons is that access to home health care for vulnerable populations can and should be optimized, particularly at times when the Medicare patient population is uniquely vulnerable. The home health community has developed policy solutions that offer Medicare beneficiaries a wider array of post-acute care options, including those that expand the availability of care at home.

Being able to “choose home” for more Medicare patients who need care, as an alternative to other institutional care, can not only ensure that high-quality clinical care is available to a wider Medicare population, but can also ensure safety and increased patient choice.

We have also seen that care in the home should be optimized through increased use of technology. The availability of telehealth should be expanded upon for Medicare home health patients, particularly in times when infection risk is high, as was the case during COVID-19. The Partnership believes that telehealth opportunities should be optimized to ensure continuity of care for our nation’s most vulnerable patients.

— Joanne Cunningham, executive director, Partnership for Quality Home Healthcare (PQHH)

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​I’m hopeful that the current election will have a very positive impact on the home health industry going forward. That is because our industry has done a wonderful job over the years of advocating for our interests with a paramount emphasis on bipartisanship that is clearly evidenced in the recently introduced federal legislation calling for home health telehealth reimbursement during national emergencies.

In both the House and the Senate, these bills are being sponsored and supported by both Democrats and Republicans. That is extraordinarily significant. And coupled with the magnificent work our industry has done treating those in need during the current pandemic, the message has been communicated far and wide that our industry’s support spans the partisan political divide and is here to simply treat patients, clients and families with the health care services they need, when they need them, in the comfort, safety, security and familiarity of their homes.

— Dean Chalios, president & CEO, California Association for Health Services at Home (CAHSAH)

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Home care and hospice have the advantage of being supported by both parties. As such, whatever the outcome of the election, we expect any health care reforms to embrace health care at home as the awareness of its value has grown significantly during the pandemic. Once the dust settles after the election, we are prepared to work with the incoming Congress and administration to further advance home care and hospice.

— William A. Dombi, president of the National Association for Home Care & Hospice (NAHC)

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The outcome of the 2020 presidential election could greatly impact legislation, support, attention and funding for home health care workers and agencies. Additionally, if the non-chronic illness Medicare-eligibility age is reduced to age 60 vs. 65, that will be a tremendous game-changer for payers, providers, patients and the entire health care ecosystem.

— Cleamon Moorer, Jr., president & CEO, American Advantage Home Care Inc.

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Half of Patients Referred to Home Health Don’t Receive Services — But Providers Can Change That

Home health is often utilized as a recovery tool when patients transition out of the hospital because of its ability to improve outcomes. But many of the Medicare beneficiaries who receive referrals after being discharged aren’t actually receiving these services.

Overall, the past several decades have seen an increase in the use of post-acute services, with more than 40% of Medicare beneficiaries receiving such care after being released from a hospital, according to a recently published study in JAMA Network Open.

When it comes to home health care, in particular, roughly 2.3 million Medicare patients were discharged from hospitals with home health referrals in 2016. Despite that large amount of referrals, only 54% of those individuals utilized home health services after their hospitalization within two weeks.

Additionally, 37.7% never received care; 8.3% were either institutionalized or died within 14 days, without receiving a home health visit. This data underscores the role these services can often play in helping patients return to prior levels of functioning.

“After 14 days, patients get home, think they’re fine, then they have a decrease in their mobility or whatever their status is from the hospital,” Mike Gregory, chief patient advocacy officer at Intrepid USA Healthcare, told Home Health Care News.

Dallas, Texas-based Intrepid USA Healthcare Services is one of the largest home health, hospice and home care companies in the country.

Although the study’s findings were gleaned from 2016 Medicare data, it’s likely that the results haven’t seen much improvement, Jun Li, one of the study’s authors and an assistant professor at Syracuse University, told HHCN.

“Certainly from speaking with discharge planners, for example, it seems like not much has changed in terms of their ability to track which patients are actually getting home health care,” Li said.

Falling through the cracks

From a home health perspective, there are a number of factors that contribute to this breakdown of whether hospital-referred patients receive care.

One factor: Providers aren’t always getting useful and accurate patient information from hospitals, Cleamon Moorer, Jr., president of American Advantage Home Care Inc., told HHCN.

“[That includes] contact information of patients, as well as emergency contacts and family members,” Moorer said. “There’s an opportunity to close the gap on clarifying correct contact information. I think from time to time, if a patient is highly sedated, or if there’s been a change to their contact information prior to leaving the hospital, discharge planners, case managers, social workers and the like may not be made aware of the latest contact information.”

Dearborn, Michigan-based American Advantage Home Care provides skilled nursing, rehab and specialty care services across nearly a dozen counties.

In order to avoid inaccurate information, it’s important to validate it on the front-end. For American Advantage Home Care, this means reaching out to emergency contacts in a timely manner.

“We take the patient referral, and we begin to validate as soon as we possibly can,” Moorer said. “To some, it may seem intrusive, if you call the emergency contact number while the patient is still in the hospital. We start by saying who we are and that it’s not an emergency, but we’re calling on behalf of the patient, because we received a referral from either a hospital or a clinic or a primary care physician.”

Providers that aren’t creating multiple points of contact with patients may find themselves having a difficult time keeping track of patients, he added.

“You almost need to be a patient navigator or tracker as a home health care provider,” Moorer said. “If you simply pass along the patient’s information to your start-of-care nurse or clinician … it may not be of the utmost urgency to start a new patient if they already have a full caseload.”

Once a patient has been discharged and an initial visit has been set, American Advantage Home Care’s call center team reaches out to patients to inform them about their assigned clinician and to nail down specifics as well as personal preferences.

“Within the first week of receiving a referral, we try to make at least four points of contact with a patient and/or an emergency contact within their profile,” Moorer said. “Some of that conversation is about educating on what to expect from a skilled care provider.”

Improving patient education

Another factor that pops up is patients leaving the hospital aren’t always educated on the difference between non-medical personal care and home health care. This results in patients turning down services because they believe a family member or friend can fill in as their caregiver.

“In the event that a patient is being discharged and they don’t know the difference between the two, they may lean on a loved one,” Moorer said. “They may say, ‘My son or daughter lives with me. I’ve got a niece or nephew that helps me get in and out of the bed. They bathe me. I don’t need anyone coming in and out.’”

Additionally, some patients may turn down services due to reservations about having someone they are unfamiliar with in their home.

“They’re quite often embarrassed about having strangers in their home,” Intrepid’s Gregory said. “For whatever reason, they’re just not comfortable having someone they don’t know. When you’re able to build that relationship up front, … they’re much more likely to allow a stranger in.”

For home health providers, working closely with referrals partners can go a long way in making sure patients don’t fall through the cracks. This means following up with discharge planners after a patient has been released.

This can also mean working with referral sources in cases where a provider is unable to accommodate a patient, Scott MacInnis, chief revenue officer at Elara Caring, told HHCN.

“If for some reason, if we are unable to see the patient, we would contact the referral source and help to coordinate the sourcing of another provider, making sure that there are alternative resources for the patient, especially in instances where the needs of the patient are beyond the scope of home health,” MacInnis said.

Addison, Texas-based Elara Caring is a home health, hospice and personal care provider that operates across several states, caring for thousands of patients each year.

Looking forward, making sure that patients actually receive quality home health care will be especially important as the U.S. prepares for a possible second wave of the COVID-19 emergency.

“Home health is still underutilized,” Gregory said. “It is one of the most cost-effective forms of taking care of the patients, especially now with COVID-19. Patients do not want to go to the nursing home, they don’t want to be in the hospital.”

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The Secret to Setting Up Shop in the SNF-at-Home Space

For years, diversion between home health providers and skilled nursing facilities (SNFs) has been a big part of the industry narrative.

On their end, home health providers have reworked their operations to handle more acute patients and individuals traditionally served in SNFs. Now, home-based care providers are being even more intentional in their efforts by leaning into the SNF-at-home model.

While the idea of SNF-at-home has been gaining plenty of buzz as of late, the concept isn’t a new one, according to Leslie Palmer, administrator and clinical director at Josephine at Home.

“[In-home care providers] have known that keeping people at home typically results in better clinical outcomes,” Palmer told Home Health Care News. “It’s less expensive. And it keeps people out of the hospital. I think what’s different now is we have the opportunity to enhance that concept. Now, we’ve named it ‘SNF-at-home,’ and we’ve formalized operational aspects.”

Josephine at Home is a branch of Stanwood, Washington-based Josephine Caring Community, a cross-continuum organization that offers transitional rehabilitation, assisted living and other long-term care services, plus early learning and child care.

The nonprofit organization’s Josephine at Home business line currently offers home care services, though it’s in the process of expanding into home health care.

Additionally, Josephine at Home has upcoming plans to roll out an SNF-at-home services line.

Currently, roughly 25% of short-stay SNF episodes can be cared for in the home setting, creating an opportunity for in-home providers, according to statistics from Lincoln Healthcare Leadership.

Complex wound care and intensive therapy patients are examples of cases that can be treated within the SNF-at-home model, according to Jenn Ofelt, COO of UnityPoint at Home.

“Both of those are examples of patients that may have traditionally gone to an SNF because of an IV antibiotic or the need for daily therapy,” Ofelt told HHCN. “Both of those can easily be provided in the home if the additional layer of support that was needed by a 24-hour setting can be provided by a caregiver.”

UnityPoint at Home, a division of West Des Moines, Iowa-based health system UnityPoint, is a company that offers a range of home-based care services.

Similar to Josephine at Home, UnityPoint at Home is in the process of developing a SNF-at-home service line — and those two aren’t alone. LHC Group Inc. (Nasdaq: LHCG) and Johns Hopkins Home Care Group reportedly have SNF-at-home models in the works as well.

The fact that more and more in-home care providers are developing SNF-at-home service lines should come as no surprise. In general, more seniors and their families are looking for higher acuity care in the home setting, according to Dr. Cleamon Moorer Jr., president and CEO of American Advantage Home Care Inc.

“Families are looking for assistance with going through the logistics of, ‘How do I get a ramp installed? How do I go about getting a ventilator from a [durable medical equipment] company?’” Moorer told HHCN. “We’re finding that whole ecosystem of … [creating] a high-acuity nursing experience in a loved one’s home seems to be a gap that we’re able to step in and start filling.”

Dearborn, Michigan-based American Advantage Home Care Inc. is a provider of home health care, medical social work and other services.

The first steps

For home health providers looking to get a new SNF-at-home product line up and running, having a strong basis in home care — either organically or through partnerships — will be crucial.

“If you’re an expert in home health but not home care, then maybe look at partnering with an existing home care agency,” Palmer said. “It’s the same thing with home care — either look into forming a partnership with a home health provider or having someone who’s an expert help launch your own home health service lines.”

Having a home care component is especially important because in order to implement a successful SNF-at-home program, providers will need to replicate the 24-hour care component of traditional facilities.

Other potential partnerships aspiring SNF-at-home operators should strive for are ones with home medical equipment providers and infusion pharmacies.

“A SNF-at-home patient likely needs to be admitted the same day they leave the hospital,” Ofelt said. “Some of the elements of their plan of care include home medical equipment, such as assisted devices, a hospital bed, oxygen and IV infusion therapy needs. That infusion therapy pump and drugs all need to be delivered the same day. Having these partnerships in place will allow you to meet the clinical needs, immediately upon discharge from the hospital.”

On the staffing side, having a strong team of physical therapists, occupational therapists and speech-language pathologists is also key.

“You need to be able to staff these positions at a SNF-type level,” Ofelt said. “Prior to last October, patients went to SNFs and needed to receive a very high level of therapy to qualify for that day and for those SNFs to bill at their highest therapy rate. That needs to translate into the home. You need to be able to provide that level of therapy service.”

Providers that are looking to thrive within this space need to make sure that, on the clinical side, nursing competency is functioning at an acute level, according to Palmer.

One potential barrier for providers looking to implement this service line is that SNF-at-home doesn’t have a clear reimbursement model.

“Of course home health is reimbursed, and there’s chatter that Congress is talking about reimbursing some home care, but not the SNF-at-home program,” Palmer said. “As leaders in health care, we’re just going to proceed forward regardless of what the reimbursement looks like. We can maybe patch some of the reimbursement together.”

Broadly, SNF-at-home will need a reimbursement model that addresses the combination of care patients need.

“Traditional home health care payment will not be sufficient given these individuals will require a mix of both skilled home health care services and also home care assistance with activities of daily living,” David Grabowski, a professor in the department of health care policy at Harvard Medical School, told HHCN in an email. “The model will have to recognize these enhanced service needs.”

Looking ahead, Grabowski believes that the unified site-neutral payment model that the Medicare Payment Advisory Commission (MedPAC) has been working on might be the right catalyst for the SNF-at-home model.

“Rather than focusing on payment by setting, the unified payment model focuses on payment by condition,” he said. “For example, an individual recovering from a hospitalization for a stroke would be associated with the same reimbursement regardless of where they were discharged. Site-neutral payment would allow the care of patients in the home who previously would have been discharged to a SNF.”

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