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Keeping Humanity in House Calls: How One Question Can Change So Much

May 15, 2020

About the Article: HCCInsights sat down with Dr. Thomas Cornwell, Executive Chairman, Home Centered Care Institute, to learn how he keeps humanity in house calls, especially during the COVID-19 pandemic, when stress and feelings of isolation can be elevated in many patients and caregivers.

HCCInsights: What is key to keeping humanity in house calls – especially during COVID-19?  And, how do you draw out what’s going on with patients when you’re seeing them in a home setting?

Dr. Cornwell: Overall, it’s important to stay focused throughout on the geriatric 5Ms, which are Mind, Mobility, Medications (polypharmacy can be a problem and we need to be skilled at de-prescribing), Multi-complexity which is why most of these patients cannot leave the home, and the most important “M” of all, which is What Matters Most to the patient. We don’t just start with their conditions and symptoms.

What Matters Most is part of every house call I make. It’s important to make the patient feel valued and ensure they know there is a caring practitioner available to help them 24/7 whenever they have a problem. When you ask a patient what matters most to him or her, it also opens a window to their emotions. It can help you understand how they’re being affected by any given situation in their life, gauge their level of loneliness, identify whether they’re experiencing anxiety or changes due to things like COVID-19, and so on.

Understanding what matters to the patient helps guide all care. For example, if you find out that what matters most to your patient is avoiding the hospital, that piece of knowledge will help guide your decisions and the advice you offer because you’ll know to focus on things that can be accomplished within the home environment.

[Editor’s Note: See also the “4M’s” approach that appears in Age-Friendly Health Systems,” an initiative of The John A. Hartford Foundation and Institute for Healthcare Improvement in partnership with the American Hospital Association and Catholic Health Association of the United States.]

HCCInsights: You’ve mentioned that you like to ask new patients to talk about something they’re proud of.  Why is that such an important question?

Dr. Cornwell: It’s part of my approach to patient-centered care and establishing a relationship and moving it forward. Not surprisingly, most of the time, I hear they’re most proud of their children and grandchildren.

Some other examples also come to mind. Like I’ve had female patients in their 80s and 90s tell me about earning their Ph.D. back in the 1930s or 40s when it was an exceedingly rare achievement for women. It is incredible to hear their stories about what it was like breaking through the barriers they faced at the time.

I’ve also heard stories from someone who was a Top Gun pilot and another who was an Olympic athlete. Also, one of my patients worked with Neil Armstrong.  Another served as a military driver to Jacqueline Kennedy Onassis. Rather than starting with their problems, I start with their life highlights.

When patients begin to share some of their personal information, it also opens them up to sharing other things, like how their mood has been, whether they’ve been feeling depressed or anxious, and so forth. Talking with the patient about their feelings helps reinforce that I listen and care. It also helps me better understand my patient on a more personal level.

I actually started asking this question years ago after one of my patients with advanced dementia passed away. That patient was never able to talk with me, and it was only from his obituary that I learned he had been a famous inventor and past president of a national professional organization.

You know, much of the home-based patient population is currently comprised of members from “The Greatest Generation.” They are amazing people with amazing stories who have lived history, and I feel it’s important to affirm to both the patients and their families how great an honor it is to care for such remarkable individuals… and every one of them is remarkable.

HCCInsights: How do you stay engaged on a personal level with the patient’s caregivers?

Dr. Cornwell: There are multiple aspects to that. First, I intentionally praise the caregivers all the time. If it weren’t for caregivers and all the sacrifices they make, home-based primary care providers wouldn’t have jobs. It’s because of the caregivers that two to three million patients are being cared for at home today – patients who suffer the same degree of infirmity as the million or so patients who are in nursing homes. A major difference is 100% of nursing home patients have a provider in the nursing home, while only 15% of homebound patients have a provider that makes house calls.

It’s also important to acknowledge caregivers as the real heroes. They find themselves in nursing roles they never imagined being in and that they were never really trained to do. In fact, there’s often an incredible lack of training provided to caregivers when their loved one leaves the hospital and it can be overwhelming.

So, in addition to praising caregivers, we also do a lot of training around medication management, wound prevention and treatment, tube feeding, how to use oxygen equipment and walkers, and much more. Through training, we help them feel more confident and comfortable in their roles and we do it because we want them to know we’re in this together.

That’s an important thing for them to know because, as seen during a focus group with caregivers conducted in the past with the University of Illinois at Chicago, we learned it was vitally important to caregivers to know they were not alone and that a competent, caring provider was available 24/7 to assist them with care of their loved one. As we also know, there’s a real need in the human spirit to not feel alone and it’s especially true when we’re talking about caregivers for homebound patients.

Remember also that many of these caregivers are part of the “sandwich” generation, meaning they are taking care of their children and their parents simultaneously, and it’s amazing that without formal medical training, they are caring for such medically-complex patients so lovingly at home. Acknowledging their role and contributions, and providing training and emotional support, plays a big part in making it all work.

HCCInsights: What do you do when a patient is having a bad day?

Dr. Cornwell: The old cliché goes something like, “Hope for the best, plan for the worst.” I prefer to say, “Hope for the best, plan for the rest.” Plus, it even rhymes better!

On the patient’s “darker” days, in addition to the treatment I provide, I ask them again to tell me what they’re proud of in their lives. For example, I had one patient who had been repeatedly hospitalized for anemia. One day, as he was sitting in a wheelchair, in a vulnerable state, being taken care of by his son and daughter, I sensed his despair. So, I asked him, “Can you tell me something you are proud of?”

He paused and said, “You know, I’m proud of having been on Normandy Beach.” Then he went on to mesmerize me with a story from World War II about being on a Navy ship that was shelling the cliffs of Normandy when the ship got grounded. His platoon had to abandon ship and somehow miraculously survived. Sometime later, while stationed in the Pacific, my patient hurt his ankle and couldn’t join his fellow sailors on one of their missions – a mission in which their ship was torpedoed. Lives were lost, and he didn’t know who lived or died.

In the end, the most amazing thing about this man’s story was that his children had never heard it. He had never talked about it before. Apparently, he had thrown his medals from his time in the service away ─ maybe he suffered from PTSD before we knew what PTSD was. But his children made the effort after hearing his story to call the VA, which replaced his medals. They also found an article online about the ship that had been torpedoed. One of his best friends from the war was interviewed in the story, so he learned his friend had not been among those who perished.

All this came from just one question and at the end of that visit, what did I tell my patient?  I said, “Thank you for my freedom.” It was such a blessing to be able to be a part of that with him and his family.

HCCInsights: How has the COVID-19 pandemic affected your ability to keep humanity in house calls, especially when you’re doing so many virtually right now through telehealth?

Dr. Cornwell: Over the past 45 days or so, 90% of my visits have been through telehealth. I have done face-to-face visits when procedures such as tracheostomy and g-tube changes were required, but in full Personal Protective Equipment (PPE), mainly to protect the patient.

I have been surprised at how effective audio and visual telehealth visits have been. These are supported by the fact that, because of the complexity of our patients, many have blood pressure cuffs and pulse oximeters at home ─ so I can get vitals. Using the audio/visual technology, I can also see how they are looking, how their leg edema or wounds are doing and so on.

Two cases have been particularly rewarding. One patient was at an assisted living facility and I was able to do a three-way video call with the daughter at her home and the nurse with the patient at the facility. It was the first time the patient was able to see her daughter in over a month, and I just sat back and let them get caught up for the first five minutes of the visit. Another younger patient had been having great difficulties. I was able, with telehealth, to make weekly virtual visits that I could not have done if I had to drive to his home every week. It really helped improve his care.

Overall, the patients and caregivers have greatly appreciated the telehealth visits. These visits, of course, are not a long-term replacement for in-home visits but complement them, especially during this challenging time.

HCCInsights: Being a house call provider is obviously not easy, so what is it about home-based primary care, and that human aspect of it, that makes it so rewarding?

Dr. Cornwell: There are many things that make home-based primary care rewarding.  As a provider, I am meeting patients in their home, seeing their artwork, their photographs, and their environment. I am seeing who they are through a completely different lens versus seeing patients in a nursing home or other clinical setting where it’s so much easier to lose the personal touch.

When you see patients in their homes, you must slow down. Home-based care is a 100% immersive experience and you learn an enormous amount about a patient within seconds, even before a single word is exchanged.

This type of care also requires the provider to be humble, as the traditional “balance of power” is shifted to the patient and family when you are in their home versus an office or clinic setting.  At the same time, you need to be sensitive to cultural differences which is another part of keeping humanity in the house call.

The home environment itself is also a factor in the patient’s overall well-being that must be considered. For example, if the patient is someone in a hoarding situation who also has problems with leg swelling, you may find that their environment makes it difficult to elevate their legs, making their condition worse, and so you must deal with that.

Finally, the difference you can make in the lives of homebound patients is unbelievable. Most homebound patients receive fragmented care, often through repeated hospitalizations. For elderly patients with multiple chronic problems, not only is this poor care, it is expensive care. Home-based primary care makes such a profound difference in their lives and the lives of their caregivers, by giving patients quality, longitudinal primary care in their homes and dramatically reducing hospitalizations and going to nursing homes.

HCCInsights: How do you manage conflicting family dynamics when they arise?

Dr. Cornwell: Family dynamics can be challenging. That’s another unique aspect of house calls: it’s impossible to ignore certain situations. If a patient is having difficulty getting medicine or food, for example, the provider needs to step in and ensure the right services are being used.

Conflicts about the patient’s plan of care sometimes must be mediated as well. For example, I like to start with “agreement” among the family members. I might first ask the family members, “Do we all agree that we love Mom?” Once that is agreed on, we move on to treatment decisions where there may be conflicts and try to reach agreement. This is always done by repeatedly asking the family what they think their mom would say if she could speak right then.

Focusing on what matters most to the patient can help reduce emotional tensions and guilt that can arise in making difficult decisions for loved ones.

HCCInsights: Though it’s not often mentioned in technical healthcare conversations, “love” seems to be behind much of what you’ve talked about today. What has your role as a home-based care provider taught you about love?

Dr. Cornwell: It has taught me that, of all the things the patient’s caregivers are doing and responsible for, their single most important responsibility is to provide “Vitamin L” – or “Love.” Love is what keeps people going, sometimes for years longer than anyone would expect, and that is particularly true, for example, with patients who have dementia.

So, I encourage the caregivers and cheer them on because it’s their love for the patients that’s making the difference.

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CMS releases additional interim final rule, creating more telehealth flexibility and featuring significant regulatory changes

On April 30, 2020, the Centers for Medicare and Medicaid Services (CMS) released a second Interim Final Rule with new flexibilities and changes relevant to home-based medical care providers. The changes in this most recent Interim Final Rule are effective immediately, with many modifications retroactively effective as of 3/01/2020. These include the following:

  • CMS increased the payment for telephone Evaluation and Management (E/M) visits to be similar to payment for an office visit. This was done to accommodate providers who are caring for patients without access to two-way audio and video technology. When seeking reimbursement for telephone visits, physicians and other qualified healthcare professionals (i.e., nurse practitioners and physician assistants) may use the Telephone E/M CPT codes listed below. CMS also designated these telephone E/M services as “Medicare telehealth services,” and as such, they will require modifier 95.
    • CPT 99441Telephone E/M 5-10 minutes; Increased Non-Facility Payment $46.19; wRVU 0.48
    • CPT 99442Telephone E/M 11-20 minutes; Increased Non-Facility Payment $76.15; wRVU 0.97
    • CPT 99443Telephone E/M 21-30 minutes; Increased Non-Facility Payment $110.43; wRVU 1.50
  • In addition, the following services can also now be billed when using audio only:
    • Advance Care Planning (CPT 99497, 99498)
    • Annual Wellness Visits (HCPCS G0438, G0439)
    • Smoking Cessation Services (CPT 99406, 99407)
    • Alcohol and/or substance abuse (other than tobacco) structured assessment (e.g., AUDIT*, DAST**), and brief intervention services (HCPCS G0396, G0397)
    • Annual Alcohol Misuse Screening and Counseling (HCPCS G0442, G0443)
    • Annual Depression Screening (HCPCS G0444)
    • Chronic Care Management (CCM) Care Planning Services; please note this service is only to be used one time for new patients or patients who are not seen within a year when first enrolled in CCM (HCPCS G0506)

*Drug Abuse Screening Test
**Alcohol Use Identification Test

  • Be aware Medicare has designated additional services, e.g., psychotherapy and other therapy-related, nutrition, and education services, that allow for payment when provided via audio-only telehealth. To review the full list of Medicare audio-only telehealth services, visit the Medicare list of telehealth services.
  • The home and domiciliary E/M codes still require a two-way audio and video telecommunication method. Please review the CMS Fact Sheet and the revised FAQ that was released on 4/30/2020 for additional details.

Additional Key Updates:

  • CMS has officially adopted the regulation allowing for nurse practitioners, physician assistants, and clinical nurse specialists to order, establish and monitor plans of care, and certify and re-certify patients for home health services as mandated under the CARES Act. This change is permanent and applies to any service provided on or after 3/01/2020. (Click here for a guide to the CARES Act.)
  • CMS finalized on an interim basis that they will not enforce the clinical indications for therapeutic glucose monitors and they’re not subject to National Coverage Determinations (NCDs) and Local Coverage Determinations (LCSs). CMS had previously finalized on an interim basis that they will not enforce the clinical indications for respiratory devices, anticoagulation management, and infusion pumps. CMS did remind clinicians that services must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member to be paid under Medicare. Physicians, practitioners, and suppliers are required to continue documenting the medical necessity for all services.
  • CMS waived the 16-day minimum requirement to bill for Remote Patient Monitoring (RPM) services, but only for patients who have suspected or confirmed COVID-19. In such cases, CMS recognized the value of short-term monitoring (no less than two days) for acute conditions and is allowing payment for CPT codes 99453, 99454, 99091, 99457, and 99458.
  • Until now, CMS used only its rulemaking process to add new services to the list of approved Medicare telehealth services. However, CMS is changing its process during the Public Health Emergency and will add new telehealth services on a sub-regulatory basis.
  • CMS waived some restrictions on the types of healthcare professionals that can furnish Medicare telehealth services for the remainder of the Public Health Emergency. Physical therapists, occupational therapists, and speech-language pathologists are now added to the list of eligible providers, which had already included physicians, nurse practitioners, physician assistants, licensed clinical social workers, and clinical psychologists. These providers can bill for telehealth services subject to the scope of practice laws.
  • CMS will no longer require a practitioner’s written order for patients to receive a COVID-19 test or other certain testing (e.g., serology testing) to diagnose and treat COVID-19. Pharmacists can also now perform COVID-19 tests if they’re enrolled in Medicare as a laboratory. Additionally, pharmacists can work with qualified healthcare professionals who are credentialed to bill Medicare to provide assessment and specimen collection services relating to a COVID-19 diagnosis. The physician or other qualified healthcare professional can bill Medicare for the test. This allows for parking-lot test sites and more rapid testing. (This is subject to state scope of practice laws.)
  • CMS is allowing hospitals to bill as the originating site for telehealth services, even if the patient is located at home. This applies to hospital-based practitioners for Medicare patients who are registered as hospital outpatients. This may be impactful for Hospital at Home® providers.
  • CMS is adjusting the financial methodology used for COVID-19 costs incurred by Accountable Care Organizations (ACOs) so they will be treated equitably regardless of the extent to which their patient populations are affected by the pandemic. ACOs can also forgo the annual application process; if their participation is set to end this year, they have the option to extend for another year. ACOs that are required to increase their financial risk during the current agreement period will have the option to maintain their current risk level for next year, instead of advancing automatically to the next risk level. CMS also includes virtual services, including virtual check-ins, remote evaluations, and telephone E/M services, as primary care services considered for beneficiary attribution.
  • CMS announced a new Coronavirus Commission for Safety and Quality in Nursing Homes. Read the Fact Sheet here.

Disclaimer: This information is current as of 5/05/2020. COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses its content on CMS guidelines relevant for traditional Medicare billing. It’s always recommended to check with local MACs for specific guidance for your geographic region. Medicare Advantage and commercial payor policies will vary.

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The Power of Three: Grant Recipients Continue to Advance Home-Based Primary Care

In the Fall of 2019, The John A. Hartford Foundation awarded a three-year, $1.6M grant entitled, Moving and Scaling Home-Based Primary Care Phase II: Quality, Training and Advocacy. The project aims to improve care for the more than two million older adults who are the “invisible homebound” with functional impairments and frailty. This phase builds on the success of the initial grant phase, with the same organizations leading three complementary grants.

While each organization has its own unique deliverables, they continue to work in close collaboration to achieve the overall goal ─ increasing access to high quality, home-based primary care that leads to improved outcomes for both patients and caregivers. Following is an overall look at the grant recipients and their respective projects:

  • The American Academy of Home Care Medicine (AAHCM) is charged with developing a home-based primary care (HBPC) national practice directory. “Our mission in phase two is to create an online Home-Based Primary Care National Practice Directory site to connect patients to practices and refer other providers to home-based primary care providers,” said Brent Feorene, executive director for AAHCM. “The site will also serve as a provider resource for timely information about HBPC, new payment policies and educational content on quality of care. Ultimately, this project will help expand services to populations with serious advanced illness.” The directory is being built using a human-centered design process to ensure it encompasses all the information its various users need and is slated to launch during the fourth quarter of this year.
  • The National Home-Based Primary Care Learning Network led by Dr. Christine Ritchie at Massachusetts General Hospital and Dr. Bruce Leff at Johns Hopkins University School of Medicine will work to expand and enhance a national quality improvement Learning Network among HBPC practices. “The Learning Network will be comprised of practices that identify new and ongoing quality and practice issues in HBPC, develop practice-guided strategies to address these issues, and use real-time, practice-based, data-driven initiatives to evaluate the effectiveness of these efforts,” said Naomi Gallopyn, program manager for Massachusetts General Hospital. The group recently completed a similar project with nine HBPC practices and is now seeking applications to grow their Learning Network with an additional 10 practices (deadline is April 24, 2020). For more information, please visit
  • The Home Centered Care Institute (HCCI) will build on its strong foundation and leverage the expertise of its staff, faculty and partners to develop and implement an enhanced multi-modal educational strategy. “HCCI is uniquely qualified to meet the current and growing demand for education and training of the home-based primary care workforce,” said Melissa Singleton, Chief Learning Officer for HCCI. “By further enhancing our offerings around clinical and practice management topics, we are equipping providers around the country with the knowledge and skills to be successful. Ultimately, this grant will help achieve HCCI’s goal of expanding the workforce, enhancing patient and caregiver satisfaction, lowering overall costs, and providing higher quality care for home-limited patients.”

“Increasing access to high-quality, home-based primary care is one profoundly important way that we can make health care more age-friendly and focused on what matters to older adults and their families,” said Scott Bane, JD, MPA, Program Officer at The John A. Hartford Foundation.  “The collaborative work of these three organizations will help more providers deliver the right kind of care in the right place for older adults with the most complex needs.”

About The John A. Hartford Foundation

The John A. Hartford Foundation, based in New York City, is a private, nonpartisan philanthropy dedicated to improving the care of older adults. Established in 1929, the Foundation has three priority areas: creating age-friendly health systems, supporting family caregiving, and improving serious illness and end-of-life care. For more information, visit and follow @johnahartford.

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HCCIntelligence™ Update: COVID-19 Telehealth Billing Requirements

COVID-19 Telehealth Billing Requirements

In our recent article, Providing Telephonic and Virtual Care Requirements as part of COVID-19 Precautions, available on HCCI’s COVID-19 Information Hub, we highlighted the requirements of virtual visits. We also provided an overview of the 1135 Telehealth Waiver as part of the president’s emergency declaration during the country’s current public health emergency.

We realize this is a challenging time for Home-Based Providers, and the Home Centered Care Institute (HCCI) is committed to supporting the field by providing timely information so you can make the best decisions for your practice. In response to recent questions, we’ve outlined more information below to clarify additional questions you may have.

Q: What are the current Evaluation and Management (E/M) codes that can be billed for when the services are provided via telehealth under the 1135 Waiver?

A: Here are the appropriate E/M codes:

  • Office/Outpatient CPT code range 99201-99215
  • Transitional Care Management CPT codes 99495 and 99496
  • Advance Care Planning CPT codes 99497 and 99498
  • Annual Wellness Visits HCPCS codes G0438 and G0439
  • Administration of caregiver-focused health risk assessment instrument CPT code 96161
  • Telehealth consultations ED or initial inpatient visits HCPCS code range G0425-G0427
  • Follow-up inpatient telehealth consultations in hospitals or SNF’s HCPCS range G0406-G0408

For a complete list of CPT codes, please refer to Medicare’s list of telehealth services

HCCI is awaiting official guidance from CMS on whether Home-Based Practices that historically bill only for home or domiciliary visits should be concerned about a potential heightened audit risk if they use the office visit code set during this pandemic. We realize, however, that many Home-Based Practices are choosing to use the set office visit code, in the interim, to maintain their practice. Our recommendation is to review all the facts before making the best decision for your practice and consider contacting your local Medicare Administrator Contractor (MAC) for specific guidance.

Q: What Place of Service (POS) and modifiers are required to bill for telehealth services?

A: For services furnished via telehealth, report Place of Service (02) for telehealth.

Per the CMS FAQs & The Medicare Learning Network’s March 20th update, CMS does not generally require additional or different modifiers on Medicare claims for telehealth services furnished under these waivers, except in the following three instances:

  • GQ – Telehealth services are furnished via asynchronous (store and forward) technology as part of a federal telemedicine demonstration project in Alaska and Hawaii
  • GT – Telehealth services are furnished under CAH Method II (Via interactive audio and video telecommunication systems)
  • G0 – Telehealth services are furnished for the purposes of diagnosis and treatment of an acute stroke

As an example of when receiving guidance from your local MAC is beneficial, a practice in Indiana reached out to their MAC (i.e., WPS Government Health Administrators) and was advised to use modifiers for telehealth claims.

Q: How do I contact and confirm who my local MAC is?

A: CMS has a contractor directory and map on their website that allows you to search by state to confirm your MAC along with links to each contractor’s site where you can find their Provider Contact Center phone number. You will need to call your MAC directly to request clarification on proper billing for home visits under the 1135 waiver. They may refer you to a specific governance email, however, HCCI is aware that practices are generally receiving timely responses within a few days.

It’s also important to note the requirement for practices to use an interactive audio and video telecommunications system that permits real-time communication between the provider and the patient at home even under the telehealth waiver. This means you cannot bill for an E/M visit via telehealth for phone call audio-only. However, under the U.S. Department of Health and Human Services (HHS), the Office of Civil Rights (OCR) Notification of Enforcement Discretion relaxed HIPAA requirements so that providers may use platforms such as Apple FaceTime, Skype, Zoom, the WhatsApp, etc., as a form of two-way audio and video telecommunications., a free HIPAA-compliant telemedicine platform that allows for two-way audio and video interaction with patients and caregivers, is another option. Consider checking with your Electronic Health Record (EHR) vendor as they may have technologies available for video visits, too.

If you are providing virtual services to patients via phone call audio-only, you must refer to the Virtual Check-in Codes (requirements detailed in previous HCCI article), or use other forms of reimbursement, such as care management services (e.g., Chronic Care Management) to bill for your time.

The E-visits codes, which capture time over a 7-day period for communicating and reviewing patient information on a digital communication platform, such as a patient portal or secure email, are listed below in an HCCI chart for easy reference:

For additional information, refer to the CMS General Provider Telehealth and Telemedicine Tool-kit, or contact a member of the HCCIntelligence Hotline staff at 630-283-9222 or email [email protected].

Disclaimer: This information is current as of 3/23/2020. Coding regulations are subject to change annually, and COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses our content on CMS guidelines relevant for traditional Medicare billing.

Online Digital E/M Services_1280

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HCCI and NNPEN Conference: Different Strategies, Shared Vision

HCCI NNPEN joint conference

How can Nurse Practitioners (NPs) and others effectively start-up and/or expand a home-based primary care (HBPC) practice? Just ask the participants who attended the February 7- 8 joint conference hosted by the Home Centered Care Institute (HCCI) and the National Nurse Practitioner Entrepreneur Network (NNPEN) in Phoenix.

With NPs being the fastest-growing segment of HBPC providers, the conference provided attendees with critical information on planning and operating a successful and sustainable HBPC practice. Participants brought varying backgrounds and HBPC experience levels to the conference, entitled, “Blueprint for Success: Building and Growing Your Home-Based Primary Care Practice.” The first day concluded with a well-attended “Open Office Hours” segment, where participants were able to ask questions about their specific situations, which invariably applied to many in the room.

The two organizations’ strategies are necessarily distinct. HCCI focuses on professional development for NPs who have a specific interest in HBPC while NNPEN, as Sandy Berkowitz, RN, JD, and Co-founder and CEO of NNPEN, explains, “focuses on supporting nurse practitioners as professionals who want to be their own boss.”

At the same time, though, HCCI and NNPEN have a similar vision. “We share the same vision and passion to create access for a primary care population of frail and elderly patients who are vastly underserved,” Berkowitz continues, “and to explore how advanced practice providers can do well by doing good.”

In sharing her own conference takeaways, Heather Hodge, Director of Education for HCCI, said, “During the conference, I was struck again by how providers are offering HBPC through a variety of business models. It’s not a one-size-fits-all. Plus, people seemed to take something from every session that they could immediately apply to their own situations. Finally, the conference gave people a place to ask their top-of-mind questions and share their successes and challenges, like managing different state laws, payer requirements, and so on. In all, the event helped many see they weren’t alone and that, if they were having an issue, someone else probably was, too.”

For NPs and others with questions about developing or sustaining an HBPC practice, HCCIntelligence™ offers webinars and a hotline at 630-283-9222 and [email protected].


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Family Caregivers’ Experiences With Health Care Workers in the Care of Older Adults With Activity Limitations

frail elderly and caretaker
JAMA Article
Original Investigation  |  Geriatrics

January 24, 2020

Authors: Jennifer L. Wolff, PhD; Vicki A. Freedman, PhD; John F. Mulcahy, MSPH

Key Points

Question  What are family and unpaid caregivers’ experiences with health care workers in the care of older adults with activity limitations?

Findings  In this national survey study, most caregivers reported that older adults’ health care workers always (70.6%) or usually (18.2%) listened to them and always (54.4%) or usually (17.7%) asked about their understanding of the older adult’s treatments, but fewer caregivers reported being always (21.3%) or usually (6.9%) asked whether they need help managing older adults’ care.

Meaning  These findings reinforce the need for health system strategies to support family and unpaid caregivers, who are the main source of assistance to older adults with physical and/or cognitive limitations.

Read the article

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Being Treated at Home Can Help People Save Money and Heal Faster


  • A new study found that the home hospital model can potentially improve care while reducing costs.
  • The cost of care was nearly 40 percent lower.
  • Trial participants receiving hospital care in their homes had a 70 percent lower rate of readmission to the hospital.

People check into the hospital expecting to get better, but there are risks — and some even wind up getting sicker.

You can face the danger of complications, like bleeding or infection. There are also the constant check-ins from nurses or physicians that can disrupt sleep.

And none of that includes the cost.

Additionally, when in a hospital, people are stuck in their hospital beds and many experience negative health impacts from this physical inactivity.

However, a pilot study by investigators at Brigham and Women’s Hospital in Boston finds that the home hospital model can potentially improve care while reducing costs. The findings were published in Annals of Internal MedicineTrusted Source today.

“Hospital at Home (HaH) as the name states, cares for hospital-eligible patients at home. Models vary, but generally patients seen in the emergency room that require hospital-level care are given the option of intensive care at home,” said Thomas Cornwell, MD, founder of Northwestern Medicine HomeCare Physicians and chief executive officer, Home Centered Care Institute (HCCI).

First study of its kind

“To date, there has not yet been a randomized controlled trial of home hospital care performed in the U.S. other than our small pilot,” David Levine, MD, MPH, MA, the study’s corresponding author, told Healthline.

The results of Dr. Levine and team’s randomized controlled trial (RCT) can strengthen the case for home hospital care, showing that it reduces costs and readmissions while increasing physical activity compared with usual hospital care.

“We wanted to show with a very high level of evidence that home hospital care could be delivered to acutely ill adults with lower cost, better physical activity, high quality and safety, and excellent patient experience,” said Dr. Levine.

“In addition, we feel this gives all Americans the information they need to choose the care for themselves and their loved ones should they need hospitalization,” he said.

Cost of care was nearly 40 percent lower

Levine and team enrolled 91 adult patients into the trial.

Each participant had been admitted via the emergency department at Brigham and Women’s Hospital or Brigham and Women’s Faulkner Hospital with acute conditions that included infection, worsening heart failure, worsening chronic obstructive pulmonary disease (COPD), and asthma, that lived within 5 miles of the hospital.

They were randomized either to stay at the hospital for standard care or to receive care at home, including nurse and physician visits, intravenous (IV) medications, remote monitoring, video communication, and point-of-care testing.

Researchers measured the total direct cost of care, including costs for nonphysician labor, supplies, tests, and medications.

The findings indicate that patients receiving at-home care had total costs that were almost 40 percent lower than for patients treated conventionally.

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International Workshop Shows How Small the World Really Is

GSA 2019 International Workshop on Home Care Medicine

On Friday, November 15, over 45 professionals in the field of gerontology attended the first-ever International Workshop on Home Care Medicine in Austin, Texas, as part of the Gerontological Society of America’s (GSA) Annual Scientific Meeting. The GSA describes itself as “the oldest and largest interdisciplinary scientific organization devoted to the advancement of gerontological research, learning, and practice.”

Recognizing the need to expand the “home care medicine conversation” globally, GSA invited the Home Centered Care Institute (HCCI) and American Academy of Home Care Medicine (AAHCM) to develop and co-lead the workshop. The session brought presenters together with participants from countries around the world, including Canada, China, France, Italy, Japan, the Netherlands, Spain, and the United States.

Aaron Yao, PhD, lead researcher for HCCI and Cheeloo Scholar Professor at Shandong University in China, played a key role in organizing the workshop. The program was designed to present recent trends and developments in home care medicine, facilitate the building of strategic partnerships to address global challenges, and provide an opportunity for peer networking.

The workshop was made up of four panel sessions featuring participants from different countries and allowed for extensive Q&A. The four panel themes were Service Delivery and Interprofessional Care, Technology (Mobile Diagnostics, EMR) in Home Care, Payments and Revenue Models, and Workforce Education and Training.

When asked what stood out most for him about the program, Yao answered, “The workshop’s message to me was simple but powerful – that aging has no borders and that great minds think alike.”

Melissa Singleton, Chief Learning Officer, HCCI, also found unique value in the event, “Having the chance to hear people from around the world talk about this growing and much-needed field of medicine reminded me of how very much alike we all are. Of course, each country has its own methodology, such as how they train providers, their payment models, and so on. But, even with that, finding our commonalities and sharing best practices make the world a little smaller, the challenges more manageable and the opportunities for collaboration even greater.”

The GSA workshop was not HCCI’s first appearance on an international stage. A little over a year ago, Yao facilitated an invitation for Dr. Thomas Cornwell, Chief Executive Officer of HCCI, to teach at the Shandong University School of Healthcare Management. Since then, much of HCCI’s curriculum has been translated into Chinese, and a total of 1,250 Chinese providers have been trained by HCCI faculty. The recent collaboration for GSA was an opportunity to bring Dr. Cornwell and HCCI back together with colleagues at Shandong University, as well as to meet new leaders in the field from around the world.

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CMS Announces Request for Applications for Primary Care First Model Options

CMS Request For Applications

CMS Announces Request for Applications for Primary Care First Model Options

(Highlights for Consideration included below)

CMS released the Request for Applications (RFA) for the Primary Care First (PCF) and Seriously Ill Population (SIP) models last Thursday, October 24. The practice application period also started that day while the deadline to apply via the live portal is January 22, 2020.

The model will now begin in January 2021 (a delay of one year from the originally anticipated start date). CMS will select practices and payers during Winter/Spring 2020 and will onboard participating practices and payer partners to the model from July to December 2020.

Following are important highlights of the new program for practices to consider:

Fees and Measurements

  • Under PCF General, the primary care flat visit fee will be reduced to $40.82.
  • HCC Risk Group 4 will be the highest-level risk group with a payment of $175 Per Beneficiary Per Month (PBPM).
  • Practice risk groups 3 and 4 will not use the acute hospitalization performance measure; instead, performance for these groups will be measured on the Advance Care Plan and Total Per Capita Cost (TPCC).


  • SIP practices are expected to have an 8-month management and transition period for stabilization of their patients and then to transition them back to another primary care setting or practice.
    • This is known as the average length of attribution (LOA).
    • If the 8-month term is exceeded, a $50 PBPM reduction will apply to the monthly SIP payment through a quality adjustment.
  • SIP patients will require a face-to-face visit once every 60 days for them to remain attributed to the practice.
  • SIP payment redesign now states that after a practice conducts its initial face-to-face visit with the SIP patient, CMS will make a one-time payment of $325. With PCF, beginning the month following the initial visit, the practice will receive a $275 PBPM minus a $50 quality withhold that can be earned back with a potential quality bonus at the end of the first performance year.
  • SIP practices must describe the service area(s) in which they are interested in participating using zip codes and must define the maximum number of SIP patients the practice has the capacity and capability to manage.

Participation and Eligibility

  • Practices participating in the Independence at Home (IAH) Demonstration are eligible to participate even if it is not offered in the region(s) of the IAH practice.
  • Practices participating in the Comprehensive Primary Care Plus (CPC+) model cannot participate in 2021, however, they can participate in 2022.
  • Concierge practices, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are not eligible to participate.
  • Eligible practitioners are those practicing in internal medicine, general medicine, geriatric medicine, family medicine and/or hospice and palliative medicine.

Home Centered Care Institute Support

If you have questions about these changes or other home-based primary care questions, you can contact our HCCIntelligence™ Resource Center Hotline at 630-283-9222, 9:00am to 5:00pm (Central Time) Monday through Friday – or email us at [email protected]. The hotline and additional offerings in the Resource Center, including monthly webinars, virtual office hours, and tools and tips sheets are available at no charge due in part to a grant from The John A. Hartford Foundation.


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AAHCM and HCCI present a webinar on new CMS Primary Cares Payment Models

Woman watching a webinar

The American Academy of Home Care Medicine (AAHCM) in collaboration with the Home Centered Care Institute (HCCI) will host a webinar Tues. July 30 at 4 pm (ET) on the new CMS Primary Cares Initiative payment models relevant to home care medicine. The three different payment models will be discussed in detail; Primary Care First (PCF), Seriously Ill Population (SIP), and Direct Contracting (DC).


CMS Primary Cares Initiative

In April, the Center for Medicare and Medicaid Innovation (CMMI) announced a CMS Primary Cares Initiative which includes new payment demonstrations meant to promote value-based care, with a shift of up to 25 percent of primary care Medicare fee-for-service patients to these new models. Primary Care First (PCF), Seriously Ill Population (SIP), and Direct Contracting (DC) will offer enhanced payment for home care medicine and other providers to provide primary care for people with advanced illness.

Primary Care First (PCF) & Seriously Ill Population (SIP)

The Primary Care First (PCF) and Seriously Ill Population (SIP) models will be offered in 22 states and 4 regions for a January 2020 start date:   STATEWIDE in Alaska, Arkansas, California, Colorado, Delaware, Florida, Hawaii, Louisiana, Maine, Massachusetts, Michigan, Montana, Nebraska, New Hampshire, New Jersey, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, Tennessee, and Virginia. In Local Regions of Greater Buffalo, NY, Kansas City (Kansas and Missouri), Greater Philadelphia (Pennsylvania), North Hudson-Capital Area, NY, and Northern Kentucky.

PCF/SIP Timeline:   A letter of intent (LOI) is not required for PCF or SIP.   A request for application (RFA) will be released in the coming weeks and is required for participation.  Both models are scheduled to begin January 2020.

Direct Contracting

The Direct Contracting (DC) path will engage practices or groups of providers who can reach 5,000 beneficiaries by Year 3 (with potential exceptions for smaller practices), as well as Health systems, Accountable Care Organizations, Medicare Advantage plans, and Medicaid Managed Care Organizations.  DC builds upon the Next Generation ACO model and has no geographic limitations on who may apply.   The DC path will include three models: Professional PBP, Global PBP, Geographic PBP (Proposed).

Timeline:  A Letter of Intent (LOI) is required to apply for participation in the DC Models and is due on Friday, August 2. The LOI is non-binding. CMS will then release the request for application (RFA), which will be required for participation. All models are scheduled to begin January 2020 except the DC Geographic Option, which will begin at a later date.