June 12, 2001

Home care staff know the payment status of their patients. However, all 13 agencies provide medically necessary home care services to every Vermonter regardless of income or place of residence. All agencies have a sliding fee scale (see attached) so that those with no insurance pay only what they can afford.

The biggest problem from the patient's perspective is that often the funding available does not pay for the services needed. Those most effected are patients with complex chronic conditions who are not eligible for Medicare reimbursement, are not Medicaid eligible yet have limited resources to pay for care.

VAHHA believes that Medicaid eligibility should be expanded for Vermonters 80 years old and older to 300% of poverty. Poverty rates are highest during older age partly because of substantial reductions in income and also because of the likelihood of major expenditures for health care. Many Vermonters face poverty for the first time after they retire.

Federal definition of "homebound" should be clarified to provide coverage for the working disabled who are bedbound without home health services, however, once they receive those services are able to leave their home and work.

A health care program for all Vermonters makes sense but probably is not politically viable at this time. Instead Vermont should assure that everyone has access to needed services. At a minimum, every Vermonter should receive medically necessary hospital, home care, physician services, and mental health services as well as receive needed prescription drugs at an affordable cost.

Yes. The current health care financing system for home care and other services is inefficient, complicated and costly. The system is marred by overwhelming paperwork and inconsistent payments from one payer to another.

Although home care staff do not prescribe drugs, home care nurses work closely with the physicians to design the best health care program for each patient which often includes prescription drugs. Our nurses and other staff are aware of the high cost of prescription drugs and frequently discuss the cost with their patients. However, the decisions made concerning the use of a specific drug are based on the medical needs of the patients. Clearly the cost of prescription drugs is a significant burden on our patients.

Recently the Rutland VNA received a $50,000 grant from the Pharmaceutical Research and Manufacturers of America to launch a statewide program to assist low income Vermont residents to obtain low cost or free medicines. Although a very valuable program, it is unlikely to solve the statewide needs.

Paperwork is a huge burden on home care agencies. One agency recently reported that it has, for the first time, more office staff shuffling paper than staff providing direct care and that does not include the paperwork time of the nurses, therapists, home health aides and other caregivers. In addition, home care agencies are caught in a tug-of-war between Medicaid and Medicare concerning the dually eligible clients. Medicaid supposedly is the payer of last resort but often the two agencies disagree on which should pay. Home care agencies are caught in the middle in an expensive, time-consuming ordeal where our staff spends literally thousand of hours sending records to one agency or the other. VAHHA estimates the cost to comply with these requests exceeds $200,000 year.

VAHHA members recognize the value of accurate records but for financial accountability and quality control. Vermont is the only state where all the agencies use a common outcome-based (critical pathways) care planning and documentation system, which is based on the client’s diagnosis.

Concerning home care, Vermont is the only state that guarantees universal access to medically necessary home health services regardless of ability to pay or location of residence. In addition, Vermont's home health system subsidizes a wide variety of services and programs from Hospice to a host of preventative programs. Moreover, home health services are provided to a greater percentage of Medicare eligible citizens in Vermont than almost any other state, while at the same time the average cost per visit and per patient are among the lowest in the nation.

The fact that home care agencies in Vermont are run by people in the community is a plus. In addition, with no significant competition in home care for Medicaid and Medicare, the agencies can coordinate and collaborate in the organization and delivery of services, rather than compete for patients, territory and funding.

Vermont has not experienced problems of patient "dumping," agency closures, cherry-picking of "profitable" patients, or fragmentation of services.

There is a serious shortage of nurses in Vermont. There is also a serious shortage of home health aides, nursing assistants, homemakers, respite workers, and personal care attendants. These shortages are already having a negative impact on health care delivery in Vermont. However, Vermont’s home health agencies are committed to addressing this issue in partnership and cooperation with Vermont’s nursing homes, hospitals and other health care providers.

As stated above, VAHHA believes that if Medicaid eligibility were expanded for Vermonters 80 years old and older to 300% of poverty much of the burden on Vermont’s frail elderly would be lessened.

• continuing education
• system improvements

Yes, both at the state and local levels. At the agency level, each agency holds extensive staff education programs for all staff and each regularly monitors patient satisfaction. At the state level VAHHA sponsors several dozen educational programs each year with the topics of study ranging from wound care, to ICD-9 coding, to Alzheimer’s and more.

National Accreditation - All VAHHA members are accredited by either the Joint Commission on the Accreditation of Health Care Organizations or by the Community Health Accreditation Program. Vermont may be the only state in the country where all Medicare-certified agencies are also accredited by these two agencies.

Statewide Consumer Satisfaction Survey - Vermont is the only state where all the certified home care agencies participate in the same consumer satisfaction survey. Results are compared on a statewide and national basis.

Critical Pathways - Vermont is the first and possibly only state where all the home health agencies use a common outcome-based care planning and documentation system based on each patient’s diagnosis.

Ombudsman Program - VAHHA runs a statewide complaint resolution program.

Consumer Advisory Councils - Most agencies have established Consumer Advisory Councils comprised of consumers of a wide variety of home health systems. These councils make policy and practice recommendation to the agencies.

Common Standards - The staff at all 13 agencies use the same high tech manual and Maternal and Child Care manual to assure that the care statewide is highest quality and consistent from one agency to the next.

Staffing - All 13 agencies guarantee that staff is available 24 hours a day, 7 days a week.

Full Service - All 13 agencies have acute care and rehabilitation programs and programs for long-term care and independent living services. All thirteen provide Hospice services, IV and high tech services. All 13 agencies provide nursing, homemaker, home health aide, and physical therapy. All thirteen, either directly or through an arrangement with another agency, provided Occupational Therapy, Speech Therapy, and Medical Social Work.

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