Home Health Providers, Staff In For ‘Rude Awakening’ Following Public Health Emergency Expiration

Though it sometimes may not feel like it, the expiration of the public health emergency (PHE) will, one day, come.

And when it does, that will have ramifications on home health providers specifically, and home-based care more generally. With the declaration came a handful of waivers and flexibilities meant to alleviate the harsh impacts of the pandemic for home health providers.

The Biden Administration extended the PHE for another three months on Friday, but providers will need to prepare for the day it will eventually come to an end. 

The PHE was originally declared in March of 2020, retroactive to Jan. 27, 2020. This past April, the U.S. Department of Health & Human Services (HHS) extended the emergency status for 90 additional days, to July 15.

Concerns around waivers and flexibilities

Along with the PHE declaration came a number of regulatory waivers and flexibilities meant to streamline health care processes and ease the overall burden of the pandemic for providers.

One of these waivers made it possible for any of the disciplines — nursing, physical therapy (PT), occupational therapy (OT), or speech language pathologists — to conduct home health admissions based on the needs of the patient.

If the PHE ends, this waiver is not expected to become permanent, according to Cindy Krafft, the co-owner and co-founder of the consulting firm Kornetti & Krafft Health Care Solutions.

“It has deeper regulatory issues and stuff that would have to be dealt with, but it is still allowable in the waiver situation,” she told Home Health Care News. “The reason I think it’s going to be a challenge is the current staffing situation in home health. We know that several agencies are at crisis levels and the ability to move admissions to therapy and take some of that off of nursing, when appropriate, has become routine.”

Krafft noted that a provider she had recently spoken to “leaned heavily” on this waiver option in order to get patients started on services.

Another concern for providers are the staff members who have practiced their entire career under this waiver.

“They came into [home health] at the same time as the waiver,” Krafft said. “What they think is routine — being a PT and doing the admission or being a nurse and not needing to always do it — may be a bit of a rude awakening. It’s normal to them, but this is technically a waiver that is going to go away at some point.”

Despite this, some of the waivers have become permanent options for home health providers.

“If occupational therapy is part of a referral with another therapy, they can do the start of care admission to service,” Krafft said. “This was a waiver, but has now shifted to permanence for our setting. Also, issues around who can sign orders in home health, the role of the nurse practitioner and such, have also moved from a waiver to permanent.”

Telehealth stays top of mind

For providers, the utilization of telehealth and virtual care has also served as a lifeline amid the pandemic.

“CMS’ easing of face-to-face rules during the early days of the public health emergency helped save lives as the pandemic emerged.” Brent Korte, chief home care officer at EvergreenHealth Home Care, told HHCN in an email. “Allowing virtual face-to-face visits in all circumstances streamlined access to home health and kept patients from taking beds in overwhelmed hospitals. This also helped increase access to home health and significantly improved timeliness of care. It helps to reduce duplicative care and even unnecessary visits when patients have to do an in-person visit.”

While home health does not receive reimbursement for telehealth services, the public health emergency brought on new flexibility for providers in regards to HIPAA scrutiny.

Trisha Crissman, vice president and COO of CommonSpirit Health at Home, believes that patients and providers alike will experience the long-term effects if permanent changes are not enacted.

“Without permanent changes to Medicare coverage for telehealth services, most Medicare beneficiaries not residing in rural areas will lose access to coverage for telehealth services,” she told HHCN. “Additionally, the provision of telehealth as an integrated and clinically appropriate part of the home health patient’s plan of care has helped to reduce overall mileage and increase nursing capacity, offsetting some of the financial constraints of decreased volumes and more recently, rising mileage reimbursement rates.”

Unfortunately for providers, the legislative efforts around home health telehealth use have fallen flat.

Plus, home health stakeholders have largely shifted their focus to responding to the proposed payment rule and its potential impact on the industry, according to Krafft.

“There are people running the numbers who are concerned that the payment cut, as it stands, could put a third of agencies in the red and put them under,” she said. “Where there was a lot of discussion about telehealth and legislation before, I think right now the industry is more focused on this payment issue: ‘It’s not going to matter if I get telehealth reimbursement if I’m out of business.’”

One positive of the proposed payment rule is that it calls for the use of G-codes for telehealth, however.

“This allows them to better track utilization, and maybe down the road, if they see that there is utilization of telehealth, it could become part of a payment methodology in the future,” Krafft said.

Hospital-at-home extension

The end of the PHE could also mean a major blow for providers that offer higher-acuity services in the home setting.

In 2021, the U.S. Centers for Medicare & Medicaid Services (CMS) introduced its “Acute Hospital Care At Home” waiver program. The introduction of this waiver allowed approved hospitals and health systems to deliver hospital-at-home services, and to be reimbursed for providing care.

Currently, 107 systems and 242 hospitals, in 36 states, are cleared to perform hospital-at-home services under the waiver program.

Prior to this, reimbursement was a major hurdle that limited the widespread adoption of the hospital-at-home model in the U.S.

Even now, there is no permanent mechanism in fee-for-service Medicare to pay for hospital-at-home care.

Looking to continue the waiver program, lawmakers introduced the “Hospital Inpatient Services Modernization Act” in March. The legislation would extend the waiver by two years.