Home Health & Hospice Week

CMS rebuffs pleas for change.

As you are rolling out OASIS-C2 in your home health agency, make sure you’re complying with new medication reconciliation guidelines.

Recap: In its 2017 Home Health Prospective Payment System final rule, the Centers for Medicare & Medicaid Services finalized a new Home Health Quality Reporting Program quality measure — Drug Regimen Review Conducted with Follow-Up for Identified Issues for the HH QRP (see Eli’s HCW, Vol. XXV, No. 39-40). Specifically, the IMPACT Act-required cross-setting measure requires HHAs to complete a drug regimen review identifying “potential clinically significant medication issues,” and contact a physician (or physiciandesignee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified issues.

Watch out:You can’t mark “Yes” on M2003 (Medication Follow-up: Did the agency contact a physician [or physician-designee] by midnight of the next calendar day and complete pre-scribed/recommended actions in response to the identified potential clinically significant medication issues?) or M2005 (Medication Intervention: Did the agency contact and complete physician [or physician-designee] prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?) unless the physician gets back to you and you have initiated any changed orders by that next-day-midnight deadline.

That physician response deadline was the biggest problem with the new measure that HHAs protested in their comment letters on the final rule. “This timeline is problematic because, for example, on a weekend we often will report an issue to the oncall physician but they can’t appropriately address the report because they have not been following the patient’s care,” said Providence Health & Services, in Renton, Wash., in its comment letter. “Providence asks CMS to finalize a more flexible timeline that will account for holidays and weekends.”

This measure “penalize[s] HHAs for something out of their control,” protested UnityPoint at Home in Iowa in its comment letter. “If a HHA admits a patient on a Saturday afternoon and notifies a physician’s office, the HHA often hears from an on-call provider that is not willing to make medication changes on behalf of a colleague causing reconciliation delay.”

The measure holds agencies “accountable for the physician’s own timely response,” the California Association for Health Care Services at Home told CMS in its comment letter. “Feedback from the Technical Expert Panel that reviewed this measure shows that post-acute care providers are concerned about being measured on how quickly the physician responds when alerted by the post-acute care provider of a potential issue. A majority of the panel agreed that 24 hours is sufficient to collect and report medication issues to the physician, however most also agreed that it is not feasible for the physician to respond to the provider within 24 hours,” the trade group said.

Despite the repeated pleas to not hold agencies responsible for physicians’ actions, CMS stood firm in the requirement without much elaboration. “The intervention timeline of midnight of the next calendar day is consistent with clinical practice when a clinically significant medication issue arises requiring intervention,” the agency said in the HH PPS final rule published in the Nov. 3 Federal Register. “This measure helps to ensure that high quality care services are furnished and that patient harm is avoided.”

Agencies Urge Additional Medication Safety Steps

CMS should go a step further in absolving agencies of responsibility for physician responses, urged Amedisys Inc. in its comment letter. “In cases where a patient’s safety is put at risk by a medication issue, and the home health agency contacts the physician without response, a subsequent ER visit (directed by the HHA) should be viewed as a positive response by the HHA, and not included in the ‘unplanned ED use’ statistics,” the chain told CMS.

CMS replied in the final rule that measures on emergency room visits are outside the scope of this regulation.

HHA Advocate at Home urged CMS to require “hospitalists or physicians employed by other PAC settings (skilled nursing facility, inpatient rehabilitation facility, or long-term care hospital) … to perform      a formal ‘handover’ of medication lists to the [primary care physician] at discharge,” it said in its comment letter. “This vital physician-to-physician communication will assist in ensuring a safe and smooth transition to home-based care.”

That requirement would help put accountability where it belongs. “Hospitalists may discharge a patient on medications without notifying the primary care physician … the practitioner most knowledgeable of the patient’s home medication regimen,” Advocate warned. “Recognizing clinically significant concerns related to medications rest with the prescribers,” the agency continued. “Home care clinicians should be responsible for identifying discrepancies in medications lists, over-the-counter medications, or any home remedies that may impact the home health plan of care.”

CMS didn’t address that suggestion specifically. “We believe that all providers should strive to ensure accurate, sufficient, and efficient patient-centered care during their care transitions across the continuum, including medication oversight,” the agency said in the final rule.

Take action: “HHAs [must] constantly manipulate their processes to remain compliant with the CMS measure,” advises consultant Anna Doyle. As with Pre-Claim Review, agencies balk at being made responsible for physicians’ actions. But “it is ultimately the responsibility of the HHA to identify and appropriately report potentially harmful medication situations to the physician as they would with any patient issue,” Doyle tells Eli. “The accountability lies here.”

Note: The PPS final rule is at www.gpo.gov/fdsys/pkg/FR-2016-11-03/pdf/2016-26290.pdf.