Self-Managing Home Care

Vol. 14 •Issue 20 • Page 20
Self-Managing Home Care * Self-Managing Home Care

By Francie Scott

I don’t get many letters from my DME company, so I wondered what I had done wrong when I opened my mail in early July. The core of the message appeared in the following paragraph: “It is with regret I must inform you that Beckett Healthcare will be closing its operations and we will be terminating our contract with your insurance carrier.”

I later learned the company that had supplied me with a wheelchair and walker was in bankruptcy proceedings. Fortunately, I am a light user of durable medical equipment, but a few haunting questions remained. What is happening to other Beckett patients and what is happening to the industry?

I had a few other changes to negotiate this past summer as well. My primary nurse took a new position at a hospital, and my home care company reassigned my care to a part-time nurse.

Now I hear I am losing the marvelous home health aide who has enhanced my life since January. She was given a new territory and no longer covers my neighborhood.


These realities of being a home care patient during the past year reflect the broader picture of home care in the 21st century. Economic viability in the post-Balanced Budget Act era requires providers to reassess their business practices. Clinical staffing shortages plaguing the nation’s hospitals and long-term care facilities also take a toll on home care.

Add bureaucratic policies such as competitive bidding to the Medicare equation and the picture grows even murkier. Patients and their families sandwiched between these changes must make adjustments and lobby for the best care they can get.

As the fourth quarter of 2001 approaches, officials associated with the home care industry assess the economic picture in positive terms.

“The market is dynamic and, as such, there is a lot going on,” observed Joe Lewarski, BS, RRT, of Cleveland, director of the National Respiratory Network for the MED Group and chair of the AARC home care section. “Some companies are successful. Some companies are failing and struggling. There are acquisition and merger activities and new start-ups.”

Home care providers worried about staying in business when the Balanced Budget Act of 1997 clipped 30 percent from their already low oxygen reimbursement rates. Already these companies struggled to include a service component when they got paid only to deliver and rent equipment.

“The industry was able to re-engineer how it did business,” explained Dexter Braff, president of the Braff Group, a Pittsburgh-based health care company which specializes in acquisitions and mergers.


Changes include a mix of telephone and home visits from caregivers such as respiratory therapists and shipping supplies via UPS instead of company delivery. The goal of providing safe, quality care remains the same, but “referral sources and patients began to recognize you can’t give them everything you used to give with the declining reimbursement dollar,” Braff explained.

Home care providers serving Medicare patients still struggle with the legacy of the Balanced Budget Act. Competitive bidding is one such item. The goal is to drive costs down by putting “Medicare lives” in a geographic area up for bid for services like supplemental oxygen therapy, Lewarski explained. While he concedes the concept might work for items like hammers, bolts and screws on a military contract, home care is a “service” not a “commodity.”

Tom Connaughton, president of the American Association for Home Care, an advocacy group for home care providers based in Alexandria, Va., agrees.


Quality issues in competitive bidding quickly emerged in two pilot projects launched in San Antonio, Texas, and Polk County, Fla., he reported. The jury remained out in the report published in January by the Centers for Medicare and Medicaid Services (CMS), formerly HCFA, (Health Care Financing Administration).

Home care advocates do not like the concept of competitive bidding because they believe it could lead to lower standards. Connaughton, for example, suggested service should be an incentive not to lower standards and, therefore, prices. “If it is your mom or dad, you want to have all that available,” he said.

Connaughton and Lewarski also worry about the average wholesale price system of reimbursing for respiratory and infusion drugs. While this might lower the cost of providing these medications to Medicare patients, it could swallow the small remaining cushion that allows home care companies to provide services.


From a patient’s perspective, service is the essence of good home care, which is why the home health aide program means so much to patients like me. Since metastatic cancer destroyed my left hip, I can no longer haul laundry two flights of stairs down to my basement. I would labor with difficulty to change the sheets on my full-size bed.

My lymphatic system failed two months ago, and my legs swell like watermelons, bulging around my ankles. After a hip replacement and spinal surgery, I can no longer reach my feet. My home health aide, Patricia Brock, wraps pressure bandages around my legs on weekday mornings. She does laundry and supervises showers, chores that represent peace of mind to members of my family who worry about falls.

Pat learned my routines quickly and touches me with her friendship. She even gave me a Siamese-cross kitten, a lively bundle of ivory fur smudged with chocolate which has become a good companion. I had to give up my beloved dog of 13 years when I could no longer walk her last year.

My primary nurse monitors my home health aide service and orders what I need to keep life running smoothly in the home, both in terms of clinical care and activities of daily living. The primary nurse also negotiate services with the third-party payer and visits when necessary to check vital signs and dress wounds. I see my primary nurse, Mary Warner, BSN, RN, every week.

Like Pat, she goes beyond the call of duty. Recently, she shopped for a dressing tool I needed after my old tool broke.

I don’t expect my caregivers to shop for my tools or bring me pets, but I am deeply grateful when they go the extra mile and care for me as a friend rather than just a patient.

This brings me to the nursing shortage. While my nursing care returned to the usual Friday visit, Mary struggles to manage a patient load of oncology patients during her three-day workweek. She chooses the part-time hours to enable her to complete a master’s degree.

Lewarski believes the nursing shortage results in prolonged hospital stays, especially for complex pediatric cases that qualify for private duty nursing.

Connaughton also worries about the impact of the nursing shortage on home care. “We’re hearing it’s a real problem,” he said.

Home care, like any other faction of health care, is subject to changes and challenges, especially when it comes to reimbursement, staffing and quality of care issues. For my own part, the system has worked fairly well since the morning in late July of last year when I hobbled into my doctor’s office in excruciating agony, no longer able to walk without assistance. He ordered the home care before I left.

I believe I lost the battle over the home health aide and will lose Pat next week. Her supervisor seemed adamant that she needed to reorganize the home health aide schedule and assured me I would like the replacement aide.

You can reach Francie Scott at [email protected].

Home Care Means Staying at Home

BALA CYNWYD, Pa.-This suburban Philadelphia neighborhood includes Stoneway Lane, a community of picturesque Tudor row houses built in the late 1920s. Their slate roofs, terra cotta chimney pots and flagstone porches give the street an English flavor.

I purchased my slice of Stoneway Lane in 1997 and told my family I intended to be carried out of this quaint old place. This was my “empty nest” home where I planned to grow old, planting a perennial garden and serving afternoon tea on my porch. In retrospect, I should have chosen a ranch-style residence with a wheelchair-accessible entrance.

I did not envision the breakdown of my health and the loss of mobility that occurred when my hip and lumbar spine crumbled from metastatic cancer. Stairs to the second floor became a liability, but I still limp up and down at least once a day. I have undergone two major surgeries, two stints at a rehab hospital and a month of convalescence with a dear friend during the past 14 months. Where would I be without home care?

A social worker who visited during the early weeks of my first crisis suggested moving to a nursing home in the area. I was in shock and my 22-year-old son considered the prospect so appalling he said he would move back home before that happened. The social worker later discovered I was too young to meet the residency age requirement, effectively eliminating that painful choice.

Other institutional options appear equally unattractive. Assisted living, for example, means I might share a room with another patient and lose the privacy I value in my own home. Hospital meals have always been difficult for me to swallow and I don’t sleep well in an institutional setting. I am easily disturbed by noises like the footsteps of staff and the coughing of other patients.

Emotionally and physically, I am at peace at home. I am surrounded by familiar items, photos, paintings and furniture. While I still struggle with the loss of my independence, I believe I am as well as I can be under the circumstances.

I know I may have to come to terms with a different way of life when my health takes more tumbles, but in the meantime, home care offers me the most attractive, healthy, cost effective option. Home care allows me to live at home.

– By Francie Scott