Legal & EthicsUncategorizedWorkplace Management

Issues up close


What’s in a word? Plenty, especially if it involves a Medicare rule that can lead to delays in services to home care patients.
Specifically, the current Medicare statute stipulates that only “physicians” can certify or order home care services and plan patients’ needed care. This is despite 1997 revisions to the Balanced Budget Act that required the Centers for Medi­care & Medicaid Services “to reimburse nurse practitioners for multiple services, including consultation, admission of patients to nursing facilities, and home institutional visits,” according to a background report provided at the American Nurses Association’s (ANA) 2010 House of Delegates (HOD).

Further, ANA notes that for nearly two decades, Medi­care has recognized the autonomous practice of advanced practice registered nurses (APRNs) in accordance with state law. Efforts are underway, however, to break the home care barrier. This past June, the New York State Nurses Association (NYSNA) introduced a resolution (ultimately approved by nearly 600 nurse delegates at the HOD) that calls on ANA to support federal legislation that would permit APRNs to sign orders for home care services and supplies for Medicare patients, as well as make changes to healthcare plans. (ANA has considered this a priority for some time.)

To that end, ANA and other nursing organizations are working hard to gain support for the Home Health Care Planning Improvement Act (S. 227), which would allow nurse practitioners (NPs), clinical nurse specialists (CNSs), certified nurse-midwives (CNMs), and physician assistants to order these services under Medicare in accordance with state law. The measure was introduced earlier this year by senators Susan Collins (R-ME) and Kent Conrad (D-ND). Congresswoman Allyson Schwartz (D-PA) is expected to introduce companion legislation in the U.S. House. (For more information on the bill, read “Home Health Care Planning Improvement Act of 2011” under “Headlines from the Hill”.)

“Middlemen” and delays in care

Evelyn Duffy, DNP, G/ANP-BC, FAANP, president of the Gerontological Advanced Practice Nurses Association (GAPNA), runs an ambulatory clinic in a senior citizens’ high-rise building and makes house calls to older adults. Most of her patients are essentially homebound and have cognitive impairment and multiple chronic conditions, such as diabetes, hypertension, and kidney disease. She knows when these patients’ blood-pressure medications need to be adjusted or when their conditions require a nurse, physical therapist, or nutritionist to visit them in their homes.

But although Duffy actually provides their ongoing care, when it comes to officially ordering home care services and supplies or adjustments to their home care plans, she must have the sign-off of her collaborating physician, who may have no direct relationship with the patients.

“The Medicare requirement that a physician sign off on all home care certification and recertification means that my physician collaborator comes in for 2 hours one afternoon a month or so and sits with a pile of charts and signs off on home care orders,” says Duffy, also an assistant professor and associate director of the University Center on Aging and Health at Case Western Reserve University in Cleveland. “He gets paid for every signature as home care oversight, because of the Medicare rule. It’s an unnecessary healthcare cost, and it forces him to spend time on paperwork rather than seeing the many patients who need primary care.”

Although Duffy considers herself fortunate to have a readily available physician collaborator, that’s not always the case for other APRNs. “It depends on the home care agency, but some hold off on care until there is that physician sign-off, which can lead to potential delays in care or breaks in home care,” she says.

Karen Zink, MS, CNP, a Colorado Nurses Association member who sees pain patients, says the exclusionary language of the Medicare rule and other regulatory measures essentially creates a middle layer that not only can impede patient care but can prevent APRNs from practicing within their full scope and ability. She recalls an 82-year-old patient who was hospitalized at a Denver rehabilitation facility after being run over by a pickup truck. Fortunately, the patient recovered, but she needed full-time care at home. “I couldn’t order home care services myself,” Zink says, “and we were having problems with the doctor in Denver reporting to her physician in Durango. So there was a 2- or 3-day delay in care.”

Pat Lazare, MSN, RNC, chair of the Idaho Nurses Association’s Legislative Committee and an HOD delegate who spoke in favor of the home care resolution, notes Idaho is a rural state that has no physicians in some communities. If NPs and other APRNs can’t directly order home care and delays occur, Lazare says, “that is not best practice; that is not helping people who are vulnerable.” For example, if a delay occurs in getting glucose testing and other follow-up home care services for a newly discharged patient, that person can be at risk for readmission for serious—and costly—complications, such as diabetic ketoacidosis. (See Making the case by clicking the PDF icon above.)

In a letter sent to Senate colleagues asking for their support, Senators Collins and Conrad pointed out that at best, requiring physicians to certify home care plans just adds more paperwork and steps before home health care can be provided. “At worst, it can lead to needless delays in getting Medicare patients the home health care they need simply because a physician is not readily available to sign the form,” they wrote.

Beyond older adults and Medicare

The quirk in Medicare law also is a barrier to CNMs who provide gynecologic services to older women and to pregnant women who are disabled and qualify for Medicare. “Three million women are disabled and of childbearing age,” notes Patrick Cooney, president of The Federal Group in Washington, D.C. and a federal lobbyist for the American College of Nurse-Midwives (ACNM). Although these women may not represent a large percentage of their patient population, Medicare-eligible, pregnant women are indeed seen by CNMs, and some may need home-care services. For example, home care may be required for women experiencing complications, such as hyperemesis gravidarum and postpartum urinary retention, as well as for follow-up home visits for breastfeeding support, explains ACNM member Heather Cates, CNM.

Cooney points out that “Medicare guides the whole healthcare ship,” meaning that if the Medicare rule is changed to allow APRNs to order home care plans, Medicaid and third-party insurers may follow suit, leading to greater patient care. “If we don’t utilize the practitioners we have,” Cooney adds, “we’re shooting ourselves in the foot as we expand health care to 30 million more Americans” under the Affordable Care Act.

For more information on the home health bill and other ANA activities, visit

Susan Trossman is a senior reporter for ANA.

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