New Centers for Medicare & Medicaid Services (CMS) regulations implemented in 2011 require that patients referred to home health agencies must have a face-to-face encounter with the physician who certifies home care either 90 days before or within 30 days of the start of home care services. The regulation also specifies that the physician must address the primary reason for home services during this encounter.
For physicians who work in collaboration with a nurse practitioner or a clinical nurse specialize, or who supervise a physician's assistant, the face-to-face encounter may be carried out by that non-physician practitioner who must document the clinical findings.
Only a physician, however, may:
- Order home health services
- Certify that a face-to-face encounter has occurred
- Certify that other eligibility criteria are met, such as medical necessity and homebound status
The Face-to-Face Encounter Must
- Be made by the physician responsible for certifying home health (or non-physician practitioner — nurse practitioner or clinical nurse specialist in consultation with the physician, or a physician's assistant supervised by the physician.)
- Be related to the primary reason for which the patient requires home health services
- Be made with 90 days prior to, or with 30 days of, the start of care
Physician Documentation Requirements
Documentation of the face-to-face encounter must be a separate and distinct section of, or an addendum to, the certification. It must be clearly titled, dated and signed by the certifying physician.
Download the face-to-face documentation form
The physician must include the following information about the face-to-face encounter:
- Date of the encounter
- Indication that the encounter was related to the primary reason for home health care
- An explanation of why the clinical findings of the encounter support the need for either intermittent skilled nursing services or therapy services
- An explanation of why the clinical findings of the encounter support that the patient is homebound
- The physician's signature and date signed
New CMS Hospice Regulations
The face-to-face encounter defined above applies to patients on home care or palliative care. For hospice patients, the hospice Medical Director or Nurse Practitioner will need to make a face-to-face encounter with hospice patients before the third or any subsequent re-certification periods. The BVNAH hospice medical director or nurse practitioner will visit patients for face-to-face encounters prior to the end of the patient's third re-certification period and then will communicate with the physician regarding their assessment.
Home Health Care
To make a home health care referral:
Call 800-249-8298 and press Option 1
Download, complete and fax the BVNAH Referral Fax Form to 413-794-6693
To make a hospice referral:
Call 800-249-8298 and press Option 2
Baystate Visiting Nurse Association and Hospice serves patients throughout Hampden, Hampshire and western Worcester counties.
Patients may benefit from home health services if:
- They have recently been hospitalized
- They have been newly diagnosed with a chronic illness
- They are trying to manage a chronic illness
- They are recovering from surgery
- They have had a heart attack or stroke
- They have had a hip or knee replacement
- They have been diagnosed with a life-limiting illness.
Home Care Admission Criteria include:
- Patient needs skilled health care — nursing, physical therapy or speech therapy.
- Patient needs part-time care on an intermittent basis.
- The attending physician will sign the initial plan of care.
Medicare and some other insurance plans also require that the patient be homebound (see below). As of January 2011, Medicare also requires that the attending physician has had a Face-to-Face Encounter with the patient either:
- 90 days prior to the start of home care services or
- Within 30 days after the start of care and that the face-to-face was related to the primary reason for home care.
GUIDE TO HOMEBOUND STATUS
Some insurance plans, including Medicare, require a patient who is receiving home health care to be "homebound." This does not mean that they are bed bound! Consider:
√ Does the patient have trouble getting to the physician's office and require someone to accompany him or her?
√ Does leaving the home require "considerable and taxing effort" for the patient?
√ Does the patient require assistance (human and/or a device such as a walker or cane) to leave home?
√ Are most absences from home due to medical reasons?
√ When leaving home for non-medical reasons, are the absences "infrequent and for short duration," such as attending religious services or beauty salon visits?
For more information, to make a referral, or for a consultation to see if a patient is appropriate for home health care, call 800-249-8298
Hospice is a set of services for terminally ill patients and their families. Hospice should not be considered as a last resort or giving up. It focuses on pain and symptom management with compassionate care to help the patient live as fully as ever. Hospice supports the emotional, social and spiritual needs of the patient as well as the whole family. Families continue to receive bereavement support for over a year after the patient's death.
Who May Be Appropriate for Hospice?
Patients may be appropriate for hospice if they have an illness where the life expectancy is approximately six months or less if the disease progresses its natural course. The patient may have cancer or another end-stage chronic disease, such as cardiovascular, pulmonary, liver, renal, neuromuscular or Alzheimer's. Patients are appropriate candidates for hospice when:
- Their illness no longer responds to aggressive, cure-oriented treatment.
- There is a need for continuing pain and symptom relief.
- The patient and family may require continuing emotional and spiritual support.
Hospice Care Admission Criteria
To be eligible, patients must be diagnosed with a terminal illness and be aware that they have a life expectancy of six months or less if the disease runs its natural course.
In addition to cancer patients, any patient with an end-stage disease may be appropriate for hospice care. Consult Hospice Referral Indicators for Non-Cancer Diagnoses.
When Is it Appropriate to Refer a Patient to Hospice?
Patients who qualify for hospice are often referred too late, if at all. Referrals made when the patient has months rather than weeks or days left provide the most benefit.
Providing information about hospice early:
- Allows the patient to make an informed decision and helps to shape the final phase of life based on personal wishes, goals and beliefs.
- Gives the patient a choice and sense of control before the illness is in medical crisis.
- Allows caregivers to address symptom management to before the illness reaches crisis proportions.
- Allows time to address the emotional, social and spiritual needs of the patient and the family, giving them time to come to terms with dying.
Initiating discussions early in the progression of the disease will give patients time to determine the services that they want at the end of life. Patients with a prognosis of less than one year should be educated about the hospice option, even if there is a "hope for the best" approach, so they know their options and can be prepared.
For more information, to make a referral or for a consultation to see if a patient is appropriate for hospice, call 800-249-8298
Patients facing a serious illness often experience pain and other symptoms such as difficulty breathing, nausea, fatigue, constipation, loss of appetite, and difficulty sleeping. Whether a patient is facing a life-limiting illness and isn't ready for hospice, or a patient is fighting a life-limiting illness and strill seeking curative treatment, the Palliative Care Program at BVNAH may be able to help provide some relief.
Palliative Care Admission Criteria
Consider palliative care for patients with life-threatening illnesses who:
- Receive comfort and/or curative treatment
- Meet homebound requirements of their insurance coverage
- Require skilled care and treatment, such as:
- Skilled wound care
- Intravenous therapy
- Complex pain or symptom management
- Complex assessment skills
- Symptom instability longer than two weeks
- New medication regimen
- Numerous medication changes.
- Require education of family and/or patient regarding disease protocol, skilled treatments, and unmet needs.
- Would benefit from case management for high-risk patients
- Coordination of multiple services
- May be eligible for hospice, but currently pursuing curative treatments or has declined hospice services.
Who Can Benefit from the BVNAH Palliative Care Program?
- Patients of any age, including children, with debilitating chronic disease or life-threatening illness at any stage of the diagnosis.
- Patients with life-limiting illness experiencing unresolved symptoms such as pain or shortness of breath.
- Patients who have frequent hospital or emergency room visits to manage shortness of breath, swelling, confusion, or other complex symptoms.
- Patients seeking aggressive treatments, to alleviate the side effects and help them to better tolerate ongoing treatments.
- Chronically ill patients and their families who are not yet ready to accept hospice care.
For more information, to make a referral, or for a consultation to see if a patient is appropriate for Palliative Care, call 800-249-8298