CMS Readies Providers for Interoperability and Prior Authorization Rule

McKnight’s Home Care | By Adam Healy

The Centers for Medicare & Medicaid Services offered providers resources to help prepare for the newly finalized Interoperability and Prior Authorization final rule, which will go into effect in 2026. 

“In this rule, we explore ways that technology can improve and streamline the complex process of prior authorization,” Alexandra Mugge, deputy chief health informatics officer and director of CMS’ health informatics and interoperability group, said during a webinar last week. “By improving prior authorization processes for providers, we hope that they will be able to put that time back into taking care of their patients. So this would have a direct impact on the provider and saving time, but hopefully they can put that time into patient care, which will have a significant impact on the patient, as well.”

The rule is primarily focused on streamlining healthcare data sharing by using specialized application programming interfaces (APIs), tools that allow programs or applications to communicate with each other, Mugge explained. CMS’ rule will create multiple APIs for patients, providers and payers, which would “greatly improve data sharing and access to information” among these parties, she said.

Home care and hospice providers have generally not benefited from interoperable health data technology and, as a result, lack critical information about their patients. A specialized “Provider Access API” finalized in CMS’ rule would give all providers the ability to see their patients’ claims and encounter data, as well as their prior authorization information, another key focus of the rule.

“Automation and technological solutions are never enough to address a complex process like prior authorization,” Mugge said. “To truly look at prior authorization reform, we have also looked at … cultural changes that will help to support streamlining these processes in the future, in addition to the technology solutions.” 

These changes include reduced prior authorization decision timelines and a requirement that payers provide a specific reason for denials, according to the rule. Specifically, the rule requires certain payers — such as MA, Medicaid and Medicaid managed care plans — to make prior authorization decisions within 72 hours for expedited requests, and within one week for standard, non-urgent requests.

Meanwhile, some critics have called on CMS to reduce decision timelines even further. The Improving Seniors’ Timely Access to Care Act, which has been endorsed by LeadingAge, would require Medicare Advantage plans to make prior authorization decisions within 72 hours of a request.

Developing a Cooperative Relationship Between Nursing Facilities and Hospice

By Barbara Karnes, RN

For many people, nursing facilities have become their home. It is therefore reasonable that Hospice services be available in facilities. BUT care in a facility is not the same as care in the home. Here are some of the differences—and challenges.

Nursing facilities’ focus, by regulations, is to keep people alive. All the care is concentrated on living the best possible life under the circumstances. Yet, most people in nursing facilities are there because of health challenges or aging that has made independent living unsafe. These people will die in the facility. I know that sounds harsh, but it is true. This is problematic because facilities are not trained in end of life. They are trained to keep life going.

Do you see where I am going with this? Nursing facilities and hospice go together but are also at odds with each other.

Here are my thoughts on developing a cooperative relationship between the facility, the patient and the patient’s family.

One hospice team is assigned to a specific facility. This team (nurse, home health aid, social worker, chaplain) becomes a set of familiar faces and provides consistency.

The team provides ongoing inservices to the entire facility staff. These inservices should include information on the signs of approaching death, end of life nutrition, what to do as death approaches, how to talk with family members, and when to begin hospice services.

When a hospice team member arrives, they should first check in with the staff. They should say their hellos, be friendly and talkative, and ask about patients. They should then check the medical records of the patients to be seen and read the notes since the last visit. Ask about the patient’s family, their visits, and their concerns. Finally, the hospice team member can see the patient. Sit by the bed, use gentle touch if it is appropriate, begin talking about the day, and ask how they are doing and feeling. Become a friend as well as a professional, all the while assessing.

The team member will chart the visit and report their assessment to the staff nurse before leaving.

Call, that day, the patient’s primary family contact and report your visit and assessment. The family is as much your responsibility as the patient.

To summarize: 

  * Have the same hospice team for each individual facility.

  * Provide inservice to the facility staff on a regular basis. Be part of new employee orientation.

  * Make yourself known among the staff. You want them to know you, and to trust you and your knowledge. 

  * On a routine patient visit: First talk with the staff, get an update on the patient's condition, progress, and activity. Check the patient’s chart. Then spend time with the patient. Sit, assess, visit. Return to nursing staff and report your assessment, answer questions. Contact the primary family member and report your assessment.

Consider the nursing facility as part of the hospice team, but also as family. They are as much caregivers as the family is in a private home. They have feelings, attachments, and concerns. They are part of our hospice care also.

The Operational Advantages Of Hiring Seniors To Provide Home Care

Home Health Care News | By Joyce Famkinwa
 
Seniors Helping Seniors has long distinguished itself from other home care companies by hiring active seniors to serve as caregivers. Josh Obeiter — an owner of one of the company’s franchise locations — has seen even more added value from this strategy as the industry at large combats labor shortages. 

At Seniors Helping Seniors, the average age of an employee is around 70 years old, and 80% of caregivers are in their 60s and 70s, according to Obeiter.
 
“People often have a lot of resistance when their family members say, ‘I think it’s time to bring in a caregiver, you need help,’ especially when there’s cognitive impairment,” he told Home Health Care News. “People lack the insight into their own deficits, so our model of having somebody who looks and feels more like a friend or neighbor allows the person receiving the help to feel a lot more comfortable and typically a lot more receptive.” 

Pennsylvania-based Seniors Helping Seniors is a personal care franchise company that has over 200 locations in 36 states.
 
Obeiter owns and operates a Seniors Helping Seniors in the Greater Boston area. This location offers non-medical home care with a focus on providing care to seniors living with Alzheimer’s and other dementias. It serves over 200 clients and employs more than 200 caregivers.
 
Through Seniors Helping Seniors Boston, Obeiter has employed more than 1,000 seniors. Over the years, he has seen the benefits of tapping into this underutilized labor pool. 

Since the majority of caregivers at Senior Helping Seniors are retirees, the company doesn’t have as many employees who are juggling multiple jobs across different home care agencies.
 
“They’re not straddling between Senior Helping Seniors and another non-medical home care agency, or an assisted living,” Obeiter said. “They’re able to come to us looking for part-time work. We’re able to fill what they’re looking for, so they don’t need to go elsewhere for work.”

Employees who aren’t juggling multiple jobs are able to bring their full energy to caregiving, Obeiter noted. 

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New Data: Long COVID Cases Surge

Medscape | By Tinker Ready

Experts worry a recent rise in long COVID cases — fueled by a spike in winter holiday infections and a decline in masking and other measures — could continue into this year.

A sudden rise in long COVID in January has persisted into a second month. About 17.6% of those surveyed by the Census Bureau in January said they have experienced long COVID. The number for February was 17.4.

Compare these new numbers to October 2023 and earlier, when long COVID numbers hovered between 14% and 15% of the US adult population as far back as June 2022.

The Census Bureau and the Centers for Disease Control and Prevention (CDC) regularly query about 70,000 people as part of its ongoing Pulse Survey.

It's Not Just the Federal Numbers

Independently, advocates, researchers, and clinicians also reported seeing an increase in the number of people who have developed long COVID after a second or third infection.

John Baratta, MD, who runs the COVID Recovery Clinic at the University of North Carolina, said the increase is related to a higher rate of acute cases in the fall and winter of 2023.

In January, the percentage of North Carolinians reporting ever having had long COVD jumped from 12.5% to 20.2% in January and fell to 16.8% in February.

At the same time, many cases are either undetected or unreported by people who tested positive for COVID-19 at home or are not aware they have had it.

Hannah Davis, a member of the Patient-Led Research Collaborative, also linked the increase in long COVID to the wave of new infections at the end of 2023 and the start of 2024.

"It's absolutely real," she said via email. "There have been many new cases in the past few months, and we see those new folks in our communities as well."

Wastewater Remains the Best Indicator

"This results in many cases of COVID flying under the radar," Baratta said. "However, we do know from the wastewater monitoring that there was a pretty substantial rise."

Testing wastewater for COVID levels is becoming one of the most reliable measures of estimating infection, he said. Nationally, viral measure of wastewater followed a similar path: The viral rate started creeping up in October and peaked on December 30, according to CDC measures.

RNA extracted from concentrated wastewater samples offer a good measure of SARS-CoV-2 in the community. In North Carolina and elsewhere, the state measures the virus by calculating gene copies in wastewater per capita — how many for each resident. For most of 2023, North Carolina reported fewer than 10 million viral gene copies per state resident. In late July, that number shot up to 25 million and reached 71 million per capita in March 2023 before starting to go down…

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