VNAA - Visiting Nurse Associations of America
VNAA The Voice of Home Healthcare

Member Update - Operational

VNAA Member Update

For the week of 02/14/2005

VNAA to Meet with HHS to Discuss Goals for Home and Community Care 

Statements recently made by HHS Secretary Michael Leavitt and CMS Administrator Mark McClellan related to the release of President Bush’s Fiscal Year 2006 Federal Budget have given reason for hope to advocates of home and community-based care, but what does it really mean?  

To answer this, VNAA will meet directly with HHS Secretary Leavitt and/or CMS Administrator McClellan.  We will request these meetings and will keep you posted on the latest buzz over "home- and community-based care."

On February 1, 2005, Secretary Leavitt gave a speech entitled "Medicaid: A Time to Act", during which he gave the following statements:  "We can ensure that seniors and people with disabilities get long-term care where they want it. The President's New Freedom Initiative points us in the right direction. Home and community care can allow many Americans with disabilities to continue to live at home, where they can enjoy family, neighbors, and the comfort of familiar surroundings. Medicaid should not force these people to live in institutions…..  Look at Vermont and New Hampshire.  Vermont has a highly developed home and community based health care system.  New Hampshire continues to relay on institutional care.  In Vermont, 85% of Medicaid population over age 65 still live at home.  In New Hampshire, only half can live at home.  And Vermont spends less than half as much per elderly person on Medicaid as New Hampshire, freeing up money that can serve more people."

Beyond these statements, the details in the President’s Budget point to only modest endeavors.   For example, under the Medicaid program, the Administration provides more funding for its New Freedom Initiative by proposing $1.75 billion for the “Money Follows the Person Rebalancing Demonstration” and $234 million for Home- and Community-Based Demonstrations.  The “Money Follows the Person” program provides grants to states to help pay for home- and community-based waiver services for individuals that transfer from institutional settings to home and community settings.  

The Home- and Community-Based Demonstrations would:  1) provide community alternatives to children’s residential treatment facilities; 2) respite for caregivers of disabled adults, and 3) respite for caregivers of children with a substantial disability.

However, the $45 billion in Medicaid savings over 10 years included in the President’s Budget is a cause for concern.  Many health care observers believe that the Administration will seek savings by supporting “block grants” for Medicaid payments for optional services, such as home health and homecare and community-based waiver services.  

VNAA believes that Block granting optional services like homecare would ultimately run counter to the Administration’s plan to shift more Medicaid dollars to home and community-based care.

The following summary of the President’s FY 2006 Budget for health-related programs is provided by The Alpine Group, a federal lobbying firm working for VNAA.

 Summary of Medicaid and Medicare Proposals in the President’s Fiscal Year 2006 Budget

Embracing Consumer Directed Care 

Suggesting to most home health agencies that they embrace consumer directed care is a bit like proposing cuddling with a porcupine.  But with an increasing number of State Medicaid programs adopting consumer directed models and the Federal government pushing States even harder in this direction, its important that VNAs begin to think of how to accommodate if not creating a useful VNA role in consumer directed care.  While VNAA continues to raise issues with Medicare consumer directed care, Medicaid consumer directed care a growing reality.  And, to the degree that consumer directed care allows more persons to live in their own homes and communities, the opportunities for VNAs to provide other services to maintain health and independence is increased.

Consumer directed care was highlighted again this week. At the same time that newly confirmed HHS Secretary Mike Leavitt rolled out the 2006 Presidential Budget proposal to grow Medicaid home and community-based services as an alternative to nursing home care, the National Council on Aging and National Association of State Units on Aging released a major study on State use of consumer directed care.  The Study, “States’ Experience implementing Consumer-Directed Home and Community Based Services”, makes the following key points:

  • 40 States and Territories are operating 62 consumer directed HCBS programs.
  • The number of programs serving elders vs. younger disability groups is increasing.
  • While many of these programs are relatively new and small, the potential for growth is characterized as “enormous.”
  • States have adopted consumer directed care because of gaps in service delivery, inadequate provider supply, consumer advocacy, Federal and State policy, and to achieve cost savings.
  • Barriers cited include Federal and State Medicaid rules and resistance from provider organizations.
  • Current funding is 47% Medicaid HCBSW, 26% State General Revenue and 22% Older Americans Act Funding.
  • There is high level of patient satisfaction with the programs and they are appropriate for elders as well as younger persons with disabilities.
  • Only 10% of programs pay consumers directly, 16% use vouchers, 24% pay the provider and 43% pay the provider through a 3rd party fiscal intermediary.

You can read the full text of the report at:

New Home Health Quality Measures Released by National Quality Forum 

The National Quality Forum, which has emerged as the official consensus building organization under the Federal mandate for national consensus standards for health quality, has announced the first round of decisions for National Quality Standards for Home Health.  The significance of these are that, under law, CMS is obligated to consider  these as new publicly reported home health quality measures unless there is some barrier to their adoption.  

While CMS has not made its full intentions in this regard know, VNAA has learned that CMS is planning changes to the publicly reported measures set to accommodate at least some of  NQF's changes.

The official list includes 15 measures, all based on OASIS, including several of the existing CMS outcome measures. It also adds some measures, deletes others, makes some more specific and holds 6 additional measures out for further consideration and possible adoption. VNAA has participated in the consensus process, to the limited extent allowed by NQF, and had submitted comments both orally and in writing, some of which were adopted. Key among these was not adopting an entirely new set of measures called ACOVE, on top of existing OASIS measures.

The new National NQF Home Health Measures are:

  • Improvement in ambulation/locomotion
  • Improvement in bathing
  • Improvement in transferring
  • Improvement in management of oral medications
  • Improvement in pain interfering with activity
  • Improvement in status of surgical wounds
  • Improvement in dyspnea
  • Improvement in urinary incontinence
  • Increase in the number of pressure ulcers
  • Emergent care for wound infections, deterioration in wound status
  • Emergent care for improper medication administration, medication side effects
  • Emergent care for hypo/hyperglycemia
  • Acute care hospitalization
  • Discharge to community
  • Emergent Care

The measures still pending decision are:

  • Substantial decline in management of oral medications
  • Discharge to the community while still needing wound care or medication assistance
  • Unexpected nursing home admission
  • Family evaluation (survey) of hospice care
  • Comfort within 48 hours
  • Unwanted hospitalization


VNAA Advises CMS on Alternatives to Further Home Health Written Notice Requirements 

VNAA attended a meeting two weeks ago at CMS to discuss a court ruling that advocates have argued significantly expands the requirement for advanced beneficiary notices.  In this litigation (Lutwin, upheld in the Second Circuit Court of Appeals), the court suggests that only de minimis changes in the plan of care would avoid notice requirements. Based on this, the advocacy community has argued that changes in staffing, changes in the time a visit is made, changes in medication, changes in treatment of any kind, require prior written notice to the beneficiary.  

VNAA raised the practical barriers to such a policy and the interest of Medicare in simply assuring prior notice of reductions in visits.  VNAA was invited to submit comments to CMS on this issue following the meeting.  In addition to participating and signing onto comments on behalf of all three home health associations, VNAA submitted the following comments on behalf of its members.

 Comments to CMS

Plan to Attend "Advancing the Agenda for Home Healthcare Quality" 

It is not too late to register for this national summit, which will examine strategies for measuring, improving, and assuring quality in home health care.

The conference, hosted by the Center for Home Care Policy and Research of the VNSNY, will be held in NYC on March 31 - April 1, 2005.

This national meeting will bring together key home care stakeholders, including providers, payers, clinicians, consumers, advocates, accreditors, regulators and researchers, and build upon the work of our June 2003 national meeting "Charting the Course for Home Health Care Quality."

This meeting builds upon the work of our June 2003 national meeting “Charting the Course for Home Health Care Quality.”  Sponsorship for this meeting is made possible by VNAA, The Robert Wood Johnson Foundation, the Agency for Healthcare Research and Quality, Home Healthcare Nurse, Journal for Healthcare Quality from the National Association for Healthcare Quality, and the Visiting Nurse Associations of America.

For a registration application and other materials related to the meeting, please visit:

Give Your Immunization Program a Shot in the Arm 

Want to know how VNAs are using immunization programs to positively impact their bottom line?

VNAA's 23rd Annual Meeting, to be held in San Diego this April, will offer a new Immunization Track, offering participants valuable clinical and management advice to grow your business through expanding and building immunization programs.

"Building A Successful Flu Program"
A panel representing four VNAA member agencies will share their successful practices.  Their programs have not only succeeded in serving their community needs but have supported the agency's community and charitable programs. Come learn their formulas for success.

"Create or Expand Your Meningitis Prevention Program!"
Hear from two agencies that have innovative community based programming and will offer great suggestions for promoting a Meningitis Vaccination Program. Also Hear from the experts about the new meningitis vaccine, Menactra™ and how the recent ACIP recommendations will impact your opportunities.

"Travel Vaccine Clinics"
Learn what needs to be done to develop and manage a successful clinic and see if it is a fit for your agency.

This new track is a must for VNA Immunization Coordinators and Business Development managers!

For more information about 2005 Annual Meeting Programs go to and click on Annual Meeting.


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