Eric: Welcome to the GeriPal podcast! This is Eric Widera.
Alex:: This is Alex Smith.
Eric: And Alex who do we have with us today?
Alex: Today we have an extra special guest.
Eric: Extra special.
Alex: Today we have Cynthia Boyd who is Professor of Medicine and a Geriatrician at Johns Hopkins. Welcome to the GeriPal podcast Cynthia.
Cynthia: Thank you so much, I’m very happy to do this with you.
Eric: So we’re going to be talking about interactions between physicians and skilled home healthcare agencies. In particular how we communicate with them, which tends to be over a form. But we’ll get to that. Before we do, Cynthia do you have a song for Alex to sing?
Cynthia: Yes. I would love to hear “The River” by Bruce Springsteen, who is from my home town in New Jersey.
Alex: Oh really? Now that’s interesting, I think he may win the award for most requested on the GeriPal podcast.
Eric: I have also heard that New Jerseyans tend to like Bruce Springsteen. There is something there-
Eric: … there’s a fondness, I think. A mild fondness?
Cynthia: Ya, I’d say so.
Alex: We’re just going to do a little taste of it at the beginning, and more at the end. [Singing].
Alex: And more at the end.
Eric: Why’d you pick that song? Aside from New Jersey, Bruce Springsteen connection?
Cynthia: Well I like just about everything that he sings. But actually where I’m from in New Jersey, there’s two rivers on two sides of our town. So, actually, I’ve always liked the song.
Alex: So we’re going to talk about this paper that you recently published in Annals of Internal Medicine titled, “Interactions Between Physicians and Skilled Home Healthcare Agencies in the Certification of Medicare Beneficiaries Plans of Care”.
So Cynthia, tell us how you got interested in this work. Was this the result of your clinical experience?
Cynthia: It was. I and some of my co-authors are primary care physicians in a geriatrics clinic in Baltimore. We pretty frequently refer patients to home healthcare. And we were struck by the fact that there was much more paperwork than there was, sometimes, actual connection with the people who are nurses or physical therapists going into the home. And that this is helped a little bit when the home health agency is in the same system. Which where I work, Johns Hopkins, does have its own home healthcare agency.
But that the forms seemed to take a significant amount of time, but not really be facilitating the meaningful communication that we needed to just actually talk to each other in order to communicate.
We were curious about whether this was a unique experience, or what it was really like for physicians around the country. And we thought, after talking to people informally, that it was an issue around the country. That people struggled with communication back and forth between home health agencies and physicians, and that it was worth understanding that in the hopes of improving it.
Eric: But me and Alex currently just do in-patient palliative care, so we don’t have a lot of communication with home health agencies.
But I remember from back when I did out-patient care, filling out these, well not filling them out, signing these forms that I get through like fax. That pile up in my mail folder, never actually looking that closely at it.
Can you describe … Is that the usual communication? What is the current state of communication between home healthcare providers and physicians?
Cynthia: The forms represent this moment of certification of the plan of care. Which is meant to reflect what the home healthcare agency staff are going to be doing for up to 60 day period in the care of someone who’s home bound.
There’s definitely other communication that can go on over the course of care, which are for many physicians also sent by fax. And will be signing like a single order, that sometimes can be signed electronically but often are still signed by mail or fax.
One of the things we’re really interested in is, to what extent does this process of certification of the plan of care, facilitate meaningful communication? And a bigger picture question is, how does that relate to communication over the episode of home healthcare, outside of the certification? Which is something that we’re actually hoping to study more in the future.
This work was focused on this time where a lot of information is exchanged. The certification of the plan of care, but that there … our hypothesis was that it didn’t help facilitate really meaningful communication.
Eric: And in the paper you describe the CMS form 485, which just sounds like a great title for a form name. Is that what we’re talking about? 45 is the re-certification, certification form?
Cynthia: The vast majority of home healthcare agencies use the CMS 485 in order to document the plan of care, because it meets CMS regulatory requirements.
It serves as the primary means of communication, at that point in time then, between the physicians and the skilled home healthcare agency. But they don’t technically have to use the 485 form. But because it is a regulatory document that needs to be signed in order for the home healthcare agency to be paid, it’s used by the vast majority of home healthcare agencies. And most physicians who know of it, know of it as the 485, which is why we called it that in the survey. But it’s not actually a required form.
Alex: What’s the worst thing that could happen if communication breaks down between the home health nurse, physical therapist, occupational therapist, speech therapist and the physician?
Cynthia: So people who get home healthcare are either temporarily or permanently home bound. Meaning that it’s either impossible or very difficult without the assistance of another person, or unsafe for the person to be leaving their home.
So we’re talking about a population that’s at high risk of hospitalizations, of death, of adverse events. So it’s a population that is in many ways, kind of vulnerable to everything that can go wrong in our healthcare system. In that they’re barely sick, and have reasons that they can’t leave their home and yet they are home.
Prior work by one of my collaborators, Jennifer Wolff, showed that actually during a home healthcare plan of care, only two-thirds of Medicare patients actually saw a physician for an evaluation and management visit, during the skilled home healthcare episode. Which means a third didn’t see anyone.
Communication is really important. And when we think about it from the geriatric perspective, a clinician, a nurse, a physical therapist, occupational therapist, speech, seeing someone in their home is really a window to the context of their lives. How they’re managing their illness. If the person was recently discharged, how the transition is going.
So communication, a failure of communication, I think really puts people at greater risk of all of those things we try to avoid.
Eric: So you had this great study in Annals of Internal Medicine. What for me seems like trying to understand what is the current state of communication between physicians and home health agencies, and how are we using the CMS 485 form. Do you want to just describe what you did to help answer that?
Cynthia: Sure, so just to back up a little bit. Skilled home healthcare services may be ordered by physicians for home bound patients who need skilled services provided by nurses or physical or occupational therapists. After admission into skilled home healthcare, a nurse or a physical therapist would develop this plan of care that needs to be certified.
And what we were interested in was physicians perspectives in this survey, about the process of communication and certification of the plan of care.
So this is a nationally representative survey of physicians. We sent a mailed survey to 2000 randomly selected physicians from the AMA Medical Association’s physician master file, after basing our selection criteria to try to find physicians who were practicing primary care.
So its important to note that not only primary care physicians sign the 485, but it’s definitely a very big proportion of the people who sign it. But for feasibility reasons, we needed to target them. But it is a limitation that we don’t have the perspective of a surgeon, say, who sometimes do sign these forms.
So we had an over 50% response rate, and we’re really thankful to all of those busy primary care physicians who filled it out. And we sent them a mailed survey which they mailed back to us.
Alex: So what did you find? Did they love the form and they read it every night before bed?
Eric: It was like the most engaging thing ever.
Alex: The form 485 is like framed. It should be framed. Put on a pedestal. The pinnacle of Medicare forms.
Cynthia: Yeah, well so I’ll get to what people thought of the form I just a second.
I would say that our main finding was the 485 does not meaningfully engage physicians in the plan of care. With physicians spending very little time reviewing or acting on it, or reaching out to communicate with a nurse or a physical therapist about it.
So just to put that into numbers, about half of doctors spend less than a minute reviewing the 485 as the plan of care. So what does that mean?
These forms are typically 4-5 pages long for those of you who’ve seen them. They have really small font, and there’s a lot of information on them. Part of it includes a list of medications, which is not presented in any particular, clinically meaningful order.
So people spend very little time considering how much information is actually on the form.
Eric: So half of physicians spend less than a minute, and the other half are not telling the truth.
Cynthia: Yes, only about 20-25% of physicians spend more than two minutes looking at the form.
Eric: In my own experience, that kind of rings true when I did out-patient care, this felt like an administrative task. It did not feel like a clinically meaningful task.
I mean it’s not just this form, we see a lot of this in medicine, just reading through an EMR on any hospitalized patients. You have these nursing forms that go on for pages that have a ton of information on it. But it’s hard to figure out, is any of this clinically actionable and meaningful? I’m sure there is, but I would say most physicians never read through that. It’s not just the 485 form, it’s a lot of how we document.
Cynthia: No it’s true. Both the American College of Physicians, as well as CMS, have in recent years been talking about the idea of patients over paperwork, or patients before paperwork.
But how do we make sure that physicians, but also other healthcare professionals, other clinicians, how do we keep people focused on the person in front of them? And have the paperwork in regulation activities that we need to do, not be taking away from that really important interaction. Which is frankly why I think most of us went into medicine, or nursing, or physical therapy, is that personal connection.
Eric: So it sounds like we spend very little time looking at the CMS form. Looking at table one, it also looks like most of us don’t have any actionable tasks with it. That we rarely change the orders on the CMS 485, and that we rarely contact healthcare physicians about information on that form. Is that right?
Cynthia: Yes, really overwhelmingly so. Less than 20% of the physicians reported changing anything more than rarely. Almost about 80% said that they never rarely change anything on the form, and about the same amount never rarely contact a skilled home healthcare clinician with a question about the information.
Alex: And how did they rate the usefulness of this form?
Cynthia: So we asked physicians on a scale of one to ten, and they rated the usefulness about a four and a half, with ten having been the most useful.
So not the worst thing ever. But certainly not a mechanism of really good or meaningful communication, or facilitation of understanding what was going on with the patient.
Alex: Now we were talking a moment ago about how there’s probably a better way we need to put patients first over forms. And one better way that is kind of obvious is well maybe they should have a call with each other, and talk to each other about the plan of care before completing a form.
And yet it seems from your study that the, I’m looking here, the mean ease of contacting the home health clinician was rated a 4.7 on that same scale out of 10. So it sounds like there are barriers as well, to just getting in touch with them.
Cynthia: Yes, so interestingly on the form, you’re not able to tell who is the clinician who is seeing your patient, or even how to reach them. Like, what’s the number that most quickly would connect you with someone who’s actually involved in the care of the patient.
So I think that’s part of why people feel like it’s very hard to reach out, and that is because that information is either not on the form or not easily accessible on the form. Obviously the form includes the name of the agency, but it’s not really like a physician to clinician information that’s there.
Eric: It sounds like the quality of communication, and relying on this form as a means of communication, just is not working.
Cynthia: Yes, and physicians had some good suggestions for improving the CMS 485. Or highlighting what they really wanted, or needed, to see.
So most physicians wanted to see changes to the existing mechanism of certification, and provided specific suggestions for how we could enhance the clinical usefulness of it. Including, increasing the font. Presenting the orders in terse and clinically useful language for all types off healthcare providers. And importantly, really highlighting what is key clinical information.
Thinking about what do the skilled home healthcare clinicians really want physicians to know, if they were trying to think about how to effectively co-manage this patient while they’re in home healthcare.
Alex: This is terrific. So this really gets into so what do we do now? We found this big problem, that this form is inadequate, it’s not useful. Physicians just glance at it and then sign it.
But what is the next step? There’s got to be somebody … I’m sure it’s a really easy process to change this form. There’s like one person you can call at CMS and they’re just going to like, change the form and accept all your recommendations. It’s not like it has to go through like a million committees or anything like that.
So what are the next steps here in improving care for home bound older adults?
Cynthia: So certainly one is to rethink the purpose, format, and design of the 485, in order to facilitate care coordination for home bound Medicare beneficiaries who are receiving skilled home healthcare. And you’re right that that obviously is not necessarily an easy or straightforward task.
Folks have actually been thinking about this before. Eugenia Siegler has developed an EHR embedded 485 that really looks different. So it basically better represents, and gives the physicians an opportunity to directly input with what is going on with their patient. And what they need the home healthcare agency to actually be evaluating and responding to. And then presenting the information back to physicians, and the plan of care that really better matches why the person was getting home healthcare.
Eric: So I got to say I’m skeptical. You know why I’m skeptical? It seems like whenever we try to accomplish both a billing goal, like re-certification things like that, and a clinically meaningful goal; billing always wins over. I mean I think that’s the number one reason people don’t like EMR’s, and sometimes these notes are impossible to read because it’s designed around billing. And I just worry that figuring out how to integrate this into an EMR, we’re going to fall into that same trap.
Cynthia: Yes, and most physicians still sign the 485 by mail or by fax. But even those that end up signing it electronically, the format, and the information, and what you actually see is every bit as cryptic and hard to unpack and hard to actually gain clinically useful information from. So I think that’s a really great point to be raising.
And to me it raises sort of the other possibility of a reaction to this work, is that we need to figure out what are the right ways to facilitate that meaningful communication.
And maybe the 485 should be left similar to the way it is and remain something that is purely regulatory. But that we need to figure out actually how to have that meaningful communication between the folks going into the home, and to the physicians who are in charge of certifying the plan of care.
And those could be face to face, so some physician house call groups have regular meetings with home healthcare agencies. Like if you’re really doing a large volume, I think that’s obviously a great model. There’s nothing like sitting around the table with your fellow interdisciplinary team members, and talking about a patient. But many patients who get skilled home healthcare are not being simultaneously cared for by a physician house call practice.
Eric: And it even sounds like looking at your work that most physicians, or at least half of physicians, are using four or more different home health agencies.
Cynthia: Exactly, so that we need to figure out mechanisms that work for physicians with multiple agencies.
So I think the idea of thinking about getting people on the phone is obviously a really important one. I think if EHR’s were really able to talk to each other, and facilitate meaningful communication, you could imagine a short terse, “Here’s what’s going on with this patient that I want you to know, and react to”. And that physicians could potentially be sending information back electronically, in a way that was much more focused on what’s clinically meaningful. But I think all of those things, we need to figure out how to develop and test them.
Alex: You know its 2018, we have these new mechanisms, technology is exploding at a rapid pace. And we can now do things like incredible video conferencing, which we’re now doing standard here at work using Zoom. We’re talking with you via Skype. Are there ways in … the home health clinicians are really the eyes and ears of the clinical team inside the home. And it’s such a vital piece of clinical information, understanding what’s going on in the home.
We’re probably not going to go back to the days of doing house calls although there are more, there’s certainly a role for that. But not routinely for all patients. Is there a way of bringing some of that technology into the patients’ home.
Could we have the home health clinician ring up the physician at a scheduled time from the patients’ home? And just sort of go over the plan of care. With the patient there in the background, and so the clinician can actually see into that home and see what’s going on.
Cynthia: I love that idea. I think absolutely we need to be thinking about ways to use technology meaningfully, that really enhance the personal connection and focusing on the patient and their family. And not be focused on technology solely for the purposes of billing or regulation.
Eric: So I just realized something, that I acknowledged that I fell into that “less than a minute” physician category. Is CMS going to come after me for fraud or…?
Alex: Oh they’re knocking on the door actually …
Cynthia: Well, I think it’s an awful lot of us. So one of the things we really tried to communicate in this paper is that the answer really should not be more regulation, or more things that actually make the problem worse.
I think that the thinking about this issue is not thinking about what we need to find all those physicians and get them in trouble. But its thinking about how do we get both those physicians, and the home healthcare clinicians, really interacting in meaningful ways. I think that you are so far from alone that I don’t think you’re going to be…
Eric: Well, I also didn’t know you could bill for it. It looks like half of physicians didn’t know that you can actually bill for it who weren’t billing for it.
Did the physicians who bill for it do they spend more time? Is the issue just, pay physicians to do this and they’ll do it better?
Cynthia: So we did examine the relationship between billing for certification of skilled home healthcare services and physicians’ interaction. And approximately one-third of physicians reported that they usually billed for certification or re-certification after 60 days.
And the people who signed more forms, so more than 30, were more likely to bill than people who did it less frequently. But even among those people who sign a lot of forms, it was still just over 50%.
Physicians who billed for certification were less likely than those who did not, to spend less than a minute reviewing the form. 40% versus 55%.
Eric: So it sounds like, just paying physicians to do this does not do the trick.
Cynthia: I don’t think so. I don’t think so.
I think that it seems like billing for the process does motivate people to spend a little bit more time. But I don’t think we’ve gotten to what we want, which is that meaningful interaction.
Eric: So what’s next for you? Are you going to survey home healthcare providers?
Cynthia: We are actually!
So together with my colleagues, including Bruce Leff, we are going to be surveying home healthcare agencies and the clinicians that work within them.
For that project were actually starting out with a qualitative piece, in part because we really want to make sure we understand all of the issues. And we also are trying to make sure we can get some questions in about communication in general. So communication outside this process of the certification of the plan of care.
And so following our qualitative work we’re going to be doing a nationally representative survey, to the extent possible, of home healthcare agencies and the clinicians that work within them.
Unlike physicians, there’s not a database of all nurses and physical therapists who are doing home healthcare. There’s actually a fair bit of turnover in the industry. So we probably will be choosing folks from a nationally representative sample of home healthcare agencies, and then trying to find the clinicians with them.
But that’s part of actually what we’re hoping to learn in the qualitative work, is how best to design this survey to make sure we’re really gaining a valid perspective from folks.
Eric: That’s great! Well I want to thank you very much for spending the time with us today, and for the great work you’re doing on this. I certainly learned a lot.
Alex: Thank you so much Cynthia.
Cynthia: Thank you for having me!
Eric: Alex you want to send us off with a little bit more of the song?
Alex: Alright! This is one of my favorite songs by the way. And this line, “Is a dream a lie if it don’t come true? Or is it something worse?”, that’s a good line. [Singing].
Eric: Thanks everybody for listening to our podcast, we look forward to joining with you … Alex you do it this time.
Alex: Hey everybody! Thanks for listening, until we do it again, we’ll sign off right now. Eric and Alex, peace out.