NHPCO NewsLine Fall 2021 - 10

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post-acute/serious illness care world. Good sources for such information include industry advocacy groups
(such as NHPCO, C-TAC, AAHPM, and others), CMS, online list services and consultants. What follows is a
partial list of current post-acute care models. More may exist in your healthcare network and others may be
introduced at any time.
▌ Palliative care: Non-hospice palliative care can be
offered in a variety of settings, including acute
care, home, clinics, and remotely. Palliative care
can be focused on many different populations
and includes a wide range of clinical provision
models.
▌ Primary care: Primary care is offered in
increasingly diversified settings, including the
rapidly growing home-based primary care field
which can be very appropriate for those coping
with serious illness.
▌ Transitional care management: Often focused on
supporting the transition from acute care to
home, transitional care management can also be
very powerful whenever patients are coping with
any major changes such as transitioning into
decreased independence and increased symptom
burden.
▌ Serious illness management: Supporting patients
with the medical, psychological, social, and
practical impacts of a serious illness can have a
tremendous impact on quality of life, symptom
burden, need for acute care, success at staying
home, and overall cost of care. More information
from CMS can be found here.
▌ Case management: As serious illness progresses,
care can become increasingly complex and
fragmented. Coordinated management of all the
care being provided for a patient on all fronts is
increasingly impactful and necessary.
▌ Care navigation: The practical act of connecting
families with the services that they need can
create an incredible impact. Having someone who
has a working knowledge of what services are
available in a community and how to access them
can really contribute to overall experience.
▌ PACE: CMS' Program for All-inclusive Care for the
Elderly (PACE) is playing an increasingly powerful
role in the post-acute field by offering
community-based care that encompasses
medical care, home care, acute care,
transportation, and skilled nursing home stays.
More information on PACE is available on the
CMS website.
▌ Home health: Many changes are being seen within
the field of home health care, with value-based
payment models paying an increasing role. Home
health as supported by CMS provides for the
skilled level of need care for patients who are
home-bound. More information on home health
can be found on the CMS website.
▌ Personal care: Skilled assistance with activities of
daily living, such as bathing, dressing, and other
needs can be provided as part of other services or
on its own. Much personal care assistance is
supported as " private duty " which is paid for
directly by the patient. More information from
CMS on personal care services can be found online.
▌ Remote patient monitoring: Taking advantage of
technology, home-based patient monitoring takes
many forms, from the recording of clinical
telemetry to the collection of patient experiences.
This can greatly extend clinicians' connection to
their patients and empower better in-home
clinical management.
▌ Telehealth: While this can include remote patient
monitoring, it also brings in video conferencing,
allowing for more direct communication and
remote assessment. Telehealth can improve
clinical access and efficiency. More information on
telehealth can be found on the CMS website.
▌ Hospital at Home: CMS has supported the Acute
Hospital Care at Home program allowing some
acute-level patients to receive their care in their
homes rather than at a hospital. While a relatively
new model, the impacts on quality and cost is
promising. More information from CMS on
Hospital at Home can be found online.
▌ Traditional Part B services: Many hospices are
establishing the ability to bill Medicare Part B
10
Newsline / Fall 2021

https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/PACE/PACE https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Personal-Care-Services https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth https://qualitynet.cms.gov/acute-hospital-care-at-home https://qualitynet.cms.gov/acute-hospital-care-at-home

NHPCO NewsLine Fall 2021

Table of Contents for the Digital Edition of NHPCO NewsLine Fall 2021