Form CMS-10201 Survey of Home Health Agencies

FORM APPROVED:

OMB No.

APPROVAL EXPIRES:

Sponsored by: Conducted by:

Andrew W. Mellon Foundation Mathematica Policy Research, Inc.

INSTRUCTIONS

This questionnaire should be completed by the person or persons who know the most about the composition of the home health agency’s caseload and activities related to CMS’s Home Health Independence Demonstration. Even if your agency did not participate in this demonstration, it is very important that you complete this questionnaire. Please use black or blue ink to complete this questionnaire. Most questions can be answered by simply placing a check mark in the appropriate box. For a few questions you will be asked to write in a response. If you are unsure about how to answer a question, please give the best answer you can rather than leaving it blank.

If you have any questions, please contact Valerie Cheh, the study director, at Mathematica Policy Research, Inc. (609) 275-2385, Monday through Friday, between 9:00 a.m. and 5:00 p.m. (Eastern Time). Valerie Cheh is also available to answer your questions via email at: vcheh@mathematica-mpr.com.

Please return the completed questionnaire in the enclosed pre-paid Federal Express mailer by October 1, 2006. If you need to arrange for Federal Express pick-up, you can call the toll-free 800 number on the mailer.

As a token of our appreciation you will receive $50 for completing this questionnaire.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection will be entered after clearance. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

The Home Health Independence Demonstration

The Medicare Home Health Independence Demonstration is a project being conducted by the Centers for Medicare & Medicaid Services (CMS) that allows qualifying Medicare beneficiaries who receive Medicare home health benefits in COLORADO, MASSACHUSETTS, and MISSOURI to leave their home more frequently and for longer periods without risking the loss of those benefits. You may know this demonstration as the Homebound Exemption Demonstration.

Who can participate in the Home Health Independence Demonstration?

To be eligible for the demonstration, the individual must be a Medicare beneficiary who is enrolled in Part B, meets all of the eligibility criteria for Medicare home health, and receives home health services under the traditional Medicare home health benefit and NOT through an HMO. In addition to these requirements, the individual must meet six additional criteria, which are as follows:

1. Beneficiary has a permanent and severe disabling condition that is not expected to improve;

2. Beneficiary requires skilled nursing services for the rest of beneficiary’s life (not necessarily daily or with any fixed frequency) and the skilled nursing is more than medication management;

3. Beneficiary requires technological assistance or the assistance of another person to leave the home;

4. Beneficiary does not regularly work in a paid position full-time or part-time outside the house;

5. Beneficiary is dependent upon assistance from another individual with at least 3 out of the 5 activities of daily living (eating, toileting, transferring, bathing and dressing) for the rest of beneficiary’s life;

6. An attendant is required on a daily basis to monitor and treat the beneficiary’s medical condition or to assist the beneficiary with activities of daily living.

This ability to leave home more often, for any purpose, and for longer periods of time is the ONLY change under the demonstration. Beneficiaries must meet ALL the other usual eligibility and coverage criteria for Medicare home health care (including having limitations that make leaving home require a considerable and taxing effort). The Home Health Independence Demonstration began on October 4, 2004 and runs for two years. A maximum of 15,000 Medicare beneficiaries (across all 3 states) are allowed to participate.

Q uestions 1-3 are how your agency defines homebound.

1. Please check all the specific activities for which the “homebound” patient may leave the house without any limits on the frequency or length of absences without jeopardizing his or her homebound status and still be eligible for Medicare home health.

CHECK ALL THAT APPLY

1  Have dinner with family members

2  Visit the doctor or medical institutions

3  Go to religious services

4  Shopping for food

5  Shopping for clothes

6  Visiting friends

7  None of the above

For the next two questions, please exclude any activities that you marked in question 1.

2. Under normal circumstances, a homebound patient can leave the house no more than:

CHECK ONE BOX ONLY

1  Once a month

2  Once every other week

3  Once a week

4  Two or three times a week

5  Four or five times a week

6  More than five times a week

7  Can’t leave the house for any other activities

3. Under normal circumstances, the maximum amount of time a homebound patient may be away from home is:

CHECK ONE BOX ONLY

1  Less than 30 minutes

2  30-59 minutes

3  1-2 hours

4  2-3 hours

5  3-4 hours

6  More than 5 hours

7  Can’t leave the house for any other activities

Please answer questions 4 through 9 based on your agency’s last fiscal year. Your state annual report may be helpful in answering these questions.

4. What was the total number of patients your agency served in the last fiscal year?

__________ NUMBER OF PATIENTS

5. Approximately what percent of these patients had Medicare as their primary payer?

| | | | % MEDICARE

6. In the last fiscal year, approximately what percent of your total Medicare patients were discharged from receipt of home health care services?

CHECK ONE BOX ONLY

1  Less than 10 percent

2  11-25 percent

3  26-50 percent

4  51-75 percent

5  76-99 percent

6  100 percent

7. Of the Medicare patients who were discharged, approximately what percent were discharged because they were no longer homebound?

CHECK ONE BOX ONLY

1  0-2 percent

2  3-10 percent

3  11-25 percent

4  26-50 percent

5  51-75 percent

6  76-100 percent

7  100 percent

8. In the last fiscal year, approximately how many Medicare referrals did your agency not admit for home health services?

CHECK ONE BOX ONLY

1  0 - 10

2  11 - 25

3  26 - 50

4  51 - 75

5  76 - 100

6  Over 100 (Please estimate specific number)

9. Of the denied Medicare referrals, approximately what percent met all of the requirements for Medicare home health except the patient was not homebound?

CHECK ONE BOX ONLY

1  0-2 percent

2  3-10 percent

3  11-25 percent

4  26-50 percent

5  51-75 percent

6  76-100 percent

7  100 percent

10. The last question is about patients who have received Medicare home health services from your agency within the past two years. We have identified 5 patients and have listed their Medicare ID number and name at the top of each column. To answer these questions, it is important to review the patient’s medical record. For each patient, please indicate whether or not the patient meets each eligibility criterion.

Eligibility Criterion	HIC # Name	HIC # Name	HIC # Name	HIC # Name	HIC # Name
a. Has a permanent and severe disabling condition Specify medical conditions and ICD-9 codes	1 YES  0 NO _________________________ _________________________ _________________________	1 YES  0 NO _________________________ _________________________ _________________________	1 YES  0 NO _________________________ _________________________ _________________________	1 YES  0 NO _________________________ ________________________ _________________________	1 YES  0 NO _________________________ _________________________ _________________________
b. Needs permanent skilled nursing care (not including medication management) Specify skilled nursing care	1 YES  0 NO _________________________ _________________________ _________________________	1 YES  0 NO _________________________ _________________________ _________________________	1 YES  0 NO _________________________ _________________________ _________________________	1 YES  0 NO _________________________ _________________________ _________________________	1 YES  0 NO _________________________ _________________________ _________________________
c. Needs permanent skilled nursing care for medication management only	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO
d. Needs permanent help with ADL:
1. Bathing	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO
2. Dressing	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO
3. Eating	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO
4. Toileting	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO
5. Transferring	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO

Eligibility Criterion
e. Requires an attendant (not necessarily paid) on a daily basis to treat and monitor medical condition or provide ADL assistance for rest of beneficiary’s life	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO
f. Requires human or technological assistance to leave the home	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO
g. Employment status: (CHECK ONE ONLY)	 NOT EMPLOYED  EMPLOYED, ON SICK LEAVE  EMPLOYED, WORKS FROM HOME  DON’T KNOW	 NOT EMPLOYED  EMPLOYED, ON SICK LEAVE  EMPLOYED, WORKS FROM HOME  DON’T KNOW	 NOT EMPLOYED  EMPLOYED, ON SICK LEAVE  EMPLOYED, WORKS FROM HOME  DON’T KNOW	 NOT EMPLOYED  EMPLOYED, ON SICK LEAVE  EMPLOYED, WORKS FROM HOME  DON’T KNOW	 NOT EMPLOYED  EMPLOYED, ON SICK LEAVE  EMPLOYED, WORKS FROM HOME  DON’T KNOW
h. Medicare coverage: (CHECK ALL THAT APPLY)
1. Part A	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO
2. Part B	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO
3. Medicare Advantage	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO
4. Hospice Benefit	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO
i. Number of 60-day episodes of home health care received in the last 12 months	| |	| |	| |	| |	| |
j. Able to leave the house if homebound requirement is waived	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO	1 YES  0 NO

Please remove the labels from the top of each column when you have completed this section.

11. How many patients did your agency enroll in the demonstration?

| | | | NUMBER OF PATIENTS YOUR AGENCY ENROLLED IN THE DEMONSTRATION

12. Please use the space below to describe any problems your agency encountered enrolling patients into the demonstration or reasons why your agency decided not to participate in the demonstration.

13. Do you think the homebound criteria are still a major issue for Medicare patients? 1 YES  0 NO 

14. Please describe the type of patients for whom you think the homebound criteria should be waived.

Thank you for completing the survey. Please fill out your name, address and telephone number on the label

below. We will use this information to send you the check for $50 for completing the survey. We will use the

telephone number to call you if we have any questions regarding your responses. All of your information is

confidential. We will remove the label from this form. Information reported to CMS will not be identified by

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