Home Health Care: An Environment of Need for Serving Persons With Dementia

The Statistics and Prevalence
The Alzheimer's Association indicates 75% of those with Alzheimer's disease and related dementias (ADRD) are living at home. And as we know, the number of people with ADRD is growing rapidly with the current number said to be 5 million people in the United States. Recently, I presented to a home health care organization and I was told the average age of their clients is 84. Current statistics indicate almost half of those aged 85 have Alzheimer's disease. Therefore, we can clearly anticipate a very high number of those being served in home health care to have some degree of dementia.


The Need
This month I presented to a group of family members and at the end of my presentation I was asked, "Where can I find a therapist who understands how to work with people with dementia?" Several family members expressed frustration as they had previously been told by a home care therapist who was seeing their loved one that they couldn't help. Unfortunately, most therapists and nurses in home care organizations are unprepared to evaluate and treat this growing population. Therapists and nurses are not adequately evaluating cognition or addressing the impact of cognitive impairment. This lack of assessment often leads to one of two unfortunate scenarios. Either the person is not served because they are deemed "unteachable" with "no potential" or the professional embarks on teaching only to set the client up for failure. Without accurate identification of safety and learning deficits, the person is left at great risk.


Medicare Coverage Available
Medicare has begun to expand its Alzheimer's specific coverage guidelines in home health care. One such example is the relatively new policy from Palmetto GBA effective October 24, 2005. This policy applies to 16 states including:

  1. Alabama
  2. Arkansas
  3. Florida
  4. Georgia
  5. Illinois
  6. Indiana
  7. Kentucky
  8. Louisiana
  9. Mississippi
  10. New Mexico
  11. North Carolina
  12. Ohio
  13. Oklahoma
  14. South Carolina
  15. Tennessee
  16. Texas

Briefly stated,

"The policy addresses a specific category of skilled nursing care currently available to Medicare home health beneficiaries with Alzheimer's disease and behavioral disturbances—the category of skilled nursing care is called 'teaching and training activities.' Teaching and training activities are defined in the CMS Manual System and in the case of the beneficiary population with Alzheimer's disease and behavioral disturbances, could be part of a unique beneficiary-centered care plan directed at teaching the family or caregiver how to manage the behavioral disturbances.


Behavioral disturbances often complicate the medical management of beneficiaries with Alzheimer's disease. At baseline many individuals with Alzheimer's disease manifest activity limitations in such domains as communication and self care. The occurrence of behavioral disturbances, if not addressed in a comprehensive and systematic manner, may further compromise the activity limitations present at baseline—resulting in sub-optimal clinical outcomes."

This policy was expanded to include skilled therapists and social workers. In particular it was noted that occupational therapists often work with caregivers to identify and address difficult behaviors and implement strategies to improve these behaviors.


Further, coverage guideline 205.2 Skilled Therapy Services section "d" states:

"Services of skilled therapists for the purpose of teaching the patient, family or caregivers necessary techniques, exercises or precautions are covered to the extent that they are reasonable and necessary to treat illness or injury."

Medicare reimbursement is not the barrier. The barrier is lack of dementia evaluation and treatment expertise. The therapist must have the skills to paint the picture to Medicare of the relationship between "dependence" and skin breakdown, falls, poor nutrition, hospitalization risk, etc. The therapist must have the ability to see remaining abilities and to identify "best ability to function" then to train the caregivers on how to present the "just-right challenge" in everyday activities in order to keep the individual actively engaged and safe.


Our Responsibility to Serve
There are many people who should be reaping their benefit of home care services that are available through Medicare. However, if they do not have an agency with therapists or nurses who are trained to evaluate and treat ADRD, they will not receive the benefit they deserve and they will face many risks. Once again, I call on all reading this article to spread the word of the opportunity and the NEED. We must adequately serve our seniors, providing them with hope for quality of life in the midst of so much despair. We must also provide support and education for their caregivers.


A fact sheet created by the Alzheimer's Association that addresses this topic can be found at http://www.alz.org. In addition, I encourage you to access the policies that govern care in your state from your intermediary.



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