Craig T. Kojima / Star-Bulletin
Esperanza and Manuel Abero relax at Manuel's
brother's home in Kalihi, where Manuel receives
physical therapy.

Home health
agency Interim
falls victim to
corporate ax

The service scrambles to
transfer patients and employees
before its April closure

By Lyn Danninger
Star-Bulletin

Interim HealthCare, Hawaii's second-largest provider of home health-care services, will close April 20 -- the sixth closure of a home health-care agency in Hawaii during the past three years.

Interim will lay off around 300 nurses, therapists and other health service workers, both full and part time. The company will work to transfer patients and employees to other home health-care agencies, said its local administrator, Iris Hashimoto.

Interim typically averages around 350 home health-care patients at any time, she said.

The goal is to keep the employees together with their patients, Hashimoto said.

"We've been working with different agencies, so as we transfer patients, we've transferred employees, too," she said.

Interim is the only Medicare-certified home health agency with offices statewide. It provides medical and support services to patients in their homes. Those patients include the elderly and the developmentally and physically disabled.

Interim provides many of the home health-care services for patients covered under a variety of state Medicaid waiver programs.

Closure trend

The company is the latest casualty in a nationwide trend of home health-care agency closures.

More than 2,000 home health-care agencies nationwide have gone out of business during the past few years, according to the National Association for Home Health-Care Agencies. But the association says unofficial estimates put the number closer to 4,000 closures.

Interim's corporate headquarters in Florida made the decision to close the Hawaii operations.

For 20 years beginning in 1977, Interim agencies in Hawaii were locally owned by individual franchisees.

In 1997 the company's mainland parent re-purchased local franchises, says Linda Shaub, senior marketing director at Interim's Florida headquarters. But with difficult economic times and a new chief executive officer, Interim decided to close its Hawaii operation.

"We've struggled with that office for the past year, but it's not been financially viable," Shaub said.

In recent years the home health-care industry has been hit with substantial cuts in insurance reimbursements, particularly from government programs such as Medicare, as well as a series of complicated federal regulations created by the federal Balanced Budget Act of 1997. Nationally, home health-care agencies have been closing their doors in record numbers or no longer treating Medicare patients.

Home health-care medical services have been covered under Medicare since 1966, as well as under most private insurance plans and the joint federal and state Medicaid program for low-income individuals.

Staying home

Eighty-six-year-old Manuel Abero, who is recovering from back surgery to correct a pinched nerve, is a typical Medicare home health-care patient. Since being released from the hospital near the end of February, he has received regular visits from his physical therapist, Buddy Los Banos, who works for CareResource Hawaii, a partnership between Queen's and Kuakini Medical Centers. The visits have helped him avoid prolonged hospital stays at Queen's and the Rehabilitation Hospital of the Pacific.

Abero also looks forward to Los Banos' visits three times a week. Abero, from Maui, is staying at the home of his brother and sister-in-law in Kalihi while he recovers. With every visit comes a little more independence and confidence. It also beats being confined to the hospital and brings him one step closer to returning home to Maui with his wife, Esperanza.

Abero's doctor ordered four weeks of home physical therapy, covered under Medicare.

Los Banos says the goal is to strengthen Abero and help him to be as independent as possible given his age.

In this case, Abero is transitioning from the walker he learned to use at Rehab Hospital to a cane. Before his surgery, Abero was able to walk independently and also drive a car. He says that is something he hopes to do again one day.

Abero's family likes the idea of physical therapy at home rather than a long stay in hospital.

"He asked to go home from the hospital because he said it was so boring," said sister-in-law Sally Ramos.

Los Banos said he knows his work will be done when Abero can walk with his cane under appropriate supervision and show he can do his home exercise program.

"Right now it's a confidence issue," says Los Banos, who took Abero down the stairs yesterday and outside the house for his first walk with the cane.

Los Banos, who is also a certified athletic trainer, likes the one-to-one contact with patients that home health care allows.

More important, he says, the home visits give him the opportunity to assess his patients' living circumstances and work with family members, a key ingredient of successful rehabilitation.

Hospitals cut costs

Home health care's popularity as an alternative to prolonged hospitalization began to increase in 1984 when the federal government decreased hospital reimbursements for Medicare recipients. The cuts were designed to encourage efficient, cost-effective delivery of health-care services.

But rather than face decreasing reimbursements, hospitals cut their expenses by discharging Medicare patients earlier and referring them to home health-care agencies for at-home follow-up. In addition, many hospitals created their own home health-care agencies.

Then, in the early 1990s, the federal government targeted home health-care agencies for greater efficiency and fraud prevention after several high-profile national fraud cases.

With payments based on 1993 costs, reimbursements to home-health care agencies have continued to decline ever since. Critics of the move have charged that what was supposed to be a modest tempering of the growth of home health services has instead resulted in a steep decline in benefits.

Home health care has long been touted as an effective, less costly alternative to prolonged hospitalization. All of Hawaii's acute-care hospitals either contract with local home health-care providers or have set up their own companies. In addition, private physicians routinely arrange home health-care services for their patients.

While medical services provided at home must be ordered by a physician to qualify for Medicare reimbursement and most private insurance, home health-care agency personnel typically can provide a wide range of services, from specialized nursing care to day-to-day support services, such as help with bathing, dressing, grooming and feeding.

Those familiar with Hawaii's home health-care population say Interim's closure is likely to reduce patient choice, particularly on the neighbor islands, which have few home health-care agencies.

Rose Ann Poyzer, executive director of the Hawaii Association for Home Care, which represents the state's home-care providers, said the challenge will now be to redistribute the care previously provided by Interim to the 13 Medicare-certified home health-care agencies remaining in the state.

For example, the state Department of Health has programs covering about 2,600 Medicaid recipients who receive a variety of services from home health-service agencies, including Interim.

"[Interim] pretty much touched the five of our programs in various degrees, but the largest by far is Nursing Home Without Walls," said Cookie Moon-Ng, branch administrator for the Health Department program.

The top priority now for Moon-Ng will be to move the 200 or so clients in her program affected by Interim's closure to other home health-care agencies. Like Interim's Hashimoto, Moon-Ng says the goal will be to keep patients together with their current home health-care providers as much as possible.

What is home health care? Home health care refers to a wide range of medical and support services, as well as equipment and supplies provided to patients in their homes. Medical care ordered by doctors and provided by registered nurses and therapists is generally covered by most health insurance plans, including the federal and state Medicare and Medicaid programs. But home health care can also include basic personal services, such as assistance with bathing and grooming and other more personal services. Those services, usually provided by home health aides, are generally not covered by medical insurance unless they are part of special Medicaid waiver programs such as the state's Nursing Home without Walls community service. Home health care services are available to people of all ages, ranging from newborns to the elderly, terminally ill, mentally disabled and those recently discharged from hospital. Closures Hawaii home health-care agency closures since the beginning of 1999: >> Kahuku Hospital Home Health Agency >> Kapiolani Home Health Services >> Waianae Comprehensive Home Health Care Service >> Maluhia Home Health Care >> Straub Home Health Agency Source: Hawaii Association for Home Care Available home health care Hawaii's Medicare-certified home health-care agencies, as of March 2001: >> CareResource Hawaii >> Interim HealthCare >> St. Francis Home Care Services >> Hale Makua Home Health Care Agency >> Castle Home Care >> Hilo Medical Center Home Care >> Prime Care Services Hawaii Inc. >> Kokua Nurses >> Hawaii Healthcare Professionals >> Kohala Home Health Care >> West Hawaii Home Health Services >> Hale Makua Home Health Care Agency >> Kaiser Permanente Home Health Agency >> Kaiser Permanente Home Health Agency