Delta Connect Blog

World Growing Grayer at a Break-Neck Pace

Posted by Rachel Alden on Aug 22, 2014 4:10:36 PM

CNNMoney posted in an article that by 2020, 13 countries will be "super-aged" -- with more than 20% of the population over 65 -- according to a report by Moody's Investor Service. That number will rise to 34 nations by 2030.

The article focuses on the negative impact on economic growth in upcoming years. However, the news means that the home care industry faces tremendous opportunities around the globe.

Click here for an interactive map showing when the nations will reach "super-aged" status. 


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Topics: home care industry

IN FOCUS: The FY2015 Hospice Payment Rule - Gear Up for Policy Changes

Posted by Lorraine Lodigiani on Aug 21, 2014 10:11:19 AM

Late Monday, August 4, the Centers for Medicare & Medicaid Services (CMS) issued a final rule governing hospice payment for fiscal year (FY) 2015: Medicare Program; FY 2015 Hospice Wage Index and Payment Rate Update; HospiceQuality Reporting Requirements and Process and Appeals for Part D Payment for Drugs for Beneficiaries Enrolled in Hospice.  PLEASE NOTE: this link will no longer work after publication of the final rule in the Federal Register, which is scheduled for Friday, August 22.  

The rule includes final payment rate information for the forthcoming federal fiscal year.  It also finalizes some key hospice policy changes and reminds hospices that other, previously-announced changes will become effective on October 1, 2014. If hospices have not previously begun to prepare, they are advised to do so now.

  • Imminent hospice policy changes addressed in the final regulation are as follows:
  • Timeframes for Filing the Notice of Election (NOE) and Notice of Termination/Revocation (NOTR)
  • Timeframe for Hospice Cap Determination and Overpayment Remittance
  • Addition of the Attending Physician to the Hospice Election Form
  • Coding Guidelines for Hospice Claims Reporting
  • FY2015 Final Payment Rates

This article provides in-depth focus on policy changes related to timeframes for filing the NOE and NOTR. Future articles will address other forthcoming changes.


Previously CMS has not imposed a time frame for submission of a notice of election (NOE) other than directing hospices to submit the NOE as soon as possible.  Similarly, there has been no requirement for filing of a Notice of Termination or Notice of Revocation (NOTR) and no explicit time frame for filing of a final hospice claim other than the existing one-year limit on claim submissions.  However, in recent years, delays in submission of hospice NOEs and filing of final claims have led to inaccuracies related to patient status in the CMS systems.   

These inaccuracies have been particularly problematic in efforts to ensure appropriate coordination of benefits for hospice patients with Part D prescription drug coverage.   As a result, earlier this year CMS proposed that hospices submit an NOE and NOTR within 3 days of the patient’s election date or patient’s termination or discharge date, respectively.  CMS finalized the rule with a timeframe of 5 days after the election date for filing of the NOE and 5 days after the termination/revocation date for the NOTR if the hospice has not filed a final claim.
Please note:  As of this writing, CMS has not issued instructions to its Medicare Administrative Contractors (MACs) to implement the timeframes for filing of the NOE and NOTR. It is unclear whether or not CMS will be able to enforce the NOE and NOTR filing requirements effective October 1.


Requirement: Effective October 1, 2014, hospices must file the NOE within five calendar days after the effective date of the election.

  • Timely filing is considered having the NOE submitted and accepted by the Medicare Administrative Contractor (MAC).
  • The date of election will count as day zero, so if a patient were admitted on a Thursday, the hospice must have the NOE filed, submitted and accepted no later than Tuesday.

Consequence: Hospices that do not submit the NOE in a timely manner cannot be reimbursed for any days of care prior to acceptance of the NOE by the MAC:

  • The hospice cannot charge the beneficiary for hospice care during this time and must continue to provide hospice care to the beneficiary.
  • CMS refers to these as ‘provider liable’ days.

Tips and Notes:

  • The NOE must be filed by DDE, mail or courier.
  • CMS did state they would look into the possibility of submitting the NOEs electronically but until then hospices must submit them via DDE, mail or courier.
  • Hospices should ensure that they are able to get the NOE submitted via DDE and develop a back-up plan for mailing or delivering the NOE by courier to the MAC should the ability to submit it via DDE be interrupted and the situation does not meet one of the four exceptions.
  • This may require a change in scheduling and staffing of personnel submitting the NOE.  For instance, if the person(s) submitting the NOEs does not come into the office at least weekly, is on vacation, or unexpectedly not able to submit the NOE, another staff member will need to be trained to submit the NOE and verify that it has been accepted.

There are four circumstances that may be eligible for an exception to the timely filing requirement.  The hospice must document the situation meeting the exception and request the exception.  

Only if the MAC grants the exception are the consequences waived for the hospice. MACs will provide hospices with information about exceptions processes/policies in the future.  The four situations CMS listed for exceptions are:

  1. Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice’s ability to operate;
  2. An event that produces a data filing problem due to a CMS or MAC systems issue beyond the control of the hospice;
  3. A newly Medicare-certified hospice that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its MAC; or
  4. Other circumstances determined by CMS to be beyond the control of the hospice.

CMS stated in its comments that it will not allow exceptions for hospice personnel issues; internal IT systems issues that the hospice may experience; the hospice not knowing the requirements; and failure of the hospice to have back-up staff to file the NOE.

NAHC and HAA recommend that hospices:

  • Add a compliance audit to their program that audits for the submission of the NOE within the required timeframe and process for documentation that the NOE has been accepted by the MAC;
  • Modify processes and staffing as needed to ensure compliance;
  • Develop a back-up submission plan;
  • Modify policies and procedures to reflect this new requirement, its exceptions, and the hospice’s modified processes, and;
  • Make every effort to submit and have the NOE accepted as soon as possible after election as CMS indicates it may consider shortening the five day requirement in the future.

NOTR (Notice of Termination/Revocation) FILING Requirement  

Effective October 1, 2014 hospices must file the NOTR within five calendar days after the effective date of discharge or revocation, unless the hospice has submitted a final claim.

  • Timely filing is considered having the NOTR submitted and accepted by the Medicare Administrative Contractor (MAC).
  • The date of revocation or discharge will count as day zero so if a patient revoked on a Thursday, the hospice must have the NOTR filed (submitted and accepted) or a final claim submitted no later than Tuesday.

Consequence:  CMS will not impose any consequences for late filing of the NOTR - or not having a final claim submitted - at this time but will consider doing so in the future.  Late filing of the NOTR could negatively impact a beneficiary’s access to Medicare-covered items and services. It could also have negative consequences for any hospice provider taking the patient onto service following the termination or revocation.

Tips and Notes:

  • CMS has not issued final instructions to the MACs to implement the NOTR requirement but it is likely that CMS will require use of bill type 81B as the NOTR.
  • If this is the case, significant systems changes will be needed.  
  • Forthcoming instructions to the MACs will provide additional detail.

NAHC and HAA recommend that hospices:

  • Add a compliance audit to their program that audits for the submission of the NOTR or the final claim within the required timeframe and process for documenting acceptance by the MAC;
  • Modify processes and staffing as needed to ensure compliance
  • Develop a back-up submission plan;
  • Modify policies and procedures to reflect this new requirement and the hospice’s modified processes, and;
  • Make every effort to submit and have the NOTR accepted as soon as possible after termination/revocation as CMS indicates it may consider shortening the five-day requirement in the future

NAHC has submitted several questions that have been raised by hospice providers specific to implementation of the NOE/NOTR requirements to the MACs and will provide responses and additional details as they become available.  

Additional updates will be featured in future issues of NAHC Report and Hospice Notes.

From the NAHC Report article


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Topics: Hospice Payments

Home Infusion Demo Maps A Way Forward For Future Medicare Changes

Posted by Lorraine Lodigiani on Aug 19, 2014 12:02:52 PM

A Medicare demonstration project bundling payment for home infusion of intravenous immune globulin (IVIG) maps a potential way forward for future reimbursement changes involving home infusion more broadly, which would benefit larger providers like BioScrip, Walgreen, CVS, Express Scripts, privately-held Diplomat that recently filed an S-1 and privately-held AxelaCare Health.  While the demonstration will have limited impact in the near term, given that insurers tend to piggy back on Medicare even though it comprises less than 15-20% of the industry payer mix for specialty home infusion providers, the policies CMS wants to test could have reverberating effects among all insurers and bring consistency to the current haphazard state of home infusion reimbursement. 

Any benefit from such potential changes would come on top of various positive underlying factors: (1) a growing Medicare population; (2) expansion of insurance coverage; (3) the need for insurers and/or PBMs to have sufficient pharmacy networks that offer specialty and home infusion drugs; (4) an increased emphasis on cost-effective strategies, especially those designed to keep people in the home; and (5) the fact that many infused therapies lack treatment alternatives for chronic conditions like immunodeficiencies, autoimmune disorders, and hematologic disorders.  These factors have led to some consolidation among this fragmented industry over the years [e.g. Walgreen's purchase of Express Script's CuraScript and Omnicare's Option Care; Express Script's merger with Medco and its Accredo unit; CVS's purchase of Coram from privately-held Apria; BioScript's buying spree of CarePoint, HomeChoice Partners, and InfuScience; and Diplomat's purchase of privately-held MedPro Rx.]

Recently, CMS said it is setting up a three-year demonstration project to bundle payment for IVIG supplies and services for home use to Medicare beneficiaries who are not home-bound or receiving home health. Ordered by statute and starting in October, the project is restricted to 4,000 patients with primary immune deficiency disease (PIDD).  Although limited in scope, this project is being watched by CMS, MedPAC, policymakers, and patient groups to monitor access, compliance, and healthcare outcomes to see if this design can apply to home infusion more broadly, considering that more people are entering the system and suffering from chronic illnesses that may be more cost-effectively treated in the home.

The current reimbursement framework for home infusion is convoluted. Most insurers and government programs pay a separate rate for the infused therapy - and potentially a per-diem amount for the supplies, equipment, and pharmacy services - and another amount for nursing.  Medicare heeds this piecemeal approach but often does not reimburse for the supplies and nursing, since such coverage depends on the actual therapy, patient's illness, and circumstances.  Given that insurers use Medicare as a guide, any policy changes to make home infusion more comprehensive would be felt more broadly, including potential disruption to smaller operators lacking the infrastructure to handle the service/patient volume or absorb cost increases. 

Medicare's various forms of home infusion:

  • Home infusion for IVIG is reimbursed under Medicare Part B for patients with PIDD at a statutory rate of 106% average sales price.  Unless the beneficiary is homebound or eligible for home health as part of post-acute care, CMS won't pay for any nursing or supplies to administer IVIG.  Additionally, most Medicare claims for IVIG are for other illnesses and are not reimbursed under this paradigm, often forcing patients to be treated outside the home, at a cost to the government.
  • Home infusion for select anti-infective, chemotherapy, inotropic, and pain management therapies may be paid under Medicare Part B at a different rate, but only for (1) certain indications; (2) homebound beneficiaries; and (3) administration with an external infusion pump - thus triggering Medicare's durable medical equipment benefit.  CMS will not pay for nursing care unless the patient is eligible for home health.
  • Home infusion for other treatments, such as antibiotics or rheumatoid arthritis, off-label indications for the therapies above, or for beneficiaries that are not homebound, Medicare Part D provides the treatment and reimburses the home infusion pharmacy at a negotiated rate, but it does not reimburse for any ancillary supplies or nursing service.

From the NAHC Report Article. The article was written by Beth Mantz Steindecker, Vice President, Health Care Analyst at Washington Analysis, an institutional research firm 


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Topics: Home Care reimbursement

Agency Lessons After California Supreme Court Decision

Posted by Rachel Alden on Aug 15, 2014 1:21:43 PM

Earlier this week, NAHC posted an excellent article following the California Supreme Court decision that the caregiver assumes risks when working with dementia patients. We wanted to point out the list at the end of the article which shares a few lessons for home care agencies as a result of the decision.

First, the agency-employer should make sure that the assigned workers are fully aware of the care setting and client’s condition on all assignments. This will help manage risks and put competent workers into the care of clients.

Second, home care agencies should provide adequate training and support for workers specific to the nature of the clients they serve. For example, serving clients with a form of dementia requires directed training and support that is different than providing services to individuals with physical disabilities.

Third, agencies should take all reasonable measures to reduce foreseeable risks in the home care environment that are due to any hazardous condition related to the nature of the client and her care needs. 

These steps help manage risks that a worker will be injured, clients needs will not be met , and agencies will fail to adhere to community standards of practice and/or licensing laws and accreditation standards. In addition, it will reduce the risks of litigation that involves any and all of the stakeholders involved.

What other advice or thoughts would you share?


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CMS Reissues Instructions for Denials on Related Claims

Posted by Lorraine Lodigiani on Aug 14, 2014 1:08:59 PM

The Centers for Medicare & Medicaid Services (CMS) has issued Change Request (CR) 8802 that allows the Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs) the discretion to deny payment on claims that are related. CMS defines a “related” claim as one where the documentation associated with one claim can be used to validate another claim.

Related claim issues are subject to CMS approval prior to the contractor’s initiating a related claim review. In addition, the MACs and ZPICs must post the related claim issue for review on their web site review within one month of initiation. The Recovery Audit Contractors (RACs) may also conduct related claim reviews but these contractors are already subject to CMS approval of claim review issues and are required to post the approved issues on their web site as part of their Statement of Work.

The following related claim situations have been approved by CMS. 

  • The MAC performs post-payment review/recoupment of the admitting physician's and /or surgeon's Part B services. For services related to inpatient admissions that are denied because they are not appropriate for Part A payment (i.e., services could have been provided as outpatient or observation), the MAC reviews the hospital record and if the physician service was reasonable and necessary the service will be recoded to the appropriate outpatient evaluation and management service. For services where the patient’s history and physical (H&P), physician progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, post-payment recoupment will occur for the performing physician’s Part B service.

In February of this year, CMS issued CR 8425 which gave the claims review contractors the discretion to automatically deny claims submitted that are related to other claims where non-coverage or non-payment decisions have been determined though medical record review. CR 8425 did not require CMS approval prior to denying related claims and was rescinded in March.

Although CR 8802 addresses issues only related to  hospital and physician claims, we fully expect at some point to see more approved issues affecting other provider types.  Therefore, this policy change could have significant implications for home health and hospice providers since they often submit multiple claims for a single incident of illness - for example, submitting claims for several episodes for home health services or several months for hospice care. If the contractor determines one claim does not meet Medicare payment criteria, any related claim could also be denied.

Click here to view the CR 8802.


From the NAHC Report article 


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Topics: RAC Audits

Medicaid is Primary Payer for Long-Term Services & Supports

Posted by Rachel Alden on Aug 12, 2014 7:00:00 AM

At the end of July, The Henry J. Kaiser Family Foundation released a report entitled "Medicaid and Long-Term Services and Supports: A Primer." If you missed this helpful overview of the current Medicaid and long-term services and supports (LTSS) system, click here.

According to their report, Medicaid is the primary payer for institutional and community-based LTSS. In 2012, Medicaid outlays for institutional and community-based LTSS totaled almost $148 billion, accounting for 30 percent of total Medicaid expenditures that year.


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Be Cautious when Comparing Hospice CAHPS to FEHC

Posted by Lorraine Lodigiani on Aug 11, 2014 3:08:39 PM

With the Hospice CAHPS requirement right around the corner, current FEHC users may be wondering how they can continue using their historical FEHC data. Unfortunately, because so many of the original FEHC questions have been altered for the Hospice CAHPS, a simple fix of mapping one survey instrument to another is not possible. Moreover, while many of the questions on the FEHC are related to questions on the Hospice CAHPS, simply comparing old performance scores to new performance scores may not get you the information that you need to seamlessly continue your improvement efforts. 

Why So Many Changes Were Made

When the Hospice CAHPS was being developed, it was based on several survey design principles:

  • capture the patient and/or caregiver experience, not the care processes that could be measured by other data sources,
  • focus on quality of life related aspects of hospice care such as the NQF preferred practices,
  • measure aspects of care that are important to the patient and/or family, and
  • contain questions that are under the control of the hospice provider.

Using a technical expert panel on survey research and hospice care quality, and a multitude of interviews with primary caregivers from across the country and from diverse care settings, Hospice CAHPS survey designers used the gathered information to develop the questions with some clear goals in mind:

  • clearly identify the time frame of interest for each applicable question,
  • highlight the importance of differentiating between questions that asked about the patient’s experiences verses the caregiver’s,
  • focus the questions more on what the caregiver needed and less on how much involvement with hospice care actually occurred.

Comparing Hospice CAHPS to FEHC

In a comparison between the FEHC and the Hospice CAHPS, only 8 non-demographic questions contain minor changes in wording which are not expected to affect the results. For these questions, trending historical data to new data is possible. That is, if your agency was receiving an 83% favorable score in Q4 2014 on the FEHC D5: How often did the hospice team keep you informed about the patient's condition? (Always, Usually, Sometimes, Never), assuming nothing drastically has changed in your agency, you could still expect to see about an 83% favorable score on the Hospice CAHPS question 9: While your family member was in hospice care, how often did the hospice team keep you informed about your family member's condition? (Never, Sometimes, Usually, Always) in Q1 of 2015. [Although, in full disclosure true survey methodologists may say that something as little as changing the order of the response options may affect results.] None the less, taking a bit of a less conservative approach, there are a total of 11 FEHC questions, including demographic and parent questions, where differences in Hospice CAHPS question wording or response options should not affect trending: B9, C2, D5, E3, E4, F1, G3, G5, H4, I3, I4.

However, another 16 FEHC questions are related to questions on the Hospice CAHPS but changes to the response options have resulted in an inability to compare old with new, which may leave you wondering what to do with that data. Your first thought may be to use your FEHC score as an internal benchmark to set a target for improvement for the Hospice CAHPS on the related question. For questions that are partially mapped (FEHC: D7, H5, H6, I1) meaning that the questions are worded similarly and some of the FEHC response options are similar to that on the Hospice CAHPS, with some reworking, this may be possible. For example, compare FEHC D7: Would you have wanted more information about what to expect while the patient was dying? (Yes, No) to Hospice CAHPS question 31: Did the hospice team give you as much information as you wanted about what to expect while your family member was dying? (Yes, definitely; Yes somewhat; No). To map the responses, you would need to collapse both Yes categories from Hospice CAHPS question 31 into a single Yes category. You then need to compare the percentage of Yes responses from question 31 to the percentage of No responses from FEHC D7 because D7 asks if you WANTED MORE information while Q31 asks if you received AS MUCH AS YOU WANTED - conceptually opposite.

In the cases where questions are related but both question and/or response option wording is different, using your FEHC score or another national benchmark as a basis for comparison for the related Hospice CAHPS questions, is frankly, just wrong. While the change may seem minor, e.g., the addition of a word or two, the way the caregiver responds to the question may be entirely different. For example, both Hospice CAHPS Q19 and FEHC B3 ask about whether the hospice team provided information regarding pain medicine but the Hospice CAHPS question 19 specifically asks about whether information on a pain medicine’s side effects was received while FEHC B3 refers to any information on pain medicine. Therefore, what may have been a positive response on the FEHC (yes, the caregiver received information on pain medication) may now be answered negatively (no, the caregiver was not given information on the side effects of medication). In fact, the specificity of the Hospice CAHPS question may result in lower performance scores at first until any needed performance improvement projects (PIPs) focusing on medication side effects education are initiated. Thus, comparing performance scores from questions with different interpretations may set you up for failure, not improvement.

So, how can you transition from one survey to the other without feeling like you are starting over?

  1. Recognize that the lessons learned from doing an experience of care survey will never be lost. The sometimes seemingly painful documentation, generating patient lists, the PIPs, and report reviews have pushed you leaps and bounds beyond your peers who have yet to begin collecting satisfaction data.
  2. Review Deyta’s Hospice CAHPS & FEHC Data Crosswalk document and note which questions are trendable with little to no work on your part. Continue monitoring those items and setting increasingly more difficult performance goals, if appropriate.
  3. Review the crosswalk for the questions that can be partially mapped and decide whether to continue trending your results. Remember, if you decide to compare the results of these questions from one survey to the other, you may need to do some mapping work to keep your results comparable.
  4. Carefully review the questions that are related but not trendable. Note the small differences in wording and decide whether or not any current PIPs need tweaking. Consider whether you expect your Hospice CAHPS performance scores to be higher or lower than the related FEHC question and set your internal goals accordingly.
  5. Finally, remember that your improvement efforts are not lost. Each and everything that you have done, and will continue to do, has been about delivering quality care and improving the hospice experience. Those efforts are not lost on the patients that you have served and will continue to serve.

Republished with permission from the Deyta Blog by Becky Van Horst 



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Topics: Hospice CAHPS

Around the World: Home Care News

Posted by Rachel Alden on Aug 7, 2014 3:13:04 PM

Singapore plans to to finalize home care guidelines (TODAY Online)

A set of home care developmental guidelines has been developed by a workgroup of home care service providers and will be finalized by the end of this year, Senior Minister of State (Health and Manpower) Dr Amy Khor told Parliament on Tuesday.

A quality improvement program will also be introduced by the Ministry of Health (MOH) next year to help the providers adopt these guidelines, which have been developed to enhance the quality of services and articulate the expected level of care.

“These home-care guidelines include good practices, such as to better enable them to coordinate care, enhance quality of care, promote independence, as well as encourage organisational excellence. These guidelines have been drafted and it is under consultations with stakeholders,” Dr Khor said.

Plans to draw up the guidelines were first announced under the Home Care Development Plan earlier this year, as part of the MOH’s Budget Initiatives 2014 to provide better home and community care for senior citizens. The development plan also includes making home care more integrated and client-centric, and continuing to invest in expanding home-based care services.

Read the full article here.


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Topics: home care industry

CMS issues final rules for inpatient, hospice payments

Posted by Lorraine Lodigiani on Aug 5, 2014 12:41:46 PM


The CMS has finalized a rule (PDF) that decreases inpatient prospective payment system payments by $756 million overall. Meanwhile, long-term-care hospitals will see payments increase by 1.1%, or approximately $62 million in fiscal 2015, which starts Oct. 1, 2014.

The CMS Monday also released its final rule (PDF) for hospice payments in fiscal 2015. Those payments are expected to increase by 1.4%, or $230 million, over the current year.

The policy also limits payment for hospital-acquired conditions and readmissions. The maximum reduction in payments under the Hospital Readmissions Reduction Program will increase from 2% to 3%. The agency estimates the program already has been successful, with hospital readmissions in Medicare declining by a total of 150,000 from January 2012 through December 2013.

Acute-care facilities struggling most with hospital-acquired conditions will have their Medicare inpatient payments reduced by 1%.

In the hospice rule, the CMS finalized a requirement that hospices file a “notice of election” within five days after a beneficiary is referred for hospice care or face financial penalties. The change is designed to reduce nonhospice claims related to a patient’s terminal illness.

“Prompt recording of the notice of election prevents inappropriate payments, as claims filed by providers other than the hospice or the attending physician will be rejected by the system, unless those claims are for items or services unrelated to the terminal illness and related conditions,” the final rule states.

In response to concerns about the new policy raised in public comments, the CMS will allow providers to make the case that they missed the five-day deadline because of exceptional circumstances and therefore shouldn’t be penalized. The agency detailed four circumstances under which a provider could qualify for the exception, including damage from a flood, fire or earthquake.
From the Modern Healthcare article and By Virgil Dickson and Paul Demko Posted: August 4, 2014 


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Topics: Hospice Payments

Around the World: Home Care News

Posted by Rachel Alden on Aug 1, 2014 9:04:46 AM

Long Waiting Lists for Nursing Homes Increase Home Care Demand in Ireland (Waterford Today)

Waiting times for nursing home funding have doubled over three months according to new figures from Nursing Home Ireland. The number of people on the waiting list further increased by more than 500 over three months. This can leave families with a bill of up to €15,000 (more than $25,000) before any funding is received.

The Fair Deal scheme was introduced five years ago to provide state financial support for nursing home costs and it is feared the long waiting times could be putting older people's health and quality of life at risk.

"Priority should be given to dealing with the Fair Deal waiting list crisis and care options for older people in the local community," said Danette Connolly, Director of Care, Home Instead Senior Care Waterford. "We need a policy that favors home and community-based care in addition to institutional care. Older people are suffering and missing out on needed care as a result of this waiting list crisis."

"We are receiving more home care inquiries as a result of the long wait for nursing home care. Older people and their families are struggling to cope and are in need of more help than is currently being provided by the Fair Deal Scheme", she added.

Click here to read the full Waterford Today article.


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