Home Health Care

Home health care, the largest component of the home care industry, includes nursing, skilled professional and paraprofessional care, hospice and respite services, durable medical equipment, and infusion services. Nonmedical components include personal emergency response systems, alarm devices and security surveillance, attendant care, homemaker services, and food programs (eg, meals-on-wheels). Patients may need several services, and their needs may change.

Generally, home health care can be classified as postacute, medically complex, or long-term (see Table 11-1). For patients who need long-term care, paraprofessional services account for 56% of home health care visits; for those who need medically complex care, they account for 45%. Home health care is being increasingly used to meet the demand for custodial care needs. Home health care, which has been shown to decrease nursing home placement of patients by 23%, is less expensive than institutional care when home health aide and skilled care visits are scheduled appropriately. Diagnostic procedures (eg, x-rays, ECGs, blood tests) and treatments (eg, IV therapy, dialysis, parenteral and enteral nutrition, ventilator support) previously available only in hospitals and skilled nursing facilities can be safely provided in the home.

Physician's role: Physicians are responsible for home health care orders for a patient to receive third-party reimbursement. One third of home care referrals are written for inpatients by hospital personnel to prescribe postdischarge care. Under Medicare regulations, certified home health care agencies report to physicians at least every 62 days, at which time orders must be rewritten. Physicians who falsely claim that a beneficiary meets Medicare requirements for home health care are subject to fines. Physicians cannot refer patients to or write orders for a home health care program in which they have a financial interest; they cannot recommend a Medicare or Medicaid service in exchange for payment.

Physicians must arrange for emergency coverage when they are unavailable; the patient, caregiver, and home health care agency must be able to reach the referring or covering physician at all times. Physicians must keep records of all necessary Medicare forms and document conversations with home health care practitioners.

Caring for patients at home requires communication among health care practitioners to ensure that the patient is maintaining function and progressing as expected. Changes in the patient's condition need to be promptly reported to nurses or physicians to ensure proper monitoring of the patient.

Reimbursement: Some private insurance companies cover home health care services (eg, infusion services) for patients who are not homebound. However, Medicare does not; it requires patients to meet the following criteria to qualify for home health care benefits:

• The patient must be homebound, except for infrequent, relatively short periods or for medical treatment.
• A physician must initially certify the patient's need for home health care (which must be recertified every 62 days) and develop a care plan.
• The patient must need at least one qualifying service (skilled nursing care, physical therapy, or speech therapy).
• Skilled care must be needed part-time or intermittently. Medicare covers daily care (eg, wound care) only for a limited time, and an end date must be established when the service is begun.
• The home health care agency that provides the service must be certified by Medicare.

Once qualified, a patient is also eligible for ancillary services, which include occupational therapy, medical social work services, limited home health aide services (eg, assistance with bathing, washing hair, using the toilet, dressing), medical supplies and equipment, and prosthetic devices. Occupational therapy can be given only if the patient needs another qualifying service, but once begun, it can be continued even if it remains the sole service. Prescribed services must be reasonable and necessary and must be provided in the patient's home.

Third-party payers are usually billed directly by vendors, although other arrangements exist. Medicare requires home health care agencies to inform patients about which services are reimbursable, and patients can choose, to some extent, which services they want. Third-party payers are increasingly limiting personal services to control costs. If a patient requires skilled care, Medicare allows a limited amount of home health care time, which varies greatly, for personal care. Usually, < 2 hours/day, 5 days/week are reimbursable, but the actual number of visit-hours is often less. However, home health care agencies cannot reduce the care ordered by physicians.

Reimbursement for physician services in home care is considered inadequate because careful documentation is required and reimbursement levels are low. To encourage home care, Medicare provides six codes for home services to allow flexibility in billing. Billable tasks include development and revision of care plans, adjustment of medical therapies, review of patient reports, and discussions with other health care practitioners about the patient. To bill for home health care services, physicians must document the amount of time spent discussing care with the patient or family members, dates and types of services provided, and discussions with visiting nurses and other home health care practitioners.

Fraud and abuse occur in home health care and have been investigated by the federal government. The most common abuses include unnecessary visits and services, care of a patient who is not homebound, absence of valid physician orders, and insufficient documentation.

Types of Programs

Certified home health care agencies: To be certified, an agency must meet state licensing requirements and federal conditions for participation in Medicare. Such agencies provide skilled care under the direction of physicians. Agencies are directly reimbursed by Medicare, Medicaid, or private insurers.

More than 6500 agencies are certified by the Joint Commission on Accreditation of Healthcare Organizations to provide services at home to Medicare beneficiaries. Home health care agencies vary in ownership, size, location, and services. In 1996, 47% of agencies were proprietary and for-profit; 7% were proprietary and not-for-profit; 28% were affiliated with hospitals, rehabilitation centers, or nursing homes; 12% were publicly (government) sponsored; and 6% were affiliated with the Visiting Nurses Association. About 25% of U.S. agencies are affiliated with chains.

Most agencies arrange for vendors to deliver supplies and durable medical equipment (eg, commodes, wheelchairs, walkers) to the patient's home. Companies specializing in devices and solutions for enteral and parenteral nutrition, IV solutions and equipment, ventilators, or other devices may function as vendors to agencies or as independent home health care services.

Program of All-Inclusive Care for the Elderly (PACE): This managed care program is designed to keep low-income, frail elderly persons living in the community by providing primary care, adult day care, rehabilitation, and preventive services. An interdisciplinary team develops a treatment plan to meet the needs of the patient and family members. Programs typically provide meals and laundry service at the day care center. Persons who meet the eligibility criteria can join PACE at any time and can disenroll at the end of any month. Enrollees must agree to use PACE physicians and providers. Service packages are comprehensive and very attractive to elderly persons who would receive fewer services from a state Medicaid program.

New York's Nursing Home Without Walls: This capitated program is a prototype for long-term home health care of patients who might otherwise require institutionalization. It provides home health aide services, case management, and limited skilled care at home. Patients receive services as long as they meet state criteria for nursing home placement and the cost does not exceed a percentage of the cost for comparable nursing home care. Unlike Medicare patients in a certified home health care agency program, patients in this program are not required to attain a therapeutic goal or continue to need skilled care to stay in the program.