Home Health Care

Home Health Care – Statistical Data Included

Susan Louisa Montauk

Home health care is the fastest-growing expense in the Medicare program because of the aging population, the increasing prevalence of chronic disease and increasing hospital costs. Patients and families are choosing the option of home care more frequently. Medicare’s regulations are often considered the standard of care for all home health agency interactions, even when a patient does not have Medicare insurance. These regulations require patients who receive home health care services to be under the care of a physician and to be homebound. The patient must have a documented need for skilled nursing care or physical, occupational or speech therapy. The care must be part time (28 hours or less per week, eight hours or less per day) and occur at least every 60 days except in special cases. A detailed referral and specific care plan maximize the care to the patient and the reimbursement received by the physician.

Home health care is a formal, regulated program of care delivered by a variety of health care professionals in the patient’s home. It is also a Medicare benefit, provided certain requirements are met. For many reasons, the need for home health care has grown rapidly in the past decade (Table 1). Between 1980 and 1996, the number of patients receiving Medicare-sponsored home care increased by more than 400 percent, and the number of agencies delivering that care increased by more than 200 percent (Table 2).[1] In addition, these figures do not take into account the significant growth in home hospice care.

TABLE 1 Reasons for the Growth in Home Health Care

Diseases that occur more often in elderly patients increase concomitantly as the population ages.

Medical advances allow better management of chronic and incurable diseases, including pathologies related to HIV and AIDS.

More widespread availability of high-technology services has resulted in increased hospital costs.

Medicare’s diagnosis-related groups have promoted earlier discharge of hospitalized patients, reducing the length of hospital stays.

Patients (or caregivers) often desire to avoid prolonged expensive care at the end of life.

Patients choose to receive care in the home.

HIV = human immunodeficiency virus; AIDS = acquired immunodeficiency syndrome.

TABLE 2

Examples of Growth in

Medicare Home Health Care(*)

Home care factor 1980 1996

Average number of visits

per beneficiary 22 76

Beneficiaries receiving

home health services 700,000 3.7 million

Home health agencies

participating in Medicare 3,125 9,800

(*)–Excluding hospice care.

Information from Vladeck BC. HCFA presentation. FY 98 Budget proposals. National Association for Home Care: April 15, 1997.

The Medicare criteria for home health care entitlement can be found in Table 3. Medicare’s regulations are frequently considered the “standard of care” for all home health agency (HHA) interactions. Another significant care standard is found in Medical Management of the Home Care Patient: Guidelines for Physicians, published by the American Medical Association (AMA) in 1998.[2] This document includes guidelines for coordination and communication by the primary care physician (Table 4).

TABLE 3

Prerequisites for Medicare Entitlement for Home Health Care

Patient is under the care of a physician.

Patient requires skilled nursing, occupational therapy, physical therapy or speech therapy on an intermittent basis.

Patient qualifies for Medicare.

Care is medically reasonable and necessary.

Patient is homebound.

Patient’s needs can be met on an intermittent or part-time basis.

Patient resides in a home or facility that does not perform skilled care (e.g., not in a nursing home or hospital).

A plan of care is rendered under the guidance of a physician.

Health Care Financing Administration. HM-11. The Medicare standards for home care. Washington, D. C.: U.S. Department of Health and Human Services, 1983.

Table 4

Communication and Coordination of Services

The primary care physician has the responsibility for coordinating the provided by multiple caregivers and the communication between them. Some activities the primary care physician is responsible for are as follows:

Arrangements for physician coverage:

The primary care physician must establish and maintain communication with the other physicians involved in the patient’s care and become familiar with the details of their treatment plans.

Twenty-four-hour physician coverage must be arranged for all homebound patients–including coverage when the physician will be out of town.

Arrangements for unstable home care patients may require that detailed instructions be communicated to the covering physician, in a manner similar to that used for coverage of hospitalized patients. The patient, the caregiver and the home health agency must know how to reach a covering physician on a 24-hour basis.

Maintenance of organized records for home care patients:

Office charts should include copies of all signed orders, evaluations and reports from team members, notes from all telephone conversations, and names and addresses of all organizations, personnel and consulting physicians involved in providing patient care.

Prompt communication with the home health care staff and all others who are providing services:

Telephone calls from home health agency staff or patients should be returned in a timely fashion, based on the urgency of the situation, by the primary care physician or the covering physician.

A system for immediate response to urgent calls should be established. A plan should also be established to answer all nonurgent calls appropriately.

Written communication is essential for documentation of home care. All forms and reports must be signed and returned promptly to ensure continuous, appropriate patient care.

In addition to meeting federal and state requirements, it is helpful for the physician and the home care agency to establish a plan regarding content, frequency and response time for written communications.

Regular verbal and written communications from the home health agency staff to the physician:

Signs and symptoms of the patient’s improving or deteriorating condition

Detection of new or unresolved problems

Documentation of the patient’s continuing homebound status (eligibility for coverage)

Documentation of the medical necessity for continuing home health services

If rehabilitation services are to be used, physicians should expect and encourage communication directly from the therapist, outlining:

Results of the assessments

Measurable goals of therapy

Expected frequency and duration of therapy to achieve these goals

Any new problems identified

Patient and family response to training

Description of outcomes reached and potential for further progress

Discharge plans and plans for maintenance of gains

Coordination of community-based health, educational and developmental services for pediatric populations:

Early intervention program

Coordination of therapies for children with special needs

Coordination of multiple specialists (children with disability and chronic disease)

Case management:

If additional case management services are used by the third-party payer or managed care organization, the physician should provide the comprehensive care plan for them. Although many decisions may need to involve the case manager, physicians should be sure to be in direct contact with the staff providing hands-on care when clinical treatment decisions need to be made.

Reprinted with permission from Department of Geriatric Health. Medical management of the home care patient: guidelines for physicians. Chicago: American Medical Association, 1998.

Requirements

A patient must be homebound to receive HHA services. “Homebound” implies that the patient is unable to leave home or that leaving home requires a considerable and taxing effort. Patients may be considered homebound if absences from the residence are infrequent, are of relatively short duration or are for the purpose of receiving medical treatment (e.g., medical appointments or trips to a medical-model adult day care agency). Attending ceremonies of a religious nature does not generally disqualify a patient from being considered homebound. A patient who is unable to leave home without the help of assistive devices such as canes or walkers or who has a mental illness that may preclude leaving the home would also be considered homebound.

A home health care patient also must have a “reasonable and necessary” need for skilled care from a nurse, therapist (physical or occupational), speech/language pathologist or social worker. Intravenous therapy and wound care are considered skilled needs, as well as monitoring for pain control or “teaching and training activities which require skilled nursing personnel to teach (the patient) or caregivers how to manage the treatment regimen.”[3] Medicare covers occupational or physical therapy or speech/language pathology assessment and treatment when ordered after an acute episode of illness or a surgery. A therapist may perform the initial assessment, and a nurse need not be involved. A home safety evaluation for patients who are physically challenged is a potentially significant and useful skilled need assessment that is often overlooked.

Frequency

There are no statutory or regulatory limits to the length of time for which coverage is available. Home care must be “part time,” defined as no more than 28 hours per week or eight hours in any given day. In some cases, this definition may be extended to 35 hours a week, but only with Medicare fiscal intermediary review and acceptance. Care is to be “intermittent;” occurring at least every 60 days, although less frequent medical indications (such as a catheter change every 90 days) will usually qualify. Skilled care that is given less than four days per week may be ordered for an unspecified time period. When skilled care is needed more than four days per week, the home health care nurse must specify a projected end point. There are, however, state-by-state exceptions that are related to state budget funding for homebound patients. Local home health care agencies should be able to provide this specific information.

Referral

Documentation

The nurse or therapist often has many different tasks to complete at the initiation of care. If a task is of particular importance to the physician, it should be noted on the referral form so that it may be given a higher priority. A checklist for a referral is given in Table 5. Many related questions are discussed in detail below.

TABLE 5

Checklist for Home Health Agency Referral

General information

Patient name

Patient date of birth

Patient medical coverage

Physician name

Diagnosis for home care

Other diagnoses

Anticipated length of care

Help with personal care

Ambulation

Toileting

Bathing

Feeding

Dressing

Hearing or sight impairment

Help with other self-care

Medication adherence

Housework

Meals

Transportation for appointments

Psychosocial issues

Support systems

Depression

Religious/spiritual influences

Blood tests

Necessary tests and appropriate timing for blood work

Reasons to call physician

When/how to disseminate laboratory test results

Parameters for calling regarding vital signs

Reasons specific to diagnoses

How to contact physician

Office telephone number

Office contact name

Pager number

Office hours

After-hours telephone number

Coverage when physician is unavailable

Address for mailing orders

Requested ancillary care

Nurse

Occupational therapist/physical therapist/speech therapist

Home health aide

Meal delivery

Nutritionist/dietitian

Volunteer visitors

Social worker

Goals

Short-term goal: length of home care (“wound healed”)

Long-term goal: continue past home care (“appropriately administer own medications”)

Medicare reviewers look for the physician’s documentation of the pathophysiologic processes that led to the patient’s functional impairments. To ensure full reimbursement, the physician must carefully list all medical diagnoses that influence the patient’s ability to function. In addition, the better the physician’s initial information reflects the patient’s baseline status, the better future communication will be between the physician and the home care nurse regarding changes.

Medicare will pay for nothing unless forms are completed and signed on time by the physician. The plan of care must be recertified every 62 days or when changes in the patient’s condition warrant it before reimbursement can be received. Any licensed physician can sign the original orders, but the physician whose name is given as the follow-up physician on the initiating orders must also be the physician who signs and dates the follow-up orders. Follow-up orders must be signed within 30 days. Any home health care agency that has initiated orders that were not signed within 30 days can jeopardize their accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). When a physician is frequently out of the primary patient care office (e.g., a resident physician on service in another setting), adding the physician’s pager number to the form can help expedite JCAHO regulatory compliance.

Medications

Complete medication lists are essential. Orders for changes in medications can usually be given to the nurse by telephone, to be signed later on a written order form. It is prudent to make a note in the medical record about any medication or other clinical changes initiated in this way. The medical record notes will be helpful later if the physician wishes to make use of the Current Procedural Terminology (CPT) codes 99375/6 for supervision (care plan oversight services) of a home health care patient when the physician provides supervision without seeing the patient on that particular day.[4]

Education

Home health care staff members are generally well prepared to conduct patient education. Early discussion between physician and staff can facilitate appropriately focused patient education as well as enhance patient outcomes. Asking the HHA about the staff-to-patient ratio and inquiring whether staff educators think there is adequate time to accomplish the necessary education can help physicians better understand the level of care that will be provided. Support (attitudinal and financial) from the HHA administrators is vital to good teaching in the home. The administration, in addition to the nurse, must recognize that patient education is critically important. A description of the teaching that has taken place and the outcome should be included in reports received periodically from the HHA.

Intravenous Fluids and Medications

Medically indicated intravenous fluids and intravenous medications qualify for HHA care. At times, a more costly medication may have to be replaced by a less costly but medically appropriate medication in order to qualify for reimbursement. Fluid/drug of choice, rate of administration, total amount and any signs or symptoms that should be monitored during infusion are all important to the order (e.g., “Check lungs for rales every 200 mL and, if rales are present, stop fluids, take vital signs and call physician”). Since many intravenous medications must be infused slowly, not “pushed,” each dose can require well over an hour for administration. Medically appropriate alternatives that can be administered less frequently will be more convenient for the patient.

Most HHAs own or have contractual relationships with a pharmacy. When an intravenous drug is to be administered by an HHA employee, the pharmacist is responsible for patient education about the drug’s side effects, although the nurse often carries out this education. When intravenous drugs are not involved, the nurse is responsible for providing information about side effects. The nurse must know the most likely adverse effects.

Durable Medical Equipment

Durable medical equipment (Table 6) is covered under home health care benefits, although the beneficiary is responsible for 20 percent of the cost.

TABLE 6

Types of Durable Medical Equipment Available Through Home

Care Agencies

Durable Common qualifying Cost per

medical equipment conditions month(*)

Oxygen concentrators Pulmonary disease,

oxygen saturation

[is less than or

equal to] 88%; CHI,

oxygen saturation

90% $400

Liquid oxygen(*) (same Patient must be

as oxygen concentrators) highly mobile 400

Compressed gas(*) (same Usually pediatric 100 to 200

as oxygen concentrators) use

Hand-held nebulizers COPD, asthma 200

CPAP machine Obstructive sleep

apnea, sleep study

required 180

BiPAP machine (same Reason for expiratory

as CPAP) pressure is required;

for ventilation

support, diagnosis

of appropriate

pulmonary disease

is required 360

Ventilators Ventilator-dependent

(COPD; respiratory

failure; RDS/BPD) 1,200

Apnea monitors Witnessed apnea

episode(s); sibling

of infant with SIDS 400

Suction machines Inability to clear

secretions (CVA,

tracheotomy, CA) 100

Oximeters Not covered by

Medicare 850

TENS units(*) Chronic intractable

pain 650

Lift chairs(*) Able to walk once

standing; needs

orthopedic,

neurologic or

medicine and

rehabilitation

(physiatry)

evaluation

(Medicare will

pay only

for motor, $300) 650 to 1,000

Hospital beds Pulmonary disease

(semi-electric) requiring rapid

repositioning; CHF 150 to 220

Ambulation aids(*) Unable to ambulate

without aid 75 to 250

Wheelchairs(*) Must need chair for

movement inside home 60 to 100

Bedside commodes Confined to one room

or floor without

bathroom 100

Toilet aids([dagger]) Not covered by Medicare 25 to 80

Shower chairs([dagger]) Not covered by Medicare 40 to 150

Glucose monitors Type 1 (formerly known

as insulin-dependent)

or type 2 (formerly

known as non-insulin

-dependent) diabetes,

if glucose must be

checked at least once

per day 100

CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; CPAP = continuous positive airway pressure; biPAP = biphasic positive airway pressure; RDS = respiratory distress syndrome; BPD = bronchopulmonary dysplasia; SIDS = sudden infant death syndrome; CVA = cerebrovascular accident; CA = cancer; TENS = transcutaneous electric nerve stimulation.

(*)–It is generally best to provide a specific medical diagnosis leading to the reason for the need for durable medical equipment (for example, a patient may need a wheelchair to move around inside the home if the diagnosis is severe degenerative joint disease).

([dagger])–Medicaid will usually cover these costs.

NOTE: All information for both qualifiers and costs is subject to change. Different home health agencies may have varying contracts. These costs are averages based on manufacturers’ figures for 1998 and may vary according to locality.

Other Available Services

Many other services are performed by HHA staff that will not qualify for a Medicare skilled need but may be ordered once a skilled need is established. Some of these services are listed in Table 7, along with some key points on ordering them.

TABLE 7

Other Services Available Through Home Health Care Agencies(*)

Phlebotomy

Laboratory results can be received through the mail, faxed or called in to the physician’s office or pager. The preferred method should be specified. Inform the home health care agency if an immediate notification is needed for results not usually considered to be out of the range of normal (e.g., a two-point drop in hemoglobin even if it remains within normal limits). Inform the home health care agency if stat notification is not needed for what might usually be considered a critical laboratory test result (e.g., a patient with AIDS who has a low white cell count but an adequate neutrophil count).

Vital sign checks

Orders should specify how often vital signs are to be checked as well as when the physician should be called regarding the results. Nurses must be informed if the physician is looking for or is concerned about a specific test result (e.g., orthostatic hypotension or an increased respiratory rate with activity).

Home health aides

Medicare will reimburse for home health aides who provide or assist with hands-on personal care (e.g., bathing or turning in bed). Patients who need help for self-care can also receive assistance with cooking and light housekeeping during the visit. The national home health care agency average is six visits per aide per day. Asking patients about their aides can strengthen assessment of a home health care agency. An extra smile and caring should not necessarily be a prerequisite for home health aides, but they add to the patient’s overall home health experience.

Social workers

Social worker services can often receive short-term reimbursement through Medicare as long as the social worker services “are expected to resolve social/emotional problems which are now or are expected to be an impediment to the effective treatment.”[3] Since knowledge concerning a patient’s ability to obtain the equipment, medication and foods prescribed is important, home health care agency nurses will usually pursue this information on their own. If they do not, the nurse should be asked to elicit the information and, when necessary, assist the patient in finding assistance through a social worker.

Dietitians

An assessment by a nutritionist or registered dietitian can be an indispensable prerequisite to expedient recovery. Orders to consider include a dietary consultation if weight loss exceeds a given amount, if weight continues to be lost after a calorie/protein supplement has been added to a regular diet or when a special diet is requested.

AIDS = acquired immunodeficiency syndrome.

(*) –Available services that do not qualify as a “skilled need” but can be ordered once a skilled need is established.

Information from Marrelli TM. Handbook of home health standards and documentation guidelines for reimbursement. 2d ed. St. Louis: Mosby, 1994.

Home Care Under Medicaid

Patients may reach their reimbursement limits earlier in the process than is medically necessary for good patient care. Many “well-insured” chronically ill patients eventually maximize their coverage and begin using Medicaid before qualifying for Medicare. Medicaid has a more lenient definition of qualifications for home health care, but it also pays very little. Medicaid visits should be financially subsidized by other sources such as public health funds or monies from other “profit-making” care within the home health care agency. It is appropriate for a physician to ask an HHA that cares for Medicare patients if care is also offered for patients who are on Medicaid, and to find out the maximum limit for Medicaid patients and what happens to patients who become dependent on Medicaid after care by the HHA.

Fraud and Abuse

Proprietary agencies are the fastest-growing segment of Medicare home health expenditures. One analysis suggests that beneficiaries receiving care from proprietary HHAs receive 21 more visits on average than those receiving care from nonprofit agencies, even after controlling for the differences in health and functional status of the beneficiary, as well as age, sex and living situation.[2] Approximately one quarter of the claims sent to Medicare seem to be inappropriate.[2] The AMA guidelines for physicians include several points that can help family physicians protect themselves and their patients (Table 8). The Health Care Financing Administration has also determined that, in many cases, the care received by the patient was different from that necessary for recovery? All physicians should keep this in mind when orders are initiated.

TABLE 8

Protecting Yourself and Your Patients

Never sign a home health plan of care or a certificate of medical necessity (CMN) for home equipment for a patient for whose care you are not responsible. While you are taking calls or covering for another physician, you have the responsibility for those patients’ care needs, including their home care.

Before you sign a Medicare home health plan of care, be certain that the patient meets eligibility requirements (through your own observations and knowledge of the patient and through discussions with the patient and home health agency staff).

Read the home health plan of care, double-checking not only the diagnosis and medications, but also the services provided and their frequencies. If you have any doubts, call the agency and ask for clarification about why the services are necessary.

Correct any errors you find on the home health plan of care or CMN and initial any corrections before you sign it.

Discuss with the patient and family the limited nature of the Medicare home health benefit and the fact that they may need to find and pay for additional home care services. Provide them with information about community resources.

While the patient is receiving home health services, periodically discuss with the patient and family whether these services are coming in, whether they are satisfied with the care, whether they can see that they are making progress, and how long they feel the services will be needed. If they identify continuing, long-term care needs, talk to the agency social worker about arranging for community resources.

If home medical equipment has been ordered, periodically check for continuing use and need.

While the patient is receiving home health services, request periodic written reports from the agency verifying the patient’s continued homebound status and eligibility for Medicare or other home health benefits.

Reprinted with permission from Department of Geriatric Health. Medical management of the home care patient.’ guidelines for physicians. Chicago: American Medical Association, 1998.

House Calls

Currently, financial and time incentives for house calls are minimal and only a very small percentage (0.88 percent) of elderly Medicare patients receive physician house calls.[5] Even one home visit every three months can enhance patient-doctor, patient-nurse and nurse-physician relationships. Hands-on follow-up of patients whose disease process is worsening is often best accomplished by a physician.

Family Involvement

Home health care is often the patient and family’s first choice of care options. As different approaches to terminal care have been introduced for essentially economic reasons, awareness has grown that such alternatives place increased demands on family members or other personal caregivers assisting the patient.[6,7] Most home health care agencies expect family members, significant others and patients to be capable of learning the necessary skills to take over at least some of the skilled care. This is particularly true of personal care, wound care and administration of intravenous medications. Home health care has the ability to lower the more obvious health care costs associated with hospitalization or long-term institutional care. However, home health care may also heighten the personal cost to family members’ emotional, social, physical and financial well-being.[8,9]

Home health care arrangements may collapse if the patient’s informal support network becomes unable to handle the increased burden resulting from disease progression, treatment intensity or depletion in available resources. Home health care for insured patients is not necessarily a cost saving for patients and family. It may have higher immediate personal costs compared with inpatient hospitalization when additional family-member caregiving and nonreimbursed expenses are considered. The information that staff members are able to glean regarding patient and family concerns and the physician’s one-on-one talks with family members play an important role in the overall quality of care.

The author thanks Tena Barker, R.N., Fran Hyc, R.N., and Darlene Samuelson for their review of the manuscript.

REFERENCES

[1.] Vladeck BC. HCFA presentation. FY 98 Budget proposals. National Association for Home Care April 15, 1997.

[2.] Department of Geriatric Health. Medical management of the home care patient: guidelines for physicians. Chicago: American Medical Association, 1998.

[3.] Marrelli TM. Handbook of home health standards and documentation guidelines for reimbursement. 2d ed. St. Louis: Mosby, 1994.

[4.] Kirschner CG, ed. Physician’s current procedural terminology. 4th ed. Chicago: American Medical Association, 1994.

[5.] Meyer GS, Gibbons RV. House calls to the elderly–a vanishing practice among physicians. N Engl J Med 1997;337:1815-20.

[6.] Gordon S. The impact of managed care on female caregivers in the hospital and home. J Am Med Women’s Assoc 1997;52:75-7,80.

[7.] Varricchio C. Human and indirect costs of home care. Nurs Outlook 1994;42:151-7.

[8.] Sevick MA, Kamlet MS, Hoffman LA, Rawson I. Economic cost of home-based care for ventilator-assisted individuals: a preliminary report. Chest 1996;109:1597-606.

[9.] Ward D, Brown MA. Labor and costs in AIDS family caregiving. West J Nurs Res 1994;16:10-22.

SUSAN LOUISA MONTAUK, M.D., is a family physician and associated professor of clinical family medicine at the University of Cincinnati (Ohio) College of Medicine. Dr. Montauk graduated from Ohio State University College of Medicine and completed a family medicine residency at Grant Medical Center, Columbus, Ohio, as well as a fellowship in family and adolescent medicine.

Address correspondence to Susan Louisa Montauk, M.D., Department of Family Medicine, University of Cincinnati College of Medicine, P.O. Box 670582, Cincinnati, OH 45267-0582. Reprints are not available from the author.

COPYRIGHT 1998 American Academy of Family Physicians

COPYRIGHT 2000 Gale Group