Am Fam Physician. 1998;58(7):1608-1614
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.
| 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. |
| 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 |
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).
| 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. |
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 care-givers 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.
| 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.
| Durable medical equipment | Common qualifying conditions | Cost per month* |
|---|---|---|
| Oxygen concentrators | Pulmonary disease, oxygen saturation ≤ 88%; CHF, oxygen saturation < 90% | $400 |
| Liquid oxygen* (same as oxygen concentrators) | Patient must be highly mobile | 400 |
| Compressed gas* (same as oxygen concentrators) | Usually pediatric use | 100 to 200 |
| Hand-held nebulizers | COPD, asthma | 200 |
| CPAP machine | Obstructive sleep apnea, sleep study required | 180 |
| BiPAP machine (same as CPAP) | Reason for expiratory 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 physical medicine and rehabilitation (physiatry) evaluation (Medicare will pay only for motor, $300) | 650 to 1,000 |
| Hospital beds (semi-electric) | Pulmonary disease 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† | Not covered by Medicare | 25 to 80 |
| Shower chairs† | 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 |
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.
| 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. |
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.2 All physicians should keep this in mind when orders are initiated.
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.