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What is Home Health Care?
"Home care" is a simple phrase encompassing a wide range of health and social services. These services are delivered at home to recovering, disabled, chronically or terminally ill persons in need of medical, nursing, social, or therapeutic treatment and/or assistance with the essential activities of daily living.
Generally, home care is appropriate whenever a person prefers to stay at home but needs ongoing care that cannot easily or effectively be provided solely by family and friends. More and more older people electing to live independent, non-institutionalized lives are receiving home care services as their physical capabilities diminish. Adults and children diagnosed with terminal illness are also being cared for at home. As hospital stays decrease, increasing numbers of patients need highly skilled services when they return home. Other patients are able to stay at home to begin with, receiving safe and effective care in the comfort of their own homes.
Who Provides Home Care?
Home care services generally are available 24 hours a day, seven days a week. Depending on the patient's needs, services may be provided by an individual or a team of specialists on a part-time, intermittent, hourly, or shift basis. Selecting the right provider is easier with this checklist. Following are descriptions of the various types of home care providers.
Home Health Agency
The term home "health agency" often indicates a home care provider is Medicare-certified. A Medicare-certified agency has met federal minimum requirements for patient care and management and therefore can provide Medicare and Medicaid home health services. Individuals requiring skilled home care services usually receive their care from a home health agency. Due to regulatory requirements, services provided by these agencies are highly supervised and controlled. Some agencies deliver a variety of home care services through physicians, nurses, therapists, social workers, homemakers and home care aides, durable medical equipment and supply dealers, and volunteers. Other agencies limit their services to nursing and one or two other specialties. For cases in which an individual requires care from more than one specialist, home health agencies coordinate a caregiving team to administer services that are comprehensive and efficient. Personnel are assigned according to the needs of each patient. A home health agency recruits and supervises its own personnel and as a result the agency assumes liability for all care delivered.
Hospice
Hospice care involves a core interdisciplinary team of skilled professionals and volunteers who provide comprehensive medical, psychological, and spiritual care for the terminally ill and support for patients' families. Hospice care also includes the provision of related medications, medical supplies, and equipment. It is based primarily in the home, enabling families to remain together. Trained hospice professionals are available 24 hours a day to assist the family in caring for the patient, to ensure the patient's wishes are honored, and to keep the patient comfortable and free from pain. Most hospices are Medicare-certified and licensed according to state requirements.
Homemaker and Home Care Aide (HCA) Agencies
Homemaker and HCA agencies employ homemakers or chore workers, HCAs, and companions who support individuals through meal preparation, bathing, dressing, and housekeeping. Personnel are assigned according to the needs and wishes of each client. Most homemaker and HCA agencies recruit, train, and supervise personnel and thus are responsible for the care rendered.
Staffing and Private-Duty Agencies
Staffing and private-duty agencies are generally nursing agencies that provide individuals with nursing, homemaker, HCA, and companion services. Tennessee does not require these agencies to be licensed or meet regulatory requirements. Some staffing and private-duty agencies assign nurses to assess client needs to ensure personnel are properly assigned and provide ongoing supervision. These agencies recruit personnel and again, are responsible for patient care.
Pharmaceutical and Infusion Therapy Companies
Pharmaceutical and infusion therapy companies specialize in the delivery of drugs, equipment, and professional services for individuals receiving intravenous or nutritional therapies through specially placed tubes. These companies employ pharmacists who prepare solutions and arrange for delivery to patients. Nurses also are hired to teach self-administration in patients' homes. Some pharmaceutical and infusion therapy companies are home health agencies certified by Medicare. Tennessee requires these organizations to be licensed. Each company assumes responsibility for personnel and the services rendered.
Durable Medical Equipment and Supply Dealers
Durable medical equipment and supply dealers provide home care patients with products ranging from respirators, wheelchairs, and walkers, to catheter and wound care supplies. These dealers employ staff who deliver and, when necessary, install these products as well as instruct patients on proper in-home use. Durable medical equipment and supply dealers usually do not provide physical care for patients, but there are a few exceptions. Some dealers offer pharmacy and infusion services, with a nurse administering medication and nutritional formulas to patients and teaching proper techniques for self-administration. Some companies also provide respiratory therapy services to help individuals to use breathing equipment. Durable medical equipment and supply dealers that bill the Medicare program are required to meet federal minimum standards. Each dealer is liable for its personnel and the services provided to patients.
Independent Providers
Independent providers include nurses, therapists, aides, homemakers and chore workers, and companions who are privately employed by individuals who need such services. Aides, homemakers, chore workers, and companions are not required to be licensed or to meet government standards except in cases where they receive state funding. In this arrangement, the responsibility for recruiting, hiring, and supervising the provider rests with the client. Finding back-up care in the event the provider fails to report to work or fulfill job requirements is the client's responsibility. Clients also pay the provider directly and must comply with all applicable state and federal labor, health, and safety requirements.
Who Pays for Home Care?
Home care services can be paid for directly by the patient and family members or through a variety of public and private sources. Hospice care is generally provided regardless of the patient's and/or family's ability to pay. Public third-party payors include Medicare, Medicaid, the Older Americans Act, the Veterans Administration, and Social Services block grant programs. Some community organizations, such as local chapters of the American Cancer Society, the Alzheimer's Association, and the National Easter Seal Society, also provide funding to help pay for home care services. Private third-party payors include commercial health insurance companies, managed care organizations, CHAMPUS, and workers' compensation.
Self-pay
Home care services that fail to meet the criteria of third-party payors must be paid for "out of pocket" by the patient or other party. The patient and home care provider negotiate the fees.
Medicare
Most Americans 65 and older are eligible for the federal Medicare program. If homebound, under a physician's care, and requiring medically necessary skilled nursing or therapy services, the patient may be eligible for services provided by a Medicare-certified home health agency. Depending on the patient's condition, Medicare may pay for intermittent skilled nursing; physical, occupational, and speech therapies; medical social work; HCA services; and medical equipment and supplies. The referring physician must authorize and periodically review the patient's plan of care. With the exception of hospice care, the services the patient receives must be intermittent or part-time and provided through a Medicare-certified home health agency for reimbursement.
Hospice services are available to terminally ill patients who have a life expectancy of six months or less. There is no requirement for the patient to be homebound or in need of skilled nursing care. A physician's certification is required to qualify an individual for the Medicare Hospice Benefit. The physician also must re-certify the individual at the beginning of each six-month benefit period. In turn, the patient is required to sign a statement indicating he or she understands the nature of the illness and of hospice care. By signing this statement, patients surrender their rights to other Medicare benefits related to terminal illness.
Medicaid
Administered by the state, Medicaid is a joint federal-state medical assistance program for low-income individuals. Each state has its own set of eligibility requirements; however, states are only mandated to provide home health services to individuals who receive federally assisted income maintenance payments, such as Social Security Income and Aid to Families with Dependent Children (AFDC), and individuals who are categorically needy. Categorically needy recipients include certain aged, blind, and/or disabled individuals who have incomes too high to qualify for mandatory coverage but below federal poverty levels. Under federal Medicaid rules, coverage of home health services must include part-time nursing, HCA services, and medical supplies and equipment.
Older Americans Act (OAA)
Enacted by Congress in 1965, the OAA provides federal funds for state and local social service programs that enable frail and disabled older individuals to remain independent in their communities. This funding covers HCA, personal care, chore, escort, meal delivery, and shopping services for individuals with the greatest social and financial need who are 60 and older. Increasingly, individuals who can afford to pay for some of these services are being asked to contribute in proportion to their income. Individuals often request the services they need through an Area Agency on Aging, which will provide them directly or in cooperation with local organizations.
Veterans Administration
Veterans who are at least 50 percent disabled due to a service-related condition are eligible for home health care coverage provided by the Veterans Administration (VA). A physician must authorize these services, which must be delivered through the VA's network of hospital-based home care units. The VA does not cover non-medical services provided by HCAs.
Social Services Block Grant Programs
Each year states receive federal social services block grants for state-identified service needs. The government allocates these funds on the basis of the state's population and within a federal limit. Portions of the funding often are directed into programs providing HCA and homemaker or chore worker services. Contact the state health department or local offices on aging for additional information.
Community Organizations
Some community organizations, along with state and local governments, provide funds for home health and supportive care. Depending on an individual's eligibility and financial circumstances, these organizations may pay for all or a portion of the needed services. Hospital discharge planners, social workers, local offices on aging, and the United Way are excellent sources for information about community resources.
Commercial Health Insurance Companies
Commercial health insurance policies typically cover some home care services for acute needs, but benefits for long-term services vary from plan to plan. Commercial insurers, including Blue Cross and Blue Shield and others, generally pay for skilled professional home care services with a cost-sharing provision. Such policies occasionally cover personal care services. Most commercial and private insurance plans will cover comprehensive hospice services, including nursing, social work, therapies, personal care, medications, and medical supplies and equipment. Cost-sharing varies with individual policies, but often is not required.
Individuals sometimes find it necessary to purchase Medigap insurance or long-term care insurance policies for additional home care coverage.
Medigap insurance is designed to bridge some of the gaps in Medicare coverage. Some Medigap policies offer at-home recovery benefits, which pay for some personal care services when the policy holder is receiving Medicare-covered skilled home health services. The policy holder's physician must order this personal care in conjunction with the skilled services. Home care coverage in Medigap policies is not designed to cover extended long-term care. This type of coverage is most helpful to individuals recovering from acute illness, injuries, or surgery.
Long-term care insurance was primarily intended to protect individuals from the catastrophic expense of a lengthy stay in a nursing home. However, as the public need and preference for home care has grown, private long-term care insurance policies have expanded their coverage of personal care, companionship, and other in-home services. Considerable care should be taken in selecting a long-term care insurance policy, as home care benefits vary greatly among plans. Consumers should be aware of limitations on coverage, such as prior hospitalization requirements, and pre-existing condition exclusions. Some policies may only pay for services already covered by Medicare.
Managed Care Organization (MCO)
Managed care organizations and other group health plans sometimes include coverage for home care services. MCOs contracting with Medicare must provide the full range of Medicare-covered home health services available in a particular geographic area. Medicare beneficiaries enrolled with an MCO may elect their hospice benefit from the hospice of their choice. These organizations only pay for services that are pre-approved.
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
On a cost-shared basis the CHAMPUS covers skilled nursing care and other professional medical home care services for dependents of active military personnel and military retirees and their dependents and survivors. CHAMPUS offers a comprehensive hospice benefit to its terminally ill beneficiaries, which covers nursing, social work and counseling services, therapies, personal care, medications, and medical supplies and equipment.
Workers' Compensation
Any individual requiring medically necessary home care services as a result of injury on the job is eligible to receive coverage through workers' compensation.
Checklist: Selecting the Right Home Health Care Provider
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