When should home health care services be considered?
Home health care is usually considered when you cannot live comfortably and safely without support services. It may also be appropriate if you require a specific medical skilled service such as intravenous (IV) medications or physical therapy that can be done at home instead of traveling to a medical center if this has become hard to do. This type of care may be suggested by a doctor or another member of a health care team. In addition to the emotional comfort that the home environment may provide, home health care is usually less expensive than care provided in a medical facility. Access to hospitals or other health care facilities remains available as needed.
If there comes a time when these services are needed, be sure to research and compare a number of licensed home health care agencies. You can also consider the possibility of hiring your own caregivers. There are major differences in how home care facilities individual caregivers operate. You may find that one method meets your needs better than the other.
What types of home health care services are available?
Home health care falls into two broad categories based on length of care:
- Short-term (or acute) care: This type of care provides assistance following an illness or injury. The goal of short-term care is to provide the necessary health care services to help you get better, regain your ability to function, care for yourself, and become as independent as possible.
- Long-term care: This type of care is for people who are chronically ill or more seriously or permanently disabled. The goal of long-term care is to help you maintain your highest level of function or health and to help you learn to adjust to and manage the changes resulting from your illness or disability.
Within these two categories there are different levels of care:
Custodial care (non-skilled care) is care that helps with activities of daily living like dressing, bathing and toileting. This type of care is often not covered by government-sponsored programs like Medicare.
Skilled care is a level of care that requires the caregiver have special training and skills. This type of care must be provided by a licensed professional and prescribed by a doctor. Government-sponsored programs may pay for medically necessary skilled care.
There are generally two types of skilled care services:
- Intermediate care services include nursing and rehabilitative care that is provided at a level between intensive and basic care. These services are ordered by a doctor and supervised by skilled medical personnel.
- Intermittent services are usually defined as skilled health care services that are needed or provided fewer than seven days each week or less than eight hours per day over a period of 21 days.
What types of care providers are associated with home health care?
Certified home health care agencies employ a variety of care providers to deliver services. In addition to nursing care and home health aide services, agencies can provide or arrange for specialized services such as with social workers or physical, occupational or speech therapists. Home health care agencies can also assist with arrangements for medical supplies and equipment as well as nutrition programs like home-delivered meals. With a doctor’s order, the following caregivers may be arranged through home health care agencies:
- Licensed care providers including:
- Registered nurses (RNs) and licensed practical nurses (LPNs) can give medication, change bandages, administer treatments, monitor pain or other symptoms and check vital signs (temperature, blood pressure, heart rate, breathing rate).
- Occupational Therapists (OTs), Registered Physical Therapists (RPTs), Nutritionists and Social Workers (MSWs) can provide home health care services prescribed by a doctor in their professional area of specialty.
- Attendant caregivers such as:
- Certified nursing assistants (CNAs) must complete a state-approved training program and competency test. CNAs perform routine tasks under the supervision of licensed nursing and medical staff. Tasks may include doing wound and skin care, checking vital signs, helping with transfers (moving from one place to another), assisting clients with ambulation (walking) and prescribed exercises.CNAs can also provide assistance with activities of daily living (ADLs). ADLs are those activities that are necessary for people to be able to live independently including bathing, toileting, eating, and moving around the home.
- Home health aides may assist with personal services and ADLs such as bathing, toileting, eating, ambulation and transfers.
- Personal care attendants (PCAs), homemakers or companions can only assist with tasks such as cleaning, cooking, laundry and other household chores. They may also provide help with shopping, accompany clients to appointments or do other errands.
- Respite caregivers. Respite care services offer the usual caregiver a temporary break from the day-to-day demands of taking care of another person on a full-time basis. Respite care is typically needed by the primary caregiver of someone who is severely or chronically disabled. Services may also include housekeeping, home health assistance, nursing and child care.
- Hospice caregivers. Hospice is a specialized service that provides a compassionate, supportive network of professionals and volunteers to help manage the physical, emotional, practical and spiritual challenges that often occur at the end of life. Services may include skilled and unskilled nursing care, emotional support, pain management, and assistance getting personal and legal affairs in order. Hospice workers might be nurses, social workers, home health aides, volunteers, therapists and pastoral counselors. Services can be provided at home or in a hospital or other care facility such as a nursing home.
When should a survivor talk with a doctor about home health care?
If you think you may have a need for home-based health care services, discuss your needs with your health care team. The doctor must prescribe (order) skilled home health care services in order for insurance to pay. Tell your doctor about any problems you are having with daily activities. Discuss the types of health care services that might be helpful to you at home.
Be certain to include the following in your discussion with your doctor:
- Your concerns about being home alone
- How often a caregiver might be required
- Types of assistance that are needed such as cooking, cleaning or help with other ADLs
- The barriers that exist to getting around your home (including stairs and physical challenges such as walking the distance to the bathroom, kitchen or bedroom)
Write down any concerns and questions before meeting with the doctor to discuss your needs. This discussion will help define how much and what type of home health care services might be needed (such as skilled or intermittent care).
How can a survivor get home health care services?
There are generally two main types of home health care services. The services are generally provided through a licensed home health care agency or by hiring a caregiver on your own (private pay).
- Using a home health care agency
Home health care agencies coordinate and supervise the provision of skilled services (such as wound care, injections and other medical care) in the home. These services are provided according to the needs of the patient and as ordered by the doctor. Home health care agencies are licensed. If the agency has also met federal and state minimum requirements for patient care, it can be Medicare-certified. This qualifies the agency for Medicare and/or Medicaid payments for home health services.
If you have a doctor’s order or prescription and work with a licensed and certified agency, costs for services may be covered through an employer-sponsored, private, or government-sponsored insurance plan. Frequently, only part-time or temporary home health care services are covered. Ask your insurance provider about your specific plan. Find out what is covered and what the plan requires for services to be covered.
Local and national cancer organizations and agencies for the aging may be able to suggest home health care providers. Generally, you have the right to choose the home health care provider that you want. However, certain insurance plans limit coverage to the agencies that are listed in the policy. Your insurance company may have a relationship with certain home health care agencies and direct you to a specific service provider.
If home health care is needed following a hospitalization, a hospital social worker will usually initiate contact with a home health care agency and coordinate services with the doctor, you, and your family. A home health agency has the right to refuse to accept any individual patient if the agency is not able to meet the patient’s needs.
- Researching home health care agencies
Begin your research by asking health care team members (such as your doctor, nurse or therapist) to help you with recommendations and contact information for home health care agencies. A hospital social worker, Oncology Social Worker, nonprofit cancer organization, or your Health and Human Services office may also be able to direct you to local resources that are available.
- Comparing the quality of care provided by home health care agencies
Home health care agencies are certified to make certain they meet federal health and safety requirements. You can get information about home health agencies and the results of their quality measures from a Medicare agency. In some cases, a local ombudsman, who can be contacted through your local agency on aging, may have information on quality care measures of home health agencies in your area.
You will have a say about which home health care agency you use, but your choices may be limited by agency availability or a factor such as Medicare rules. Some hospitals have their own home health care agency, but this does not mean you have to choose the hospital’s agency.
Quality care means doing the right thing, at the right time and in the right way to obtain the best possible results for the patient. Quality care measures give you information about how well home health agencies provide care for patients. Patients are monitored for quality measures in areas such as:
- Improvement in mobility (ability to move around the home)
- Patient medical emergencies
- Improvement in mental health
- Ability to perform ADLs such as bathing, dressing, and eating
- Infection control
Developing a patient care plan
You and your loved ones have a right to participate in planning care and discussing treatment options. Patient care plansaredeveloped for individuals as part of the case management process. These written plans are based on the doctor’s orders and outline all of the services and caregiving arrangements that are needed. A multi-disciplinary team (that may include family members, nurses, dieticians, doctors, therapists, activities and social services professionals) defines timeframes and specific care services to be provided.
Your care plan is periodically reviewed by the home care team and adjustments are made to the care plan as needed to reflect your current needs. Home health care staff cannot make changes to the care plan your doctor has ordered without the doctor’s knowledge and permission.
Using private home health care workers
Private home health care workersare individuals hired directly by you or your family. They may be found a number of ways including through a friend or by using a classified ad or a similar “help wanted” posting. These caregivers typically provide companionship and help with ADLs such as housecleaning and meal preparation.
If you plan to hire and pay an unlicensed personal care attendant for home health care services on your own, you do not need a doctor’s order. However, licensed nursing services that are provided by a RN or LPN do require a doctor’s order.
If you do decide to find your own home health care worker, be aware that you will be required to take responsibility for certain things. Carefully consider these responsibilities including:
- The need to withhold taxes as an employer for the worker.
- The need to have a written contract (including a job description) with the home health care worker, particularly if he or she is going to live in your home. If the caregiver is going to live with you, it must be clear in the contract that their right to stay in your home continues only as long as that person works for you.
- The need to be certain that the home health care worker is covered by personal liability or worker’s compensation insurance so that you are covered in case there is a liability claim such as an injury in your home.
- The need to do background check to make certain that the health care worker you hire has no record of criminal activity or abuse. Some states have registries (many are available online) for personal care attendants and home health aides that make it easier for you to do the background check.
- The need to have a back-up plan for care in case the worker becomes ill or unavailable at short notice.
Interview potential health care workers in your home where there is an opportunity for the caregiver to become acquainted with you and any family members. The interview and selection process should be a time for an open and honest discussion between the patient, family, and the health care provider. This is the time to ask questions and to cover all topics that are of concern to you. Ask the caregiver how he or she would respond in specific situations and request that they provide examples from past experience that show how they solve problems.
Make it clear to the home health care provider that you will not tolerate abuse, neglect, chronic tardiness, absenteeism or failure to perform assigned duties. Discussing a set of rules and job requirements is important before signing an employment agreement.
Home health care registries are independent contractors that provide services at prices that are usually lower than home health care agencies. They operate somewhat like an employment agency in that they screen, interview and do reference checks on home health care workers that are referred. Be sure that any agency you select can provide the type of caregivers you need.
Some states and counties offer home health care services to people who are disabled or to family caregivers. An application for assistance is reviewed and evaluated by need. If you qualify for program services, home health care aides may be provided.
Finally, some families elect to set up formal caregiver contracts (also called personal service or personal-care agreements) to hire a family member to provide care services. These legal contracts name the specific services to be performed, the rate of pay to be provided the caregiver and when it will be paid, such as in one lump sum or in regular payments. Talk with an attorney who specializes in this area to receive guidance if you decide to set up such a contract. There is also information on caregiving contracts and related matters available online, such as through the National Academy of Elder Law Attorneys.
How might home health care services be paid for?
Home health care services can be costly. Some services may be partially covered by private medical and disability insurance policies. However, home health care on a long-term basis may have to be financed through personal funds and state and federal medical assistance programs.
If your insurance policy or a government program will not normally cover those needs, your doctor or a home health care company may be able to negotiate for you with the insurance carrier. Specifically, if it can be shown that it is less expensive to deliver the needed services to you at home rather than in a hospital, they might consider covering costs for a time.
- Medicaid is a government assistance program for people who meet certain low income requirements. It is jointly funded by the federal and state governments and operates under national and individual state guidelines. Eligibility for Medicaid varies from state to state. Some states have “medically needy” options to cover the cost of medical care for persons who would qualify for Medicaid on the basis of the services they require, but have too much income to qualify for the program and too little to pay for the needed medical services.
- Medicare is a national health insurance program that pays for acute medical care services for people age 65 or older or those who have qualified for government disability benefits.In most cases you need to meet all of the following conditions to be eligible for insurance or Medicare-covered home health care benefits:
- Your doctor must determine that you need medical care, and write a prescription referring you to home health care services.
- You must need at least one of the following care services: intermittent skilled nursing care or physical therapy, speech-language therapy, or ongoing occupational therapy.
- You may need to choose a home health agency that is certified or approved by the insurance company or assistance program. For example, the agency may need to be Medicare-certified.
- You must meet certain requirements such as not being able to leave home unassisted or being confined to home by illness. Leaving home for medical treatment, adult day services or short, infrequent trips is allowed.
- Private insurance may cover some home health care services. Check your policy to find out if your home health care needs will be covered. If so, find out the length of time services will be covered. In some cases, it may be possible to use a long-term care insurance policy to pay family members who provide the caregiving services. Some government benefit programs provide funding to pay family members for “consumer-directed care.” Local agencies on aging or departments of social services may be able to provide more information on government funding.
Rates for home health care are based on the level of service, individual agency rates, and the rates typically charged in the area in which the services are provided. Contact several agencies to compare services offered and rates charged before deciding to contract for services.
There may be limits on the number of hours per day and days per week that you can get skilled nursing or home health aide services. Contact your insurance company to find out specifically what home health care services are covered. If you have Medicare or Medicaid, the Centers for Medicare and Medicaid Services can provide you with information.
If you are eligible for home health care, services ordered by a doctor such as the following are likely to be covered:
- Skilled nursing performed by a registered nurse or a licensed practical nurse on a part-time or intermittent basis
- Home health aide services on a part-time or intermittent basis
- Physical therapy, speech-language therapy and occupational therapy for as long as the doctor says you need it
- Medical social work services to help you with social and emotional concerns related to your illness such as counseling
- Certain medical supplies, but not prescription drugs
- Rental or purchase of medical equipment such as a hospital bed, wheelchair or walker
If your insurance company will not automatically pay for needed home health care equipment, try taking the following steps:
- Compare and discuss the costs of obtaining the treatment at home to the cost of getting the care at a medical facility.
- Check to see if it is possible to borrow the equipment.
- An area agency on aging or another community service group may be able to assist you to find a supplier from which you can borrow the equipment.
- Compare costs to see if it is cheaper for you to rent the equipment or buy it.
- When comparing the costs of renting or purchasing medical equipment, include the cost of servicing the equipment. If you rent, equipment maintenance may be free.
What if you have concerns about the quality of home health care services?
If you have concerns about the home health care services, start by speaking directly with the care provider to let him or her know your concerns. If that does not improve the situation, speak with the provider’s supervisor or the agency owner. If there is still no improvement in the work, ask for a new health care worker. Be sure to let your doctor know of any unresolved concerns or problems with the agency.
If you find that you do not feel comfortable with the home health care you receive, you can change home health care providers. A close friend or family member can speak on your behalf if you do not want to personally deal with the problem. Keep in mind that because of federal laws about health privacy, the home health care agency will need written permission to speak with someone other than you about your care.
If a problem with the health care provider cannot be resolved to your satisfaction, you will likely want to change agencies and/or health care workers. The following are basic guidelines for changing your home health care provider:
- You may choose to end your relationship with one home health care agency and choose another at any time.
- If you need to change agencies, contact your doctor to get a referral to a new home health care agency. You must notify both the agency you are leaving and the new agency of the date that the change will take effect.
- Before you make any arrangements to change home health care agencies, be certain that the change is pre-approved by your insurance provider(s).
- Keep in mind that you can only get care from one home health agency at a time. However, it is common for people to receive skilled services through one agency and homemaker services through another.
Most home health care agencies and their staff are honest and use accurate billing information. Unfortunately, fraud (cheating), waste or abuse can occur.
Watch for possible signs that something is wrong such as:
- Home health visits that your doctor ordered, but you never received
- Visits by home health staff that are not needed
- Bills for services and equipment you never got
- Forging of your signature or your doctor’s signature
- Pressure to accept items and services that you do not need