Home Health Care - Statistical Data Included

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.

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.

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