In the United States, the term “home health ” has come to represent the home visiting services and supports provided by HHAs. Generally speaking, there are two types of HHAs:

Many home health organizations provide both skilled and private duty services and a range of other community services and supports such as hospice and palliative care, transitional care, telehealth, care coordination, social work services, and prenatal and early childhood programming.

Throughout this chapter, we will refer to the Medicare home health regulations which cover the majority of skilled home health services in the country [5]. These regulations change frequently. Medicare-managed care organizations and commercial insurance often have preferred providers and varying benefits that need to be determined on a case-by-case basis. Home-based medical providers can contact their local HHA billing specialists for home health coverage determination for different insurance plans.

The goal of home health is to maximize the patient’s health and function in the home, reduce acute episodes of care, and support the caregiver. Services include nursing care, rehabilitative therapy, personal assistance (hygiene), and social work services. Quality HBPC coupled with the resources of home health services can improve the health and quality of life of home-limited patients through comprehensive primary medical care, nursing, and rehabilitative services. It is important to note that to receive Medicare home health services, the patient must have a skilled need. Per Medicare, skilled nursing services are covered when an individualized assessment of the patient’s condition demonstrates that the specialized judgment, knowledge, and skills of a registered nurse are necessary to maintain the patient’s current condition or prevent or slow further deterioration. In addition, physical, speech, and occupational therapy is a skilled service if the inherent complexity of the service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist. The skills of a qualified therapist must be needed to restore function, establish or design a maintenance program in order to ensure the safety of the patient and effectiveness of the program, or perform maintenance therapy.

Nursing care provides comprehensive patient assessments and education on disease process, medications, diet, and self-management skills. Goals of care include improvement or stabilization in symptom control (e.g., pain, dyspnea), medication management and compliance, and improvement in knowledge of disease process and symptoms to report. Teaching and training activities can include self-administration of injectable medications, administration of oxygen, self-catheterization, maintenance of peripheral and central venous lines and administration of intravenous medications, bowel or bladder training, and proper body alignment and positioning to prevent pressure sores. Nursing treatments/procedures include wound and ostomy care, urinary catheter and gastrostomy tube changes, injections, and venipuncture. Some agencies also have specialized home health nursing services including certified wound and ostomy care, infusion services (intravenous hydration, parenteral nutrition, and antibiotics), and psychiatric care. Many but not all HHA provide 24/7 nursing availability, by telephone or with in-person nurse visits. Venipuncture for the purpose of obtaining a blood sample cannot be the sole reason for Medicare home health services. If the patient has a qualifying skilled need, venipuncture can be done as part of the plan of care.

Home health therapy provides rehabilitative treatment in the home. The goals of therapy are to maximize safety in the home environment, train the patient and family in a home exercise program, optimize assistive devices, attain maximum function, and possibly progress to the appropriate next level of care (such as outpatient therapy).

The three areas of therapy are described below:

Social workers provide intervention and consultations for social or emotional problems that are or are expected to be an impediment to the effective treatment of the patient’s medical condition or rate of recovery. They can assess the relationship of the patient’s medical and nursing requirements to the patient’s home situation, financial resources, and availability of community resources (note: Medicare does not cover the social worker completing applications for Medicaid, as federal regulations require the state to provide this assistance). Short-term counseling can be provided to patients or caregivers when the HHA can demonstrate that a brief intervention (2–3 visits) is necessary to remove a clear and direct impediment to the effective treatment of the patient’s medical condition or rate of recovery. They also assist patients in accessing community resources.

Per Medicare, to receive home health aide services, the patient must have a skilled need (e.g., nursing care) and need hands-on personal care to maintain the patient’s health or to facilitate treatment of the patient’s illness or injury. Personal care involves bathing, dressing, grooming, and oral hygiene needed to facilitate treatment or to prevent deterioration in health. Examples of additional services include changing bed linens, shaving, skin care, feeding, assistance with elimination including enemas, routine catheter and colostomy care (if determined safe for aide to do), assistance with ambulation, changing bed position, and assistance with transfers. Aides can also provide non-skilled wound care and reinforcement of the home therapy program.

Skilled home health is a valuable partner to the HBPC provider. In our experience, approximately one-third to one-half of HBPC practices’ patients require skilled home health services in a given year. The service is relatively ubiquitous, with over 99 %84 % living in an area with five or more HHAs [6].

To qualify, the patient must:

It is important to note that patients do not need to meet Medicare’s homebound definition to receive medical care at home. The home-based medical provider must document a medically necessary reason for the visit, but the patient can be fully ambulatory and not homebound. Examples include patients with mental illness, poor compliance, failure to follow up in the provider’s office, or recurrent hospital admissions.

For a patient to be eligible to receive covered home health services under both Medicare Part A and Part B, the law requires that a physician certify in all cases that the patient is confined to his/her home. The following two criteria must be met:

The Medicare regulation states the patient may leave the home and still be considered homebound if absences are infrequent, for short duration, or are attributable to the need to receive healthcare. They go on to provide specific examples of permitted absences from the home including therapeutic, psychosocial, or medical treatment in an adult day care program licensed or certified by a state, outpatient dialysis, outpatient chemotherapy or radiation therapy, attendance at religious services, occasional trip to the barber, a walk around the block or a drive, and attendance at a family reunion, funeral, graduation, or other infrequent or unique events [8].

The final requirement to receive skilled home health services is being under the care of an allopathic, osteopathic, or podiatric doctor and have a documented face-to-face visit 90 days before or 30 days after start of care. The face-to-face note must include the visit date and document how the patient’s clinical condition (including primary diagnosis and clinical findings) supports the patient’s homebound status and need for skilled services. In situations when a physician orders home healthcare for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care, the certifying physician or nonphysician practitioner must see the patient again within 30 days after admission. The specific home health services being ordered need to be documented. The face-to-face encounter does not need to be done by the certifying doctor. Examples include the face-to-face visit being done by a hospitalist or post-acute care provider upon discharge or by a resident or nurse practitioner under the supervision of the certifying physician. The patient must require nursing care, physical therapy, or speech therapy as the qualifying service. Occupational therapy, social work, and aide services can also be ordered but by themselves do not constitute a basis for eligibility for Medicare reimbursement. Medicare permits HHAs to inform the certifying physician of their findings from their comprehensive assessment that supports the patient eligibility for skilled home healthcare. The certifying physician can sign the additional information and incorporate it into his/her medical record to further substantiate need for home health services. The face-to-face documentation must corroborate the HHA’s findings. Below is an example of face-to-face documentation:

John Smith seen today at home for exacerbation of congestive heart failure with hypoxemia (oxygen saturation 86 % on room air). Did not desire hospitalization and ordered increased diuretics and oxygen. He is also having increased difficulty transferring and decreased gait. Ordered home health nursing to follow response to change in medication and addition of oxygen, and to provide education regarding congestive heart failure and low salt diet. Ordered physical therapy to evaluate and treat decreased gait and transfer difficulty. Ordered occupational therapy to evaluate and treat difficulty with transfers and recommend assistive equipment to help with ADLs. The patient is homebound because of dyspnea with minimal exertion from his heart failure and inability to walk more than 20 ft.

Home health certifications are for 60-day episodes of care. At the end of the initial 60 days, if the patient still has a skilled need, services can be recertified for subsequent 60-day episodes, with recertification required for each episode. Medicare does not limit the number of recertifications for beneficiaries who continue to be eligible for the home health benefit. The recertification assessment must be done during the last 5 days of the previous episode and signed and dated by the physician who reviews the plan of care indicating a continued need for skilled services. The need for continued OT may be the basis for recertification even though it cannot be used for the initial certification. Medicare also requires an estimate of how much additional time the skilled services will be required. Examples of appropriate recertification include patients with chronic urinary catheters requiring monthly and “as needed” catheter changes or wounds that have not healed and require continued skilled nursing services.

As the result of a January 24, 2013, settlement of a class action lawsuit challenging Medicare’s improvement standard, Medicare clarified its stance on paying for home health services when a skilled provider was needed to maintain functional gains [9]. The updated “Medicare Benefit Policy Manual” now clarifies that services that are required to maintain the patient’s current function or to prevent or slow further deterioration that require skilled nursing care or therapy be covered. In addition, coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patient’s potential for improvement from the nursing care or therapy, but rather on the patient’s need for skilled care. Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, to prevent or slow further deterioration of the patient’s condition [7].”

According to the Medicare Conditions of Participation (CoPs) [10], the HHA is required to see the patient within 48 h of the referral if the patient allows. An initial comprehensive assessment is performed by a nurse (or physical therapist) of the patient, the home, and the availability of caregivers. The patient assessment includes a history and physical along with the completion of the Outcome and Assessment Information Set (OASIS-C1/ICD-10 version).

The final product from the initial comprehensive assessment performed by the HHA is the care plan which for Medicare has to include defined key elements and be signed by the physician (a nurse practitioner or physician assistant cannot sign). The CMS Form 485 (the Home Health Certification and Plan of Care) meets regulatory and national survey requirements [11]. HHAs are not required to use Form 485 and may submit any document that contains all the required data elements and is signed by the physician. The key elements for certification are listed below.

During the 60-day home health episode of care, the home health personnel carry out the plan of care and make necessary changes in communication with the home-based medical provider. Goals include reaching maximizing function and self-care, healing and/or proper care of wounds, and teaching family and caregivers how to safely care for patients. Laboratory and point of care (such as finger-stick anticoagulation monitoring) tests can be done. Advance care planning including resuscitation wishes and healthcare power of attorney may be discussed.

Effective and efficient communication between home health personnel and the home-based medical provider optimizes care. Non-emergent home health communications can be called to the home-based medical provider’s office or sent electronically and dealt with during non-patient care time. There should be guidelines for emergent communication that can include calling the home-based medical provider directly. Effective collaboration can reduce hospitalizations. The rate of hospital readmission within 30 days of initial discharge to home health has remained high at 28 % [12]. Home-based medical providers can work with HHAs to provide better primary care and more timely acute care in the home to reduce unnecessary readmissions [13].

Knowledge of home healthcare reimbursement can help home-based medical providers work more effectively with agencies by understanding financial limitations and incentives that can affect patient care decisions. HHAs are paid on a prospective basis. Payment is based on which of 153 home health resource groups (HHRGs) a patient falls into. Determination of HHRGs includes a clinical, functional, and service severity level based on the number of therapy visits during the certification. The degree of impairment and needs in these areas are derived from the OASIS [14]. The 2015 national standardized 60-day episode payment is about $2900 [12]. The great majority of Medicare home health is paid for by Medicare Part A, for which there is no co-pay. Rarely, patients do not have Medicare Part A, in which case Medicare Part B, if available, will cover.

Medicare requires HHAs to cover all medical supplies while the patient is under a home health plan of care. Medical supplies are bundled into the prospective payment. Medicare supplies are classified as routine and nonroutine. Routine supplies are customarily used in small supplies in the course of most home care visits, such as alcohol preps, paper tape, cotton balls and 4 × 4’s, and infection control protection such as non-sterile gloves, masks, and gowns. Nonroutine supplies are identifiable to an individual patient, are furnished at the direction and order of the patient’s physician, and are specifically identified in the plan of care. Examples of nonroutine supplies include more complex dressings, intravenous supplies, ostomy supplies, and catheters and catheter supplies. The cost of non routine supplies is also factored into the prospective payment. If supplies are still needed when the patient is discharged from a HHA, the HBPC provider needs to arrange for them, often from a Medicare Part B supplier.

Understanding that the HHA is responsible for supplies can help the medical provider order cost-effective wound care products. Dressings that require less frequent nurse visits can help reduce HHA costs. It is also important to realize the current system to determine prospective payment favors patients with high therapy needs but low nursing needs. This makes patients with high nursing needs but low therapy needs such as bedbound patients with wounds and significant supply costs more expensive to the agency. HBPC providers need to work with HHAs on these highly complex, high-nursing care patients both to make sure they are cared for in a cost-effective manner and to advocate for them to make sure they get all the care they need.