Skilled Intermittent Home Care
The key point is that this is skilled care and it is intermittent; therefore, it is not custodial or long term. A skilled need is defined as being something that takes the skill of a registered nurse or physical therapist to perform. In many cases, the nurse or therapist will be instructing the patient or caregiver how to perform these duties for the patient and reducing the frequency of visits to supervise, evaluate the care and outcomes, and revise the care to meet the ongoing need. These duties are provided under the direction and orders of a physician.
The visits are intermittent and last for an average of thirty minutes to an hour. The frequency of visits usually ranges from once or twice a week to once or twice a day as the skilled need dictates.
In the majority of cases, the object is to get the patient or family independent in the care as soon as possible and to reduce the frequency. Home care is, in general, thought of as a bridge between an acute level of care such as a hospitalization and complete independence as far as healthcare issues go. It is not meant to be an intense and long-term service, nor does it meet custodial needs.
Medicare (both standard and managed-care plans), Medicaid, and private insurance provide reimbursement for home care for patients who qualify. For Medicare there is no copay from the patient; however, for share-of-cost Medicaid patients there may be a fee, and most private insurance providers have copays for home-care services. Medicaid, HMO Medicare plans, and most private insurance plans usually require prior authorization for home care and may have set limits on the number of visits a patient can have in a given time period. These numbers are cumulative, so from one episode of care to another, the limits can be reached quickly if not carefully planned out.
Medicare reimburses home-care agencies in a lump sum based on a number of factors including diagnosis and functional limitations of the patient. Medicare requires the patient to be homebound. Homebound means that it takes a taxing effort for the patient to leave home, and therefore he could not go to the doctor, clinic, or other outpatient setting for this care. The patient doesn't have to be bedbound, and the homebound status can be temporary due to this spell of illness. It does not mean that the patient doesn't drive or has no means of transportation; lack of transportation does not equal homebound.
Besides being homebound, Medicare requires the care to be skilled and have a specific ending point. The patient must demonstrate the potential to make measurable gains such as significant rehabilitative progress, and the care must be ordered by a physician. The care must be provided by a Medicare-certified home-health agency.
Medicaid and private insurance companies don't always require the patient to be homebound, but they usually expect the other guidelines to hold true. In fact, in many instances they will pay for more visits because it is more cost effective than being hospitalized or going to an outpatient setting for the care, even if the patient is not homebound.
Home care is often initiated after a hospitalization, but it can be ordered at any time by a physician. The discharge planner or case manager at the hospital will recommend the physician order home care at discharge for follow-up care and will make the referral. If not hospitalized, a patient can make a request for home care from his physician or the physician may suggest the care so the home-care nurse or therapist can provide her with a bird's-eye view of the home situation.
Most commonly, home care is ordered if the patient is going home with surgical or other wound dressings that need changing, requires intravenous antibiotics, or continues to need a pain-management device such as a PCA pump. Diabetics newly on insulin might need a home-care nurse to visit daily for a few days to instruct in glucose testing and insulin administration.
Physical therapy visits are usually ordered for patients after joint-replacement surgery or fracture repairs. They could also be ordered for patients who need home-safety evaluations and instructions, especially anyone who has been significantly weakened by the hospitalization or the underlying disease or has a reported history of falls with or without injury.
Other home-care services include:
Occupational therapists
Speech therapists
Home-health aides
Medical social workers
Occupational therapists provide such care as education in energy conservation, home safety issues, and adaptive equipment for assistance with dressing, grooming, bathing, and other activities of daily living. This would include such things as long shoehorns, reachers, and devices to help button clothing. They can also help designate proper placement of grab bars.
Speech therapists typically work with patients who have impediments from such things as strokes. They also work with patients who have cognitive-thinking issues that can result from strokes, early dementia, or the after effects of chemotherapy and other treatments.
Home-health aides primarily assist with bathing and grooming services, but they can also provide some limited personal laundry services, meal preparation, bed-linen changing, and assisting with ambulation or exercises prescribed by the physical or occupational therapist. A home-health aide is a certified nurse's aide who has additional training to work in the home.
Medical social workers provide services such as assistance with short-and long-range planning by providing community resources and assisting with applications for Medicaid or other medical or financial assistance programs. They can also provide counseling services for coping with life changes and loss. In instances of neglect or abuse, they can assess and make appropriate reports as well as assist families in correcting such circumstances.
Hospice care is another branch of home-health care and will be discussed in Chapter 16.
Anytime there is a significant change in condition or a new care-giving situation, a home-care referral can be beneficial to instruct the patient and caregivers in safe care, medication safety, and other safety issues. If the situation doesn't meet reimbursement guidelines, most home-care agencies offer the services on a fee-for-service basis. One visit from a physical therapist could provide sufficient education to prevent a novice caregiver from suffering a back injury, and the cost is worth its weight in gold.
