A. Throughout history, medical care was provided in the home by family members, with some guidance from outpatient or home visiting professionals.

B. During the second half of the 20th century, medical practice shifted from this home-based model of care to the acute hospital-based care model. This allowed medical practice to expand its knowledge, widen its services, and improve individual outcomes and dramatically increase life expectancy.

C. As medical care costs have dramatically increased, they have brought about the necessity of controlling costs.

D. Hospitals have found that using interdisciplinary health care teams to collaboratively develop posthospital discharge and transition plans for their patients can confidently reduce length of stay without compromising patient safety and quality of care. These teams are best facilitated by case managers, as formal or informal leaders, to produce the most cost-effective care outcomes.

E. Home health care, when appropriate, serves two vital functions in reducing costs and limiting length of stay in institutional settings:

F. Case management in the home health care setting is designed with similar goals in mind as those of case management in the acute care setting (Box 7-1). An overarching goal is ensuring the delivery of reliable, consistent, and cost-effective home care services to help the home care client achieve and maintain overall health and wellbeing, with reasonable degree of independence and self-care or self-management.

G. Patients who are eligible for home care services include those who were hospitalized in an acute care/hospital setting, those with chronic illnesses, or those with seriously complex medical conditions or injuries.

H. The demand for home care case management services has increased since the implementation of the federal home care PPS, the increase in managed care health insurance plans and capitation, the popularity of demand management programs, the growth of integrated care delivery systems, value-based purchasing, and the Patient Protection and Affordable Care Act of 2010, including CMS’ Hospital Readmissions Reduction Program.

A. Advance Request Payment—A home care services claim submitted at the completion of the initial assessment of the patient, upon admission into home care services, and at the completion of an initial Outcome and Assessment Information Set (OASIS) score. This claim includes a partial payment amount that does not exceed 60% of the specific Home Health Resource Group (HHRG)-designated reimbursement.

B. Certified Home Healthcare Agency (CHHA)—A company that meets all the eligibility criteria required by CMS before it is permitted to provide home care services for Medicare beneficiaries.

C. Custodial care—Care provided primarily to assist a patient in meeting the activities of daily living, but not requiring the services of a licensed professional, such as bathing and eating.

D. Home care—Health care services that are provided to patients while in their own homes. These services may include professional (i.e., skilled) and paraprofessional (i.e., supportive) services.

E. Home Health Resource Group (HHRG)—Groupings for prospective reimbursement under Medicare for home health agencies. Placement into an HHRG is based on the OASIS score. Reimbursement rates correspond to the level of home health services provided.

F. Homebound—Being confined to the home setting all (or almost all) the time. A patient who is considered homebound is only able to leave the home very infrequently and for short periods of time. Leaving the home requires a considerable or taxing effort with or without help. An example is a patient who experiences an unbearable and extreme effort to leave the home just for a clinic visit or to receive some sort of medical treatment.

G. Intermittent services—Care that is provided on a part-time basis; that is, for a portion of hours in a day and for few days of the week; for example, home care services provided by a nurse for 1 to 2 hours per day, 1 to 3 days per week.

H. Nonskilled services—Health care services that are provided by a paraprofessional or an unlicensed person. Examples of these services may include close observation, bathing, feeding, and transferring from bed to chair.

I. Outcome and Assessment Information Set (OASIS)—A uniform and standardized set of home care services-related outcomes data used by the CMS to examine the quality of home care services received by Medicare beneficiaries. The set includes clinical, financial, and administrative outcome indicators and is used by home health agencies for quality improvement.

J. Reasonable services—Services provided based on a patient’s medical condition, acuity and severity of the disease, and the course of treatment meets what is described in national guidelines or standards.

K. Skilled services—Health care services that require delivery by a licensed professional such as a registered nurse, social worker, and physical, occupational, or speech therapists. Examples of these services may include wound care, vital signs assessment and monitoring, patient and family education, Foley catheter care, psychosocial counseling, physical rehabilitation, and intravenous medications administration.

A. The Case Management Society of America (CMSA) describes in its standards of practice for case management that case management extends across all health care settings across the continuum of care and patient populations. This also includes home care settings and care of patients while at home (CMSA, 2010).

B. The practice of case management in all care settings results in availability of case managers in these settings. Therefore, case managers in the home care settings may apply the CMSA standards in their practice, in addition to the organization-based policies, procedures, and guidelines.

C. Case managers in home care settings are often registered nurses. Sometimes, social workers function in the role of case manager, especially for patients with behavioral and mental health conditions. In these situations, nurses collaborate with social workers, especially during the initial assessment of the patient, which takes place during the first home visit.

D. Case managers who are nurses may assume responsibilities for both direct care provision and case management services.

E. Having awareness and knowledge of CMSA’s standards of practice for case management allows case managers to gain more comfort in their roles and contributes to greater effectiveness. The standards may be used as a guide to identify expectations and assure appropriate focus of the role, especially in an environment of scarce case management resources.

A. The primary care physician (attending physician of record), in cooperation with consulting physicians (i.e., specialty care providers), has responsibility for discharging a patient to home or transitioning to another care setting. All those involved in the patient’s treatment plan, including the nursing staff, the case manager, the social worker, and the home care agency team, share in the responsibility and liability for providing appropriate posthospital discharge care.

B. Hospital-based interdisciplinary health care teams include physicians, nurses, social workers, care coordinators or case managers, physical therapists, occupational therapists, chaplains, nutritionists, and others.

C. Daily interdisciplinary patient care management rounds provide an effective forum to discuss the medical, financial, spiritual, functional, emotional, and psychosocial issues that impact the posthospital discharge/transition plan.

D. The role of the hospital-based case managers, whether they are called discharge planners or care coordinators, is to assess patient and family needs and available resources for posthospital discharge planning and to assist with linkage to the appropriate community-based providers who can provide services determined to be necessary by the interdisciplinary health care team.

E. Before considering home care services, the interdisciplinary health care team must know that the patient and family would appreciate and agree to a home care referral. The case manager can facilitate such discussion
and follow-up on the referral with the patient, family, and a number of home care agencies depending on the type of health insurance plan the patient holds (i.e., payer).

F. The case manager, in collaboration with other members of the health care team, conducts an assessment of patient needs to identify type of home care services appropriate for the patient’s condition (Box 7-2).

G. For a patient to be eligible for Medicare reimbursement of home care services, the patient must:

H. In addition to the assessment of needs, the case manager must: