Tina M. Marrelli*
Home Health Care
Focus Questions
What is the relationship between community/public health nursing and home health care nursing?
In what ways do third-party payers influence care that is provided in the home?
What is the impact of the Patient Protection and Affordable Care Act (PPACA) on home health care?
What is the philosophy of hospice?
Key Terms
Conditions of participation (COPs)
Deemed status
Home health care nursing
Home health care
Homebound status
Home health agencies (HHAs)
Hospice
Interdisciplinary care
Medicare certification
Medicare hospice benefit
Outcome Assessment and Information Set (OASIS)
Prospective payment systems (PPS)
Skilled services
Visiting nurse associations (VNAs)
Home health nurses make up the largest number of nurses in community health work settings (U.S. Department of Health and Human Services [USDHHS], 2010b). Care of ill clients in their homes was an integral part of public health nursing at its inception in the United States (see Chapter 2) and there are numerous reasons that home health care will continue to grow. Advances in technology allow equipment to move from hospitals to homes, which allows more complex care to be provided at home. Health care policies aimed at cost containment in health services encourage care in less expensive settings, including homes. Public demand for quality health care in the home continues.
This chapter describes ways in which home health care nursing incorporates principles of nursing practice that are both old and new. Like all health care settings, home health care is intricately bound to governmental regulations, yet home health care nursing blends concepts of community/public health nursing with holistic disease-focused care.
Trends and statistics reveal the nature and future of home health care. For example, the National Association for Home Care (NAHC) reports that approximately 7.6 million people in the United States require some form of home health care (NAHC, 2008). More than two-thirds (68.6%) of home health care recipients are over age 65. Almost two-thirds (64%) of home health care recipients are women. Conditions most frequently requiring home health care are diabetes, heart failure, chronic ulcer of the skin, osteoarthritis, and hypertension. Medicare remains the largest single payer of home health care services. Medicaid expenditures for long-term care have also shown a trend toward home and community-based care. The percent of Medicaid dollars spent on home and community-based care grew from 27% in 1999 to 45% in 2009 (Eiken et al., 2010). The U.S. Department of Health and Human Services (USDHHS) reports that we can expect to see a very dramatic increase both in the absolute number of elderly persons and in the proportion of elderly persons in the population. The most rapid increases in the number and share of persons 85 years and older will occur between 2030 and 2050, when the baby boom cohort reaches these ages (USDHHS, 2007). The cumulative growth of the population 85 years and older from 1995 to 2050 is expected to be over 400%, and this group will make up nearly 5% of the population in 2050 compared with 1.4% today. In addition, data indicate that as more patients and families are educated about the many benefits of hospice care, its use will grow as an attractive alternative to facing death in a clinical setting (Hospice Association of America, 2010). Hence, home care in all its forms will continue to play a significant role in U.S. health care.
Home care is not a new concept—public health nursing began with the offering of services to sick poor persons in their homes. As early as 1859, William Rathbone of Liverpool, England, set up a system of visiting nurses after a nurse cared for his wife at home before her death. With the help of Florence Nightingale, Rathbone started a school to train visiting nurses at the Liverpool Infirmary. The graduates were prepared to help the sick poor in their homes.
In the late 1800 s, the United States experienced rapid urban growth fueled by large waves of immigration to America. Poor living and working conditions gave rise to problems of hygiene and communicable diseases. Visiting nurse associations (VNAs) were developed in the United States by philanthropists, usually wealthy women who wanted to assist the poor in improving their health. Like their counterparts in England, VNAs focused their services almost exclusively on ill people who were poor.
The first VNA in the United States was established in 1885 in Buffalo, New York, and was followed closely by VNAs in Boston and Philadelphia. At this time, agencies operated on private contributions. By the early 1900s, care of ill and disabled people in their homes was the traditional form of health care for most people.
From the late 1800 s to the mid-1960s, VNAs were established across the country in major cities and small towns (see Chapter 2). In 1965, home health care changed dramatically with the passage of Medicare legislation through the Social Security Act. VNAs that had previously served the health needs of the poor were used more frequently because home health care was a benefit provided to older adult Medicare patients. No longer did home health agencies (HHAs) rely on the charitable giving of the wealthy for the money needed to provide care. Care also was no longer provided primarily to the sick poor. Medicare legislation changed the populations that received home health care as well as the system of paying for that care.
Medicare HHAs continue to undergo change based on regulatory changes. Interestingly, the federal health care reform changes are steps toward integrating care across care settings with an emphasis on prevention, primary care, and the transition points of care. Both individual care and population care are emphasized. Transition points can be defined as the areas of gaps that patients experience when moving or migrating to the next or another care setting. For example, these include hospital to home and home to and from the hospital. Specialized nurses in home care can assist patients to make effective transitions—both with safety and quality factors addressed. Areas that are problematic and costly in transitions include medications, follow-up care, and continuity of the care plan from site to site. Home health nurses (HHNs) have an important role to play in transitions and keeping their patients safe while navigating the complex health care system (Marrelli, 2012a).
In 1967, there were about 1750 Medicare-participating HHAs in the United States; most of these were VNAs and public agencies. In 1995, there were more than 9100 Medicare-certified HHAs, the largest percentage of which were proprietary agencies (freestanding, for-profit home health care agencies), followed by hospital-based agencies. The VNAs that provided many free visits and services continued to care for the indigent patient population while experiencing a loss of paying patients, sometimes to these proprietary and hospital-based agencies. However, the quality of VNA services and the dedication of VNAs to their missions and communities continue to be well-respected and much emulated.
In the early 1980s, in an attempt to curb the increasing costs of hospitalization, a system of reimbursement for hospitals based on diagnosis-related groups (DRGs) was phased in. A significant result of the DRG system was a decrease in the length of clients’ hospital stays and an increased demand for home health care to provide care to clients while they were still recovering from surgery or an illness.
Changes in the health care market, as well as the passage of the Patient Protection and Affordable Care Act (PPACA) in 2010, parallel in magnitude and scope the changes that took place when the Medicare legislation was initially passed. These changes have had a significant impact on the way the home care system has developed and the way in which home care nurses provide and manage care.
Home health care continues to be viewed as not only the most preferred way to provide care to clients but also the most cost-effective. The Nursing Home without Walls (NHWW) program in New York state was designed to provide home health care services to eligible clients to prevent institutionalization in nursing homes. The cost of services for clients in the NHWW program has consistently been half of the cost of corresponding institutional care (NAHC, 2003).
Medical technology has developed so that clients can receive more complex, highly technological care at home. Bulky equipment that was difficult and impractical for use in the home has been modified so that it is smaller, portable, and user-friendly. For example, clients can receive continuous parenteral nutrition using a feeding system that is stored in a pouch resembling a fanny pack. Patient-controlled analgesia pumps that resemble a beeper can be worn by clients on belt straps. This and other technology have enabled some clients to maintain daily activities, including work and school.
Advances in telehealth have also moved forward the delivery of home health care nursing to clients (Arnaert & Delesie, 2007). Telehealth is the use of remote computer equipment to monitor the condition of a client and relay information over a telephone line or wireless connection back to a central nursing station. Clients can use sensing devices to monitor blood pressure, respirations, pulse, arterial oxygen saturation, weight, and such and have that data transmitted to the home care nurse regularly and as needed, based on the client’s condition. Telehealth has had an impact on client hospitalization and emergency department visits as well as nurse performance, satisfaction, and retention (Tweed, 2003). Most importantly, telehealth and its ultimate expression, telecare, place the home health nurse and patient/family in a virtual environment of care that we are just beginning to understand (Rice, 2003).
Clients and caregivers have recognized the positive therapeutic effect that home care can have on the client. No matter how receptive or competent hospital staff may be, the hospital environment is foreign and antiseptic compared to one’s own home. Adults who are ill may be comforted by the familiarity of their homes and control over the environment. For children, the ability to remain at home and be an integral part of the family in the presence of severe illness is critical to their development.
For some clients, home care prevents the need for admission to a hospital or nursing home. Other clients may enter an inpatient setting and return to their homes to receive home care after hospitalization. An understanding of the home health care system is essential to effectively and economically assist clients through the continuum of care from home to hospital and back to home again.
Definitions
The term home health care conjures up a variety of images. Many professional organizations involved in home health care, such as the NAHC or the Visiting Nurses Associations of America (VNAA), have developed their own definitions. Traditionally, home health care includes an arrangement of services provided to people in their places of residence. The following comprehensive definition has been offered by Warhola (1980):
Home health care is that component of a continuum of comprehensive health care whereby health services are provided to individuals and families in their places of residence for the purpose of promoting, maintaining, or restoring health, or of maximizing the level of independence, while minimizing illness. Services appropriate to the needs of the individual patient and family are planned, coordinated, and made available by providers organized for the delivery of home care through the use of employed staff, contractual arrangements, or a combination of the two patterns.
Home health care services can be classified into two broad categories: professional and technical. Professional home health care is practice driven—that is, the boundaries of practice are determined by legal and professional standards with a basis in scientific theory and research. This type of home care is provided by professionals with licenses, certifications, or special qualifications. Home health care nursing is an example of professional home health care (Humphrey & Milone-Nuzzo, 2000).
Technical home health care is product driven and these providers do not always have standards, regulations, or licensure that guides their practice. Instead, they follow reimbursement guidelines outlining their payments. Technical home health care providers include durable medical equipment suppliers.
Varying types and models of home health care providers are necessary to ensure comprehensive care to clients. If a client needs oxygen therapy in the home, a supplier is needed to provide equipment such as the oxygen tank and nasal cannula and to service the equipment on a regular basis. The home health care nurse makes home visits to assess the client’s respiratory status and observe for side effects of the therapy and/or for teaching and training. The home health care nurse is also involved in instructing the client and family about special precautions when a client is receiving oxygen in the home. Either provider alone could not meet the client’s total health care needs. Through their collaboration, however, the client can be maintained safely and effectively in his or her own home.
The roots of home health care nursing can be found in the proud heritage of public health nursing. The initial focus of the U.S. public health nurse was on caring for the sick in the home and preventing disease. An emphasis on health promotion and disease prevention with groups rather than individuals emerged by the 1930s. Grounded in the concepts and theory of public health, a specialty called community/public health nursing developed. The Quad Council of Public Health Nursing Organizations has defined public health nursing as more than generic nursing carried out in a nonhospital setting. It is a “synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations” (American Nurses Association [ANA], 2007, p. 72). Inherent in the practice of community/public health nursing is health promotion and disease prevention for population groups, with a family-centered focus. Consideration is given to the environmental, social, and personal factors that affect the client’s health.
The theory and principles that form the foundation for the practice of community/public health nursing are also the foundation for home health care nursing. The client’s family, which can be defined as any significant other of the client, is an integral part of home health care. Family-centered care is critical as the home care provider shifts the responsibility for care from the professional to the patient or the significant other. The individual client as part of the family is influenced by the activities of the family. In addition, the client’s illness in some way affects the other members of the family. Home health care nursing, as a subspecialty of community health nursing, is defined as the provision of nursing care to acute and chronically ill and well clients of all ages in their homes while integrating public health nursing principles that focus on health promotion and on environmental, psychosocial, economic, cultural, and personal health factors that affect an individual’s and family’s health status (Humphrey & Milone-Nuzzo, 2000).
Standards and credentialing
The American Nurses Association (ANA) (2008) has developed standards of practice for home health care to fulfill the profession’s obligation to provide a means for assessing quality of care and to develop measures for improvement of care. Standards reflect the current state of knowledge in the field and are the basis for characterizing, measuring, and providing guidance in achieving quality care. The home health care standards are grounded in the nursing process and are based on the ANA standards for community health nursing. The standards for care, without their interpretive statements, are presented in Box 31-1.
The role of the generalist nurse includes teaching, providing direct care to clients, managing resources needed to provide care, collaborating with other disciplines in the provision of that care, and supervising ancillary personnel. The role of the advanced practice nurse in home care includes such activities as provision of direct care to clients with complex conditions, consultation with other providers, development and evaluation of agency policy, and staff development. The advanced practice role also focuses on supporting and developing the system within which home care services are delivered (ANA, 2008).
In 1992, the American Nurses Credentialing Center (ANCC) approved a certification in home health care at the generalist level of practice (Home Health Nurse). The first certification examination was offered in 1993. In October 1996, the ANCC offered an advanced practice certification examination for the home care clinical specialist (Home Health Nursing CNS). This certification recognized the need for a home care clinical specialist to engage in research, management, education, and consultation as well as to provide direct care in the home. Examinations for both Home Health Nurse and Home Health Nursing CNS were retired in 2005 (ANCC, 2007). Those already certified can renew their certification through professional development and practice hours. Certification as a Home Health Nurse is not available for new applicants (ANA, 2008).
Home Health Care Today
Although home health care providers have been delivering high-quality health care to clients in their homes since the late 1800s, most growth in home health care nursing has taken place since 1970. As described earlier, this growth is due in part to the enactment of Medicare legislation in 1965, and growth is largely due to the influence of managed care, patient choice, and technology. There are many different types of home care agencies that provide various services to clients in their homes. The regulations for operation of such an agency differ from state to state and may also depend on the type of services provided by the agency. Through licensure law, the states set specific rules and requirements for staffing, policies, and practices and establish minimal operating standards for various programs and services.
In some states, only those agencies that provide professional services are required to have a license. For example, agencies that provide skilled nursing or physical therapy services need a license, whereas agencies that provide unskilled service or custodial care (e.g., companion services) may not need a license for operation.
For an agency to be reimbursed by Medicare for services provided to clients, it must become Medicare-certified. In 2006, there were more than 8800 Medicare-certified home health care agencies (NAHC, 2007). Medicare certification means that the agency meets the Medicare conditions of participation (COPs), which are a structure that outlines rules, standards, and criteria established by the federal government. These regulations dictate things such as the type and number of personnel, agency structure, and billing methods. For example, the administrator of a home health agency must be a licensed physician or a registered nurse with at least 1 year of supervisory experience in a home health agency. Because it is a federal program, the requirements for Medicare certification are consistent across the country. Medicare certification is required even in those states that already require licensure for agencies. To maintain Medicare certification, an agency is required to periodically undergo an unannounced site visit by an external evaluator who reviews the agency’s records and makes home visits to determine that the COPs are being met.
State licensure laws are usually written to identify the minimum standard for patient safety and quality of care that an agency must achieve. Medicare certification standards are slightly more rigorous than licensure standards and regulations. Agencies that want to further define the quality of their services to their clients and the community may also seek voluntary accreditation, which is a rigorous process in which an agency seeks to be evaluated on the basis of comprehensive criteria that influence the quality of care. The cost of this process is assumed by the home health care agency. An agency that is accredited seeks to demonstrate to consumers that it exceeds the minimum standards for operation and has achieved a standard of excellence that is superior to that of its nonaccredited competitors.
There are three accreditation programs for home health care agencies in the United States: 1) the Community Health Accreditation Program (CHAP); 2) the Joint Commission; and 3) the Accreditation Commission for Health Care (ACHC). These programs require the agency to conduct a thorough self-evaluation based on identified objectives and to compile a self-evaluation report that is reviewed by a group of professionals. An unannounced, on-site survey is also conducted by peer reviewers as part of the review process. Based on review of the self-evaluation report and the site visit, which includes home visits to clients, record reviews, and other processes, the accrediting agency determines whether the agency achieves accreditation.
An accredited home health care agency is considered to have deemed status, which refers to the Medicare COPs. Because accreditation standards are more rigorous than the Medicare COPs, an agency that meets accreditation standards is deemed to have met the Medicare standard as well.
Types of Agencies
There are many different types of HHAs. In the early days of home health care, services were likely to be delivered by a nurse from a VNA. In some parts of the country, this continues to be true. In most of the country, however, the mix of home health care agencies more commonly includes other types of agencies, such as official, proprietary, and/or hospital-based agencies. Some are a blend of types.
Official Agencies
Official or public agencies are supported by tax dollars and are given power through statutes enacted by legislation. An example of an official agency involved in home health care is a state or local health department with a nursing division or a HHA. Home health care services (care of the sick) and traditional public health nursing services (preventive care) may be combined in the same nursing division of the health department.
There has been a gradual decline in the number of local health departments with HHAs. Increased competition oftentimes left health departments with the task of caring only for those people unable to pay for services. More importantly, the growth of public health problems, such as bioterrorism and influenza, and maternal and child health needs in high-risk populations, has necessitated that official agencies focus their energy and resources primarily on public health needs.
Voluntary Agencies
Voluntary home health care agencies are governed by a volunteer board of directors and are supported primarily by nontax funds such as donations, endowments, United Way contributions, and reimbursements from third-party payers (e.g., Medicare, Medicaid, and private insurance). They are considered to be community-based because they provide services within a well-defined community or geographical location.
Because voluntary agencies have a charitable mission and are nonprofit, they are tax exempt. Nonprofit status is not exactly what the name implies. An agency that is nonprofit must operate in a fiscally responsible manner designed to either break even or end the year with a surplus. Nonprofit status means that the accrued profit goes back into the functioning of the agency to support its mission in the form of free client care, staff development, or capital expenditures. A nonprofit agency that continually runs a fiscal deficit will soon be out of business. An example of a voluntary agency may be a VNA.
Private Agencies
Private home health care agencies can be either for-profit or not-for-profit. Private not-for-profit home health care agencies are governed by either a board of directors or the agency’s owner. Most private agencies are proprietary, which means they plan to make a profit on the home care they provide. Proprietary agencies make up the largest percentage of HHAs and can be locally owned or part of a national or international chain. Unlike in voluntary agencies, the profit made on home care goes to either the stockholders of the corporation or the owners of the company and therefore is not tax exempt. There is no requirement that the profits be returned to the agency. The stockholders or the owners determine how profits are allocated.
Hospital-Based Agencies
Hospital-based home care agencies allow collaboration to facilitate the movement of the client across the health care continuum. A hospital-based home health care agency is governed by the sponsoring hospital’s board of directors and may receive most of its referrals from the sponsoring affiliated hospital.
Home Care Aide Agencies
A home care aide agency or “private duty” organization provides paraprofessional services such as homemaking, nonmedical care, companionship, or custodial care to clients. These agencies are usually privately owned and receive direct payment from a client or a private insurance company.
Certified Hospice Organizations
Many communities have hospice organizations that provide hospice care to the terminally ill in the community. These organizations may have received certification from the federal government as a Medicare hospice provider. Like home health, there are specific COPs for hospices to be Medicare-certified. Hospices can also be accredited. Hospice home care has grown as a result of a trend toward improving end-of-life care in the home. In 2006, there were over 3000 Medicare-certified hospices (NAHC, 2007). Some hospices are “freestanding” and serve only hospice clients, whereas others are part of a larger organization, such as a VNA. Reimbursement for hospice care is provided by Medicare, Medicaid in most states, and private insurance companies.
Types of Services
Home care services are traditionally divided into three categories of service: 1) care of the ill, 2) public health (also known as preventive care), and 3) specialized home care services (e.g., high-technology care). Although each category is unique, the categories are not mutually exclusive either in theory or in practice. In theory, they are not mutually exclusive because high-technology care, such as care for a ventilator-dependent client, may also be part of the program for care of the ill. In practice, when a home care nurse visits a 60-year-old woman who needs wound care, the nurse also provides instruction about the need for routine preventive health care measures (e.g., mammogram and Pap smear test, influenza or other immunizations) in addition to performing (assessing, managing) the wound care.
Care of the Sick
Older adults are the largest population in home health care. These patients require specialized services to improve their health outcome(s) and/or prevent hospitalization(s). Most of the care for qualified clients is covered by a third-party payer, such as Medicare, Medicaid, or a private insurance company.
Public Health Services
Public health services focus on the promotion of health and the prevention of disease. They include such services as instruction for a new mother on how to care for an infant, physical examinations for children, and diet teaching or immunizations for older adults. Although VNAs were founded on the principles of public health services, most home health care agencies do not provide traditional public health services. Traditional third-party payers do not reimburse home health care agencies for care that is exclusively preventive. The home care agencies that do provide public health services usually fund these programs through money donated to them from the jurisdiction in which the services are provided or through private donations or grants.
Specialized Home Care Services
Specialized home care practice includes such programs as pediatric care, psychiatric mental health care (Freed, 2006), cardiac care, pediatric high-technology care, and hospice care. Home care has grown in response to shortened hospital stays of clients and the need to reduce health care costs related to treatment in the hospital. Technology that was previously available only in the hospital has been adapted for use in the home. For example, clients who would previously have had to remain hospitalized to receive long-term antibiotic therapy may now receive it at home as a result of changes in infusion technology.
However, not all clients or situations are suited for high-technology home health care. Discharging a client who requires high-technology care to the home requires thorough assessment of the client, the caregiver, and the home environment. This can be accomplished through the collaborative efforts of the discharge planner in the hospital and the home care nurse who will be involved after discharge. Before the client is discharged, decisions must be made and plans developed. To evaluate the client’s suitability for discharge home, the home health care nurse and the discharge planner in the hospital should discuss the following questions before the client is discharged (Humphrey & Milone-Nuzzo, 2000):
• What kinds of services or care does the individual client/family need or want?
• What is the availability of equipment, supplies, and expertise?
• What is the availability of financial resources to pay for the proposed services?
• What is “covered” care—from the payer/insurance perspective?
Pediatric programs can focus on providing short-term care to the acutely ill child (e.g., total parenteral nutrition for a child after bowel surgery) or providing long-term care to the chronically ill child (e.g., care for a child with failure to thrive or home ventilator care for a child with a respiratory condition). Whatever the need, there is significant benefit to providing care to children in the home rather than in an institution. Unlike in the hospital setting, at home a child’s development tends to advance, even in the presence of a debilitating or chronic illness. In addition, children at home have fewer infections, and socialization occurs more rapidly (McEvoy, 2003). The appearance of normalcy has a positive impact on the ill child as well as on other family members. Funds for pediatric home care come from Medicaid, private insurance carriers, local community organizations, and private foundations or state entitlement programs (see Chapter 27).
Some agencies deliver psychiatric and mental health services to clients in their homes. Medicare guidelines for the reimbursement of care for psychiatric clients require that the client be under the care of a physician (not necessarily a psychiatrist), that the evaluation and psychotherapy needed by the client require the care of a nurse with psychiatric training, and that the client meet all the requirements for Medicare home care services, which include being homebound and needing intermittent, part-time care that is reasonable and necessary (Freed, 2006). Other agencies have developed psychiatric home care programs for both children and adults to meet the increasing demand for psychiatric care in the home. These services may also include care related to Alzheimer disease, other dementias, and depression (see Chapter 33).
Other specialty programs such as cardiac, diabetes, or oncology programs may be developed in response to the identification of a large number of clients (population) with a particular problem, or need by the referral source or an insurance company with which the agency contracts. These specialty programs generally consist of a defined set of services and identified client outcomes, with a price designated for the package of services. Often, the package involves some level of specialty nursing practice for the design of the plan of care. Hospice home care as a specialty service is described in detail later in this chapter.
Reimbursement Mechanisms
Home health services are reimbursed by both commercial and governmental third-party payers as well as by individuals. Governmental third-party payers include Medicare, Medicaid, the Civilian Health and Medical Program of the Uniformed Services (now TRICARE), and the Veterans Administration system. These programs have specific conditions that must be met for services to be covered. Commercial third-party payers include insurance companies, health maintenance organizations (HMOs), preferred provider organizations, and case management programs. Commercial insurers may allow for more flexibility in their requirements than does Medicare. For example, the home care nurse may negotiate with an insurance company to obtain needed services for the client in the home, based on the cost-effectiveness of the home care plan.
Home care costs may be reimbursed either after the services are provided (i.e., retrospective reimbursement) or before the services are delivered based on the anticipated cost of providing care (prospective payment) (see Chapter 4). In the retrospective payment method, an agency makes a determination about the client’s care needs, provides the needed care within the agency’s interpretation of the guidelines of the third-party payer, and then bills the payer for the services delivered. At times, third-party payers will question or deny payment for the care provided. If it is determined that the provided care is not reimbursable, the agency must assume financial responsibility for that care provided.
In a prospective payment system (PPS) model, the agency is reimbursed based on the anticipated cost of providing care. Using a variety of factors, including a standardized assessment tool, the cost of the care for a client is calculated. The agency that provides care efficiently and discharges the client to self-care in a shorter amount of time and with a smaller number of visits than expected may see efficiency rewarded financially. If a patient takes more visits than anticipated, the agency has to provide the care and assume this risk and the financial costs.
Medicare
Medicare is a federal insurance program for adults (65 years of age and older). It also is for persons with end-stage renal disease, and persons disabled for more than 24 months in the United States. Because it is a federal program, procedures and qualifying criteria should not vary significantly from state to state. To be eligible for this program, a person or his or her spouse must have contributed to Social Security through payroll deductions. The Centers for Medicare and Medicaid Services (CMS), a department of the federal government, regulates payments for services under Medicare (see Chapters 3 and 4). The rules developed by CMS that guide the Medicare home care program are detailed at the CMS Home Health Agency Center (http://www.cms.hhs.gov/center/hha.asp). CMS contracts with insurance companies to process the Medicare claims submitted by home care agencies; these insurance companies or contractors are Medicare Administrative Contractors or MACs.
In 1997 the Balanced Budget Act (Public Law 105-33) (U.S. Congress, 1998) mandated a prospective payment system (PPS) for home health agencies beginning in October 2000. Most other health care organizations, including hospitals (DRG), nursing homes, and hospice, were already PPS models. In the prospective payment model of home care, each Medicare client is assessed on admission by the home care nurse or physical therapist using a set of standardized criteria called the Outcome Assessment and Information Set (OASIS) (Health Care Financing Administration, 1999) (Box 31-2). This instrument consists of many questions, of which a specific number are used to determine the home health resource group (HHRG) in which the client will be placed. These OASIS-C items are based on the clinical, functional, and service needs of the client. A specified dollar amount is attached to each of the possible HHRGs based on the anticipated complexity of the clinical situation. For example, for care of clients in one HHRG, the reimbursement to the home care agency may be $2100, but for those in a different HHRG, which represents a more complex clinical situation, the reimbursement to the agency may be as high as $5000.
“CMS has emphasized the importance of OASIS accuracy. The OASIS-C Guidance Manual details the required data quality audits… the first and foremost question every clinician should ask is ‘Does the comprehensive assessment, including the OASIS data elements, accurately reflect of the acuity of the patient?’ The challenge for the clinician is to determine the optimal interventions/best practices and discipline mix within the organization’s resource constraints.” (Marrelli, 2012b, p. 97)
Managed Care Considerations
In a Medicare managed care model, the Medicare client enrolls with an HMO provider to receive care. The HMO makes specific arrangements with one home care agency or a group of agencies to provide care when needed. The home care agency may be paid a capitated rate; that is, a set amount based on the number of people enrolled in the managed care program. For example, if the home care agency is responsible for 100 clients and is paid $10 per client per month, the income to the home care agency will be $1000 per month. If 1000 people enroll in the HMO, then the home care agency will be paid $10,000 per month. The home care agency is responsible for providing care to the enrollees who need home care services. It is anticipated that many of those enrollees will remain healthy and will not require home care services. Home care nurses are responsible not only for treating those people who are sick but also for making sure the healthy enrollees stay well.
Criteria for Reimbursement under Medicare
There are specific criteria a client must meet to be eligible for Medicare home care services. A Medicare beneficiary must meet all of the following criteria to be covered under the Medicare Benefit:
1. Is provided services by a Medicare-certified HHA.
2. Is homebound. A client must be considered essentially homebound to be eligible for home care benefits under Medicare. Homebound status means that the client has difficulty with mobility and can leave the home only with considerable and taxing effort. CMS defines homebound as the patient having “a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort. If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment” (CMS, 2011). The criteria for homebound status may also be considered met if the client attends adult daycare and the purpose of attending is related to the client’s receipt of medical care.
5. Services are reasonable and necessary. Under Medicare, services provided to a client must be considered “reasonable and necessary.” This term refers both to the nursing care clients receive to effect a positive health outcome and to the frequency with which that care is provided.
• The care is appropriate to the client’s diagnosis.
• The care meets generally accepted professional standards.
• There is physician certification and oversight of the patient’s plan of care.
• The care meets new requirements based on Federal laws and regulations (e.g. face-to-face).
The decision about whether these criteria are met is based on the client’s health status and medical needs as reflected in the plan of care and the medical record. For example, daily visits may not be deemed reasonable for a client who requires twice-weekly blood glucose level determinations. Similarly, if a care plan has been ineffective over a long period of time, continuation of that care plan would not be considered reasonable. Therefore, comprehensive documentation by the home health care nurse is essential to validate that the care provided is both reasonable and necessary.
Medicaid
Medicaid is an assistance program for the poor and some disabled. Unlike Medicare, Medicaid is jointly sponsored by the federal government and the states; therefore specific Medicaid coverage differs from state to state (see Chapters 3 and 4). These differences may be dramatic and in some cases are dependent on the state’s financial health. Eligibility for Medicaid is based on income and assets (called “means tested”) and is not contingent on any previous payments to the federal or state government.
Unlike Medicare, Medicaid may cover both skilled and unskilled care in the home and sometimes does not require that the client be homebound (again, based on the state—so varies). To qualify for home care benefits under Medicaid, the client must meet income eligibility requirements, the client must have a plan of care signed by a physician, and the plan of care must be reviewed by a physician, usually every 60 days.
Many states are also changing the way care is reimbursed for the Medicaid population. For example, in Connecticut, the care of women and children receiving Medicaid benefits has been converted to a managed care model of reimbursement. Other populations of Medicaid clients will be transitioned into managed care in an effort to control costs and ensure high-quality care for clients in all phases of health care delivery, including home care.
Commercial Private Payers
Many commercial insurance companies are involved in health insurance for individuals or groups. These local or national companies often write policies that may include a home care benefit. Commercial insurers often cover the same services covered by Medicare in addition to covering preventive, private duty, and supportive services such as those provided by a home health aide or homemaker (discussed later).
Commercial insurance often has a maximum lifetime benefit specified as part of the policy. Because of the high cost of high-technology care, more patients reach this maximum and face the loss of coverage. This has resulted in the development of case management programs administered by insurance companies. The case manager, oftentimes a nurse, projects the client’s long-term needs and costs of care and develops a plan with the client to meet those needs in a cost-efficient manner. Consideration is given to the life expectancy of the client in relation to the maximum lifetime benefit.
Types of Home Care Providers
Interdisciplinary care and collaboration is a hallmark of home health care practice. The home health care team is made up of several, if not all, of the home health care disciplines and specialties discussed in this section. The client’s needs mandate the home care disciplines that may be a part of the home health care team. The standards of home health nursing practice specify that the home care nurse is responsible for initiating collaboration with other providers (ANA, 2008). In addition, collaboration is mandated as part of the conditions of participation for those agencies that are Medicare certified.
The role of the professional in home health care involves both the provision of direct care to clients and consultation with other professionals and paraprofessionals involved in care. For example, a client needing skilled nursing service for a dressing change and assessment of a leg wound may also need some range-of-motion exercises for the affected extremity. Because of the complexity of the patients referred to home care, the home care nurse may consult with the physical therapist (PT) to suggest some exercises that can be done by the client. Depending on the patient and the collaboration between the therapist and the nurse, the physician may wish to consider a PT consult. The nurse in home care is often the clinician who identifies other patient needs and initiates the discussion that may trigger referrals for other services (e.g. PT, occupational therapist, Medical Social Worker, aide).
Home Health Care Nurse
Nursing services are the most frequently provided skilled service in the home. Nursing care in the home is provided by a registered nurse or a licensed practical nurse, is authorized by a physician, and is based on the client’s unique needs. A registered nurse must have a physician’s order to initiate and continue care.
Advanced practice nurses (nurse practitioners, clinical nurse specialists, and nurse–midwives) are being integrated into home care practice because of the complexity of the health care being delivered in the home. Advanced practice nurses can provide direct care to patients with complex conditions or serve as an expert consultant to the home care nurse. In addition, they can provide for staff development through education and case analysis. By integrating advanced practice nurses into home care, agencies are hoping to raise the quality of clinical practice and improve patient outcomes (Milone-Nuzzo, 2003).
Primary Physician
Clients receiving care in the home must be under the care of a physician. For Medicare HHA purposes, a physician is defined as “a doctor of medicine, osteopathy, or podiatry legally authorized to practice medicine by the State in which such function or action is performed” (CMS, 2005). Although physician home visits were once a widespread practice, physicians rarely make them anymore. The role of the physician in home care is to provide information to the home care provider regarding the medical condition of the client, to serve as a resource to other home care providers, and to certify the patient’s plan of care. The plan of care must be reviewed by the physician at least every 60 days, with more frequent review if a change in the client’s situation warrants it. The PPACA, as of April 1, 2011, requires that each patient has a documented face-to-face encounter with a physician or NP within 90 days prior to the start of care or at other specific intervals.
Physical Therapist
The focus of the physical therapist (PT) in home care is on improving the client’s ability to use his or her large muscle groups. PTs provide maintenance, preventive, and restorative treatment in the home for clients of all ages and with varying diagnoses. The body systems most likely to be associated with the need for home physical therapy are the musculoskeletal, neurological, and cardiopulmonary systems. PTs focus on gross motor skills, the upper and lower extremities, and the respiratory system. They also try to improve balance, range of motion, strength, and conditioning in older adult patients. For example, a client who has suffered a stroke may have home visits by the physical therapist for gait training and the implementation of a home exercise program.
Occupational Therapist
The occupational therapist (OT) helps the client acquire the skills necessary to perform the activities of daily living. Occupational therapists focus many of their interventions on the upper extremities and on the fine muscle skills needed to perform functional activities, such as eating and dressing. In addition to teaching self-care activities, the occupational therapist is involved in assessing the home for safety and suggesting modifications for improving the client’s ability to function more independently. Modifications may include installation of adaptive equipment, such as a grab bar in the bathtub, or modification of existing structures in the home to make self-care possible. For example, the OT may suggest modifications to a kitchen to allow the client to prepare his or her own meals; these might include recommendations for the installation of a sink that allows a wheelchair to fit under it or cabinets that have easily accessed pulls.
Speech Therapist or Speech-Language Pathologist
The speech therapist (speech-language pathologist) works with clients who have difficulty with communication, including both expressive and receptive. The speech therapist’s goal is to help the client develop optimal communication skills. Speech therapists may also work with clients who are experiencing difficulty in swallowing. These might include patients with cancer of the throat or larynx as well as those who have suffered a stroke (CVA).
Medical Social Worker
The Medical Social Worker (MSW) helps clients and families deal with the social and emotional issues associated with illness and long-term care. Often families are unprepared for the adjustments required to care for an ill member. The social worker can be helpful in easing this transition to the caregiver role. Traditionally, MSWs have helped clients identify health and social service needs and have made referrals to community agencies that address those needs. In home care, the social worker also assists clients with applications for services and provides financial assistance information. Social work is appropriate when there is an impediment to the patient’s Plan of Care (POC) being implemented. Examples are when a patient cannot afford medications or food.
Home Care Aide
The home care or home health aide (HHA) is a paraprofessional providing services ranging from housekeeping to complex personal care and assistance with ADLs. Services performed by the HHA include ensuring a clean, healthy home environment; shopping and preparing meals; and grooming, bathing, and performing other personal care. Home health aides are very important to maintaining patients safely at home; they can be the “eyes and ears” of the nurse.
Supervision of aides is primarily the responsibility of the home health care nurse. If the home health care nurse is not directly involved in the client’s care, the nurse may delegate this supervisory responsibility to a professional such as the physical therapist or speech therapist. Medicare mandates that the home care aide be supervised every 2 weeks, which means that the home care nurse visits the client’s home either when the home care aide is present to observe the aide providing care or when the aide is absent to assess the relationship between the aide and the client. Licensure requirements vary from state to state regarding the frequency of supervision for clients not covered by Medicare. In addition, there are annual mandated hours of in-service for aides.
Business Office Staff
Business office staff include bookkeepers, clerks, and computer operators who manage many of the busy daily operations of the business. These include staff who prepare bills, track reimbursements, and maintain the agency’s databases. The business office is integral to an agency’s ability to effectively deliver home care services. A home health agency cannot function without an efficient business office staff that works effectively with the clinical staff. The relationship between the business office staff and the clinical staff is unique in home care. All staff must have an understanding of the financial aspects of the client’s care and be able to provide information to the business staff so that appropriate reimbursement can be obtained for the services provided.
Responsibilities of the home health care nurse
This section focuses on the differences in nursing practice between the home care and inpatient care settings.
Direct Care
Direct care is defined as the actual nursing care that is provided to clients in their homes (Humphrey & Milone-Nuzzo, 2000). Nursing care may involve assessment of physical or psychosocial status, performance of a skilled intervention, or teaching. In performing assessments and skilled interventions, the home health care nurse (HHN) must give consideration to the 24-hour needs of clients. Integration of the client, family, and caregiver into the care plan is essential to ensure continuity of care during the time the nurse is not in the home. HHNs generally provide care on a short-term, intermittent “visit” basis (see Chapter 11). Most care provided in the home may be the responsibility of someone other than the nurse. Therefore, teaching family or other caregivers becomes a common skill performed by the HHN. Nurses are responsible for providing the client and family with the necessary knowledge and skills to provide safe care between home visits by nurses and other team members, and after discharge from the organization.
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