Frequently Asked Questions About Home Care

• Who uses Home Care?

• Who provides Home Care?

• Do I (or a loved one) need Home Care?

• What types of services can Home Care Providers deliver?

• How do I find a Home Care provider?

• What questions should I ask about a home care provider?

• Who pays for Home Care?

• What are my rights as a Home Care recipient?

• What do I do if a problem develops?

• What is Home Care's role in the Health Care System?

Each year home care agencies provide over 700 million visits to Americans who need in-home health care and assistance. These consumers include patients of all ages requiring medical and non-medical home care services. The elderly are the largest segment of this market. Pediatric and maternal home health programs are very popular and growing alternatives to hospitalization. Disabled individuals receive assistance from home care providers that allow them to lead very productive lives.

Consumers who may benefit from home care:

• Persons discharged from the hospital who are not fully recovered;

• Persons with chronic conditions such as diabetes, kidney disease, or stroke, which require frequent monitoring;

• Persons with terminal disease, such as cancer or AIDS, who need personal care, pain management, and emotional support;

• Persons with limited mobility who need assistance with activities of daily living;

• Families that need respite from care giving and emotional support in dealing with a loved one who needs special care;

• A child with special life sustaining medical equipment who can thrive at home and school with nursing support.

Advantages of home care:

• Allows for early discharge from hospitals and prevents or postpones institutionalization;

• Provides an extension of the physician into the home, which imparts confidence and peace of mind. Home care agencies are the physician's "eyes and ears" in the home. Monitoring of patients allows for early diagnosis of complications or infections.

• Offers personalized, one-to-one care, tailored to the needs of each individual and allows maximum freedom for the client;

• Is cost effective care compared to hospital or nursing home care;

• Supports (does not replace) the family's efforts in caring for loved ones at home; and

• Allows individuals to maintain their independence in their own homes.

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Home care services are delivered by over 19,000 providers nationwide. Home care agencies are categorized by type of services delivered, and ownership or affiliation. Agencies range in size from very small agencies that care for a hand full of patients to national chains serving tens of thousands of patients. Agencies can operate on a for-profit or a not-for-profit basis. Only agencies that are Medicare certified may provide services reimbursed under the Medicare home health benefit.

Types of agencies include:

• Freestanding - agencies that are not affiliated with a hospital or chain operation. These agencies are usually for profit and are operated by local owners.

• Hospital Based - agencies are owned or operated under contract for a hospital or chain of hospitals

• Hospital Affiliated - affiliated agencies serve the patients of the hospital, but do not share common ownership or management control.

• Visiting Nurses Association (VNA) - agencies are not-for-profit and are typically locally owned and operated by a charitable foundation. VNAs operate in most metropolitan areas and serve surrounding rural areas.

• Franchises - home health agencies that are part of a national or regional franchise operation. Franchises are usually locally owned and operated by the franchisee with support and expertise lent by the franchiser.

• Chains - agencies that operate in multiple markets under common ownership and management control. There are national, regional and state chains serving most of the country. Many times these chains have contracts with the larger insurers and HMOs to provide home care services over a large geographic area.

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Generally, home care is appropriate whenever an individual prefers to stay at home, but requires ongoing care or assistance that cannot be easily or efficiently provided solely by family and friends. Many people prefer to stay at home rather than go to a hospital or nursing home when they can no longer manage their own care without assistance.

Assessing the care recipient's needs will assist in determining if home care is appropriate. Review the following questions. If the answer to any of the questions below is "yes", then the individual would likely benefit from home care services.

• Does the individual need assistance with activities of daily living - those activities such as bathing, dressing, and eating that people usually do independently?

• Does the individual require ongoing medical treatment such as IV therapy or wound care, or assistance with medical equipment such as catheters, ostomy bags, or prostheses?

• Do you or the family have concerns about safety issues with the individual being alone in the home?

• Does the individual suffer from loneliness, isolation, depression, or need for companionship?

• Are the individual's family and friends unable to meet his/her needs without significant stress themselves?

Early warning signs that a person needs in-home care include:

• Difficulty with walking

• Difficulty with activities of daily living

• Falling at home

• Errors with medication

• Confusion

• Depression

• Weight loss

• Disheveled appearance

• Frequent, nonspecific phone calls

• Frequent visits to the Emergency Room and/or frequent hospitalizations

• Expressed family concerns about the individual

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Agencies may provide one or a combination of the following types of services:

• Medicare Certified Medical Services - these include skilled nursing care, physical therapy, occupational therapy, speech therapy, and services of home health aides and medical social workers.

• Non-Medicare Medical Services - can include services certified by a physician as medically necessary and custodial care, but most commonly involve primarily nursing care and therapies.

• Home Infusion Services or IV Therapy - these services allow the patient to receive intravenous therapy in the home. This includes various kinds of IV drugs, but most often involves antibiotics and chemotherapy.

• Home Pharmacy Services - typical home pharmacy services include administration of IV drugs, other injectable medications, and medications that are administered as inhalants.

• Home Support Services or Private Duty Services (non-medical) - these services include many types of support services that allow the individual to remain safely in the home. Common services include: assistance with ADLs (activities of daily living) such as bathing, grooming, dressing, transferring, toileting, etc. Housekeeping, yard work, minor home repairs and modifications may also be included. Custodial care such as sitters and companions also come under this heading.

• Home Medical Equipment/Durable Medical Equipment - this includes all medical equipment used in the home setting such as: hospital beds, walkers, canes, wheelchairs, commodes, bedpans, orthotics, oxygen, etc.

• Hospice - hospice services are provided to terminally ill patients, generally with six months or less of life expectancy, that have elected to have only palliative care (comfort) measures provided. Hospice professionals are trained to assist patients and families with dying and end of life issues. Hospice services may be provided in the home or in an institutional (inpatient) setting.

The staff of the home care agency may include any combination of the following:

• Registered Nurses

• Licensed Practical Nurses or Licensed Vocational Nurses

• Home Health Aides

• Physical Therapists

• Occupations Therapists

• Medical Social Workers

• Physicians

• Dietitians

• Pharmacists

• Companions, Homemakers and House Cleaners

• Volunteers

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Home care services vary widely from community to community, however there are multiple resources to assist you in locating a provider. You can begin your search with a referral from your doctor or a hospital discharge planner. Medical home care services must be provided under the supervision of a physician: As a result, many home care referrals are made by physicians or their support staffs. If the patient's insurance is through an HMO, you may be limited to pre-approved agencies. Always be sure to ask for a complete list of approved agencies from the insurer. In most cases, home care must be arranged before a patient may be discharged from the hospital or institution.

Family, friends, community services and churches or synagogues may also recommend a home care provider.

It is very important that you understand that you have the right to choose a home care provider. Finding the home care agency best suited to you requires identifying your specific needs. Important factors to consider are availability of services (24 hours a day if needed), geographic areas served, ability to provide specific medical services, non-medical and social services provided, training and expertise of agency personnel, quality of care, agency accreditation and certifications, and coverage provided by insurance.

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When choosing a home care provider, consider the following questions:

• How long has the provider served the local community?

• What type of services do they provide?

• Do the services provided match your needs?

• What is the reputation of the provider?

• Is the provider certified by Medicare? Only Medicare certified agencies can provide Medicare covered services.

• Does the provider have a state license?

• What other credentials does the provider maintain?

• Does the provider have written policies relating to description of services, hours of operation, eligibility requirements, fees, patient rights, confidentiality, complaint procedures, and emergency arrangements?

• How does the provider select employees? Does the provider ensure that employees are operating under written personnel policies, clinical protocols, and malpractice or professional liability insurance? What backup systems are in place to ensure continuity of care?

• Will the agency continue to provide services if Medicare or other sources of reimbursement are exhausted? What back up plans are in place if the agency fails to continue operating?

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Most home care services are paid for by a third party payor, such as Medicare or private insurance, or by individuals or their families. Sometimes payment involves a combination of third party payor and self pay. The most common payors for home care services are:

• Medicare

• Insurance (Managed Care, Traditional, Long Term Care Policies, etc.)

• Medicaid

• Champus

• State Programs

• Workers Compensation Insurance

• Self Insured Employers

• Self Pay

• Other Private Payors

• Private Charitable Organizations

When Does Medicare Pay for Home Care? Medicare Part A (Hospital Benefit) will pay 100% for home care visits if:

• Services are ordered by a physician.

• The patient qualifies as homebound because of illness or injury.

• The patient needs part time or intermittent nursing care, or physical therapy, speech therapy, or occupational therapy. Non-medical home care services, or home health aide services (i.e. personal care), are only covered if the patient is receiving nursing care, physical, speech or occupational therapy.

In addition, routine medical supplies needed by the home health nurse are also covered under the Medicare Home Health benefit.

Services that are not covered include:

• Fulltime nursing care,

• Drugs and IV therapy (with some exceptions),

• Homemaker/housekeeping help, and

• Routine custodial care.

Medicare Part A will pay for Hospice services if the patient:

• Is certified to be terminally ill, with a prognosis of six months or less.

• Understands that hospice care is palliative care that provides comfort, not curative care.

• Elects the Medicare Hospice benefit that waives coverage of other Medicare services for only the terminal diagnosis. Other services provided in relation to conditions other than the terminal diagnosis are covered under the regular Medicare benefit.

Medicare Part B (Medical Insurance) will pay for home visits by your physician, and management of the care plan by your physician, with a 20% co-payment.

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Federal law requires that all individuals who receive home care services be informed about their rights as a care recipient. Many states also have specific requirements regarding patient rights. While the exact wording of these rights may differ somewhat from agency to agency, and state to state, the general principles should be the same. Care recipients' rights are enforceable by law.

A home care recipient has the right to:

• Be fully informed of his/her rights and responsibilities by the home care agency;

• Choose his/her care providers;

• Professional care that is consistent with his/her doctor's orders;

• Know what care he/she will receive;

• Participate in planning care;

• Be admitted to an agency's service only if the agency has the ability to provide safe, professional care at the level required;

• Continuity of care;

• Receive the information necessary to give informed consent before the start of any treatment or procedure;

• Be advised of any changes in the care plan prior to their implementation;

• Refuse treatment and be informed of the possible consequences of this refusal;

• Be informed of the state laws regarding advanced directives;

• Have home care providers comply with properly executed advanced directives;

• Be informed within reasonable time of anticipated termination or transfer of service;

• Be informed of the home care agency's policies and charges for services;

• Know what care will be covered by insurance and what the family or care recipient may have to pay;

• Be referred elsewhere if denial of service is based solely on the patient's inability to pay;

• Suggest changes and voice complaints regarding the agency without fear of reprisal;

• Some forum for recourse if services are denied, reduced, or terminated by the agency against the patient's wishes;

• Be informed of what to do in the event of an emergency;

• Be advised of the state's home health hot line to address questions and complaints about Medicare certified and state licensed home care agencies.

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If a problem develops during the delivery of home care services, or if you are dissatisfied with the care delivered, first notify the home care provider's administrator or chief supervisor. The state health department, state Medicare hot line, and/or the Better Business Bureau will also be able to assist you.

If you suspect fraudulent activity involving the home care agency, you should report this to your state department of health. If a case involves delivery of Medicare home care service, contact the Office of the Inspector General hot line at 1-800-HHS-TIPS.

The Food and Drug Administration, Division of Drug Compliance and Surveillance, regulates home medical equipment companies that provide oxygen. Agencies that provide legend devices are licensed as medical device retailers by the FDA Center for Devices and Radiological Health or the Board of Pharmacy in your state. Concerns and complaints regarding these services should be directed to the appropriate agency:

• FDA Division of Drug Compliance and Surveillance: 301-594-2073

• FDA Center for Devices and Radiological Health: 800-638-2041

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Home care has a unique position in the global health care system. The presence of caregivers within the home allows insight into all of the difficulties, needs, strengths and weaknesses of the individual and his/her support systems. Because home care providers are committed to home-based care, they support community and family involvement in the care process. They will refer to other agencies that will assist in providing care at home. Home care services may allow an individual to avoid institutional care altogether, despite diminishing physical or mental capabilities. Furthermore, home care can provide continuity of care for an individual who requires hospitalization for an acute incident but then is discharged home to fully recover. Home care can act as a link between the care recipient and the physician, and can interface with other healthcare entities such as outpatient services and long term care facilities. For individuals with multiple care needs, home care agencies can coordinate the efforts of the entire care giving team, allowing for a successful home care experience.

Home care has proven effective in reducing the incidence hospitalizations in many patient populations. It provides a safe alternative to institutional care or unsafe situations that arise from patients remaining in the home without assistance or monitoring. Some conditions such as those involving changes in mental status are treated with best results in the home setting. With advances in tele-healthcare and telecommunications, noncompliant patients can often be helped to achieve compliance and better health status with minimal intervention.