Usually, home health care is indicated when patients need monitoring, adjustment of medications, dressing changes, and limited physical therapy. Home health care is commonly used
After hospital discharge (postacute care), although hospitalization is not a prerequisite, particularly for older patients
Home health care can also be used for
Patients with conditions that require many days of hospitalization each year (medically complex care)
Medically stable patients with severe functional impairment (long-term care)
Sometimes patients with acute or chronic problems
Sometimes patients who are dying (end-of-life care)
Home health care is being increasingly used to meet the demand for long-term care. Home health care, which can reduce nursing home placement significantly, is less expensive than institutional care when home health aide and skilled care visits are scheduled appropriately.
Home health care is provided by agencies, which vary in ownership, size, location, and services. Some are certified. To be certified, an agency must meet state licensing requirements and federal conditions for participation in Medicare. Such agencies provide skilled nursing care under the direction of referring physicians. Nurses provide services under the supervision of a physician, who consults with them as changes in care are needed.
Caring for patients at home requires communication among health care professionals to ensure that patients are maintaining function and are progressing as expected. The patients or caregivers need to promptly report changes in the patient’s condition to nurses or physicians to ensure that patients are monitored appropriately.
Home health care may provide medical and nonmedical services (see table Services That May Be Provided in Home Health Care).
Services That May Be Provided in Home Health Care
Type | Specific Services |
|---|---|
Medical | Nursing Other skilled professional and paraprofessional care, such as physical and occupational therapy Hospice and respite services Durable medical equipment (eg, commodes, wheelchairs, walkers) IV therapy Dialysis Parenteral and enteral nutrition Ventilator support Diagnostic procedures (eg, radiographs, ECGs, blood tests) |
Nonmedical | Personal care (eg, help with bathing, washing hair, using the toilet, and dressing) Housekeeping services Personal emergency response systems Alarm devices Security surveillance Food delivery programs |
(See also Overview of Geriatric Care.)
Reimbursement for home health care
Few patients with a serious, chronic disorder can afford full-time home care even though most would prefer to remain at home. Medicare covers some home care services for patients who are unable to leave their home, but it has certain requirements, which depend on the Medicare option chosen. Some private insurance companies cover some home health care services (eg, infusion services) for patients who are able to leave their home.
For patients’ care to be reimbursed by a third party, physicians must certify that home care is required and, for Medicare, that patients meet Medicare requirements for home care. Medicare requires that home health care agencies tell patients which services are reimbursable. Home care services that are delivered are based on a detailed assessment (Outcome and Assessment Information Set [OASIS]) that is completed by a registered nurse or therapist when the patient is admitted to Medicare. Third-party payers are increasingly limiting personal services to control costs. Home health care agencies are directly reimbursed by Medicare, Medicaid, or private insurers.
Home health care alternatives to inpatient care
In the past few years, several new models of health care delivery have been developed in which the patient is managed in the home instead of in inpatient settings (1-3). The overall goal of these models is to provide a higher quality of care and management that keeps older adults out of both hospitals and skilled nursing homes and promotes aging in place. Overall, these are known as home- and community-based services that include traditional home health services but have been expanded to include other models, some of which have been initiated as demonstration projects.
Independence at Home (IAH) is a demonstration project that is sponsored by the Centers for Medicare and Medicaid Services (CMS). This model started in 2012 and has been renewed multiple times. In this model, homebound, frail older adults receive physician or advanced practice provider (eg, nurse practitioners, physician assistants) services in their home. The goal of this model is to keep the patient in their home and out of the hospital. To be included in this model of care, patients must be homebound and have 2 or more chronic conditions. Patients have benefited from the IAH model with fewer hospitalizations and greater satisfaction (see Centers for Disease Control and Prevention: Evaluation of the Independence at Home Demonstration).
The Hospital at Home (HAH) model adopted by the CMS enables organizations to provide hospital-level care in the patient's home. Most of the participating patients are acutely ill older adults. The goal of this model is to decrease the number of days a patient spends in the hospital, reduce hospital costs, improve patient satisfaction, and improve outcomes. In most cases, these patients are generally stable but require extended hospital-level skilled care such as daily visits from a physician or advanced practice provider and daily monitoring of their medical condition. The benefits of this model include lower morbidity, less delirium caused by sedating drugs, less use of restraints, and high caregiver satisfaction (4, 5).
In 2020, CMS launched the Acute Hospital Care at Home (AHCAH) initiative to provide hospitals expanded flexibility to care for patients in their homes during the COVID-19 pandemic. This program was preceded by Hospital Without Walls, which had a broader application. Both initiatives allowed hospitals to suspend the requirements of 24-hour registered nursing care and the immediate availability of registered nurses for patients who met certain criteria. Although the COVID-19 pandemic ended, the AHCAH initiative was extended through December 31, 2024 and may continue thereafter. Participating hospitals must submit patient data and safety monitoring data to CMS.
The Emergency Triage, Treat, and Transport (ET3) model developed by CMS allows ambulance care teams to have greater flexibility in deciding where a patient should receive care. Instead of transporting a patient to a hospital emergency department, the ambulance care team, often in consultation with an advanced practice provider (APP), can divert the patient to an urgent care center or physician office or can facilitate care in the patient's home with the help of an APP who may be in the ambulance or accessible via telehealth.
References
1. Wolff-Baker D, Ordona RB: The Expanding Role of Nurse Practitioners in Home-Based Primary Care: Opportunities and Challenges. J Gerontol Nurs 2019;45(6):9-14. doi:10.3928/00989134-20190422-01
2. Maniaci MJ, Torres-Guzman RA, Garcia JP, et al: Overall patient experience with a virtual hybrid hospital at home program. SAGE Open Med. 2022;10:20503121221092589. Published 2022 Apr 22. doi:10.1177/20503121221092589
3. McElroy V, Ordona R. & Bakerjian D: Post-Acute Transitional Services: Safety in Home-Based Care Programs. AHRQ PSNet. Published April 27, 2022. Accessed July 3, 2024.
4. Kanagala SG, Gupta V, Kumawat S, Anamika F, McGillen B, Jain R: Hospital at home: emergence of a high-value model of care delivery. Egypt J Intern Med. 2023;35(1):21. doi: 10.1186/s43162-023-00206-3. Epub 2023 Mar 17. PMID: 36969500; PMCID: PMC10023005.
5. Shepperd S, Doll H, Angus RM, et al: Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ. 2009 Jan 20;180(2):175-82. doi: 10.1503/cmaj.081491. PMID: 19153394; PMCID: PMC2621299.
