Qualify for Home Health Care

How do I know if my patient/family member qualifies for homecare?

There are certain conditions that must be met for a patient to qualify for skilled home health services under Medicare, Medicaid, and some insurance companies; they are:

• Be confined to the home (homebound);
• Be under the care of a physician;
• Receive services under a plan of care established and periodically reviewed by a physician;
• Need of skilled nursing care on an intermittent basis or need physical therapy or
• Speech therapy;
• Have a continuing need for occupational therapy

Clarification of Homebound:

This does not mean the patient must never leave their home. In general terms, a patient is considered "home bound" if they:

• Have a medical condition or an injury that restricts their ability to leave their home unless they use an assistive device (crutches, cane, wheelchair, walker);
• Require the use of special transportation;
• Require the assistance of another person;

Or, leaving their home is not medically advised
Patients may leave their homes occasionally; for church services, hairdressing, attending a family functions while being driven in a vehicle by another person. Absences from the home to receive medical treatments are also allowed, such as:

• Attending adult day centers (licensed by the State of Pa) to receive medical care;
• Kidney dialysis;
• Chemo/radiation therapy;
• And outpatient physical therapy, including whirlpool therapy

Examples of Patients who qualify for Homecare Skilled Services:

• Patients who require intravenous and intramuscular injections
• Patients needing Foley catheter insertions
• Patients with pre-existing peripheral vascular or circulatory disease (needing observation for complications, pain management, teaching related to skin care, preservation of skin integrity,and prevention of skin breakdown)
• A patient who requires teaching related to illness or injury until they can demonstrate Independence in their care.
• Patients in need of medication management which also requires a nursing assessment (such as blood pressures, pulses, respiratory assessment, blood sugars, oxygen saturations),
  Monitoring of medication changes or physician consults.

Examples of patients who do not qualify for skilled care:

• Skilled nurse admits a patient to agency for bathing, and completes the teaching of Medication Administration and safety in the home, at the admission visit.
• Patient is not compliant with taking medications, and needs reminders to take them on
  time.
• Patient has a wound, which the caregiver manages competently, and patient is driving their own vehicle.
• Medication set-up when the medications taken do not require ongoing nursing
  assessments,
  Monitoring or physician consults.

Venipunctures alone do not qualify a patient for home care. The documentation must
support the rationale behind the venipunctures, for example:

• A patient is taking Coumadin (blood thinner) and requires Prothrombin time to monitor its effectiveness.Documentation reflects no changes in the Coumadin therapy for 6 weeks. This patient would not qualify for skilled care based on this alone.
• A physician requests a chemistry panel and CBC drawn on his patient prior to the patient’s 6 month checkup. This patient would not qualify for skilled care based on this alone.