Home Health Care (HHC) is a specialized service providing skilled medical treatment for an illness or injury within a person’s residence. Licensed health professionals, such as registered nurses and physical therapists, administer this care under a doctor’s established plan. HHC is distinct from non-medical custodial care, which involves assistance with activities of daily living like bathing, dressing, or housekeeping, and does not require professional medical skill. Accessing HHC involves meeting clinical requirements, securing funding, and coordinating the care itself.
Establishing Medical Necessity for Care
Accessing Home Health Care requires a physician’s order and the establishment of “medical necessity.” This necessity is determined by two non-financial requirements: the need for intermittent skilled services and the patient’s homebound status. Skilled services must be performed by or under the supervision of a licensed professional. Examples include injections, complex wound care, patient education on new medication regimens, or physical, occupational, and speech therapy. The care must be part-time or intermittent, typically defined as less than eight hours a day and no more than 28 hours per week.
The patient must also be certified as homebound. A person is considered homebound if leaving the home requires assistance from another person, a supportive device like a walker, or special transportation. Leaving the home must not be a normal occurrence. Occasional, short absences for medical appointments, religious services, or adult day care are permitted. This criteria ensures the care is delivered in the home because the patient is physically unable to access equivalent care outside of it.
Navigating Payment and Funding Options
Securing funding is the next step after medical necessity has been established, as Home Health Care can involve significant costs. Medicare is a primary funding source, covering 100% of approved HHC services for eligible beneficiaries. This coverage includes skilled nursing, physical therapy, speech-language pathology, and home health aide services when provided in conjunction with skilled care, as well as necessary medical supplies.
Medicare coverage has strict limitations and will not pay for services such as 24-hour-a-day care, meal delivery, or purely custodial care when it is the only care needed. For durable medical equipment, Medicare Part B typically covers 80% of the approved amount, requiring the beneficiary to pay the remaining 20% coinsurance. Medicaid, a joint federal and state program, often provides broader coverage, including both skilled and non-skilled personal care services. However, the specific eligibility and scope of benefits vary significantly by state.
Private insurance and Medicare Advantage plans may offer coverage, but benefits, deductibles, and co-payments vary widely. Before HHC services begin, contact the payer directly to verify the extent of coverage, including any limits on the number of visits or hours. Out-of-pocket costs are possible, especially if a patient requires non-skilled care or needs care that exceeds the intermittent limits established by Medicare.
Selecting and Vetting a Home Health Agency
Once eligibility and funding are confirmed, the next step is selecting a qualified provider. A Home Health Agency (HHA) must be licensed by the state and, if the patient uses Medicare, must be certified by Medicare. Medicare’s Care Compare website is a valuable tool for comparing agencies, providing star ratings for both the quality of patient care and the patient experience.
The Quality of Patient Care Star Rating ranges from one to five stars. Ratings of 3.5 stars or higher indicate performance above the national average, serving as a good starting point for comparison. When interviewing agencies, ask specific questions regarding their experience with the patient’s medical condition, their emergency protocols, and their typical clinician-to-patient staffing ratios.
After the agency is selected, a registered nurse or therapist will conduct an initial comprehensive assessment in the patient’s home. This assessment is used to develop the Plan of Care. This plan is derived from the physician’s orders and details the specific services, frequency of visits, measurable goals, and expected duration of care.
Ongoing Care Management and Coordination
Effective communication is necessary once Home Health Care services have started. Patients and family caregivers must maintain communication with the agency staff. Scheduling changes, unexpected clinical concerns, or new symptoms must be reported promptly to the assigned clinician or case manager. The care team, which may include nurses, therapists, and social workers, works collaboratively to monitor the patient’s response to treatment and progress toward goals.
Federal regulations require the agency to periodically reassess the patient’s condition and the Plan of Care, typically every 60 days. These reassessments lead to updates in the Plan of Care, reflecting changes in the patient’s health status or functional abilities. As the patient recovers or stabilizes, the skilled need for HHC services will eventually conclude, leading to a transition of care.
The agency coordinates the transition, which may involve discharge from skilled services, a move to non-medical custodial care, or a referral to outpatient rehabilitation services. Transition planning focuses on ensuring continuity of care, including medication reconciliation and scheduling follow-up appointments with the primary care physician. A smooth transition helps prevent health setbacks and reduces the risk of re-hospitalization.