What is most important to plan for a home service practice?

Essential Planning Elements for a Home Service Practice

The most critical element for planning a home service practice is establishing comprehensive discharge planning with clear communication pathways among an interdisciplinary care team, patients, and families, while simultaneously securing appropriate reimbursement structures and regulatory compliance mechanisms. 1

Core Operational Requirements

Interdisciplinary Team Structure

• Assemble a multidisciplinary team including physicians, registered nurses with specialized home care competencies, respiratory therapists (if applicable), physical/occupational therapists, social workers, and case managers 1
• Ensure nurses possess specific practice elements: expert health assessment skills, hands-on technical proficiency, strong interpersonal communication abilities, and capacity to function independently in uncontrolled environments 1
• Designate a case manager to coordinate all services and serve as the primary communication hub between team members 1

Physician Role and Oversight

• The physician must direct all home health care through ongoing oversight of treatment plans, determining medical needs, approving care plans, and reviewing them every 60 days for Medicare certification 1, 2
• Establish protocols for making home visits, particularly for complex patients requiring mechanical ventilation or other intensive interventions 1
• Create systems for regular communication with the case coordinator and home care personnel to ensure appropriate clinical care 2

Reimbursement and Financial Infrastructure

Medicare Compliance Requirements

• Document that patients are homebound and require intermittent skilled nursing care, physical therapy, or speech-language pathology services - this is mandatory for Medicare reimbursement 3, 4
• Understand that Medicare reimburses personal care (ADL assistance) only when skilled nursing or rehabilitation services are also required 3, 4
• Establish billing mechanisms and payment structures that account for services provided outside face-to-face visits 1

Documentation Systems

• Implement standardized documentation protocols that specify: exact ADL/IADL impairments with level of assistance required (standby, minimal, moderate, maximal, total), homebound status barriers, and medical justification for services 4
• Avoid critical pitfalls: never order home health aide services alone without concurrent skilled services, never use vague language like "needs assistance," and never omit homebound status documentation 4

Technology and Information Systems

Electronic Medical Records Adaptation

• Recognize that most EMR systems are not designed for mobile home-based practices and require significant work-arounds 5, 6
• Plan for challenges with scheduling systems not built for home visits 5
• Invest in information technology that optimizes patient care, communication, and education while supporting evidence-based medicine 1

Access and Service Delivery Models

Enhanced Access Demonstration

• Establish 24/7 availability or clear after-hours protocols - most physicians' offices close nights, weekends, and holidays, creating access barriers that undermine the home care model 1
• Develop urgent care delivery methods, potentially including community paramedics or telehealth technology 5
• Create systems for frequent telephone contact and home visits as needed for patients with acute exacerbations 1

Patient Selection Criteria

Refer patients who meet at least one of these criteria 1, 4:

• New disease diagnosis or multiple comorbidities
• Unstable/fragile medical status requiring close supervision
• Cannot attend outpatient services due to mobility limitations
• FEV1 less than 30% predicted (for respiratory patients)
• Multiple new medications requiring monitoring
• Functional limitations requiring ADL/IADL assistance
• Living alone without adequate support systems
• History of more than one emergency room visit or hospital admission in past year

Partnership Development

External Vendor Relationships

• Establish partnerships with home medical equipment companies that employ respiratory therapists or registered nurses to teach equipment use, monitor safe operation, and troubleshoot complications 1
• Coordinate with home infusion therapy companies that provide pharmacists and specialized infusion nurses 1
• Build relationships with durable medical equipment vendors for adaptive bathroom equipment and mobility devices 1

Communication Protocols

• Create explicit communication pathways between hospital-based staff and home care providers for seamless transitions 1, 2
• Establish protocols for the home health nurse to contact the physician after initial assessment to discuss findings and recommendations 2

Quality and Safety Infrastructure

Patient-Centered Care Framework

• Adopt a patient- or family-centered model recognizing that providers are visitors in the patient's context 1
• For pediatric patients, work with parents to develop daily care plans that maximize developmental potential 1
• Respect professional boundaries while allowing families to direct care, particularly for medically fragile or technology-dependent children 1

Continuity Requirements

• Ensure the medical home continues regardless of insurance status or ability to pay once a patient is enrolled 1
• Maintain ongoing relationships rather than rotating patients through multiple providers in large group practices 1
• Allow patients freedom to switch medical homes and select specialists without coercive restrictions 1

Common Pitfalls to Avoid

• Provider retention challenges are common across practices of all sizes - plan recruitment and retention strategies early 5
• Underestimating unmet community demand for home-based care services leads to capacity problems 5
• Failing to address the complexity of caring in uncontrolled home environments with variable family dynamics and physical spaces 7
• Inadequate preparation for regulatory barriers and health system policies that require work-arounds 6