What are the key components of a health at home referral for a patient with complex medical needs?

Health at Home Referral for Complex Medical Needs

For patients with complex medical needs, initiate home health referral when any one of the following criteria is present: new diagnosis or multiple comorbidities, need for complicated care coordination, inability to attend outpatient services, unstable medical status requiring close supervision, multiple new medications, caregiver inadequacy, functional ADL/IADL limitations, more than one emergency visit or hospitalization in the past year, or need for high-technology equipment. 1

Core Referral Criteria

The American Thoracic Society provides specific triggers for home health referral that apply broadly to patients with complex needs 1:

• Medical complexity: Patient diagnosed with new disease or has multiple comorbidities 1
• Care coordination needs: Complicated assessment and/or health care coordination required 1
• Access barriers: Patient cannot attend outpatient services and needs monitoring and/or education 1
• Medical instability: Unstable or fragile medical status requiring close supervision and frequent assessment 1
• Medication complexity: Multiple medications prescribed or medication regimen is new to patient 1
• Psychosocial factors: Patient or caregiver is anxious, confused, forgetful, or has poor coping skills 1
• Social isolation: Patient is older, living alone, and/or has no support system 1
• Functional impairment: Patient has functional limitations requiring assistance with ADLs (bathing) or IADLs (food shopping) 1
• High utilization history: More than one emergency room visit or urgent hospital admission in the past year 1
• Technology dependence: Need for complicated treatment regimens, high technology or other durable medical equipment, and/or intravenous therapy 1

Essential Components of the Referral

1. Comprehensive Discharge Planning

Before discharge, establish medical, respiratory, and psychological stability along with a comprehensive discharge plan 1:

• Medical stability with controlled symptoms and stable organ systems 1
• Stable medication regimen established before discharge 1
• Absence of acute infectious processes 1
• Psychological readiness of patient and family to manage care at home 1

2. Individualized Care Plan Development

An individualized health care plan must be in place before discharge, involving patients, families, a designated case manager, and interdisciplinary team members 1:

• Assessment of patient's medical needs specific to their conditions 1
• Evaluation of the discharge site and home environment 1
• Financial resources assessment for posthospital care 1
• Education and training needs of patients and families identified 1

3. Multidisciplinary Team Coordination

The combination of disciplines involved depends on primary problems identified and reimbursement mechanisms 1:

• Registered nurses: Required for patients with active comorbid conditions and high risk of complications, medication management, and complex assessment needs 1
• Physical/occupational therapy: For patients with primary problems of deconditioning, impaired mobility, or need for home adaptation 1
• Home health aides: For assistance with ADLs or IADLs, but only when skilled nursing or rehabilitation services are also required 1
• Social workers: For psychosocial assessment and resource coordination 1
• Speech-language pathologists: When communication or swallowing issues are present 1

4. Patient-Centered Care Model

Home care services must use a patient- or family-centered model, recognizing that care occurs in the patient's context where the provider is a visitor 1:

• Address medical, functional, psychosocial, developmental, and advance care planning needs holistically 1
• For pediatric patients, ensure early services to achieve normal age-dependent function 1
• Develop daily care plans that maximize developmental potential for children 1

Critical Documentation Requirements

Medicare Coverage Justification

Medicare reimburses for personal care (ADL assistance) only if skilled nursing or rehabilitation services are also required as determined by physician evaluation 2, 3, 4:

• Physician must certify that patient is homebound and requires intermittent skilled nursing care, physical therapy, or speech-language pathology services 3
• Home health aide services cannot be ordered alone and must accompany skilled services 2, 4
• Document specific IADL impairments using standardized language (e.g., "patient requires moderate assistance with meal preparation due to cognitive impairment") 2, 3, 4

Functional Assessment Documentation

Document specific ADL and IADL impairments with level of assistance required 3:

• ADLs: Bathing, dressing, toileting, transferring, continence, feeding, grooming 3
• IADLs: Using transportation, managing money, taking medications, shopping, preparing meals, doing laundry, doing housework, using telephone 3
• Specify level of assistance: standby, minimal, moderate, maximal, or total 3

Home Environment Assessment

Document home safety evaluation findings and environmental modifications needed 3:

• Problems with stairs, bathtubs, rugs, lighting 3
• Environmental modifications: handrails, adequate lighting, removal of loose rugs 3
• Fall risk factors and history 3

Caregiver Assessment

Identify and document all available caregivers, their capacity to meet care needs, and any limitations 3:

• Caregiver availability and capability 3
• Whether patient is living alone or has inadequate support systems 3
• Caregiver anxiety, confusion, forgetfulness, or poor coping skills 3

Common Pitfalls to Avoid

Do not order home health aide services alone without concurrent skilled nursing or therapy justification—Medicare will deny coverage 2, 3, 4:

• Always specify the need for skilled services that justify home health aide coverage 2, 3, 4
• Use specific, standardized language when describing needs rather than vague terms like "needs assistance" 3, 4
• Document homebound status—this is mandatory for Medicare coverage 3
• Do not delay documentation of equipment needs—early adaptive equipment provision prevents complications 3

Special Considerations for Complex Populations

Patients with Multiple Psychiatric Conditions

For patients with intellectual disability and multiple psychiatric conditions, skilled nursing services should include psychiatric medication monitoring, mental status assessment, and coordination of care 2, 4:

• Order skilled nursing visits at least 2-3 times per week initially to establish adequate skilled service justification 2
• Home health aide services can be daily or multiple times per week for meal preparation, housekeeping, ADL prompting, and medication reminders under nursing supervision 2, 4
• Document specific barriers to homebound status such as severe anxiety in community settings or history of psychiatric decompensation 4

Mechanically Ventilated Patients

For ventilator-dependent patients, ensure medical, respiratory, and psychological stability before discharge 1:

• Stable ventilator settings with FiO2 less than 0.40 1
• Limited use of PEEP with minimal fluctuations in airway resistance and compliance 1
• Stable "free-time" periods established 1
• Family ability to cope with patient's physical and emotional needs in home setting 1

Pediatric Patients

For infants and children with chronic disease, ensure patient, family, home, and community factors are in place before discharge 1:

• Involve patients, families, designated case manager, and interdisciplinary team members in planning 1
• Pediatric pulmonologist can play central role in coordinating respiratory care 1
• Early services are critical to achieve normal age-dependent function as respiratory impairment improves 1

Clinical Decision-Making Framework

Clinical judgment is the deciding factor in whether to order home care referral, as predictive validity tools remain unestablished 1:

• Use the American Thoracic Society criteria as a guide for identifying need 1
• Consider that patients with ADL/IADL limitations, lack of spouse caregiver, low social support, educational attainment less than 12 years, and prior home care use are at higher risk for needing services 1
• Evaluate the patient's holistic needs including medical, functional, psychosocial, and developmental factors 1