What are the conditions and management strategies for patients requiring home health care?

Conditions for Home Health Care

Home health care should be ordered when patients meet Medicare's homebound requirement AND need intermittent skilled nursing, physical therapy, or speech-language pathology services, with specific qualifying conditions including medical instability, functional limitations requiring ADL/IADL assistance, multiple comorbidities, or complex care coordination needs. 1, 2

Core Medicare Eligibility Requirements

Homebound Status Certification

• The physician must certify that the patient is homebound and cannot attend outpatient services due to mobility limitations, unstable medical status, or multiple comorbidities 2
• Document specific barriers such as severe anxiety in community settings, history of decompensation, or cognitive limitations requiring a familiar environment 1

Skilled Service Requirement

• Medicare reimburses for personal care (ADL assistance, meal preparation, housekeeping) ONLY when skilled nursing or rehabilitation services are also required and ordered by the physician 1, 3, 2
• Home health aide services cannot be ordered alone and will result in Medicare denial 1, 2

Specific Qualifying Conditions for Referral

Medical Complexity Criteria (consider referral if one or more present):

• New disease diagnosis or multiple comorbidities requiring complicated assessment and care coordination 4
• Unstable or fragile medical status requiring close supervision and frequent assessment 4, 2
• Best FEV1 less than 30% predicted (for respiratory patients) 4
• Multiple medications prescribed, particularly new regimens requiring monitoring 4
• History of more than one emergency room visit or urgent hospital admission in the past year 4, 2

Functional Limitation Criteria:

• Patient requires assistance with ADLs (bathing, dressing, toileting, transferring, continence, feeding, grooming) 4, 2
• Patient requires assistance with IADLs (meal preparation, housekeeping, medication management, shopping, transportation) 4, 2
• Patient has deconditioning, impaired mobility, or needs home adaptation 4, 2

Psychosocial Risk Factors:

• Patient is older, living alone, and/or has no support system 4, 2
• Patient or caregiver is anxious, confused, forgetful, or has poor coping skills 4
• Lack of availability of spouse caregiver or low level of social support 4

Complex Treatment Needs:

• Need for complicated treatment regimens, high technology equipment, durable medical equipment, or intravenous therapy 4
• Continuous oxygen therapy, nebulizer therapy, tracheostomy care, CPAP therapy, or mechanical ventilation 4

Patient Stability Criteria Before Discharge

General Medical Stability (must be present):

• Control of sustained dyspnea and stable airway 4
• Ability to clear secretions and protect airway 4
• Acceptable arterial blood gases with FiO2 less than 0.40 that can be maintained at home 4
• Stable metabolic and acid-base status 4
• Absence of acute infectious processes 4
• Stable medical regimen before discharge 4
• Absence of life-threatening cardiac dysfunction or arrhythmias 4
• Adequate nutrition and stable other organ systems 4

For Ventilator-Dependent Patients (additional criteria):

• Stable ventilator settings with FiO2 less than 0.40 4
• Assist/control or pressure-limited mode (pediatrics) 4
• Limited use of PEEP with minimal fluctuations in airway resistance and compliance 4
• Stable "free-time" periods established 4

Psychosocial Readiness:

• Ability to cope with patient's physical and emotional needs in home setting 4
• No need for unscheduled or acute readmission or physician visit within at least 1 month 4

Discipline-Specific Referral Guidelines

Skilled Nursing Services (order when):

• Patient has active comorbid conditions and high risk of complications beyond the primary system 4
• Medication management needed, particularly psychiatric medications requiring monitoring 1, 3
• Assessment of mental status, medication side effects, and patient education required 1, 3
• Care coordination needed for multiple services or complex conditions 4
• Frequency should be at least 2-3 visits per week initially to establish adequate skilled service justification 3

Physical or Occupational Therapy (order when):

• Primary problems involve deconditioning, impaired mobility, or need for home adaptation 4
• Patient requires caregiver education on range of motion, positioning, and proper use of assistive devices 2

Home Health Aide Services (order when):

• Patient needs assistance with meal preparation, light housekeeping, prompting and supervision with ADLs, and medication reminders 4, 1, 3
• Must be ordered in conjunction with skilled nursing or therapy services 1, 3
• Can be daily or multiple times per week as needed, but only with concurrent skilled services 3

Critical Documentation Requirements

Functional Assessment Documentation:

• Document specific ADL impairments using standardized language: specify whether patient requires "some help," "unable to perform," or can perform independently for each ADL 2
• Use specific language such as "patient requires moderate assistance with meal preparation due to cognitive impairment" rather than vague terms like "needs assistance" 1, 2
• Specify exact level of assistance required: standby, minimal, moderate, maximal, or total 2

Medical Justification:

• Document at least one qualifying condition from the criteria above 2
• Include home safety evaluation findings: problems with stairs, bathtubs, rugs, lighting 2
• Record environmental modifications needed: handrails, adequate lighting, removal of loose rugs 2

Caregiver Assessment:

• Identify and list all available caregivers in the medical record 2
• Document caregiver capacity to meet care needs and any limitations 2
• Record caregiver anxiety, confusion, forgetfulness, or poor coping skills if present 2

Plan of Care:

• Develop comprehensive discharge plan addressing medical stability, respiratory status (if applicable), psychological readiness, and home environment preparedness 2
• Document specific goals for ADL improvement or maintenance with measurable outcomes 2
• Record frequency and duration of each service type (skilled nursing, therapy, home health aide) 2

Common Pitfalls to Avoid

Documentation Errors:

• Never order home health aide services alone without concurrent skilled nursing or therapy justification—Medicare will deny coverage 1, 2
• Do not use vague language—specify exact ADL impairments and level of assistance required 1, 2
• Do not omit homebound status documentation—this is mandatory for Medicare coverage 2

Service Ordering Errors:

• Do not delay documentation of equipment needs—early adaptive equipment provision prevents complications 2
• Do not provide generic recommendations—tailor documentation to the specific discharge living environment with structural barriers noted 2

Special Populations

Pediatric Patients:

• American Academy of Pediatrics guidelines require individualized health care plan before discharge with involvement of patients, families, designated case manager, and interdisciplinary team members 4
• Children must have early services to achieve normal age-dependent function as respiratory impairment improves 4
• Progression of growth and development must be documented 4

Patients with Intellectual Disability and Psychiatric Conditions:

• Document specific IADL impairments using standardized language 1
• Order skilled nursing for psychiatric medication monitoring, mental status assessment, and patient education 1, 3
• Consider Medicaid referral for additional services Medicare does not cover, including more extensive personal care hours 3

Expected Outcomes

Functional Improvements:

• Home health care significantly improves ADLs and IADLs between start of care and discharge or 60 days 5
• Overall quality of life, general health, and physical, psychological, and environmental domains improve significantly 5

Cost and Utilization Benefits:

• Comprehensive geriatric assessment combined with post-discharge home intervention reduces length of hospital stay, rate of immediate nursing home placement, and direct costs 6
• Initial cost savings for ventilator-dependent children at home are at least 70% compared to hospital care 7