Who Qualifies for Home Health Care Services?

When it comes to taking care of our loved ones, especially an older family member or someone who is disabled, we want to make sure that they receive the best possible care. Home health services (HHS)can provide a fairly convenient way for family caregivers to get medical and personal care for their loved ones in the comfort of their homes.

However, it would be good to know what HHS are and who qualifies for them because, as you probably already know, dealing with healthcare can be confusing.

My aim in this blog post is to try and explain what HHS is and how you know if your loved one is eligible for these services.

Let’s look at the short answer first.

To qualify for home health services you need the following:

1. A referral from a medical doctor or prescribing practioner
2. The services, supplies or equipment must be needed to help diagnose or treat an illness, injury, condition, disease, or its symptoms which must meet accepted standards of medicine.
3. Require the skilled services of a medical professional to administer the treatment
4. The patient that has been referred must be “home bound”. This means that its difficult and takes undue effort for the patient to leave the home to receive treatment as an outpatient.

What’s Included in Home Health Care Services?

Keep in mind that HHS is different than “Home Care Services. In the general sense, HHS are medical services that are provided in the comfort of a patient’s home. The purpose of them is to help people recover from a medical procedure (surgery), an illness or injury and to help maximize their independence where possible. And, in many cases, provide education to the family and caregivers about the best ways to support these patients when returning to independence will take a longer time, or if it’s possible at all.

The real importance of HHS can’t be overstated. The goal is to keep people out of or returning to the hospital or a nursing home by providing “skilled” services in the person’s home. As we continue, we’ll look at what “skilled” means and who qualifies for it.

What does “Skilled Care” Mean?

The term “skilled care” refers to any service that “can only be safely and effectively performed by, or under the supervision of, professionals or technical personnel.” For instance, if a person is receiving IV antibiotics at home, then a nursing professional should be the one that administers them. Or, if a person has had a stroke and needs to learn to talk or walk again, then a speech therapist or physical therapist should be the professionals that develop a program for them.

So, what isn’t “skilled”? Well, an activity or procedure that is routine or can be done by most anyone safely would not be considered “skilled”. Making a meal, changing a soiled diaper, even separating pills into a pill box would not be considered skilled.

It’s important that family members also understand that if there is little chance of improvement with a person’s function or condition, then skilled services are not indicated. Again, for example, if a person has dementia and is prone to falling, ongoing skilled physical therapy would probably not be a covered service because the person with dementia will not be able to “learn” to change their behavior.

Or, in the case of a chronic condition like diabetes, on going skilled nursing is not indicated because the condition cannot be “cured” and the individual or family will need to learn to “manage” the condition.

What are Home Health Care Services?

Home health care services are actual medical services that professionals provide in a person’s home. Medical professionals, such as nurses, physical therapists, occupational therapists, speech therapists, medical social workers, dieticians and home health aides can be prescribed by a doctor as they are needed and they design a “plan of care” to meet the unique needs of each person enrolled, being tailored to their individual medical condition.

Receiving any of these services can be particularly beneficial for patients who are recovering from surgery, illness, or otherwise have physical or cognitive limitations.

Eligibility Requirements for Home Health Care Services

In general, anyone who has access to health insurance in the US will qualify for home health care services. For those with medicare, they must have “Medicare A” benefits (Medicare A covers inpatient and home health services while Medicare B covers outpatient services). Patients who may qualify for home health care services include those with chronic conditions, those recovering from surgery, those with physical or cognitive disabilities, and those requiring skilled nursing care.

Patients with chronic conditions, such as diabetes, heart disease, or chronic obstructive pulmonary disease (COPD), may qualify for home health care services if they require skilled medical care on a short term basis. Patients recovering from surgery may also qualify for home health care services if they require skilled medical care during to help them getting started on their recovery.

Another area where people qualify for HHS is if they struggle with activities of daily living (ADLs) due to an illness, injury, or procedure. Again, if a person has had a stroke and has difficulty bathing, grooming, dressing themselves, or have difficulty preparing meals, they would qualify for HHS.

Patients who have wounds from surgery, injury, or pressure sores would qualify for skilled nursing care and possibly also home medical equipment.

These are just a few examples.

How to Qualify for Home Health Care Services

To qualify for home health care services, certain things have to be put in place first. It starts with a “referral” or prescription from a medical doctor. Once a referral has been made, the home health agency will send someone out to evaluate the patient (usually a nurse or physical therapist) to see if they meet the specified requirements for admission to home health care services.

The evaluation looks at the current diagnosis and why the individual was referred. During the evaluation, the health care professional will consider the diagnosis, whether the individual is “safe” and able to function independently, if there are equipment needs, or, if the caregiver(s) need any training to help the individual stay in their home safely.

During the evaluation, the healthcare professional will also assess if it is safe for the clinicians to be able to provide services without risk of harm or injury to themselves also.

Medical necessity is another requirement for home health care services. Which means, will the person “benefit” from skilled services. In some cases, a person is functioning at what healthcare professionals call their “baseline”. An example would be if a person has been bed bound for a long time, it is unlikely that they will be able to learn to walk again and thus, skilled physical therapy is not “medically necessary” as the patient is functioning at their “baseline”.

Being “home bound” is a final requirement to qualify for home care services. If a person is able to easily leave the home to run errands, shop, or participate in social activities, then they are not considered home bound and could travel to an outpatient setting to receive skilled services.

However, if a person has difficulty walking, say, after a hip replacement, or they are dependent on having oxygen due to respiratory disease, or, that they are confined to a wheelchair and require a wheelchair van for transportation, they are considered homebound because it is difficult and requires undue effort or assistance to leave the home.

What Services are Covered by Home Health Care?

We’ve touched on it above, but for clarification, home health care services may include a range of medical and even non-medical services. Skilled nursing care is the primary service people are most familiar with. Skilled nursing services may include, but aren’t limited to, wound care, medication management, and the administering intravenous (IV) medications.

Physical therapy, occupational therapy, and speech therapy are also typical services seen in home health care. Each of these provide specific treatments to patients to help them recover from an injury or illness and return as much as possible to indepencence. Mose HHS will also provided home health aide services. Typically home health aides help with bathing and hygeine issues on a temporary basis.

Medical social workers are also included to assess a person’s need and qualifications for any community resources that may be available. Things like transportation services, meals on wheels, and un-skilled caregiving services are included in these. In addition, the social worker can also be a sounding board for patients and families and help them navigate the health care systems and help with long term planning.

In conclusion, Home health care services are an important alternative to hospitalization and nursing home care. They allow patients to receive skilled medical care in the comfort of their own homes and maintain their independence. Patients who may qualify for home health care services include those with chronic conditions, those recovering from surgery, those with physical or mental disabilities, and those requiring skilled nursing care. To qualify for home health care services, patients must meet certain eligibility requirements and must have a referral from a physician.