Current Geriatric Diagnosis & Treatment, 1st Edition

Section II - Environments of Care

6. Home Care

  1. Gwen Windham MD

Bruce Leff MD


Specific home care models have proved effective. These models include interdisciplinary home care programs that integrate medical and social supportive services focusing on the care of chronically disabled persons, home geriatric assessment, posthospital case management/facilitated discharge schemes, home rehabilitation, and home hospital.


Interdisciplinary home care consists of a functioning multidisciplinary team of physicians and other health care professionals, including nurses, home health aides, social worker, and physical and occupational therapists. The team meets on a regular basis, manages the care of active patients carefully, and integrates medical and social supportive services. Such programs have demonstrated improvement in function, reduced costs, decreased medication use, improved satisfaction, improved end-of-life care, and fewer nursing home admissions and outpatient visits.


Home geriatric assessment programs work to identify patient problems in several spheres and provide targeted interventions with the aim of improving clinical outcomes for patients. Results of these studies are varied; however, some have been associated with long-term functional benefits and reductions in nursing home placement.


Specific home-based case management strategies, especially those that are focused on conditions associated with complex management issues and high rates of early hospital readmission (eg, congestive heart failure), have been associated with a significant reduction in the number of acute hospital readmissions.


Home rehabilitation (specifically after a stroke) has proved to be feasible, acceptable to patients and caregivers, and as effective as hospital-based rehabilitation.


Home hospital models that provide hospital-level services in the home setting as a substitute for a needed hospital admission have been developed and have demonstrated comparable clinical outcomes, reduced length of stay, and reductions in important geriatric complications such as confusion.



Medicare will pay for certain home care services. Physicians who care for older patients need to be familiar with the basic entry criteria for these services. Medicare was designed as an acute illness benefit rather than insurance to pay for the long-term care of older persons with chronic conditions. Thus, Medicare home health benefits are linked to transitions from acute care settings and to what Medicare refers to as a “skilled need.” Home health care services for Medicare patients are covered by Medicare Part A. Physicians and approved home health agencies are reimbursed for services as long as certain criteria are met. The basic requirements for Medicare to reimburse home health expenses are as follows: The physician certifies that the patient is homebound, the patient has a skilled need, the skilled need is reasonable and necessary, the rendered service is intermittent or part time, and the physician signs Form CMS-485, which is the plan of care.

Homebound Requirement

To qualify as “homebound,” a patient must have a condition resulting from illness or injury that makes it a “considerable and taxing effort to leave the home”


without the aid of supportive devices such as crutches, canes, wheelchairs or walkers, special transportation, or another person or if leaving the home is medically contraindicated. However, a person does not have to be bedridden or absolutely homebound. Absences from the home must be infrequent, of short duration, or for medically relevant services. Examples of nonmedical reasons for leaving the home are attending religious services or taking a stroll or drive. No specific definition of “short duration” is provided in the Medicare guidelines. Illnesses or injuries that result in a person's confinement to the home include stroke, blindness, dementia, amputation, or a psychiatric problem in which the patient refuses to leave the home or would be unsafe leaving the home unattended.

Skilled Need Requirement

A skilled need is required to receive reimbursement from Medicare for home health services. Skilled needs are those that require special training and certification to administer to be safe and effective, such as those provided by nurses or therapists. An example of a skilled need is the monitoring of a patient with a complex medical condition that requires readjustment of medicines and reevaluation by a skilled nurse. Examples include wound care treatment, catheter care, physical therapy, and training of patients or caregivers to manage medical conditions such as diabetes or wound treatment. Single home visits by a skilled nurse for the sole purpose of obtaining a blood specimen do not qualify as a skilled need. Once a person has home health services for a skilled need, other covered Medicare home health services such as social work, occupational therapy, and home health aide can also be obtained. Thus, the skilled nursing or physical therapy need unlocks the Medicare home health benefit for the patient, and a broad range of services may be used as appropriate for the care of the patient. Services can be provided as long as the skilled need exists.

All skilled needs are not reimbursable. For example, if a patient has been managing his or her diabetes with injections without difficulty and the glucose is well controlled, training would not be appropriate, and payment would be denied. If the patient had been taking oral medications, however, and the physician adds insulin to the medical regimen, it would be appropriate to request nursing services to train the patient to manage diabetes on the new insulin regimen.

Reasonable & Necessary Skilled Need

Skilled needs must be reasonable and necessary. Documentation should be provided on the plan of care (Form CMS-485) and any supplementary forms. If appropriate medical information is not present, the medical record will be reviewed by a regional intermediary designated by the Center for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration [HCFA]) to determine whether the services are reasonable and necessary. One example of a reasonable and necessary skilled need is that of the patient discharged home after hospitalization with heart failure. However, this person's need would not qualify as reasonable and necessary if there was no documentation of changes to the medical regimen and Form CMS-485 documented the patient as having stable vital signs and no functional impairments. Another example provided in the Home Health Agency Manual is a patient who was discharged from the hospital after a hip fracture, and home health services were requested for monthly vitamin B12 injections. Although the injection is a skilled need, if there is no documentation of approved conditions for the administration of vitamin B12, there is no evidence that the injection is medically necessary or reasonable, and the claim would be denied.

Centers for Medicare & Medicaid Services: Home Health Agency manual:

Part-Time or Intermittent Service

According to the 1997 BBA, “intermittent” means skilled nursing care that is provided fewer than 7 days per week or less than 8 h per day for 21 days or less for a medical condition that is expected to require skilled services for treatment at least once every 60 days. Therefore, a one-time intravenous infusion (eg, the condition is not expected to recur and will not require intermittent service) would not qualify for reimbursement. Exceptions to the time limit may be made on an individual basis if appropriate documentation is provided.

Plan of Care

Form CMS-485 is the comprehensive plan of care for each patient. This form lists diagnoses, medications, diet, activities, and services needed, such as wound treatments, in addition to other information. The patient must be under the care of a physician qualified to sign the physician certification at the time of enrollment into home health, and the physician must review and sign the form at least every 60 days. Additional state requirements regarding timing of signatures may also exist. Physicians can bill Medicare for certifying the plan of care.


Medicare Part B pays for care plan oversight (CPO) using CMS common practice coding system code G0181. Separate codes must be used for initial certification,


recertification, and CPO. CPO responsibilities include time spent in discussion with members of the home care team or pharmacists. It may also include time spent reviewing records or coordinating care with other disciplines. CPO does not include time spent in discussion with pharmacists for the purpose of calling in prescriptions, nor does it include time spent in discussions with patients or family members. CPO billing information is provided in Table 6-1.


Single visits are common reasons for payment denial, even if the visit resulted in administering a skilled need. If a patient complained of urinary symptoms, Medicare would not pay for a home health nurse to make a single visit to obtain a urinary specimen, even if the patient was diagnosed and treated with antibiotics for an infection. The patient would need to be hospitalized, placed in hospice, or die as a result of the presenting problem to receive reimbursement for that home visit.

Another common reason for denial is the determination of nonacute events (eg, when physical therapy is ordered for frail patients with medically stable diseases or with gradual progressive disability). Since its inception, Medicare has operated based on an acute care model, and reimbursements are primarily for acute events with a foreseeable period of recovery. In most cases, there must be a clear end point before services will be approved. Before home health services are requested, the physician should consider whether the service is expected to improve the patient's condition.

Table 6-1. Care plan oversight (CPO) billing information.

Medicare beneficiary is receiving Medicare-covered home health services.
30 minutes physician supervision per patient per calendar month.
Physician face-to-face encounter within 6 months before the month for which CPO is billed.
No financial or contractual relationship with the home health agency.
Only 1 attending physician bills during the calendar month.
If billing for CPO services during postoperative period, CPO services must not be related to the surgery.
Must have the provider number of the home health agency.
Physician who bills must also sign plan of care and furnish services.
Physician is not billing for Medicare ESRD capitation payment and CPO for the same beneficiary during the same month.

One of the most common reasons for denial is failure of physicians to sign Form CMS-485. The plan of care should be reviewed at least every 60 days, updated, if needed, and signed.



Medicare recipients may also receive Medicaid (“dual eligible”) if they meet the income and wealth requirements.

Medicaid provides reimbursement for many home health services for which Medicare does not. In addition, several states have launched Medicaid waiver programs to provide home care services for Medicare patients who are Medicaid and nursing home eligible in hopes of reducing nursing home admissions. States must assure CMS that the cost of providing these services in the home or community will not exceed that of placing individuals in an institution. Some of the services provided include personal care, respite care, and other needed assistance in the home.


Area Agencies on Aging (AAAs) were established in 1973 under the Older Americans Act to provide resources for older adults. Local AAAs provide several types of assistance: information and access services, community-based services, in-home services, housing services, and elder rights services.

Information and access services include providing information and referrals for services outside the AAA, caregiver support, and retirement planning and education. Community-based services include employment services such as skill assessment, testing, and job placement. They also offer information on senior centers, congregate meals, adult day care, and volunteer opportunities. In-home services consist of Meals on Wheels, assistance with personal care, shopping and housekeeping, telephone calls and personal visits for homebound adults, personal emergency response devices, financial assistance with gas and electric bills for low-income individuals, and respite care for caregivers. AAAs help older adults find alternative housing as they transition from independent living to varying levels of need for assistance, usually in an attempt to avoid nursing home placement. Senior housing facilities, group homes, assisted-living facilities, and adult foster care are options that AAAs help individuals to explore. AAAs can also provide information on nursing home placement. Finally,


AAAs provide legal assistance and investigate elder abuse charges and neglect, including self-neglect both in the community and within long-term care facilities.


Medicare recipients may elect to use the Medicare hospice benefit in cases of terminal illness. Terminal illness is defined as a condition from which the person is expected to die within 6 mo if the condition runs its normal course. Patients who decide to use the hospice benefit must be eligible for Medicare Part A, be certified by their physician and the hospice medical director as terminally ill, sign a statement choosing hospice care instead of routine Medicare benefits for the specified illness, and receive care of their terminal illness through a Medicare-approved hospice program. Hospice care is provided in hospice facilities, nursing homes, and residences.

The focus of hospice is comfort care rather than treatment with intent to cure. Certified staff members have special training in hospice care work. They include physicians, nurses, counselors (including those for family members after the death of their loved one), dietitians, speech therapists, physical and occupational therapists, clergy, social workers, and volunteers, who help with daily tasks such as shopping and personal care. Hospice benefits also include provision of medical supplies and equipment and medications for symptom control and pain relief.

Although cancer is the most common diagnosis in the hospice program, nontraditional terminal illnesses such as dementia, cardiac disease, and neurologic diseases are eligible for hospice. Physicians must certify that the expected life expectancy is less than 6 mo. However, patients who outlive the 6-mo expectancy may remain in the hospice program if their condition is believed to be terminal and the physician certifies their terminal status. Forms are available through hospice programs and home health agencies to help physicians and other providers determine whether a patient meets requirements for hospice benefits.

Some physicians and hospice programs are reluctant to provide hospice care if they are not certain of the patient's actual life expectancy or if the person has lived beyond the initial 6-mo period within the hospice program for fear of fraud and abuse charges. This fear is unfounded. In fact, the benefit appears to be underused; physicians tend to refer patients to hospice at the very end of their lives. According to the National Hospice and Palliative Care Organization, 33% of hospice patients died within 1 week of admission to hospice, whereas only 6% lived for more than 6 mo.


A physician may provide home care at several distinct levels: community-based long-term care, posthospitalization and rehabilitation care, acute home care, and assessment visits. In providing such care, the physician often works in conjunction with the resources of a home health agency, including skilled nursing care, home health aide care, physical and occupational therapists, and social workers. A review of these types of care, the physician's role, and the key advantages and disadvantages of each is provided in Table 6-2.

One inference to be drawn from the description of these categories is the importance of selecting appropriate patients for home care. Patient selection requires an understanding of the patient's medical condition; suitability of the patient's environment, including the level of available caregiver support; and ability of the home health agency to support the patient's particular needs.


The focus of the physician's role varies, to some extent, depending on the patient's circumstances and the level of home care. In long-term care, the physician provides ongoing medical services, coordinates activities of the interdisciplinary team when skilled services are involved, and serves as an advocate for patients, referring them to appropriate community services to foster continued independence.


In posthospitalization care and home rehabilitation care, the focus is on restoring function and completing the management of medical problems. The interdisciplinary care team provides much of the care in this setting.


In acute home care, the physician is actively involved in management of acute illness. Physician home visits and close coordination of the interdisciplinary care team are crucial to assess and manage the patient. In addition, assessment home visits, which may be performed on a one-time basis, allow a physician to evaluate the impact of the home environment, caregiver, or functional disability on the patient's health, including nonadherence, difficult diagnoses, and excessive use of health services.

Table 6-2. Types of physician home care.

Type of care


Who is in charge

Level of care


Main services


Acute home care

Management of acute illness


May be similar to hospital level of care

Patient at home; avoid iatrogenic illness; efficient comprehensive assessment

Physician, nursing

Health care system may not be able to deliver care of this nature.


Complete hospital treatment; restoration of function

Home health agency staff

Less than acute

Continue care in home environ- ment; ease transition from hospital to home

Occupational and physical therapy, nurse, nurse aide, physician


Community- based long- term care

Alternative to nursing home care or assisted- living facility care

Often informal family caregivers with intermittent formal health agency staff

Less intensive than acute or postacute/rehabilitation focused home care

Long-term manage- ment of medical problems

Physician, case manager, home home health agency resources on intermittent basis

Careful balance between auto- nomy and risk; must address social issues




Similar to community-based long-term care

Direct observational assessment of environment, caregiver, functional disability



Table 6-3. Home care equipment.

   Phlebotomy equipment
   Specimen cups for urine, sputum
   Ear wax removal equipment
   Reflex hammer
   Vibration fork
   Occult blood cards and developer
   Lubricating jelly
   Toenail clippers
   Tongue depressors
   Prescription pad
   Sharps container

   Digital camera
   Laptop computer
   Blood analyzers
   Pulse oximeter
   Wound care kit
   Gynecological speculum
   Peak flowmeter






In addition to the usual components of a patient encounter (ie, the history and physical examination and counseling), the house call permits and encourages functional, caregiver, and environmental assessments. Inspecting the home environment (eg, rooms and obstacles, lighting, bathroom setup, kitchen setup, refrigerator contents, medication setup [with patient and caregiver permission]) can help the physician understand functional and medical issues. Also, observations of patient-caregiver interactions in the home are often remarkably different from those observed in the office setting and can provide valuable insight into management issues. Recommended equipment for house calls is listed in Table 6-3.


Binstock RH, Cluff LE (editors): Home Care Advances. Springer, 2000.

Calkins E et al (editors): New Ways to Care for Older People—Building Systems Based on Evidence. Springer, 1999.

Oldenquist GW et al: Home care: What a physician needs to know. Cleve Clin J Med 2001;68:433. [PMID 11352323]

Leff B, Burton JR: The future history of home care and physician house calls in the United States. J Gerontol A Biol Sci Med Sci 2001;56:M603. [PMID 11584032]

McCall N et al: Medicare home health before and after the BBA. Health Aff (Millwood) 2001;20:189. [PMID 11585166]

Stuck AE et al: Home visits to prevent nursing home admission and functional decline in elderly people. Systematic review and meta-regression analysis. JAMA 2002;287:1022. [PMID 11866651]

van Haastregt et al: Effects of preventive home visits to elderly people living in the community: A systematic review. BMJ 2000; 320:754. [PMID 10720360]

American Academy of Homecare Physicians: (This organization is an excellent source of information on home care as it relates to physician practice in home care.)

Center for Medicare and Medicaid Services: http://www.cms.hhs. gov (Various sites have excellent information on the Medicare home health and hospice program.)

National Association of Area Agencies on Aging: (This site has a number of helpful links to find local services.)

National Association for Home Care: (This site—for a trade group that represents home care agencies, hospices, home care aide organizations, and medical equipment suppliers—provides general information and links related to the home care industry.)