Home care services are provided by home care organizations but may also be obtained from registries and independent providers. Home care organizations include home health agencies; hospices; homemaker and home care aide (HCA) agencies; staffing and private-duty agencies. Home care services generally are available 24 hours a day, seven days a week. Depending on the patient’s needs, these services may be provided by an individual or a team of specialists on a part-time, intermittent, hourly, or shift basis.
Home care providers deliver a wide variety of health care and supportive services, ranging from professional nursing and HCA care to physical, occupational, respiratory, and speech therapies. They also may provide social work and nutritional care and medical equipment and supply services. Services for the treatment of medical conditions usually are prescribed by an individual’s physician. Supportive services, however, do not require a physician’s orders. An individual may receive a single type of care or a combination of services, depending on the complexity of his or her needs.
Once you acquire the names of several providers, you will want to learn more about their services and reputations. Following is a checklist of questions to ask providers and other individuals who may know about the provider’s track record. Their insight will help you determine which provider is best for you or your loved one.
How long has this provider been serving the community?
Does this provider supply literature explaining its services, eligibility requirements, fees, and funding sources? Many providers furnish patients with a detailed “Patient Bill of Rights” that outlines the rights and responsibilities of the providers, patients, and caregivers alike. An annual report and other educational materials also can provide helpful information about the provider.
How does this provider select and train its employees? Does it protect its workers with written personnel policies, benefits packages, and malpractice insurance?
Are nurses or therapists required to evaluate the patient’s home care needs? If so, what does this entail? Do they consult the patient’s physicians and family members?
Does this provider include the patient and his or her family members in developing the plan of care? Are they involved in making care plan changes?
Is the patient’s course of treatment documented, detailing the specific tasks to be carried out by each professional caregiver? Does the patient and his or her family receive a copy of this plan, and do the caregivers update it as changes occur? Does this provider take time to educate family members on the care being administered to the patient?
Does this provider assign supervisors to oversee the quality of care patients are receiving in their homes? If so, how often do these individuals make visits? Who can the patient and his or her family members call with questions or complaints? How does the agency follow up on and resolve problems?
What are the financial procedures of this provider? Does the provider furnish written statements explaining all of the costs and payment plan options associated with home care?
What procedures does this provider have in place to handle emergencies? Are its caregivers available 24 hours a day, seven days a week?
How does this provider ensure patient confidentiality?
In addition, ask the home care provider to supply you with a list of references, such as doctors, discharge planners, patients or their family members, and community leaders who are familiar with the provider’s quality of service.
Contact each reference and ask:
Do you frequently refer clients to this provider?
Do you have a contractual relationship with this provider? If so, do you require the provider to meet special standards for quality care?
What sort of feedback have you gotten from patients receiving care from this provider, either on an informal basis or through a formal satisfaction survey?
Do you know of any clients this provider has treated whose cases are similar to mine or my loved one’s? If so, can you put me in touch with these individuals?
When services are covered by Medicare and/or Medicaid, home care providers must bill their fees directly to the payor to Medicare or Medicaid. Providers often will bill other third-party payors directly as well. Any uncovered costs are later billed to the client. However, if a client receives services from a registry or independent provider, he or she must pay the provider directly. Later the client may file for reimbursement from the insurance company if the services qualify as covered benefits. Payment options are detailed below.
Home Health Agencies
Medicare, Medicaid, and most private insurance plans pay for services that home health agencies deliver. Payment from these sources depends on whether the care is medically necessary and the individual meets specific coverage criteria. Individuals may opt to pay out of pocket for services that are not covered by other sources. Some agencies receive special funding from state and local governments and community organizations to cover the costs of needed care when other options are not available.
Coverage for hospice care is available through Medicare, Medicaid programs in 38 states, and most private insurance plans. If insurance coverage is insufficient or unavailable, the patient and his or her family may pay for services out of pocket. Most hospices may provide free services to individuals who have limited or no financial resources.
Homemaker and Home Care Aide Agencies
Individual consumers usually pay for services from homemaker and HCA agencies. However, some states contract with these agencies to deliver personal care and homemaker services within their social services and medical assistance programs. On rare occasions, commercial insurers may pay for a portion or all of the costs of these services. Some agencies draw assistance from charitable community funds when other sources of payment are not available.
Staffing and Private-duty Agencies
Typically, the individual or his or her commercial insurance carrier pays for services provided by staffing and private-duty agencies, provided that the insurance policy’s coverage requirements are met. Some staffing agencies contract with state Medicaid programs to provide nursing and personal care services.
Pharmaceutical and Infusion Therapy Companies
Pharmaceutical and infusion therapy supplies and services are almost always paid for by commercial insurance companies and Medicaid. Medicare covers the cost of nutritional supplements and certain medications when the situation meets strict coverage.
Durable Medical Equipment and Supply Dealers
Fees for durable medical equipment and supplies are usually covered by Medicare, Medicaid, and commercial insurance programs, provided that the products are ordered by a physician and are medically necessary to treat an illness or injury.
The individual client generally pays for registry services. In some cases, commercial insurance companies may reimburse a portion or all of these costs.
Usually the individual pays for services rendered by independent providers. Some commercial insurance policies will provide reimbursement if the services qualify as covered benefits.
To determine the caliber of a Medicare-certified provider, you can review its Medicare Survey Report. For assistance in obtaining this document, contact your state’s health department or health insurance counseling program ( WA Statewide Health Insurance Benefits Advisors), which offers free information specifically about the Medicare home health benefit. These offices also can direct you to the state’s Medicare hot line for information about the quality of services provided by Medicare-certified home health agencies and hospices in your area. Telephone numbers for the health insurance counseling programs representing each state, the District of Columbia, and Puerto Rico are listed on pages 21 through 28.
In addition, many states require home care providers to earn a license to operate. To obtain a license, a provider must meet the basic legal and operating standards imposed by the state department of health. Your state health department can provide you with information on its licensed providers.
Last, several professional organizations have established standards to define quality in home care services. Through a voluntary process, many home care providers seek accreditation from these organizations to signify that they have met national standards for quality care. Home care accrediting agencies include the Accreditation Commission for Home Care, Inc., the Community Health Accreditation Program, the Joint Commission on Accreditation of Healthcare Organizations, the National Committee for Quality Assurance, and the National HomeCaring Council. Consider contacting one or more of these organizations for information about their accredited members.
Accreditation Commission for Health Care, Inc.
Phone: (855) 937-2242
Community Health Accreditation Program
Phone: (212) 363-5555 or (800) 669-1656, ext. 242