HOME HEALTH THERAPIES

As health care costs continue to increase and the trend toward consumerism in health care accelerates, older adults are seeking more information about the health care options available to them. In many cases they are also thinking about how they will handle their future long-term care needs. Though home health care can address many short-term and long-term health problems, it is often overlooked or not fully understood.

Benefits of home care

Home health care or "home care" offers many advantages to patients, particularly older adults. For the chronically ill and disabled, home care allows the patient to live at home—a home that is usually familiar and comfortable. Studies show that patients recuperating from an acute illness or accident recover faster in a home environment. At home, family and friends can play a vital role in the person's recovery process and mental well-being. What is more, home care gives an older adult a sense of independence by offering an important measure of control over day-to-day events.

Home care improves the quality of care provided and increases patient satisfaction. When it is available, patients often have shorter stays in inpatient settings. Home care ensures a safe discharge to the home while providing continuity of care.

The comparably low cost of home care is another benefit. In 1998, the average Medicare cost for a home visit from a professional nurse was $93, which makes it an economical alternative compared to inpatient hospitalizations and nursing home stays. Combined with good outcomes and high quality, the cost of home care can make it a practical and favored option for many people.

Limits of home care

While twenty-first century technology allows many services to be performed at home that were impossible even a few years ago, there are limits to what home care can do. In some cases a person is simply too ill or has needs that are too complex to be cared for safely in a private home. In other cases a person cannot be cared for at home because the home environment is unsafe (e.g., no one in the home can help care for the patient). The need for informal caregiver support as a supplement to home care is especially important for people with cognitive impairments.

There is also a question of paying for care. Under many insurance plans home care coverage is limited or does not exist. If a person cannot afford to pay for home care, the only option may be to return to a hospital or nursing home where services are covered by insurance. Many areas of the country are also experiencing a shortage of home care providers (especially nurses and home health aides), which can prevent home care from being a feasible alternative.

Home health therapies

Home care includes a wide range of therapies that can be curative, palliative, or restorative. These therapies are delivered in a person's residence, whether it is a private or a group home (e.g., an assisted living facility or other type of senior housing). Home health therapies include medical, nursing, social, and rehabilitative treatments. These therapies are classified as "skilled needs" and must be provided by a health care professional. Registered nurses (RNs) and licensed practitioner nurses (LPNs) provide skilled nursing care and home infusion care. RNs also serve as case managers, perform the home care assessment on the first home visit (or in the hospital or nursing facility before discharge), and create and manage the care plan. Physical therapists, occupational therapists, and speech pathologists all provide rehabilitation therapy. Social workers help patients to deal with social and emotional issues, such as living arrangements, family problems, and financial matters.

In addition to skilled needs some people need help with the essential activities of daily living (ADLs)—bathing, dressing, getting around inside, toileting, transferring (e.g., from bed to chair), and eating. People also have difficulties with activities that are less basic than ADLs. These instrumental activities of daily living (IADLs) include paying the bills, shopping, cleaning, and doing laundry. Both home health aides and personal care attendants provide personal care (assistance with ADLs) and homemaker services (assistance with IADLs). In addition, home health aides are trained paraprofessionals who change dressings, help with medications, and provide other services that support skilled care.

The major services involved in each of the therapies are outlined in Table 1.

Home care patients

Anyone requiring treatment, assessment, or education is a candidate for home care. Home care patients range from premature babies to people over one hundred years old. Most people receiving home care fall into one of the following categories:

• People who are recuperating from an acute illness
• The chronically ill
• The physically/mentally disabled
• People diagnosed with a terminal illness.

Various home care programs are available, depending on a person's needs. Most home care patients are in "post-acute care" programs, in which they receive services for a limited period of time (e.g., after a hospital stay). Some agencies may have special acute care programs for adults, children, or maternal/child health.

There are also long-term care (LTC) programs, many of which are governmentsponsored (often through Medicaid), and their availability varies by location. Examples of LTC programs include the Program for All-inclusive Care for the Elderly (PACE) programs, and long-term home health care programs (also known as "nursing homes without walls"), and managed long term care programs.

The last major type of home care program is hospice. Hospice programs provide palliative care and counseling to patients who are terminally ill, as well as counseling and bereavement services to family members. Because of the nature of the program, care is provided for a limited period of time (from a few weeks to one year).

Home care providers

The RNs, LPNs, therapists, social workers, home health aides, and personal care attendants who provide home health services work for a variety of organizations that are authorized to provide home care. The main differences between the types of home care providers are the specific services/programs offered, the types of healthcare workers who provide them, and the types of insurance coverage accepted.

Certified home health agencies (CHHAs) are certified by Medicare to provide nursing and home health aide services, and provide or arrange for other services, such as physical therapy, home infusion, and social work. Services are generally paid for by Medicare or Medicaid, and are provided for a limited period of time. Long-term home health care programs are similar to CHHAs, except that they provide long-term care (with no specific limitations on the duration of treatment). Licensed home health agencies (LHHAs) are licensed by the state to provide nursing, home health, and personal attendant services, but are not certified to provide Medicare- or Medicaid-financed home care. LHHA services are available only to patients who pay privately or have private insurance.

Other sources of home care include social welfare agencies, community organizations, and adult day care centers, as well as nurse registries and staffing and private duty agencies.

Paying for care

There are a number of sources for paying for home care, depending on the insurance coverage available, the primary diagnosis, and the type of services needed. In 1997 over $32 billion was spent on home care in the United States. Table 2 shows the breakout by payer.

The types of services that are covered vary by payer, and approval of all services depends on the needs of the patient. Though coverage varies, common payment requirements are that the patient is under a physician's care, and that the services ordered are reasonable and necessary to treat the patient's condition. In many cases the patient must also be homebound.

Please note that the information in this article is a general guide to what different types of insurance cover, and should be used for reference purposes only. Because of the potential for financial liability, both a physician and the insurance provider should be consulted before a person receives home care.

Medicare is a national health insurance program designed primarily for people age sixty-five and over. Limited home care coverage is available under Medicare Part A. Medicare provides home care only if there is a need for intermittent skilled nursing care or physical, speech, or occupational therapy. In addition a physician must certify that the patient is homebound. (Medicare's definition of "homebound" is that the condition of the patient is such that there is a normal inability to leave home and, consequently, that leaving home would require a considerable and taxing effort.) The patient has to be under the care of the physician who certifies that care in the home is necessary. All home care services must be provided through a CHHA. There is no copayment for home care services under Medicare, though any related durable medical equipment is subject to a 20 percent copayment. No Medicare coverage is available for people who require only personal care.

Medicaid is a program, jointly funded by the federal and state (and in some cases local) governments, that provides comprehensive medical care coverage for people whose income and assets fall below a specific level. Each state administers its own Medicaid program, so eligibility requirements and the specific benefits vary by state. In some cases, Medicaid may provide a more generous home care benefit than Medicare. Coverage is often available for unskilled needs over longer periods of time.

Private health insurance, usually administered through employers, typically covers only relatively short periods of post-acute home care. Managed care organizations (e.g., HMOs) usually have strict precertification requirements for all nonemergency services, including home care. Many managed care plans require a copayment for each home care visit (e.g., $10 per visit) and limit the number of home care visits allowed in a plan year. Coverage is usually limited to a post-acute benefit focused on skilled nursing or rehabilitation therapies.

Since the 1990s, long-term care (LTC) insurance has become increasingly popular. Many LTC policies provide some compensation for home care within a specified period of time. The actual amount paid for each home care visit, the limit on the number of visits, and what triggers the LTC payments vary widely, depending on the policy. Therefore the LTC policy that is chosen determines the extent of the home care benefit (as well as how using that home care benefit affects the nursing home benefit).

Persons who are not covered by insurance or who need care in addition to what is covered by insurance, can pay for home care themselves. Home care costs vary by location and agency, so it is important to find out the cost of care beforehand. It may be helpful to compare the costs of different agencies and to check with the local department of health or aging to get a better understanding of home care prices.

Important questions

Someone who is a candidate for home care should have the following questions answered— by a doctor, a hospital, a home care agency, or a state or local health agency—before starting care.

1. What kind of agency is providing the care?

• Find out the full name of the agency and what type of agency it is (e.g., a CHHA or hospice).
• Ask if the agency is accredited (e.g., through the Joint Commission on Accreditation of Health Organizations (JCAHO) or Community Health Accreditation Program (CHAP)).
• Call the state licensing agency (usually the state Department of Health) to find out if there are any outstanding complaints against the agency.

2. Who will provide the care?

• Ask for the credentials and experience of the person(s) who will provide the care.
• If the patient has a rare or difficult-to-treat problem, find out if the health care provider has received specialized training.

3. Who is in charge?

• Find out who is responsible for coordinating care and how to contact them.
• Ask who the home health aide reports to.
• Find out what kind of backup system exists if the home care provider does not show up.
• Ask for phone numbers to call to (1) contact the case manager, (2) report a no-show or other urgent problem, (3) report a nonurgent problem, and (4) make a complaint.

4. What services will the patient receive?

• Ask the case manager for the care plan after the first assessment visit is made. The plan of care should include the condition the patient is being treated for, the expected outcome when service ends, the type of therapies that will be received and from whom, the frequency of visits, and when the home care is expected to end.
• Be sure to ask the case manager or the doctor any questions about the plan of care.
• Ask the case manager to update the patient, the doctor, and the insurance company if the plan of care changes or is expected to change.

5. How much will the patient pay?

• Ask the insurance company if precertification or any other requirements must be met before beginning care.
• Ask the insurance company what the patient will be obligated to pay, based on the plan of care. Call the insurance company directly; benefit booklets, Web sites, and other sources may be out-of-date or may not be specific enough.
• Ask the agency about the option of paying out of pocket for extra care or for care after the insurance coverage runs out.
• Ask the agency if the patient is eligible to receive any charitable care dollars or is eligible for Medicaid or any special government programs or long-term care plans.

6. Is home care the best choice?

• Ask the case manager or doctor what can be done to get the most out of the home care experience.
• Ask the case manager or doctor what the alternatives to home care are.
• Find out what should be done when home care ends.

The future of home care

Home care will continue to be an integral part of the health care system in the future. In fact, its importance is expected to grow as a result of the aging population and the increasing number of frail older adults living at home. In 2000 there were approximately thirty-five million people age sixty-five or older in the United States.

The size of this group is expected to double to seventy million by 2030.

At the same time there is also an increasing number of people with chronic illnesses. In 1995 there were ninety-nine million people of all ages with some type of chronic disease. This number will increase to one hundred and forty-eight million by 2030. Almost one-third of the people in this group have a major limitation as a result of their chronic condition.

Finally, the continued emphasis on providing cost-effective health care options and the growth of consumer choice are working to move home care into a more prominent light.

Carol Raphael, MPA Joann Ahrens, MPA

See also Health and Long-Term Care Program Integration; Home Care and Home Services; Long-Term Care.

BIBLIOGRAPHY

Health Care Financing Administration, Office of the Actuary. "Home Health Care Expenditures and Average Percent Change, by Source of Funds: Selected Calendar Years 1970–2008." www.hcfa.gov

Health Care Financing Administration, Office of the Actuary. "Home Health Care Expenditures, Percent Distribution and Per Capita Amounts by Source of Funds: Selected Calendar Years 1970–2008." www.hfca.gov

Health Care Financing Administration and the Office of Strategic Planning. A Profile of Medicare Home Health, August 1999, 80.

National Association for Home Care. "Basic Statistics About Home Care." www.nahc.org

RWJ Foundation. Chronic Care in America: A 21st Century Challenge. August 1996. (1995 data).

U.S. Bureau of the Census. "Projections of the Total Resident Population by 5-Year Age Groups, and Sex with Special Age Categories: Middle Series, 1999 to 2100." www.census.gov

Visiting Nurse Service of New York. Finding Home Health Care for Seniors in New York. 2000.