Given the enormous volume of information written about home care services, I continue to be amazed at the frequency with which skilled home health care is conflated with non-medical home care, as if they were similar concepts. Some authors even use the terms interchangeably. Nothing could be more off the mark. In this article, I would like to make clear some of the key distinctions between these two kinds of home care.
Skilled home health care is virtually always provided by Medicare-certified agencies and is covered by Medicare and commercial health insurers. The services consist of intermittent visits by skilled professionals, usually a nurse and/or a rehabilitative therapy professional-physical therapy, speech therapy or occupational therapy. Visits take place intermittently over a limited period of time lasting no more than a few weeks, usually initiated after a hospital or nursing home discharge. In conjunction with skilled services, a home care aide may visit once or twice a week for a brief visit to provide in-home assistance with personal care, such as bathing.
Medicare covers skilled home health care under the following conditions (commercial insurers usually adopt the same criteria): 1) The services must be prescribed by a physician; 2) They must be provided by a Medicare-certified home health agency; 3) The patient must be home-bound, a requirement that is loosely defined; 4) The patient must need the care of one or more of the professionals mentioned above, as certified by a doctor.
Now, the eligibility criteria and insurance coverage of home health care have certain implications for consumers that are not always explained. First of all, the patient and family rarely have any role in choosing the agency they prefer. That decision is in the hands of the doctor in conjunction with the hospital or nursing home. Sure, a patient can express a preference for a particular provider if he or she has had a previous experience with home health care, but this is unusual in practice. Fortunately, Medicare has begun to make comparative information available on the internet through the Home Health Compare database. This may help to shift some control back to the consumer over time, because it permits patients and families to obtain quick information within the limited time frame permitted by discharge planning.
The second implication for consumers is that the frequency of home visits and the duration of home health services is also largely out of the control of patients and families. It is the home health agency, governed by the physician's orders and Medicare's eligibility requirements, that makes those determinations. And, just to be sure that the home health agencies can't profit unreasonably from more and more services, Medicare typically pays them by the episode of care, not by the volume of services they perform.
Non-medical home care is a completely different animal. Companies that provide such in home caregiver services employ unskilled personnel, variously called certified nurse aides, home caregivers, home health aides, home companions and other designations. The caregiver services they perform include help with personal care, such as bathing, toileting, dressing and mobility assistance, as well as general companionship, safety supervision and various household tasks. Typically each visit is several hours in length, and many highly impaired care recipients require round-the-clock or live-in care. Conceptually, non-medical home care can be thought of as "assisted living at home." The care recipient is usually referred to as a client, reflective of the consumer-controlled nature of non-medical home care. Unless the client meets the low-income criteria to qualify for Medicaid, this type of home care is almost always paid out of pocket or by long-term care insurance. Clients select the company that provides the care and can fire the company if dissatisfied.
Here is a summary of the key factors that characterize skilled home health care:
- Requires a doctor's prescription
- Nursing, therapists, social workers
- Patient must be house bound
- Performed by a Medicare-certified agency
- Limited visit frequency and duration of services
- Consumer usually not in control
- No sustained presence in the home
- Covered by Medicare or health insurance
- Providers paid by the episode of care
- Accountability to doctor and insurer (Medicare), not just to patient
And here are the ways non-medical home care is different:
- No doctor's prescription required
- Home companions, nurse aides, home caregivers
- Irrelevant whether client is house bound
- Agency does not need to be Medicare-certified
- Length of visits and duration of care determined by client and family
- Consumer in control
- Sustained presence is central to the service: "assisted living at home"
- Not covered by Medicare or health insurance
- Providers paid by the hour or by the day
- Accountability to the client and family
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