Navigating Home Health Service Coverage

In the realm of healthcare, understanding what services are covered by insurance can be a labyrinthine task. For many seniors in the United States, Medicare serves as a vital lifeline for accessing healthcare services, including those provided in the comfort of one’s own home. Home health services under Medicare encompass a range of crucial medical assistance tailored to meet the needs of individuals requiring skilled care without the need for hospitalization or confinement in a healthcare facility.

Here’s a concise breakdown of what home health services are covered by Medicare:

  1. Skilled Nursing Care: Medicare covers skilled nursing care provided by registered nurses (RNs) or licensed practical nurses (LPNs) under specific circumstances. This includes wound care, disease process training, monitoring of vital signs, and other medically necessary services.
  2. Home Health Aide Services: Assistance with activities of daily living (ADLs) such as bathing, dressing, and toileting is covered by Medicare if deemed medically necessary and prescribed by a physician. However, it’s important to note that Medicare does not cover full-time home health aide services. These services are temporary in nature during the acute (or recent) change to support identifying your long-term needs.
  3. Physical Therapy: Medicare covers physical therapy services aimed at restoring or maintaining mobility and function. This includes exercises, manual therapy, and education on safe movement techniques.
  4. Occupational Therapy: Occupational therapy focuses on helping individuals regain the ability to perform activities of daily living, such as cooking, dressing, and household chores. Medicare covers occupational therapy when it’s deemed necessary for the patient’s recovery.
  5. Speech-Language Pathology Services: Medicare provides coverage for speech-language pathology services when needed to address speech, language, cognitive, or swallowing impairments.
  6. Medical Social Services: Medicare covers medical social services provided by licensed social workers when necessary to address emotional, social, or financial factors affecting the patient’s treatment.
  7. Medical Supplies and Equipment: Some medical supplies and equipment, such as wound dressings, may be covered by Medicare if deemed medically necessary for use at home.

It’s essential to keep in mind that Medicare covers home health services only when certain conditions are met:

  • The individual must be homebound, meaning leaving home requires a considerable and taxing effort.
  • The services must be ordered by a physician and provided by a Medicare-certified home health agency.
  • The services must be deemed reasonable and necessary for the treatment of the individual’s condition.

Moreover, Medicare typically covers only short-term, intermittent home health services. Long-term care or custodial care, which involves assistance with activities like bathing, dressing, and eating for extended periods, is generally not covered by Medicare.

Understanding Medicare coverage for home health services can significantly ease the burden for seniors and individuals with disabilities who wish to age in place or recover from illness or injury in the comfort of their homes. However, navigating the complexities of Medicare coverage often requires guidance from healthcare professionals and diligent advocacy on behalf of the patient.

By staying informed about the coverage options and requirements, individuals and their families can make informed decisions about their healthcare needs and access the support necessary to maintain independence and quality of life at home.

What are the quality ratings for home health?

Medicare.gov provides resources to review your home health options. Honestly, it provides resources to review doctors/clinicians, hospitals, skilled nursing rehabilitation services, inpatient rehabilitation, long term care facilities, dialysis, hospice, and medical equipment suppliers using the Care Compare feature. If you haven’t reviewed it, medicare.gov/care-compare/ is a necessary stop on your web surfing today!

The quality of patient care is rated along 5 items.

Managing daily activities: Are patients getting better at walking or moving around? At getting in and out of bed? At bathing? Were functional abilities assessed at admission and discharge and included in the care plan?

Treating symptoms: Is patients’ breathing improving? Frequency of pressure ulcers/injuries that are new or worsened?

Preventing harm: Are services started in a timely manner? Are patients getting better at taking their medications correctly? Are patients getting their flu shots for the current flu season? Are physician directions being implemented timely? Are patients experiencing one or more falls with injury?

Preventing unplanned hospital care: How often are patients admitted to the hospital? Needing urgent, unplanned care in the emergency room and not being admitted into the hospital? Remaining in community after discharge from home health services? Re-admitted to the hospital for a potentially preventable condition after discharge? Admitted to the hospital for a potentially preventable condition while receiving home health?

Payment & value of care: How much Medicare spends on episodes of care at this agency?

Elite is surveyed in the state of Washington every 3 years. Our goal is to strive for continuous improvement. It is why we review areas of challenge, establish teams to work collaboratively from different perspectives, and believe in the power of trial and error until we get it right. While no agency is perfect, we think we take feedback seriously to improve the services we provide every day.

How do I choose a Home Health Agency?

Home health is a program created and overseen by Medicare. Therefore, programs in general will look and feel very similar to be compliant with the laws that oversee how Home Health is provided. Depending on the state, agencies go through “surveys” at a regular interval (e.g., yearly, every 3 years, etc.) that review the operation, the clinical services, the documentation, the adherence to techniques, and patient satisfaction.

According to Medicare.gov, questions to ask yourself and review before selecting a home health agency include:

  1. Is the agency Medicare certified?
  2. Is the agency Medicaid certified?
  3. Does the agency offer the specific services I need?
  4. Will the agency be able to meet my special needs, like language or cultural preferences?
  5. Does the agency offer personal care services, such as bathing, dressing, and using the bathroom?
  6. Does the agency offer support services or help me arrange for additional services, such as meal delivery?
  7. Is the agency well-staffed to give the type and amount of care I need?
  8. Is the agency respected in my community, recommended by the hospital discharge planner, my doctor, or a social worker?
  9. Does the agency have staff available for emergencies at night or on the weekends?
  10. Is the agency transparent about what my insurance will cover, what must be paid out-of-pocket, and include me in discussions of resources?
  11. Have prior patients attested to the good care received by the agency?

Some additional questions that we have found helpful for patients and families include:

  1. How soon will my services start? Specifically, for each discipline?
    • Some agencies will start services with one discipline, e.g., nursing, and wait a few weeks before starting the next service, e.g., physical therapy. If your goal is physical therapy, then this timeline might be a reason to consider a different agency.
  2. How frequent will my services for each discipline be?
    • Some agencies plan for only 1 visit per week for the disciplines involved, e.g., 1 visit from the nurse, 1 visit from the physical therapist, 1 visit from the aide. If you have specific goals and needs, this cadence may not be right for you. If there is limited flexibility, this might be a reason to consider a different agency.
  3. Am I involved in my care plan? Does my opinion affect my services?
    • Some agencies have to submit care plans for review and approval. This may or may not take into consideration your needs, health plans, and environmental circumstances. If you are not comfortable with a third-party review, this might be a reason to consider a different agency.
  4. How much choice do I have in selecting an agency?
    • In states where patient choice is the law, you as the patient can freely choose an agency that serves your area. Your provider – doctor, nurse practitioner, physician assistant – may have a preference for whom they prefer to work with, but you ultimately have the choice of your provider for home health. In states where a certificate of need is issued, there may be a restriction on the number of providers. If you are displeased with your offerings, you can reach out to your state’s department of health for guidance on other options.

Elite Home Health & Hospice serves in both Washington and Idaho. We are the Certificate of Need holder for Asotin and Garfield counties. We also serve in Nez Perce, Latah, and Clearwater counties in Idaho where patients have choice. We are Medicare and Medicaid certified, as well as maintaining working agreements with multiple insurance companies.

We offer skilled nursing, physical therapy, occupational therapy, speech-language pathology, aide, and social work services through our home health program. We utilize qualified interpreters or a language service to communicate with members of the community whose primary language is different from English.

Our aides, or certified nursing assistants, are part of your rehabilitation program, and can be scheduled to support learning strategies for dressing, grooming, and bathing in coordination with our occupational therapy services.

Elite is proud to employ residents of the Lewis-Clark Valley, Moscow, and Orofino communities. We believe in hiring within the communities we serve, and we have been doing so since 1984. Our staff supports services 24 hours a day, 7 days a week.

If your insurance benefit does not cover services 100%, you will receive a call from our insurance team who will discuss with you the costs of your services before we send the nurse out to your home. You are a critical member of our healthcare team, and your financial health is important to us. Our customer reviews are publicly available, and we use positive and negative reviews to assess our quality of services and make changes.

Elite works with your schedule to get all of your ordered disciplines started within your first week of service. If you have a preference to delay a particular discipline, let us know, so we can accommodate that change. Our care plans are proposed and discussed with you at your evaluation session. That means, your voice helps determine how often you are seen and by whom. We do not send your care plan for review to a third-party to determine your frequency of visits from our team.

In Asotin and Garfield Counties, we are your provider. We are happy to serve and support your health goals.

In Idaho, you have a choice. We hope you will consider Elite for all of your home health and hospice needs. We are here to provide you with life-changing service.

Hospice and Palliative Care

Are they different? YES

Hospice is a Medicare program. Medicare has designed and created this program.

Palliative is not a designated service. Elite has created its program, so this will look different from agency to agency.

Here is a fun way to understand how these two services are different!

What is Hospice?

Hospice is not a place. Hospice is not a death sentence.

Hospice is the specific service that is provided when you are no longer seeking curative treatments. The goal of hospice is your comfort to support you in living your life. Hospice is flexible in where it can be provided.

Hospice does not require that you stop all medications. The goal of hospice is to make sure the medications you are taking serve you. If you are uncomfortable, because of side effects of your medications, these might be removed, because the goal of hospice is comfort.

In hospice, you do not have to be a DNR (do not resuscitate). The goal of hospice is to help you understand these decisions and honor what you have requested.

Hospice is prescribed by your provider and can support individuals with various forms of cancer, dementia, cardiac disease, pulmonary disease, renal disease, liver disease, HIV/AIDS, neurological disease, and stroke or coma.

At Elite, we do hospice differently. Our team designs your program based on your needs where your voice has a say in your visits, your care goals, and your family’s needs.

October is Home Health & Hospice Month

Elite has the pleasure of serving both home health and hospice. Because we are a dual agency, we are able to support our patients along the continuum of their rehabilitation phases and in their end-of-life process. We believe that these relationships that we build with our patients and their families allows us to give care in a unique manner. Specifically, we are able to contextualize rehabilitation with the background of working through past rehabilitation stays and recoveries, facilitating family support or needing to hire additional aid, and building care plans based on your goals of care.

Elite does it differently. One of our key pieces of building your care plan is to discuss what your goals of care are. What procedures? What treatments? What family members? What friends? What resources? Our liaisons meet with current, prior, and potential patients to go through what your goals of care mean, and what needs to be done to make them a reality. We are intentional in these meetings to support you in making the choice for you in that moment. And, we are available to meet again if those goals change, and a different decision needs to be made.

Home health and hospice are about relationships.

This month we have the honor of celebrating the work our team does every day. Please join us in learning about home health and hospice services this month!

Healthy Aging Month

September is the month we look at how to support healthy aging. Healthy aging is a combination of physical and mental health as well as building community and resources for spiritual and emotional well-being. The aging process changes the mind and the body, and depending on lifestyle, community and social well-being may also evolve (dhs.gov).

Aging well involves learning new strategies and supporting the body’s changing abilities. Accident prevention is a critical element of this in order to best support healthy living and reduce emergency visits. Engaging the physical wellbeing often means learning new exercises and routines to safely engage in home life and access the community (cdc.gov).

Resources:

https://www.dhs.gov/employee-resources/news/2022/09/06/healthy-aging-month#:~:text=Healthy%20Aging%20Month%20is%20observed,our%20minds%20and%20bodies%20change.

https://www.cdc.gov/stillgoingstrong/index.html

What really matters

How we approach healthcare matters.

As healthcare professionals, our job is to reframe how we look at people’s health and treat our patients with their goals in mind. We are intentional in our approaches to put our patient’s goals as an integral component of their care plan. Our challenge is often to reframe how we provide this care, because it breaks from expectations. And, it is constantly evolving.

One of the areas of reframing is in how we look at the end of life, and this is why we do hospice.

Hospice is designed to provide comfort and care for the end-of-life. But, this also means looking at what is meaningful in the first place for our patient. It also means bringing in people that facilitate what is meaningful and how that changes as the individual is on our service.

Hospice is provided for cancer, dementia, cardiac disease, pulmonary disease, renal disease, liver disease, HIV/AIDS, neurological disease, and strokes/coma. It is a service that is provided by a nurse, a chaplain, and a social worker. That’s the basic.

We add in massage therapy, nurses aides, volunteers, physical therapists, occupational therapists, and speech language pathologists.

Patient-directed care means that you lead the process. It also means that you help reframe what it looks like for you.

Pain is a disease

September is Pain Awareness Month.

Understanding chronic pain is critical to how we support our patients on our service.

Join us in our learning:

Pain Awareness Month – International Association for the Study of Pain (IASP) (iasp-pain.org)

September is Pain Awareness Month: Complexity and Progress in Pain Research | National Institute of Neurological Disorders and Stroke (nih.gov)

Pain Awareness Month 2023 – U.S. Pain Foundation (uspainfoundation.org)

What is Psoriasis?

Psoriasis is an immune-mediated disease* (a disease with an unclear cause that is characterized by inflammation caused by dysfunction of the immune system) that causes inflammation in the body. There may be visible signs of inflammation such as raised plaques (plaques may look different for different skin types) and scales on the skin. 

This occurs because the overactive immune system speeds up skin cell growth. Normal skin cells completely grow and shed (fall off) in a month. With psoriasis, skin cells do this in only three or four days. Instead of shedding, the skin cells pile up on the surface of the skin. Some people report that psoriasis plaques itch, burn, and sting. Plaques and scales may appear on any part of the body, although they are commonly found on the elbows, knees, and scalp.

Inflammation caused by psoriasis can impact other organs and tissues in the body. People with psoriasis may also experience other health conditions. One in three people with psoriasis may also develop psoriatic arthritis. Signs of PsA include swelling, stiffness and pain in the joints and areas surrounding the joints. PsA often goes undiagnosed, particularly in its milder forms. However, it’s important to treat PsA early on to help avoid permanent joint damage.

Symptoms often start between ages 15 and 25, but can start at any age. Menwomen, and children of all skin colors can get psoriasis.

From https://www.psoriasis.org/about-psoriasis/

Learn More at…