1. An Introduction to Home Health Care in the United States:
Overview and History of Home Health Care
and the Medicare Home Health Care Program
Tracy Gutman, MD
Geriatrics Fellow
University of Kansas

2. OBJECTIVES By the end of this module, the learner will do the following:
List the types of home health care providers and the specific tasks that they perform in the home.
Differentiate the focus of Medicare home health care services before and after the Balanced Budget Act of 1997.
Define the requirements for participation in Medicare home health care.
Explain under what circumstances Medicare home health care will cover personal care services.
Describe Medicare reimbursement for home medical equipment.
Describe a typical Medicare home health care episode.

3. Pretest 1. True or False Home health care providers can include
dentists, podiatrists, psychologists,
dieticians, optometrists, and pharmacists.

4. Pretest 2: Multiple choice
Factors that shifted medical care from the home to the hospital include all of the following except:
There was a lack of nurses to provide care in the home.
New medical technology required space and maintenance that could only be provided in the hospital.
Physicians started to specialize more and offer their services in centralized locations.
Increased use of cars and public transportation allowed patients to travel to hospitals.

5. Pretest 3: Multiple choice
Which of the following best describes how the Balanced Budget Act of 1997 (BBA) impacted home health care?
The BBA expanded home health care to include chronic long term care.
The BBA liberalized the Medicare criteria for receiving home health care.
The BBA set limits on Medicare spending, refocused home health care to post acute care, and cut the increased Medicare home health care services available in the 1980s and early 1990s.
The BBA increased the Medicare home health care budget.

6. Pretest 4: Multiple choice
Which of the following patients does not meet the Medicare home health care homebound participation requirement?
Betty leaves her home for dialysis three times per week.
John attends an adult day care program several times per week.
Norma goes to church every Sunday.
Peter goes out with friends to a restaurant every Wednesday.

7. Pretest 5: Multiple choice
Which of the following patients does not meet the Medicare home health care skilled need requirement?
Victor needs help with blood sugar monitoring and diabetic education.
Virginia needs rehabilitation for her hip replacement.
Cecil needs a bath aid.
Rose needs wound care for her pressure ulcer.

8. Pretest 6. True or False A patient must meet the Medicare homebound
requirement in order to receive home medical
equipment from Medicare.

9. Pretest 7: Multiple choice
A typical Medicare home health care episode includes all of the following except:
an initial evaluation including basic teaching and counseling
development of a 60-day care plan
a mandatory home health visit from a physician
physician reviews and signs the care plan

10. Pretest Answers
true a. c. d.
false

11. Section One: What is Home Health Care?1,2
Any diagnostic, therapeutic, or social support service provided in the home
Health care providers who provide home care
Home diagnostics
Home equipment
A variety of services designed to provide care for patients in their homes
Home health care offers the opportunity to provide care that takes into consideration patients’ home lives, living situations, chronic illnesses, and functional limitations and aims to deliver patient-centered care.2 11

12. Home Health Care Providers3,4
Physicians, nurse practitioners, physician assistants
Physical therapists, occupational therapists, speech therapists
Nurses
Social workers
Home health aids
Dentists, podiatrists, psychologists, dieticians, optometrists, and pharmacists
Skilled, medically centered home health care services involve skilled nursing, physical therapy, occupational therapy, and speech therapy. Nurses make overall assessments of patients; provide teaching on medications, disease processes, and disease management; provide dietary counseling; and provide bowel and bladder training.3 They also perform procedures in the home such as wound care, ostomy care, tracheostomy care, catheter care, injections, venipuncture, and IV therapy.3 Psychiatric nurses provide mental health services. Physical therapists provide home exercise plans, help with exercises for strength, gait, balance, and transferring, instruct on proper use of assistive devices, and provide modalities such as ultrasound.3 Occupational therapists provide training in activities of daily living and instrumental activities of daily living.4 They also help with home safety assessments, environmental modifications of the home, fitting of orthotics, and use of self-help/assistive devices.3,4 Speech therapists assess and treat speech and language disorders, swallowing disorders, and cognitive disorders.3 Physicians and other health professionals also participate in home care by making home visits and by coordinating care in the home. 12

13. Diagnostics and Equipment2
Lab work, x-ray, ultrasound, EKG, holter monitoring, other diagnostics that can be done in the home.
Beds, wheelchairs, lifts, commodes, infusion therapy, and other assistive devices used in the home. 13

14. Other Home Health Care Services1,2
Home health aids, home attendants, housekeepers, and meal delivery
Telemedicine monitoring (using the telephone to provide care)
Hospice
Home health services also provide social support and personal care assistance. Social workers help with long term planning, community resources, and crisis and other counseling.3 They also help patients create new social networks.4 Personal assistance services include home aids to provide help with activities of daily living and instrumental activities of daily living including assistance with bathing, dressing, grooming, hair care, nail care, oral care as well as housekeeping, laundry, and meal preparation.3,5 14

15. Section Two: A Brief History of U.S. Home Health Care
Historically, most health care was provided in the home.
Physicians provided services in the home as well as nurses.
Visiting nurses associations played a large role in making home visits.6,3
Historically, the majority of medical care was provided in the home in the United States. In addition to physicians’ services in the home, nurses delivered care in the home. As early as the 1790s, visiting nurse associations and other charitable organizations provided nursing care to the poor, primarily mothers and children.6 In the early 1900s, concerns about protecting public health and preventing spread of disease prompted many community organizations such as women’s clubs, churches, hospitals, charitable organizations, health departments, and settlement houses to send visiting nurses to homes.3 15

16. Shift in Care to Hospitals7
Advances in medicine shifted care.
New medical technology required space and maintenance that could only be provided in hospitals.
Physicians started to specialize more and offer their services in centralized locations.
Increased use of cars and public transportation allowed patients to travel to hospitals. 16

17. Home Health Care for Long Term and then Post Acute Care3,8
By the 1930s
most care of acutely ill patients had transitioned to the hospital and
visiting nurses provided long term care in the home to chronically ill patients.
In the late 1950s hospitals began to make referrals to home care nurses
to help with the discharge of patients from the hospital to the home and
to provide post acute care.
Home health care agencies were funded by charitable and public contributions until the passage of the Medicare Act in 1965.
Home health care services began to shift in the 1950s to focus on convalescent post acute care in the home after discharge from the hospital with services including nursing, social work, and rehabilitation.8 17

18. Medicare Expanded Home Health Care2,3
Medicare covered care for:
patients sent home from the hospital (post acute)
post-hospital home health benefit under Part A limited to 100 visits following a 3-day hospital stay
Medicare also covered more chronic care:
general home health benefit under Part B limited to 100 home visits per calendar year 18

19. Medicare Home Health Care Continued to Expand in the 1980s
Omnibus Reconciliation Act of 19803
removed the limits on the number of home care visits,
removed the prior hospitalization requirements,
extended participation in Medicare home care to for-profit home care agencies.
More than half of the patients receiving home health care did not have immediate prior hospitalizations, and many people received services for more than 6 months1
As the requirements liberalized, home health care services provided to patients encompassed both post acute as well as chronic care. 19

20. Increase in Home Health Care in 1980s-1990s
During the 1980s, the hospital prospective payment system was implemented resulting in faster discharges from hospitals and the need for post hospitalization home care services.3
During the 1980s, with the removal of the requirement for a recent hospitalization, services increased as well to the chronically ill needing more long term care.8,2
Medicare home health care payments increased an average of 33% per year between 1989 and 20

21. Home Health Care in the1990s1
Throughout the 1990s, home health care services continued to expand due to:
earlier hospital discharges,
declines in nursing home beds,
increased numbers of frail adults and elders,
cost-based financing of home care. 21

22. Home Health Care in the1990s (cont.)
In the early 1990s, Medicare reimbursement for home visits also increased.2,3
Majority of Medicare home health episodes extended past 6 months.2,3
Between 1990 and 1997, home health care was 9% of the Medicare budget.1
In 1997, there were 10,444 Medicare certified home health care agencies in the U.S.3 22

23. 1997 Balanced Budget Act Curtailed Medicare Home Health Care1,8
Balanced Budge Act (BBA)
set limits on Medicare spending,
refocused home health care to post acute care only,
cut the increased services available in the 1980s and early 1990s.
More stringent criteria for home health care
set new requirement of homebound status and
refocused home health care on post acute care and episodic care. 23

24. BBA: Prospective Payment System1,3
The 1997 BBA created a home health care prospective payment system (PPS)
home health agencies would be paid a set amount for each 60-day episode, regardless of the number of visits provided and
payment broken down into 80 separate clinical categories.
BBA also created a requirement for agencies to report outcome data on all Medicare and Medicaid patients using the Outcome and Assessment Information Set (OASIS) 24

25. BBA PPS
Cost-based reimbursement with a prospective payment system resulted in a 20% decline in home health care, with more rural area agencies closing.1
BBA reduction in home health care reimbursement led to closure of 14% of home health agencies between 1997 and
In 1999, home health care was 4% of the Medicare budget, as compared with 9% between 1990 and1997.1
By 2001, more than 1/3 of home health agencies closed.3
The changes created by BBA resulted in decreased use of home health care services with fewer patients receiving home health care, fewer visits, lower payments, and shorter durations of service.3
Home health care shifted to focus on post acute hospital and episodic care only usually lasting weeks to months at the most.1
Over time, however, agencies adjusted to the prospective payment system. Home health care agencies have gradually increased in number.
In 2007, 9,284 Medicare certified home health care agencies existed in the U.S., and Medicare spent more than $14 billion on home health care.3
However, the current Medicare home health care program no longer encompasses long term chronic care of patients in their homes but instead focuses on filling in the gaps in post hospitalization short term post acute and episodic care. 25

26. Section Three: Medicare Home Health Care Program2,3
Pays for skilled nursing care, physical therapy, occupational therapy, speech therapy, medical social work, home health aide services, medical supplies.
Limits services through program participation requirements.
Focuses primarily on short term care and post acute, post hospitalization care.
A physician must make the referral for home health care to a home health care agency and oversee the plan of care.
All home health care must be deemed medically necessary by a physician.3 26

27. Participation Requirements2,3
Patients must be temporarily or permanently homebound.
Patients must have a need for skilled services. 27

28. Homebound
Patients must have an inability to leave their homes, i.e.,2,3
leaving the home requires considerable and taxing effort on the part of the patient, caregiver, or both,
and/or requires the assistance of another person or an assistive device or special transportation.
Nonmedical absences from the home must be infrequent and of short duration.3
Medicare allows homebound status for those who must leave the home for medical appointments, dialysis, and adult day health programs.2 Medicare also allows trips outside of the home for religious services, family events, and hairdresser appointments.2 However, absences from the home for nonmedical treatment reasons must occur infrequently, generally three times or fewer per month and for short periods of time.10 Patients fail to meet the homebound requirement and thus do not qualify for Medicare funded home health care services if they leave their homes for social reasons more than a few times per month.10 28

29. Skilled Care Need1,2 Skilled nursing:
includes monitoring vital signs such as blood pressure, pulse, temperature, monitoring drains, dressing wounds, managing medication regimens, and providing patient and family education
Physical and occupational therapy, speech therapy, and other therapies:
includes gait and balance training, home safety assessments, exercise instruction, and help with assistive devices
Skilled care need must be intermittent not continuous and must be episodic and for brief periods of time only. 29

30. Medicare Part A2,3
Pays for home health care if patients meet the two requirements.
Patients do not pay additional costs or co-payments.
Patients must have a referral from a physician who certifies home health care as medically necessary.
Pays for 60-day episodes.
Medicare will pay for home health care only part time and intermittently.3 30

31. Medicare Part A3,10 (cont.)
The 1997 Balanced Budget Act (BBA) created a home health care prospective payment system (PPS) for reimbursement which developed 80 separate clinical categories with set amounts for each 60 day episode of care
Payment is based:
in part on patient acuity and is not based on the actual number of visits provided
on the BBA’s data gathering tool, the Outcome and Assessment Information Set (OASIS), which assesses severity of illness, disabilities, and nursing needs 31

32. Additional Medicare Services1,2
Once homebound patients meet the skilled care need requirement and receive skilled services through nursing or therapy, they can also receive social work and home aid services.
However, if patients do not have a skilled need, Medicare will not pay for any home aid or personal care services.
Medicare will only pay for home aid and personal care services for short periods, such as a few hours per day and only if patients have a concurrent skilled need for home health care.
Medicare does not pay for 24 hour care at home, meal delivery, or homemaker services such as shopping, cleaning, laundry, personal care assistance when patients only need these services without a concurrent skilled need.3 32

33. Medicare Coverage of Home Equipment1,2
Will pay for home medical equipment:
even for those patients who do not meet the homebound requirement and
includes such durable medical equipment as hospital beds, special mattresses, commodes, wheelchairs, walkers, lifts, and oxygen.
Medicare Part B pays 80% of the cost; then patients have a 20% co-pay. 33

34. Medicare Home Equipment (cont.)1,2
Private insurance will often cover the remaining costs.
Physicians must complete a Medicare certificate of medical necessity.
Medicare does not pay:
for nondurable, smaller medical equipment such as diapers, wipes, gloves, dressing materials, grab bars and other bathroom modifications, canes, and reachers,
but in some states Medicaid does pay for some of these above types of supplies. 34

35. Typical Medicare Home Health Care Episode3
Physician makes a referral to a home health agency, and an initial evaluation occurs within 48 hours of the referral.
RN must complete the initial evaluation unless the patient requires only physical, occupational, or speech therapy services (then the therapist performs the initial evaluation).
At the initial visit, the nurse determines eligibility, obtains consent for care, completes paperwork, and performs a comprehensive initial assessment.
The initial assessment includes collecting OASIS data, reviewing medications, and providing basic teaching and counseling.3 35

36. Typical Medicare Home Health Care Episode (cont.)3
After this initial visit, the patient receives a number of subsequent visits based on the patient’s needs for care.
The admitting nurse or therapist develops a 60-day care plan that describes all services needed and establishes goals.
Referring physician reviews and signs care plan.
Home health care providers then proceed with the specific tasks and goals and update the care plan which the physician then periodically signs along with any new orders. 36

37. Medicare Home Health Care Focus
Medicare-funded home health care provides patients with services for discrete acute episodic periods based on patient acuity and needs.
Patients are discharged from home health care when the discrete acute defined goals have been met, even though they continue to have chronic debilitating medical conditions and functional limitations.
The focus is on post acute and episodic, not long term care.
If patients continue to meet the homebound and skilled care requirements, home health care agencies could theoretically continue providing Medicare funded services for years of sequential 60 day episodes if home health care providers document medical necessity for such services.3 However, long term, continuous provision of home health care services to patients with chronic medical conditions and decreased functional ability rarely occurs because patients are discharged when acute goals are met.3 37

38. Post-test 1. Multiple choice
Which of the following best describes home health care personal assistance services?
A nurse providing ostomy care
A speech therapist evaluating swallowing dysfunction
A home health aid providing assistance with bathing and dressing
A physical therapist providing teaching on safe transfers

39. Post-test 2. True or False
The Omnibus Reconciliation Act of 1980 expanded Medicare home health care by removing the limits on the number of home visits, removing the prior hospitalization requirement, but limited participation to non-profit home health agencies.

40. Post-test 3. True or False
In the early 1990s, the majority of Medicare home health care episodes extended past 6 months.

41. Post-test 4. Multiple choice
Which of the following did the Balanced Budget Act of 1997 not do?
Resulted in fewer patients receiving home health care, fewer visits, lower payments, and shorter durations of service
Introduced new participation requirements for Medicare home health care
Introduced a data gathering tool, the Outcome and Assessment Information Set (OASIS)
Improved long term home health care services for patients with chronic diseases

42. Post-test 5. Multiple choice
The Medicare home health care homebound requirement includes all of the following except:
Permits weekly social visits
Requires that patients have difficulty leaving their homes
Permits leaving the home for doctor’s appointments
Permits trips to church

43. Post-test 6. Multiple choice
Which of the following best describes the Medicare home health care skilled need?
Can be a continuous need for 24 hour care
Includes physical, occupational, and speech therapy
Includes social work needs
Includes home health aids and attendants

44. Post-test 7. Multiple choice
Which of the following applies to the Medicare provision of home medical equipment?
Patient must be homebound.
Medicare pays 100% of the cost.
Physicians must complete a Medicare certificate of medical necessity.
Medicare will pay for bathroom modifications.

45. Post-test Answers c.
false
true d. a. b.