Home care is an organized, non-physician health service provided by health professionals to clients in their homes. Services provided include nursing care, physical therapy, speech therapy, occupational therapy, nutritional counseling, and medical social work. Home health care nursing is a subspecialty of community health nursing, offered to clients of all ages. Home health care nursing focuses on health restoration and promotion. Alternatively, hospice care is holistic care provided to terminal clients when a cure is not possible.

Home health care began as a service to mothers and children in poor, urban areas, and then expanded into the rural areas where care was provided to clients of all ages. The Medicare Act of 1965 extended home health services to qualified elderly in their homes. The benefit was extended in 1973 to younger recipients with disabilities. According to the conditions of participation (COPs) for Medicare, home health care recipients must be homebound and require skilled services on an intermittent basis.

With the institution of the prospective payment system (PPS) for Medicare clients in 1983, hospitals were paid for care they provided according to set amounts for each diagnostically-related group (DRG) and were forced to discharge the elderly from the hospital as early as possible. The number of people needing home health care increased, leading to a restriction of home care reimbursement by the federal government to restrain costs. The prospective payment model has since been applied to home health agencies. Medicare pays for the bulk of home care but reimbursement is also possible through Medicaid, the Older Americans Act, Title II Social Services Block Grants, the Veterans’ Administration, and TRICARE (the military medical system).

The Outcome and Assessment Information Set (OASIS), a data model to collect information on Medicare home health beneficiaries, began in 2000. The purpose of OASIS is to provide information for Outcome Based Quality Improvement (OBQI), a process for improving quality in home care.

Home care organizations include home health agencies, home care aide organizations, and hospices. Home health agencies and hospices provide skilled care by health professionals. Home care aide organizations provide attendant care, companionship, homemaking, shopping, and other assistance in activities of daily living (ADLs). Respiratory care, home medical equipment companies, and nutrition counselors also work within home care.

Credentials for home care agencies include state licensure, Medicare certification, and voluntary accreditation. State licensure addresses minimal standards for staffing, policies, and procedures of the agency. Medicare certification surveys the charts, policies, procedures, billing practices, qualification of care providers, and administrative structures of the agency. Voluntary accreditation is through the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the Community Health Accreditation Program (CHAP). JCAHO and CHAP standards are more stringent than Medicare standards, so these organizations have deeming authority to certify and accredit agencies at the same time.

Home health agencies are either non-profit agencies or proprietary agencies. Non-profit agencies are tax-exempt voluntary agencies financed by concerned citizens. Any profits they make must be reinvested in the agency in some way. Proprietary agencies are not tax exempt and their profits may be used to reward investors. Hospitals also provide home care, whether non-profit or proprietary.

“Skilled” services in home care are those delivered by a professional, licensed health care provider. Both registered nurses (RNs) and licensed practical nurses (LPNs) provide skilled nursing, but only the RN can assess the client and write a plan of care. Nursing is usually the primary service provided in home care under Medicare, but physical therapy (PT), speech therapy (ST), or occupational therapy (OT) may also be the primary service. The medical social worker (MSW) assists clients with accessing community, financial, and mental health services. Home health aides/home care aides (HHAs/HCAs) provide three levels of services, from providing a safe home environment to providing personal care to assisting clients with medications, dressings, and exercises.

Hospices provide comfort and quality of life to clients with terminal illness and to their families. The hospice movement was started by Dr. Cecily Saunders at St. Christopher’s Hospice in London in 1967 and spread to the United States in 1974. Hospices offer palliative and supportive services provided by an interdisciplinary team that includes trained volunteers. A separate specialty, “palliative care,” focuses on relief of physical symptoms only.

According to Medicare guidelines, skilled care is reasonable and necessary, intermittent (not continuous) care provided to clients who are homebound. The client must be under a physician’s care and the physician must certify the need for home healthcare. Skilled care (1) must be done by licensed caregivers (RN, LPN, PT, OT, and ST) and (2) must include observation and assessment; teaching and learning; performance of skilled, direct hands-on care; and management and evaluation of a client care plan. Skilled treatments and procedures are services that require the knowledge of a skilled or licensed nurse to prevent complications in high-risk clients, such as wound care, injections, intravenous therapy, peritoneal dialysis, and catheter management. Management and evaluation of care plans focuses on integration of care, establishing the medical safety of the client, and preventing exacerbations and rehospitalizations.

Certain requirements apply for reimbursement for intermittent home care. Medicare will reimburse for skilled nursing care that is provided on fewer than seven days each week, or less than eight hours each day (combined) for 21 days or less. The care that is provided must be delivered periodically and not continuously and must be provided for a homebound client. Homebound clients are persons with a medical condition restricting the ability to leave the house except with assistance. They may attend adult day care programs, therapeutic sessions, medical treatment, or religious services. The adult day care programs must be approved by the United States Centers for Medicare and Medicaid Services (CMS).

The nursing process in home health care usually begins after a referral by a physician or by an in-patient discharge planner; however, anyone can initiate a visit. Assessment includes taking a health history from the client and family or caregiver, including the client’s medications, legal and financial support, and the safety of the environment. One tool for assessing the functional status of the client is the SANE tool. The SANE model includes assessing the senses, activity, neurological status, and emotional status. Another tool to assess functional independence is the Katz Index of Independence in Activities of Daily Living, which assesses the ability of the client in bathing, dressing, toileting, transferring, continence, and feeding.

The nurse may also ask the client and caregiver to describe a typical day, revealing challenges they may face. Several important components of a caregiver assessment are (1) their knowledge of technical skills, signs and symptoms, and how to advocate for the client; (2) their stress level; (3) family financial resources; (4) evidence of legal planning, such as living wills and durable powers of attorney; and (5) the family’s extent of social support and coping. Aspects of home safety include such components as lighting, floor hazards, electrical hazards, warmth or cooling, fire safety, and availability of emergency numbers.

Nursing diagnoses common in home care are caregiver role strain/risk for caregiver role strain, ineffective management of therapeutic regimen, noncompliance, impaired home maintenance management, and deficient knowledge. The plan of care consists of identifying skilled nursing interventions and disciplines needed, client goals, measurable outcomes, and inclusion of the client and caregivers. Implementation of the plan of care requires collaboration with caregivers, community agencies, and other members of the health care team. Home care nurses may employ telehealth, the use of telecommunications equipment and communications networks for transferring information among all involved in the clients, such as the Interactive Voice Response (IVR) system, video conferencing, or special programs that transfer results of diagnostic tests.

The requirements for home health care nursing vary by agency, but may include a baccalaureate of Science in Nursing (BSN), due to its emphasis on community health nursing. Additionally, home health care nurses need experience with complicated medical equipment, must be skilled in physical assessment, and must be knowledgeable about Medicare/Medicaid guidelines and case management. Nurses may also become certified in home health care nursing, hospice nursing, advanced practice, and case management through the American Nurses Credentialing Center (ANCC) and other organizations.