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Top 8 Things To Know About Home Health Care After a Hospitalization

An older adult man sits on a couch with a woman health care worker who is wearing scrubs and holding a tablet.
Home health care has many benefits for people who are returning home after a hospitalization or skilled nursing facility stay. Here are the top things to know to help you plan for this recovery stage. Photo Credit: iStock.com/Jacob Wackerhausen

A hospital visit alone may not always be enough to get a senior back on their feet after a fall, injury, surgery, or rapid health decline. Even once the immediate crisis has passed, people often need support to recover and get stronger. Home health care bridges the gap between the hospital and the home. It offers valuable medical care and rehabilitation after a hospitalization or short-term stay in a subacute rehab facility by helping people regain their health, strength, and independence.

However, home health care isn’t always straightforward. Here are some important things you should know to help your family navigate this critical phase of recovery. 

1. What home health care is and is not

Home health care is short-term medical care provided in a person’s home, usually after a hospital stay, surgery, or illness. It’s ordered by a doctor and covered by Medicare if certain conditions are met. The goal is to help someone recover, stay safe at home, and avoid going back to the hospital.

Depending on the individual’s needs and what their doctor recommends, they can receive services such as:

  • Skilled nursing care, like wound dressing, IV medications, and education in chronic condition management.
  • Physical, speech, and occupational therapy provided by skilled professionals to help improve independence.
  • Medical social services, which target the social and emotional impacts of health issues, including helping families find local services and support.
  • Short-term personal care assistance (assistance with the activities of daily living like dressing, grooming, and eating), but only when a doctor deems it medically necessary alongside medical home health care. (Personal care assistance is considered nonmedical home care and, therefore, typically not covered by insurance, but under these circumstances, Medicare may cover it for a short time.)

Home health care is not long-term or custodial care. It doesn’t include full-time caregivers, help with housekeeping, or ongoing personal care unless it’s part of a prescribed skilled medical plan. If your loved one needs daily help with cooking, cleaning, or getting dressed beyond what’s medically necessary, you may need to arrange separate nonmedical home care services.

2. When Medicare covers short-term home health care

Medicare is one of the main funding options for short-term home health care, but it has strict eligibility requirements. Recipients must be signed up for Medicare and be homebound, and a doctor must prescribe the care as medically necessary.

Being homebound doesn’t mean you can’t ever leave your home. It means that leaving home without help is difficult or not advised because of your health.

Recipients must also need only part-time or intermittent care. Specifically, you must need no more than eight hours per day of care for no more than 28 hours per week. This limit can occasionally be increased up to 35 hours per week for a short time.

People who receive Medicare-covered home health services do so because their health care providers recommend it, so you won’t be able to hire home health services on your own and assume Medicare will cover it.

There are no copays for Medicare-covered home health services if all criteria are met.

3. How home health care begins

Home health care begins with a doctor’s order from your primary care physician or your doctor in a hospital or skilled nursing facility.

If you’re using Medicare to cover these services, you’ll need to find a Medicare-certified home health care provider.

Once you leave the hospital or rehab, the first visit from the home health care provider should happen shortly after you return home. This is a consultation visit and may last longer than normal. Questions and topics to cover include:

  • Your schedule.
  • Areas you need assistance with.
  • Mobility assistance.
  • Insurance information and other relevant details.

After the visit, the agency consults your physician to develop an appropriate care plan. This plan acts as a guide for your care, providing details about:

  • The services provided.
  • Frequency of visits.
  • Who provides the services.
  • Any required medical equipment.
  • Goals for treatment.
  • Expected results.

This plan will be regularly assessed and adapted as your needs change.

Once the care plan has been developed, you’ll start to receive regular home health care visits.

4. How often providers visit

Visit frequency varies based on your needs and care plan. Often, recipients of home health care get a few visits per week, with each visit ranging from 30 to 60 minutes.

You might also receive longer and more frequent home health aide visits if you need help with daily tasks and your doctor has deemed it medically necessary.

The frequency may vary over time. For example, you might receive daily skilled visits when you first leave the hospital, with visits becoming less frequent as your health stabilizes.

When each professional visits with you, you can review the schedule to understand how often they’ll visit, for how long, and the goals of their involvement with your care plan.

5. How family and caregivers are involved

Family and caregivers have important roles when their loved one receives home health care. These include:

  • Coordinating activities and home health visits.
  • Providing emotional support and companionship.
  • Helping to communicate wishes and problems with the care team.
  • Providing support that isn’t covered by home health care, like help with housework or extra personal care assistance.
  • Encouraging the person receiving care.

6. Why communication with the care team matters

Your care team needs to know about symptom changes, discomfort levels, what’s working, and what isn’t. Otherwise, they can’t provide the care you need.

Much of this information isn’t obvious, so you’ll need to be specific. Making regular notes can help ensure you don’t forget anything.

Communication is also crucial for resolving problems. Depending on the issue at hand, you may need to talk to the care team members themselves or perhaps someone higher up in the agency.

7. What happens if care needs change or progress stalls

Most home health agencies will assess care plans regularly and adjust the plan as your needs change, but you may sometimes need to inform them of changes yourself.

Alternatively, a care plan change might be needed if progress stalls. This could include specifying a shift in the frequency, type, or intensity of services to ensure progress continues. However, a stall in progress could also mean that home health care won’t lead to the desired changes.

8. What happens when home health care ends

Sometimes home health care ends because the service is no longer needed. Here, the end of the service may be reflected in the care plan, and staff will help patients prepare for the transition to living independently.

Other times, it may end for a different reason, like if Medicare is no longer willing to cover the care. In this case, families are typically provided with a Notice of Medicare Noncoverage. There’s an option to appeal the end of coverage; alternatively, families might look for another source of funding or perhaps shift their loved one to a different care situation.

Regardless of the reason, it’s important to plan for the transition out of home care. Think carefully about the type of care that will best suit your needs and where to obtain it.

Possible next steps include:

  • Independent living for patients who have significantly recovered and no longer need substantial medical support.
  • Home health care through another payer, like Medicaid (if you qualify) or paying for it privately (out of pocket).
  • Home care through another payer.
  • Assisted living for people who need practical assistance but do not have significant medical needs.
  • A nursing home for people who still have medical needs.
  • Living with a family caregiver.

It’s also important to talk to your care team. They can help you plan next steps and may have valuable recommendations.

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