What referral sources need to know about home care

By Elizabeth E. Hogue, Esq., Burtonsville, MD

The importance of referring patients for home care and hospice services is becoming increasingly clear to referral sources. Other providers have a better understanding that referrals for home care, home medical equipment (HME), and hospice are likely to enhance quality of care for patients, improve financial performance, and manage the risks of legal liability, especially as inpatient stays become shorter.

In order to help ensure that these benefits are realized, it is helpful for referral sources to know more about which patients are appropriate for these types of services. Specifically, patients who are referred for home health, HME, and hospice services must meet the following criteria, regardless of payer source:

  • Patients' clinical needs must be able to be met in their homes.
  • Patients must either be able to care for themselves or they must have a paid or voluntary caregiver available to meet their needs in between visits from professional staff.
  • Patients' home environments must support home health services.

In other words, some patients are not appropriate for home health, HME, and hospice services. The idea that all patients who do not have another source of care should be referred for these types of services is definitely risky business for referral sources.

Home care and hospice providers usually can meet the clinical needs of patients in their homes in view of the complex types of care they can render. Referral sources will undoubtedly have difficulties evaluating patients' home environments without going to visit. Home care and hospice providers will surely do so during the initial assessment visit.

However, referral sources can evaluate whether or not patients are likely to be able to care for themselves and, if not, whether they have relatives or friends who are willing to serve as primary caregivers. Referral sources should educate patients before they make referrals for these types of services. Home health, HME, and hospice are different models of care from institutional care. Unlike institutional care, there is a crucial role for primary caregivers to play when patients receive these types of care. This role must be made clear to patients and primary caregivers before referrals are made for home care and hospice services.

Referral sources should be as specific as possible about at least the initial role of primary caregivers. They may, for example, help patients and their families understand some of the tasks that primary caregivers initially will have to perform. Potential primary caregivers may be especially reluctant to care for incontinent patients, to dress wounds, or to give injections. If these types of care are needed, referral sources should clearly explain these activities to potential caregivers.

Referral sources should also make it clear to potential primary caregivers that their role is likely to change over time. Their activities and responsibilities are likely to change as patients' conditions either improve or deteriorate further. Or perhaps patients' conditions are chronic with little likelihood that they will improve or deteriorate; in this case potential primary caregivers should be aware that they may be involved over the long haul.

It may also be helpful for referral sources to help potential primary caregivers realistically evaluate whether they can fulfill the role of primary caregiver. Depending upon patients' needs, potential primary caregivers who work may not be able to perform the activities required of them. If patients need assistance with multiple transfers and potential primary caregivers have back problems, for example, they may not be appropriate for this role.

When patients cannot care for themselves and no primary caregivers are available on a voluntary basis, referral sources should also explore the possibility of using paid primary caregivers. Home health and hospice agencies are often able to provide so-called private duty services that may include "sitters," live-ins, aides, etc. Paid private staff may serve as primary caregivers.

When referral sources recognize that patients cannot care for themselves at home in between visits from home care and hospice staff and they cannot identify either a voluntary or paid primary caregiver, patients should not be referred for home care or hospice services except for hospice services provided in inpatient hospice units. Referrals should not be made for these types of services on the basis that patients will have no services if referrals are not made and that "something is better than nothing."

This is especially true when referral sources know that patients need institutional care, but patients refuse these types of care. Patients have an absolute right to refuse services. That does not mean, however, that home health, HME, and hospice providers must provide services to them in inappropriate settings.

Provision of services to patients at home when they cannot care for themselves and have no primary caregiver greatly enhances the risk of legal liability. It is also likely to violate the important ethical principle of justice, which dictates that all patients are entitled to appropriate care.

Home health, HME, and hospice services are often extremely beneficial for both patients and referral sources, but only if referrals are appropriate; otherwise, they are likely to enhance risks of legal liability for referral sources and violate important ethical principles. Now is the time for referral sources to appropriately evaluate patients before they make referrals for these types of services.