By Jeanie Davis

Typically, when discharge planning involves the need for home care assistance, case managers rely on the patient’s family and friends to assist with activities of daily living (ADL).

In many families, this can work just fine. But where there are odd family dynamics or if a family member is not equipped to be a caregiver, there is a need for outside help, explains Gavin Ward, a regional director with California-based 24 Hour Home Care.

“A lot of family members are not equipped to be caregivers, or are not comfortable with the role,” Ward explains. “If the patient is their parent, they may not want to cross into the personal care — dealing with a naked parent, or incontinence care. They prefer to have a professionally trained, nonfamily member perform those tasks to maintain barriers. Or, the family member may have burnout issues.”

These families could benefit from a home care agency, but the case manager may not think the family can handle the expense. “We highly recommend the case manager refer to a home care agency, even if there seems to be family support or financial support,” Ward says. “Don’t take it for granted they don’t need it.” Also, if the patient’s prognosis indicates that home care may be a future need, family members should know that as well.

“Many case managers believe families can’t afford nonmedical home care services,” Ward says. “They believe this type of nonskilled care won’t be covered by insurance, Medicare, or Medicaid.”

Funding for nonmedical in-home care has been available since 1965 through the Older Americans Act, which funds Area Agencies on Aging. “This isn’t 40-hours-a-week care, but could help someone just enough a couple hours a week to stay in their own home,” says Ward.

The Department of Veterans Affairs offers similar programs. Groups like the Alzheimer’s Association provide respite programs for primary caregivers. Medicaid waiver programs allow Medicaid dollars to fund nonmedical in-home care to help with transitional and respite care.

In 2018, CMS announced that Medicare Advantage Plans can include nonmedical home care as a supplemental benefit starting in 2019. “It’s not common yet,” says Ward. “CMS did not give health plans much notice to do this; they announced it in April, but plans had to submit their 2019 designs in June per CMS requirements.”

Only 3% of health plans nationally have opted into the personal care benefits; 10-15% offer a respite benefit. Most health plans are taking a wait-and-see approach, as they are not ready to take on the additional risk, Ward explains. “We do anticipate during 2020-2021 seeing more plans adopting the benefit,” he adds.

Identifying Reputable Home Care Services

To ensure that the referral agencies are reputable, Ward outlines the following criteria:

• Licensing. Some states license home care agencies; if so, ensure the agency’s license is active. This can be validated through the state licensing agency; for example, California is licensed through the California Department of Social Services, Home Care Services Bureau.

• Registries. Often referred to as direct referral agencies (DRAs), these serve as “matchmakers” and do not employ the caregivers. Read the fine print; the liability likely will fall on the family if anything goes wrong. If the goal is to provide a full-service agency to patients and prevent the family or patient from taking on employment responsibilities, steer clear of these agencies, Ward advises.

• Background checks. A DRA will claim that it runs background checks, but if fingerprinting must go back the entire lifetime, says Ward, it is the best option (if available). The family should get a copy of the background and fingerprint check, which, in most states, should be an FBI and Department of Justice check going back to birth. If the agency or caregiver refuses to provide this, it is a red flag.

• Best practices. Refer families only to home care agencies that employ their caregivers, and provide insurance and “full service” for those caregivers. Do not refer to an agency that only provides insurance for office staff (which is a practice among registries to keep costs down). Ask for the “fidelity bond,” a certificate of insurance for the caregivers. Ask what the insurance covers to ensure caregivers (not just officer staff) are covered.

“Most hospital risk management and legal departments recommend a case manager only refer to a licensed or ‘full-service’ agency that employs its caregivers and provides insurance for those caregivers,” says Ward. “If something goes wrong, the family will be covered — including any theft,” he adds.

“It should not be difficult for a case manager to find legitimate home care agency in their area,” Ward adds. “Metro areas and rural areas typically have multiple legitimate options.”