Identification of Patients for Referral to Home Care Services

Guidelines for Home Care Assessment

The following qualifiers can help determine those patients appropriate for home care services:

  • Patients requiring assessments/education relating to:
  • New diagnosis
  • New medications or change in medications
  • Change in patient’s physical environment and/or new assistive device.
  • Patients with unstable disease process; cardio/pulmonary, diabetes, neurological, neuromuscular, metabolic, cerebrovascular, cardiovascular, renal, cancer, pediatric/including asthma, premature infants, psychiatric
  • Patients with open wounds, VAC wound care, pressure ulcers
  • Patients with ostomies, trachs, feeding tubes
  • Patients with drainage tubes and catheters
  • Patients requiring I.V. and injectable drug therapies
  • Patients with recent change in functional status including but not limited to: falls, paralysis, fractures, amputation or other physical impairment, change in custodial needs, ortho, neuro and/or deconditioned diagnosis
  • Patients with pain control management
  • Patients with end-stage disease and palliative care needs
  • Patients with new oxygen and/or nebulizer treatments
  • Patients receiving any type of home care services, i.e., CHHA, LTHHCP, PCA, private care, at time of hospital admission
  • Patients re-hospitalized within 60 days and/or known history of repeated hospital readmissions.
  • Patients requiring expedited discharges (EHD/Bridge Program)

The above guidelines can be utilized at:

  • Admission
  • Patient care rounds
  • Individual case conference with members of the health care team
  • Inquiry from patient/family/physicians
  • eview of medical records


CMS Pub 100-02

For a patient to be eligible to receive covered home health services, the law requires that a physician certify in all cases that the patient is confined to his/her home. For purposes of the statute, an individual shall be considered "confined to the home" (homebound) if the following two criteria are met:

1. Criteria-One:

The patient must either:

- Because of illness or injury, need the aid of supportive devices such as crutches, canes,

wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence


- Have a condition such that leaving his or her home is medically contraindicated.

If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional requirements defined in Criteria-Two below.

2. Criteria-Two:

- There must exist a normal inability to leave home;


- Leaving home must require a considerable and taxing effort.

For the complete definition please refer to






Home w No Services (as % of Discharges)





Home Care (as % of discharges)





Acute Rehab (as % of discharges)





Sub-acute Rehab (as % of discharges)





Long Term Care (as % of discharges)





Other (as % of discharges)