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When is home health care appropriate?

By Elizabeth E. Hogue, JD
Health care attorney
Elizabeth Hogue, Chartered
Burtonsville, MD

Across the country as the home health industry comes to terms with IPS, agency administrators are doing everything in their power to trim costs and keep budgetary expenses at a minimum. Part of this increased attention to cost-effectiveness has resulted in the spotlight being turned on patients, namely what it will cost to properly care for them. It’s not surprising then that one of the most significant issues facing agency managers today is determining whether a patient is even appropriate for home care services.

Making this determination early on is critical for a host of reasons, but perhaps none is more basic — and more obvious — than the simple fact that caring for patients, no matter their status, is extremely costly, utilizing not only financial resources but time and staff energy as well. Now, in light of the reductions in reimbursement for Medicare home care services and the new aggregate beneficiary limits, agency directors cannot afford to take on patients that will act as drain on the agency’s precious resources.

Still, it’s more than just the depletion of resources that should concern agency managers. There is also the matter of legal liability. By caring for patients that they need not be treating, or worse still, are unqualified to treat, agencies are opening themselves up to an increased chance of being named the defendant in a lawsuit.

Perhaps even more frightening is the very real likelihood that an agency submitting claims for patients who are inappropriate to receive home care will be charged with fraud and accordingly may find itself on the receiving end of both civil and criminal penalties.

Deciding factors

Clearly, determining a patient’s appropriateness for home care must be done before an agency agrees to take on the client. When working to assess a potential patient’s status, staff should be aware of the possibility that the referring party arranged for home care without being certain that it is what the patient truly needs.

Although it can be difficult for staff to judge a patient’s appropriateness, in general a patient is considered ill-suited for home care if:

• the patient’s clinical condition requires services at a different level of care;

• the patient cannot care for himself or herself and there is no reliable volunteer or paid primary caregiver to meet the needs of the patient in between home care visits;

• the patient’s home environment will not support the provision of home care services.

In order to receive home care services, a patient must be able to care for him- or herself between home care visits. If they are unable to do that themselves, it may be necessary to hire a primary caregiver or, if they are fortunate, patients may find primary caregivers who will volunteer to take responsibility for the patient’s care.

Finding reliable caregivers

No matter the situation, the main criteria is that the primary caregiver be reliable. For example, should primary caregivers be required to care for patients’ wounds, staff must speak directly to them about their willingness to provide care that many may find repugnant (especially if the wounds are in the advanced stages).

Granted, it can be extremely difficult for staff to effectively evaluate primary caregivers during the initial assessment. In fact, sometimes all that can be said for certain is that the individual is vertical and breathing. Even so, providers need to work harder at this evaluation than they have in the past.

Evaluation doesn’t stop with the patient: Agencies must also evaluate patients’ home environments to make certain that they will support home care services. Such an evaluation should take into account the differences in lifestyles and cultures that staff may encounter and that some patients may choose to live differently than the professionals caring for them.

One example is the so-called "path patient" where, because of all the clutter in a home, staff must pick their way along a path from the front door to the patient’s room.

Staff members must also be prepared to accommodate religious, cultural, and ethnic differences and realize that these differences are not always barriers to home health services.

The importance of documentation cannot be stressed enough. Exchanges with primary caregivers, home inspections, a change in a patient’s status — all should be recorded in the patient’s chart.

When it comes to assessing the patient’s home, it is important that documentation not be couched in terms of "safety," which can mean anything from the belief that there are too many scatter rugs on the floor which pose as a potential trip hazard to an observation of rats chewing on ventilator tubing. Rather, staff must specifically state that patients’ home environments will not support home care services and the precise reasons for this determination.

Once a patient is on board, it is the agency’s duty to monitor that person on an ongoing basis to determine whether that status holds true, and should a change occur, agency managers are then justified in terminating services. Although it may be tempting at first glance to continue providing those patients with home care, a second look at this complex issue shows the inherent risks, both legal and financial, in doing so.

Whereas once Medicare-certified agencies operated with a "big tent" mentality, in which all beneficiaries were welcome, this is no longer the case. Now, agencies must be extremely careful about whom they admit and how long they continue services for those patients. When it comes to freedom from malpractice suits, the honeymoon is over for home care providers.

Editor’s note: To receive a copy of Preventing Fraud and Abuse, including information on the issues related to Medicare/Medicaid fraud and abuse, send a check for $25 payable to Elizabeth E. Hogue at 15118 Liberty Grove, Burtonsville, MD 20866.