LegalEase: How can you tell who is right for home care?

By Elizabeth E. Hogue, Esq.
Burtonsville, MD

Both Medicare-certified and private-duty home health agencies must manage their patient mix in order to be economically viable. Thus, all home health agencies carefully must control admission and continuation of services.

Admitting patients who are not appropriate for home care gobble up resources with an ultimate adverse effect on the ability of Medicare-certified agencies to provide care at a cost that is below the episodic payment and on the bottom line of private duty agencies. In addition, providing services to patients who are inappropriate for home care enhances the likelihood of legal liability in this so-called litigious society.

Consequently, staff must evaluate every patient for general appropriateness for home care services before they are admitted. Just because patients meet the criteria of payer sources, such as the Medicare, does not mean that they should be admitted.

Likewise, patients continuously must be monitored in terms of these criteria. Patients who fail to meet one or more of the criteria prior to admission should not be admitted. Services should be discontinued to patients who met these criteria upon admission but no longer meet them later.

To be appropriate for home care services, patients must continuously meet the following criteria:

  • The patient’s clinical needs can be met at home.
  • The patient could take care of him or herself, or there is a paid or voluntary reliable primary caregiver to meet the needs of patients, in between home care visits.
  • The patient’s home environment supports home care services.

The ability of home care providers to care for medically complex patients has been greatly enhanced in recent years. As a result, it is rare that the clinical needs of patients cannot be met at home. These rare instances may involve, for example, patients who are prematurely discharged from an institutional setting. In addition, patients must be able to self-care or there must be a paid or voluntary reliable primary caregiver prepared to meet the needs of patient when agency staff members are not present. Staff may encounter significant difficulties with this as follows:

• When staff members evaluate patients for admission, they certainly will identify a potential primary caregiver. But realistically speaking, about all they can tell about potential primary caregivers during the admission visit is that they are vertical and breathing. The competence and reliability of primary caregivers only can be assessed over a period of time.

• Staff members often are working uphill against the expectations of patients and their families. Specifically, discharge planners in institutional settings are under so much pressure to move patients out of the institution that they rarely explain to patients and their families what their role in home care must be. Because of this, patients often are referred to home care with the expectation that nurses will take care of everything, just like they did in the institution. This expectation further is enhanced by the general lack of understanding by many patients and their families about home care. In addition, in the face of illness, it is only human for vulnerable patients and families to want agencies to simply step in and take care of everything.

• In addition, some of the tasks that primary caregivers may be expected to perform are repugnant to them. The "big three" such tasks are: wound care, changing diapers, and giving injections. When these tasks are involved, the reliability of primary caregivers may be sorely tested.

Identifying capable primary caregivers

What can agency staff do to increase the likelihood that they can identify capable, reliable primary caregivers?

• During the admission visit, staff should be direct with primary caregivers about the role they must play. They further must make it clear that if primary caregivers fail to fulfill their role, services may be discontinued. This very direct discussion and potential primary caregivers’ agreement or refusal to perform required tasks must be documented.

• If it appears that there is a reliable caregiver and the patient is admitted, staff must continue to monitor for reliability. Staff specifically must document every instance of noncompliance by primary caregivers. It is not sufficient to document that the caregiver generally is noncompliant. Rather, staff must document specific instances of noncompliance. Then staff must reteach primary caregivers and, if appropriate, get a return demonstration that also must be documented. This process should encourage reliability by caregivers.

Finally, the patient’s home environment must support home care services. Documentation related to this issue often is provided in the form of safety in the patient’s home.

The term "unsafe" is vague and can mean everything from too many scatter rugs on the floor to rats gnawing on intravenous tubing. So staff members should be careful to document that the patient’s home environment will not support home care services for specific reasons.

Home care providers must, however, be cautious with regard to assessment of this point. First, there are many people who choose to live differently than home care staff.

So-called "path patients" illustrate this point. There is so much rubble and debris in the patient’s home that workers can only pick a path from the front door to the patient’s bedside. These patients, however, are not necessarily inappropriate for home care services.

In addition, our society increasingly is diverse. Home care providers must be prepared to accommodate this diversity without drawing erroneous conclusions about the appropriateness of patients’ home environments.

Staff members who provide services to patient on tribal lands or Indian reservations have encountered instances when patients and their families refused to answer the door when they knocked.

Staff later learned that it was the custom in those tribes for visitors to wait in their cars until they were acknowledged in some way such as the raising of a shade or the opening of a door before they walked to the door of patients’ homes. These were not homes that would not support home care services. Rather, these were cultural and ethnic differences that must be accommodated by home health providers.

When patients meet all of these criteria, it is appropriate to admit them for services. Patients who no longer meet them are not generally appropriate for home care, and services may be discontinued. Agencies ignore these criteria at their own risk.

[A complete list of Elizabeth Hogue’s publications is available by contacting: Elizabeth E. Hogue, Esq., 15118 Liberty Grove, Burtonsville, MD 20866. Telephone: (301) 421-0143. Fax: (301) 421-1699. E-mail:]