Misunderstanding Home Care

There is so much misunderstanding about homecare that I want to help clarify the misunderstandings. Many refer to homecare as home health or just homecare without ever realizing there are 3 types of homecare. This isn't a just a misunderstanding in the lay community, but there is an enormous lack of understanding among medical professionals and those working in the medical field. Even websites that provide health information can be very wrong in their description of home care. They use home health and homecare interchangeably as if it were one in the same.


The lack of knowledge, particularly in the medical community is a huge disservice to patients. Because of the changes we have witnessed in healthcare in the last several years patients are being left to their own accord to educate themselves, and advocate for the best care. If doctors, nurses, social workers, and discharge planners don't understand homecare, or teach their patients about home care options, how are patients supposed to find the resources that would best suit their needs?  I have spent most of my career working as a nurse in Home Health Care, Hospice, and for the last 8 years owning Visiting Angels Private Duty Homecare in Ann Arbor.  I speak about this from years of experience, and care for countless families in all 3 types of home care.

There are 3 types of home care as I mentioned. Home Health Care, Private Duty Homecare, and Hospice Care.

The most confusion comes between Home Health and Private Duty. There is also a need for Hospice education, but that is specifically related to hospice services, and when hospice is appropriate. I will briefly touch on Hospice care in this article.

HOME HEALTH CARE-

Home health care is medical care in the home for homebound patients. It is a benefit of Medicare, Medicaid, and most private health insurances if the patient meets very specific criteria. Home Health provides Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Social Work, and Home Health Aides.

To qualify a patient typically has had an acute health change requiring hospitalization, and home health is initiated upon hospital discharge. The patient must be homebound, meaning they only leave the home for medical appointments. Qualifications don't require hospitalization, but that is the most common qualifier for home health. A patient can also qualify if there is a significant change in health status, such as an acute illness or injury not requiring hospitalization. For example, if a patient went to ER for trouble breathing, and was having a hard time controlling congestive heart failure, they would most likely qualify, but again would have to be homebound. If a patient was physically debilitated due to an illness or injury, and needed therapy to regain strength and balance, they could qualify.

Patients also can qualify based on a new and life altering diagnosis, such as insulin dependent diabetes. Diabetics are at risk for a multitude of problems from uncontrolled blood sugar so education and monitoring is essential to prevent complications.

Home Health is always set up on a short, temporary basis. It must include either nursing or physical therapy to obtain services. Home Health must be ordered by a physician to be covered by insurance. Visits are determined based on the nurse’s initial assessment, and the therapist’s assessment. Nurse typically determines which of the services available will be initiated and how often they and the home health aide visit. Therapists either initiating care or being initiated by the nurse provide their own evaluation to determine the frequency and length of their visits.

The goal of home health is to improve health outcomes. Their services are guided by .Medicare Guidelines  Medicare expects the home health team to educate the patient and family specific to the ordering diagnosis and discharge as soon as possible. Medical procedures that were once done by nurses, such as dressing changes on wounds, daily catheterization and injections, are now being taught to patients and families with the expectation that a responsible party within that patient's family or friends will provide those medical procedures, after being taught by the nurse.

Home health aides can only provide personal care according to Medicare guidelines. This includes bathing and grooming, but does not include providing meals, housekeeping, or any type of tasks that aren't directly related to personal care.

Therapists provide therapy but their main job is to educate the patient how to perform the therapy and all the work is up to the patient. No one really improves if they don't follow the therapist’s directions to follow the exercise plan when they are not there.

There is always a care plan that is followed by the team, with the inclusion of the patient, and family if applicable. Home Health is set up on a 60 day basis. The professionals who visit will typically be in the home for 45 minutes to an hour. As weeks go on in the 60 day certification period, visits decrease, unless the patient’s health status declines. If the team determines the patient improves to the point they no longer qualify for services, or they do not remain homebound, discharge will be before the 60 day certification period ends. If the patient continues to have significant health needs that cannot be improved in the 60 day period, home health can recertify the patient beyond the 60 days.

PRIVATE DUTY HOMECARE-

Private duty homecare is non medical. The services are provided by caregiver's and/or certified home health aides (may be dependent on individual State regulations). The services provided are considered custodial care, and do not require a physician's order. Services are designed to help the care recipient remain in their home as independent as possible by providing hygiene, meals, light housekeeping, companionship, errands, and medication reminders. Some agencies or individuals providing services transport clients, some do not.

The amount of services is determined by the care recipient, and/or family, because Private Duty is not covered by health insurance. Most Private Duty Homecare services are paid out of pocket, but may be covered in part or whole by  Long Term Care Insurance, or Veterans benefits.  Individual States may have programs providing limited Private Duty services for low income residents, but my experience is they are very limited on the number of residents they can qualify for services. There is typically a waiting list for these programs, or they are closed to new applicants. They provide very little amount of services from agencies that contract with them.

My Visiting Angels Private Duty Home Care agency in Ann Arbor, Michigan,  does not contract with the State of Michigan for the  MI Choice Medicaid Waiver program, as it's called in Michigan, because their reimbursement rate is so low I would personally have to cover a portion of care for the care recipient. Agencies that contract for these services typically pay their caregiver's a very low wage, therefore don't attract or retain the best staff. We choose to pay a higher wage to attract and hire the best caregiver's possible.  Check with your local or State Department of Aging for your State programs.

Private Duty often works in collaboration with Home Health agencies because the services are very different in nature and typically if someone needs home health, they also need assistance with activities of daily living (ADL'S). Because I am a nurse and geriatric care manager, I always assess the need for home health care if our client comes to us before home health. I make referrals so our client's can improve to the best quality of life possible. Many Private Duty agencies do not involve themselves with health care at all because of the lack of knowledge in understanding health care needs.

Private Duty Homecare is available 24 hours a day, 365 days a year. Clients can obtain services long term or short term. Some agencies require a minimum amount of hours either per shift, per day or per week, some do not. This varies by the agency, as well as the rates, so check around.

Each State determines if they will regulate Private Duty agencies, so check with your State to determine whether they license Private Duty agencies or not. Michigan is an unlicensed State, so there are no regulations on Private Duty homecare in the State of Michigan. Ethical, legitimate agencies, like my own, are pushing for regulation for the protection of the elderly.

Private Duty agencies are NEVER certified by Medicare, because Medicare does not cover these services. Long Term Care Insurance companies have been difficult to deal with in the recent years because the language in their policies states the home care agency must be licensed or Medicare Certified. They are beginning to understand this varies by State, and paying claims they tried to deny in the past.

Some Home Home Health agencies also operate Private Duty, but they are run as separate companies. Even when their Home Health division is Medicare certified, their Private Duty is not. Very few companies that offer both Home Health and Private Duty do both well. The focus tends to be ion the Home Health division with little attention to providing excellent Private Duty.

I've always believed that if a company diversifies itself too much they typically don't do it all well.

I would rather contract a company whose sole concentration and expertise is in Private Duty, or Home Health than one that tries to do it all.

HOSPICE-

 Hospice , as most know is care for the dying. The perception is usually not accurate with what hospice is or what they provide. Hospice can be provided in homes, hospice facilities, long term care facilities and in hospitals. Medicare, Medicaid and most private insurances cover hospice care. This also requires a physicians order, but does not require the patient to be homebound. It is initiated based on a terminal diagnosis. The old rule of thumb used to be if the patient was given 6 months or less to live. That is no longer the case. Although it is expected that death is impending from a terminal diagnosis.

Hospice consists of Nurses, Home Health Aides, Social Work, Spiritual Care, and Volunteers, as well as a Bereavement Counselor. Patients may use all or some of the services based on their needs and preferences. Visits are short, typically between 45 minutes and 1.5 hours. Volunteers may be scheduled longer, and of the staff may be in the home much longer than a typical visit if the patient is in need of pain control or other comfort measures.

Although Hospice operates under a primary physician or medical director who is a physician, hospice nurses direct care. Nurse’s case manages the care and work as a team with other hospice professionals, as well as the family and even friends of the patient.

Some Home Health companies have hospice as well, and often have a transitional program. Patients may start out with Home Health, and as they decline decide to transition to Hospice services. Patients never have both. The focus of Home Home Health and Hospice are very different. Home health concentrates on improvement, and Hospice concentrates on comfort, support, and the best quality of life possible for however long the patient will live. They specialize in pain control and the process of dying. They address physical, emotional, and spiritual needs, not only with the patient, but with their loved ones.

Private Duty will often work in collaboration with Hospice, to provide care when families are unable or need respite. Private Duty follows the direction of the Hospice team to maintain comfort and support for the patient. Rather than contacting EMS or the client's physician for help with changing status, Private Duty caregiver's contact the Hospice nurse for instruction.

I hope this clarifies the misunderstand of home care. There is no charge for most Hospice or Private Duty companies to meet with you to assess your needs, and provide information. Home Health is a bit different in the fact that is it's physician ordered, and they make the appointment to assess, and plan the start of care. Hospice and Private Duty are more optional. Understanding your health status, or your loved one's status, and what your needs are can help you obtain the best services for your situation. Most companies are very receptive to calls for information.




My suggestion is to always check out the company before beginning services. Most consumers don't realize they have a choice. You have the right to choose a Home Health, Hospice or Private Duty company. Just because a hospital or care facility owns their own home care companies doesn't always mean they are good or the best for you or your loved one. Keep in mind some health care companies want to provide it all and keep their patient's in their system for financial reasons. Their financial goals will not benefit your care. Ask the tough questions, ask for references, Google the company you are interested in. Know the owner's name and Google them as well. Many consumers are now voicing their dissatisfaction with providers that are all over the web. Just realize one person's dissatisfaction isn't verifiable to exclude a company. A few dissatisfied consumers can provide be the basis for exclusion.

I wish you the best care for your needs, and the needs of your loved ones!

Angil Tarach can be reached for questions or comments at visitingangelswc@comcast.net, or www.visitingangels.com/annarbor