An Introduction to Home Health Care in
the United States:
Overview and History of Home Health Care
and the Medicare Home Health Care Program
Tracy Gutman, MD
Geriatrics Fellow
University of Kansas
OBJECTIVES
By the end of this module,
the learner will do the following:






List the types of home health care providers and the specific
tasks that they perform in the home.
Differentiate the focus of Medicare home health care services
before and after the Balanced Budget Act of 1997.
Define the requirements for participation in Medicare home
health care.
Explain under what circumstances Medicare home health care
will cover personal care services.
Describe Medicare reimbursement for home medical
equipment.
Describe a typical Medicare home health care episode.
Pretest
1. True or False
Home health care providers can include
dentists, podiatrists, psychologists,
dieticians, optometrists, and pharmacists.
Pretest
2: Multiple choice
Factors that shifted medical care from the home to the
hospital include all of the following except:
a.
b.
c.
d.
There was a lack of nurses to provide care in the
home.
New medical technology required space and
maintenance that could only be provided in the
hospital.
Physicians started to specialize more and offer their
services in centralized locations.
Increased use of cars and public transportation
allowed patients to travel to hospitals.
Pretest 3: Multiple choice
Which of the following best describes how the Balanced
Budget Act of 1997 (BBA) impacted home health care?
a.
b.
c.
d.
The BBA expanded home health care to include
chronic long term care.
The BBA liberalized the Medicare criteria for
receiving home health care.
The BBA set limits on Medicare spending, refocused
home health care to post acute care, and cut the
increased Medicare home health care services
available in the 1980s and early 1990s.
The BBA increased the Medicare home health care
budget.
Pretest
4: Multiple choice
Which of the following patients does not meet the
Medicare home health care homebound participation
requirement?
a.
b.
c.
d.
Betty leaves her home for dialysis three times per
week.
John attends an adult day care program several
times per week.
Norma goes to church every Sunday.
Peter goes out with friends to a restaurant every
Wednesday.
Pretest
5: Multiple choice
Which of the following patients does not meet the
Medicare home health care skilled need requirement?
c.
Victor needs help with blood sugar monitoring and
diabetic education.
Virginia needs rehabilitation for her hip replacement.
Cecil needs a bath aid.
d.
Rose needs wound care for her pressure ulcer.
a.
b.
Pretest
6. True or False
A patient must meet the Medicare homebound
requirement in order to receive home medical
equipment from Medicare.
Pretest
7: Multiple choice
A typical Medicare home health care episode includes
all of the following except:
a.
b.
c.
d.
an initial evaluation including basic teaching and
counseling
development of a 60-day care plan
a mandatory home health visit from a physician
physician reviews and signs the care plan
Pretest Answers
1.
2.
3.
4.
5.
6.
7.
true
a.
c.
d.
c.
false
c.
Section One:
What is Home Health Care?1,2





Any diagnostic, therapeutic, or social support service
provided in the home
Health care providers who provide home care
Home diagnostics
Home equipment
A variety of services designed to provide care for
patients in their homes
Home Health Care Providers3,4






Physicians, nurse practitioners, physician assistants
Physical therapists, occupational therapists, speech
therapists
Nurses
Social workers
Home health aids
Dentists, podiatrists, psychologists, dieticians,
optometrists, and pharmacists
Diagnostics and Equipment2


Lab work, x-ray, ultrasound, EKG, holter
monitoring, other diagnostics that can be done in the
home.
Beds, wheelchairs, lifts, commodes, infusion
therapy, and other assistive devices used in the
home.
Other Home Health Care Services1,2



Home health aids, home attendants, housekeepers,
and meal delivery
Telemedicine monitoring (using the telephone to
provide care)
Hospice
Section Two:
A Brief History of U.S. Home Health Care



Historically, most health care was provided in the
home.
Physicians provided services in the home as well as
nurses.
Visiting nurses associations played a large role in
making home visits.6,3
Shift in Care to Hospitals7




Advances in medicine shifted care.
New medical technology required space and
maintenance that could only be provided in
hospitals.
Physicians started to specialize more and offer their
services in centralized locations.
Increased use of cars and public transportation
allowed patients to travel to hospitals.
Home Health Care for Long Term
and then Post Acute Care3,8



By the 1930s

most care of acutely ill patients had transitioned to the hospital
and

visiting nurses provided long term care in the home to
chronically ill patients.
In the late 1950s hospitals began to make referrals to home care nurses

to help with the discharge of patients from the hospital to the
home and

to provide post acute care.
Home health care agencies were funded by charitable and
public contributions until the passage of the Medicare Act in
1965.
Medicare Expanded
Home Health Care2,3

Medicare covered care for:



patients sent home from the hospital (post acute)
post-hospital home health benefit under Part A
limited to 100 visits following a 3-day hospital stay
Medicare also covered more chronic care:

general home health benefit under Part B limited to
100 home visits per calendar year
Medicare Home Health Care Continued to
Expand in the 1980s

Omnibus Reconciliation Act of 19803




removed the limits on the number of home care
visits,
removed the prior hospitalization requirements,
extended participation in Medicare home care to forprofit home care agencies.
More than half of the patients receiving home health
care did not have immediate prior hospitalizations,
and many people received services for more than 6
months1
Increase in Home Health Care
in 1980s-1990s



During the 1980s, the hospital prospective payment
system was implemented resulting in faster
discharges from hospitals and the need for post
hospitalization home care services.3
During the 1980s, with the removal of the
requirement for a recent hospitalization, services
increased as well to the chronically ill needing more
long term care.8,2
Medicare home health care payments increased an
average of 33% per year between 1989 and 1996.9
Home Health Care in the1990s1
Throughout the 1990s, home health care services
continued to expand due to:




earlier hospital discharges,
declines in nursing home beds,
increased numbers of frail adults and elders,
cost-based financing of home care.
Home Health Care in the1990s




(cont.)
In the early 1990s, Medicare reimbursement for
home visits also increased.2,3
Majority of Medicare home health episodes extended
past 6 months.2,3
Between 1990 and 1997, home health care was 9%
of the Medicare budget.1
In 1997, there were 10,444 Medicare certified home
health care agencies in the U.S.3
1997 Balanced Budget Act
Curtailed Medicare Home Health Care1,8

Balanced Budge Act (BBA)




set limits on Medicare spending,
refocused home health care to post acute care only,
cut the increased services available in the 1980s
and early 1990s.
More stringent criteria for home health care


set new requirement of homebound status and
refocused home health care on post acute care and
episodic care.
BBA: Prospective Payment System1,3

The 1997 BBA created a home health care
prospective payment system (PPS)



home health agencies would be paid a set amount
for each 60-day episode, regardless of the number
of visits provided and
payment broken down into 80 separate clinical
categories.
BBA also created a requirement for agencies to
report outcome data on all Medicare and Medicaid
patients using the Outcome and Assessment
Information Set (OASIS)
BBA PPS




Cost-based reimbursement with a prospective
payment system resulted in a 20% decline in home
health care, with more rural area agencies closing.1
BBA reduction in home health care reimbursement
led to closure of 14% of home health agencies
between 1997 and 1999.9
In 1999, home health care was 4% of the Medicare
budget, as compared with 9% between 1990
and1997.1
By 2001, more than 1/3 of home health agencies
closed.3
Section Three:
Medicare Home Health Care Program2,3




Pays for skilled nursing care, physical therapy,
occupational therapy, speech therapy, medical
social work, home health aide services, medical
supplies.
Limits services through program participation
requirements.
Focuses primarily on short term care and post
acute, post hospitalization care.
A physician must make the referral for home
health care to a home health care agency and
oversee the plan of care.
Participation Requirements2,3

Patients must be temporarily or permanently
homebound.

Patients must have a need for skilled services.
Homebound

Patients must have an inability to leave their homes,
i.e.,2,3



leaving the home requires considerable and taxing
effort on the part of the patient, caregiver, or both,
and/or requires the assistance of another person or
an assistive device or special transportation.
Nonmedical absences from the home must be
infrequent and of short duration.3
Skilled Care Need1,2



Skilled nursing:
 includes monitoring vital signs such as blood
pressure, pulse, temperature, monitoring drains,
dressing wounds, managing medication regimens,
and providing patient and family education
Physical and occupational therapy, speech therapy, and other
therapies:
 includes gait and balance training, home safety
assessments, exercise instruction, and help with
assistive devices
Skilled care need must be intermittent not continuous and
must be episodic and for brief periods of time only.
Medicare Part A2,3




Pays for home health care if patients meet the two
requirements.
Patients do not pay additional costs or co-payments.
Patients must have a referral from a physician who
certifies home health care as medically necessary.
Pays for 60-day episodes.
Medicare Part A3,10


(cont.)
The 1997 Balanced Budget Act (BBA) created a
home health care prospective payment system (PPS)
for reimbursement which developed 80 separate
clinical categories with set amounts for each 60 day
episode of care
Payment is based:


in part on patient acuity and is not based on the
actual number of visits provided
on the BBA’s data gathering tool, the Outcome and
Assessment Information Set (OASIS), which
assesses severity of illness, disabilities, and nursing
needs
Additional Medicare Services1,2



Once homebound patients meet the skilled care need
requirement and receive skilled services through
nursing or therapy, they can also receive social work
and home aid services.
However, if patients do not have a skilled need,
Medicare will not pay for any home aid or personal
care services.
Medicare will only pay for home aid and personal
care services for short periods, such as a few hours
per day and only if patients have a concurrent skilled
need for home health care.
Medicare Coverage
of Home Equipment1,2

Will pay for home medical equipment:



even for those patients who do not meet the
homebound requirement and
includes such durable medical equipment as
hospital beds, special mattresses, commodes,
wheelchairs, walkers, lifts, and oxygen.
Medicare Part B pays 80% of the cost; then patients
have a 20% co-pay.
Medicare Home Equipment



(cont.)1,2
Private insurance will often cover the remaining
costs.
Physicians must complete a Medicare certificate of
medical necessity.
Medicare does not pay:


for nondurable, smaller medical equipment such as
diapers, wipes, gloves, dressing materials, grab bars
and other bathroom modifications, canes, and
reachers,
but in some states Medicaid does pay for some of
these above types of supplies.
Typical Medicare
Home Health Care Episode3
1.
2.
3.
Physician makes a referral to a home health agency,
and an initial evaluation occurs within 48 hours of
the referral.
RN must complete the initial evaluation unless the
patient requires only physical, occupational, or
speech therapy services (then the therapist performs
the initial evaluation).
At the initial visit, the nurse determines eligibility,
obtains consent for care, completes paperwork, and
performs a comprehensive initial assessment.
Typical Medicare
Home Health Care Episode (cont.)3
4.
5.
6.
7.
After this initial visit, the patient receives a number
of subsequent visits based on the patient’s needs for
care.
The admitting nurse or therapist develops a 60-day
care plan that describes all services needed and
establishes goals.
Referring physician reviews and signs care plan.
Home health care providers then proceed with the
specific tasks and goals and update the care plan
which the physician then periodically signs along
with any new orders.
Medicare Home Health Care Focus



Medicare-funded home health care provides patients
with services for discrete acute episodic periods
based on patient acuity and needs.
Patients are discharged from home health care when
the discrete acute defined goals have been met, even
though they continue to have chronic debilitating
medical conditions and functional limitations.
The focus is on post acute and episodic, not long
term care.
Post-test
1. Multiple choice
Which of the following best describes home health care
personal assistance services?
a.
b.
c.
d.
A nurse providing ostomy care
A speech therapist evaluating swallowing dysfunction
A home health aid providing assistance with bathing
and dressing
A physical therapist providing teaching on safe
transfers
Post-test
2. True or False
The Omnibus Reconciliation Act of 1980 expanded
Medicare home health care by removing the limits on
the number of home visits, removing the prior
hospitalization requirement, but limited participation
to non-profit home health agencies.
Post-test
3. True or False
In the early 1990s, the majority of Medicare home
health care episodes extended past 6 months.
Post-test
4. Multiple choice
Which of the following did the Balanced Budget Act of
1997 not do?
a.
b.
c.
d.
Resulted in fewer patients receiving home health
care, fewer visits, lower payments, and shorter
durations of service
Introduced new participation requirements for
Medicare home health care
Introduced a data gathering tool, the Outcome and
Assessment Information Set (OASIS)
Improved long term home health care services for
patients with chronic diseases
Post-test
5. Multiple choice
The Medicare home health care homebound
requirement includes all of the following except:
a.
b.
c.
d.
Permits weekly social visits
Requires that patients have difficulty leaving their
homes
Permits leaving the home for doctor’s
appointments
Permits trips to church
Post-test
6. Multiple choice
Which of the following best describes the Medicare
home health care skilled need?
c.
Can be a continuous need for 24 hour care
Includes physical, occupational, and speech therapy
Includes social work needs
d.
Includes home health aids and attendants
a.
b.
Post-test
7. Multiple choice
Which of the following applies to the Medicare
provision of home medical equipment?
a.
b.
c.
d.
Patient must be homebound.
Medicare pays 100% of the cost.
Physicians must complete a Medicare certificate of
medical necessity.
Medicare will pay for bathroom modifications.
Post-test Answers
1.
2.
3.
4.
5.
6.
7.
c.
false
true
d.
a.
b.
c.