by Joyce Good Henderson

Created on: May 29, 2010   Last Updated: May 30, 2010

As a home health care nurse, I must determine when home care is appropriate for every patient I see.  Medicare guidelines, which are also used by most insurance companies, are very clear and specific in detailing when home care is reimbursable. 

People who do not qualify for Medicare, Medicaid or insurance-paid home care may still be appropriate for care, but they will need to hire private duty care and pay for it out-of-pocket.

Under Medicare guidelines, a patient must first be an eligible Medicare beneficiary who needs “reasonable and necessary” services. The person must be confined to home because of an illness or disability. 

Leaving home must require considerable and taxing effort, occur infrequently and for short periods of time.  Absences from home for medical treatments are always acceptable. 

Reasonable and necessary services involves at least one of the following: skilled nursing care, physical therapy, speech therapy, or occupational therapy.  Care must be provided under a Plan of Care established and directed by a physician. 

A person who requires daily wound care or an injection does not necessarily require skilled nursing care.  A family member, or the patient himself can be taught to perform such care. 

Skilled nursing care involves observation, assessment, teaching and training in situations where only a nurse, because of education and experience, can provide the necessary care. 

For exmple, nurses do not normally give a patient a bed bath.  A home health aide provides personal care, but only under the supervision of a nurse. 

Home health care is appropriate when someone has been hospitalized and continues to need care after discharge home.  Home health care serves as a bridge between the hospital and complete return to normal functioning and self-care. 

Today, patients leave the hospital “quicker and sicker,” and home health care allows them to continue receiving assistance, treatments and therapy. Home health care is a safe and less costly alternative to going to a rehab facility or nursing home.

Home health care is appropriate when someone has had a significant change in a medical condition that, even though it did not require hospitalization, would benefit from ongoing assessment and treatment by a nurse or therapist. 

For example, when a patient has had several falls, the physician will frequently request an evaluation and treatment

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