Home Health 101: What You Need to Know to Advocate, Educate, and Discharge Safely
Disclaimer: This post is for educational purposes only and reflects general guidelines and professional experience. It should not be used as a substitute for clinical judgment, employer-specific protocols, or legal advice.
Please review the full disclaimers and references listed at the bottom of this post for more information.
As a new hospital-based case manager, one of the most frequent and often misunderstood discharge referrals you'll coordinate is for home health care. While many patients qualify, there are specific clinical and logistical requirements you need to know to ensure your referral is appropriate, covered, and successful.
This guide covers the essentials of home health services, including eligibility, provider responsibilities, scope of services, and how to communicate realistic expectations to patients and families.
What Is Home Health?
Home health is a short-term, intermittent, skilled service provided in the home setting for patients recovering from illness, surgery, or a medical event. It is not daily care, not personal caregiving, and not a substitute for private-duty help.
The care must be medically necessary, ordered by a provider, and based on a specific skilled need.
What Disciplines Are Available?
Home health care can include several licensed professionals:
Registered Nurse (RN): Wound care, medication management, chronic disease education, assessments
Physical Therapist (PT): Mobility training, strengthening, gait improvement, fall prevention
Occupational Therapist (OT): Training for activities of daily living (ADLs), home safety, fine motor coordination
Speech Therapist (ST): Swallowing disorders, communication deficits, cognitive retraining
Medical Social Worker (MSW): Resource support, counseling, long-term care planning
Home Health Aide (HHA): Intermittent personal care (e.g., bathing), only when a skilled service is also active
The combination of services is based on the initial assessment by the admitting clinician.
What Is Homebound Status?
To qualify for Medicare-covered home health care, the patient must be considered homebound. This means:
Leaving the home requires considerable effort, the assistance of another person, or an assistive device
Absences from the home are infrequent and primarily for necessary purposes (e.g., medical care, religious services)
Homebound status must be documented clearly in the patient’s chart and supported by the provider’s face-to-face evaluation.
Hospitalist vs. Primary Care Provider: Who Oversees Home Health?
As the hospital case manager, you can initiate the referral process before discharge. However, once the patient is home, a community-based provider—typically their primary care provider (PCP)—must assume responsibility for signing and managing the plan of care.
Hospitalists or inpatient providers may complete the required face-to-face encounter (which must occur within 90 days prior or 30 days after the start of home health), but they do not provide ongoing oversight once the patient is discharged.
🔑 Tip: Always confirm that the patient has a PCP or outpatient provider willing to follow them. Without an available provider, home health services may be delayed or denied due to lack of care coordination.
How Long Does Home Health Last?
Home health is structured as an episode-based service, generally reviewed in 30-day periods. It is designed to address specific, short-term needs—not to serve as long-term care.
Examples of frequency:
RN: 1–2 visits per week for wound care or medication management
PT: 2–3 visits per week for rehabilitation
HHA: A few times per week (only in conjunction with another skilled service)
Once goals are met or the patient no longer qualifies, services are discontinued. Recertification may occur if continued skilled care is warranted.
What Does Insurance Cover?
Medicare
Covers home health at 100% under Part A or Part B, with no co-pay or deductible if eligibility requirements are met (Centers for Medicare & Medicaid Services [CMS], 2023).
Commercial Insurance
Coverage varies. Some plans require authorization, have visit limits, or apply co-pays.
Encourage patients to confirm their benefits and cost-sharing responsibilities with their insurer.
Home Health vs. Outpatient Services
Most payers will not authorize home health and outpatient services concurrently for the same discipline. For example, a patient receiving HHPT (home health physical therapy) generally cannot also attend outpatient PT.
⚠️ Exception: Wound Care
Occasionally, patients may receive outpatient wound care and home health nursing, but the outpatient visit is typically billed as a physician service, not as duplicate skilled nursing. This varies by payer and must be coordinated with both the provider and agency.
When It’s Not Home Health: Private Caregiver Needs
Families may mistakenly believe home health will help with:
Meal preparation
Grocery shopping
Dressing and grooming every day
Transportation
Daily companionship
These are non-skilled, custodial services and not covered by home health. When these needs exist, families should explore:
Private-pay caregivers
Long-term care insurance (if applicable)
County IHSS or Medicaid waiver programs
🗣️ Suggested script:
“Home health will send a nurse or therapist to help a few times per week for medical needs like wound care or therapy. If you’re looking for daily help with meals or getting dressed, we can talk about caregiver options outside of home health.”
Quick Checklist for Hospital Case Managers
Before making a home health referral:
☑️ Confirm homebound status
☑️ Ensure the patient has an outpatient provider to follow the plan of care
☑️ Verify a face-to-face visit has been or will be completed
☑️ Document skilled needs clearly
☑️ Explain frequency and duration expectations to patient/family
☑️ Identify non-skilled needs that may require private services
References
Centers for Medicare & Medicaid Services. (2023). Medicare Benefit Policy Manual: Chapter 7 - Home Health Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf
Medicare.gov. (n.d.). Home health services. U.S. Department of Health and Human Services. https://www.medicare.gov/coverage/home-health-services
