Home Care

Physicians and Home Care

Building new partnerships

BY Kathy Messerli

A definition of home care and the range of services it provides can be unclear. Simply put, home care is any health care provided in the patient’s home, but what oftentimes flies under the radar is that home care can provide essentially all the services a long-term care facility can, from the beginning of life to end of life, pediatric to hospice, including personal non-medical care to skilled nursing and complex care, all in the comfort of a patient’s home.

Personal care services assist patients with the activities of daily living (ADLs), such as dressing, grooming, eating, bathing, transfers, mobility, positioning and toileting, as well as light housekeeping, laundry and meal preparation for adults. Intermittent skilled care can offer post-surgical care, wound care and disease and medication management. In addition to nursing, this may also include therapy services, including physical therapy, occupational therapy and speech therapy. Complex skilled care can go so far as to function as an ICU in the home.

Benefits of Home Care

Conducting more care in the home results in numerous benefits for patients, taxpayers and the health care ecosystem in general. First and foremost, home care keeps people out of hospitals and at home where they want to be, saving them and taxpayers money and reducing time away from loved ones, which has proven to expedite the healing process.

Home care keeps people out of hospitals.

People feel better when they can recover in their own home surrounded by their loved ones, and oftentimes assistance with simple tasks is all it takes to keep them from being hospitalized. A patient may fear being forced to leave their home, may not know home care services are available and may not want to share the extent of their needs.

Further, the use of home health services generates cost savings to state and federal programs. Genworth, a New York-based life insurance company has collected and published interactive maps with cost of care data since 2004. Data gathered for 2021 indicate that home care services cost around $6,000 per month, about half the average cost of a nursing home. By comparison, nationwide average hospital costs are around $2800 per day.

Barriers to Access

While home health care is a critical component of our health care ecosystem, it is not without barriers today. A significant barrier keeping patients from receiving home care is a lack of awareness between both patients and medical staff of the range of services available.

Elevating both physician and patient awareness and the dialogue around how home care might be the best way to improve health status is an important goal. Hospital discharge is an ongoing crisis costing Minnesota billions of dollars because when hospital patients reach a sub-acute level there is nowhere for them to be discharged and they remain in the hospital. A fairly high level of care can be provided in-home, as indicated above, and should be considered as one of many solutions.

When patients are hospitalized, the discharge planners who are arranging their next level of care often aren’t aware of the range of services available through home care and sometimes misunderstand the various eligibility requirements. For example, Medicare covers eligible home health services for as long as a patient needs part-time or intermittent skilled services and as long as a patient is “homebound.”

Patients may leave the home for short periods only, and for things that are a necessity of life, such as follow-up doctors’ appointments. Leaving the home multiple times a week for social activities does not meet the definition of a homebound patient.

The average patient requiring ongoing care when being discharged from a hospital generally faces the choice between entering a nursing home or a transitional care unit. In many cases, home care would be preferred, more effective, and less expensive. If physicians indicate the patients’ specific needs in their medical records, it could prove useful in facilitating the best referral.

A second barrier is the workforce crisis, which impacts access to home health care as well as to other facilities. Staffing is such an industry-wide challenge that even if a discharge planner does refer to home care, sometimes agencies have to turn away the referrals because of insufficient staffing.

This challenge is partially related to the low home care provider reimbursement rates, which exacerbate the workforce shortage challenges. These low rates directly affect the salaries that agencies can pay home care workers. Base pay for nurses who work in hospitals is more than 50% higher than in most home health agencies, making it understandably very challenging to find staff.

Advocacy from the entire health care system is needed to ensure that patients can also be cared for in their homes to decrease boarding in our hospitals and to improve cost efficiency and improved outcomes. We must work together to ensure that care in all settings is available to patients.

Creating a Referral

IFor all skilled home care services, a home care referral order and follow-up must come from a physician. Not only are there many types of home care services, but there are also eligibility standards and regulations, many of which physicians aren’t expected to track.

When home care is being considered, it’s vital to recognize that while patients will prefer to remain at home, they may not be aware that services can be brought to them. They may well count on you, their physician, to provide guidance. And, you can count on home care providers to partner with you in this determination. 

If a physician makes a referral, home care agencies will guide the appropriate process that is determined by the payer. Furthermore, the home care provider will do a comprehensive assessment to determine whether home care services are appropriate for the patient. To ensure patients receive services as quickly as possible, it is important for physicians to submit the requests and authorizations without delay.

Home care services continue to offer one of the most effective methods for improving patient health status.

Communication and timely responses between physicians and home care providers are important when home care is used by patients. Communication is as important on an ongoing basis when developments in care occur as it is during the referral process.

Many payers require specific documentation from physicians in order for your patients to receive the services. A few examples of what will be required from you, the physician, are:

As the referring physician, you must provide a description of the patient’s needs and an order for an assessment to initiate the care. The referring physician is typically the patient’s primary care physician or a hospital doctor helping assist with discharge plans. After the home care agency has conducted an assessment and established a need for skilled home care services, the doctor following the patient (usually the primary care provider for the patient) will need to provide continuing home care orders to the agency, sign a plan of care established by the home care agency and be available to collaborate with the home care agency to ensure the patient’s care and treatment are achieving optimal outcomes. 

A face-to-face appointment with the patient is also required by Medicare and Medicaid home care services, conducted by the physician certifying the need for home care and the one following the patient/client throughout the home care episode. This must be related to the reason home care is needed. If the patient is being referred from the hospital to home health, this part of the referral decision is often completed in the hospital.

For personal care services, assessments are handled by the county and care requests will be sent from the county to physicians.

Hospital discharge planners and clinic care coordinators will be able to assist in getting the patient the necessary information to pursue both personal care and skilled home care services.

Improving communication

Not every home care agency offers the same services, and it is important to match a patient with an agency providing all the required care. Some agencies offer only non-medical services such as PCA or homemaking, whereas others offer “skilled services” such as nursing, PT, OT, speech, etc. Doctors may be hesitant to recommend home care services because they’re uncertain how to determine a patient’s eligibility. This burden does not rest squarely on the physician’s shoulders. The physician needs only to make the initial referral, after which the home health agency will provide an assessment and provide the necessary navigation.

“There are some confusing rules about who qualifies and who is going to pay for these services…all of which can and should be answered by the home health agency staff. It is impossible for physicians to keep up with these ever-changing qualifiers. Sending a referral to an agency for review is the best way to truly know whether the patient is appropriate for care at home,” said Kristy Husen, director of Home Care and Hospice at CentraCare. She added, “The types of patients that can be cared for at home can vary from some that need help with basic things, like ADLs or homemaking, all the way to really complex disease management, wound care, therapy, and more.”

Advances in technology have enhanced communication between home care providers and hospitals and clinics. That said, challenges remain when it comes to the timing of sharing the information and the ability for home care providers and physicians to have a clear idea of what is currently happening with the patient. While a small number of home care agencies can access certain hospital system EMRs, many do not have access to these records and rely on referring hospitals/clinics to send them the information needed to start home care services.



It’s important to establish a communication plan to ensure home health care providers have updates when a patient has had a change in medications or a change in condition, or has been hospitalized. “Home care providers sometimes show up at a patient’s home for a visit, only to learn that the patient is in the hospital. It can be really challenging for agencies to communicate adequately when they don’t even know their patient is seeking medical care,” said Husen. By the same token, the home health care provider may have important data on the patient’s health status and needs to have a way to share this with the physician.

In Summary

Providing care in the home isn’t just what patients prefer, it’s also more cost effective – for patients and taxpayers. Despite the clear economic advantages, low reimbursement remains a serious problem and has exacerbated staffing shortages. New state and federal legislative initiatives are underway that offer promise but will take time to make meaningful change.

Meanwhile, home care services continue to offer one of the most effective methods to improving patient health status. CMS data reporting on Minnesotan patients showed the following results after patients were discharged from hospitals to home care settings:

• 83% of patients got better at walking or moving around.
• 84% of patients got better at getting in and out of bed.
• 85% of patients got better at bathing.
• 85% of patients’ breathing improved.
• 78% of patients got better at taking their meds orally.

The process of health care delivery is evolving into multidisciplinary, community-based care. Ensuring our patients’ needs are met depends on building and strengthening the relationship between physicians and the home care industry.

Kathy Messerl is the executive director of the Minnesota Home Care Association representing home care agencies from across the state.