Tuesday, June 1, 2010

What is the Difference Between Home Healthcare, Homecare and Homemaker Service?

What is the difference between home healthcare, homecare and homemaker service and why does it matter? These terms are used often and interchanged extensively however there is a difference in the type of care provided and personnel used to support the different “care” programs. It is important to know the difference so that when you are exploring agencies you know what type of agency to go to for the type of service needed.

Let’s start with the term home healthcare first. Home healthcare is provided by home health agencies usually Medicare certified, state licensed and often accredited by an accreditation organization. Home healthcare agencies provide medical care in the home environment under the direction of a physician who orders care to be performed by licensed healthcare professionals. Typically these medical care programs help the patient recover from an illness, injury, disease or exacerbation of a chronic condition and includes services such as wound care, infusions, invasive catheter care, assessments, patient/caregiver teaching, medication management and administration of complex meds like injections as well as in home rehabilitation for those that are homebound. Medicare will pay for these services under the Part A benefit however the services must be provided by:

  • Nursing - RN and LPN
  • Therapy - Physical, Occupational and Speech-Language Pathologist
  • Social Work – MSW

Homecare is typically provided by residential care agencies that are state licensed and provide non-medical care also known as personal care service in the home environment under the direction of a licensed Registered Nurse (RN). The RN will develop a care plan for the individual requiring help in the home on a day to day basis. These programs tend to focus on the long term care needs of a patient and are considered alternative options to nursing homes. The intent of the personal care program is to keep the individual safely in the community for as long as possible. Personal care services typically consist of assistance with Activities of Daily Living (ADLs) including: bathing, dressing, grooming, shaving, medication reminders, feeding/meal preparation, toileting, linen changes, laundry and other activities to keep the patient in the home. Until recently Medicare did not cover this service but starting in 2016 this type of care will be covered. For more information visit the CLASS act that was included in the healthcare reform law. Many Elderly and Disabled Waiver programs under the Medicaid benefit will cover these services and the service must be provided by:

  • CNA, Certified Nursing Assistant/Certified Nurses Aide
  • HHA, Home Health Aide
  • PCA - Personal Care Aide
  • DCA – Direct Care Aide

It is important to recognize that a CNA or home health aide is not the same thing as a “nurse”. Often patients and even the aides will refer to themselves as nurses. Remember CNA/Home health aides do not have the same level of education, experience or training of a nurse nor do they take the same licensure exam or carry the same license as a registered nurse or licensed practical/vocational nurse carries. When you are shopping for in home services be sure that you are asking for the right type of personnel for the type of care needed.

Last there has been a significant increase in concierge homemaker care programs with the recent growth in the aging population. These agencies offer non-medical, no touch services which are typically provided under the direction of a non-licensed individual who develops client service plans for clients who wish to receive companion or homemaker services. Most agency requirements for a companion are a high school education or GED and the individual must be able to provide services like reading, transportation, conversation and socializing, activities and games, meal preparation, laundry, and light house keeping. Typically these services are paid out of pocket by the client or family as Medicare and Medicaid will not pay for these type of services.  However I have experienced on occasion local social service agencies as well as local Veterans Affairs (VA) programs pay for these services on a limited basis up to 2 - 4 hours per week.  Family members should be mindful that when their loved one "the client" starts requiring hands on service such as assistance with toileting, bathing or grooming, the individual should consider moving into a personal care program as home health aides have been trained and are more fully equipped to provide the more intensive hands on service.

Thursday, May 6, 2010

What to do When You Are Not Happy with Your Home Health Agency?

From time to time patients and their families may have a less than optimal experience while receiving care from a home health agency. There are many reputable home health agencies that when notified of a negative experience will make every effort to remedy the situation. But if an unfortunate set of circumstances occur and the home health agency has less than stellar customer service and response many patients and their families believe they have no other options. However there is a course of action that patients and their families can exercise to resolve issues and seek the quality care and service deserved. Here are the list of steps that can be taken.

1. Contact your home health agency and ask to speak to your patient care manager. Advise the manager of your complaint and solutions you believe will resolve the situation.

2. If you are not satisfied with the response or the agency does not respond, notify the agency in writing of your complaint with proposed solutions you believe will resolve the situation. Direct your communication to the Director of Patient Services or Director of Compliance/Performance Improvement.

3. If you are not satisfied with the response or the agency does not respond, you then can contact your state survey agency who is responsible for allowing the home health agency to operate under the state license. To find your state survey agency phone number and Website visit State Survey List.

4. If you remain concerned about the quality of care that the agency is providing you can contact your state quality improvement organization (QIO). To find your state QIO phone number and Website visit State QIO List.

5. If you remain concerned about the quality of care that the agency is providing and they are accredited by one of the three accreditation organizations (AO) you can contact the AO:
6. If you are a Medicare beneficiary, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or visit their Inquiries and Complaints Webpage.

Remember that quality healthcare and patient choice are rights rather than options. If you are unable to find a home healthcare agency that is willing to provide the care and service required, there are other agencies in your area that you can contact.

To find other home health agencies you can explore the Medicare.gov Home Health Compare website. This Website allows you to search for home health agencies in your area and compare their quality outcome measures. The quality measures describe how well home health agencies provide care. Visit the Home Health Compare Website.

Friday, April 30, 2010

6 Things You Need to Know About Medicare and Home Health

As a former home health organization CNO, I spent countless hours educating nursing staff as well as Medicare beneficiaries on what is covered under the Medicare Part A benefit for home healthcare. Many times I found that I was battling misinformation as a result of non home healthcare organizations not understanding the Medicare benefit. It is understandable since other healthcare facilities like hospitals and SNFs have their own regulations to follow. So I thought I would list the top 5 things every nurse, patient and other healthcare professionals need to know when suggesting home healthcare or referring individuals for home healthcare services.

1. Medicare will only pay for medical services on a short term, intermittent, part-time basis that are ordered by a physician and provided by (skilled professionals) licensed nurses, physical therapists, occupational therapists, speech language pathologists and medical social workers. Medicare does not reimburse agencies for services provided on a 24/7 basis nor do they cover service provided by a registered dietitian.

2. Medicare will only pay for home healthcare for patients that are considered homebound. Homebound is when the patient is confined to his/her home. An individual does not have to be bedridden to be considered confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort. Home healthcare agencies have issues with this definition of homebound status. For a detailed summary with examples go to link section 30.1.1 - Patient Confined to the Home.

3. Medicare does not pay for patients only requiring (nonskilled) home health aide service. Many times patients will be referred to home health at time of discharge from a facility for extra help however the help that is needed does not require the service of a skilled nurse. Home health aide services are only covered when a licensed registered nurse and/or physical therapist is actively treating the patient for a medical condition.

4. Medicare does not reimburse agencies on an hourly basis. Medicare pays the agency on episodic fee for service basis and the lump sum payment covers all care that is provided for a 60 day period. It is up to the agency on how to manage the dollars allocated for the patient for this time period.

5. Medicare does not pay for long term home healthcare service. Any service that falls under the category of personal care, companion, and/or are considered long term care, custodial or domestic in nature is not covered. These are all considered nonskilled services that are typically supported by home health aides.

• Personal care focuses on long term care needs of a patient and include bathing, dressing, grooming, shaving, medication reminders, feeding/meal preparation, toileting, linen changes, laundry.

• Companion Care/Homemaker nonmedical/no touch care and focuses on services like reading, transportation, conversation and socializing, activities and games, meal preparation, laundry, and light house keeping.

6. Medicare does not pay for nursing visits that occur for the sole purpose of veni-puncture and obtaining blood samples. If the only need is for blood draws, then the patient will need to go to an outpatient center. However if the doctor orders more than just veni-puncture to include other skilled nursing interventions like assessment, observation and education related to disease process and the medication that requires veni-puncture and monitoring then it would be covered.

For more information about what Medicare will cover please visit:

For a more detailed explanation about what Medicare will cover from a home health agency operating perspective please visit:

Monday, April 19, 2010

Evidence Based Practice in Home Health: Why is it nearly Impossible to Implement?

Evidence based practice (EBP) is when a nurse utilizes knowledge and experience and integrates it with current evidence based research. This integration creates wisdom and when applied to nursing practice enables quality nursing care and improvement in patient outcomes.

So why is it nearly impossible to implement EBP in home health? The organizational infrastructure of home healthcare does not support this type of nursing practice because it requires a shift from skilled nursing interventions "the act of doing" to skilled nursing assessment, planning and evaluation "the act of thought and judgment."  Supporting evidence based nursing practice means that home health organizations need to provide the following to support discovery of fact and evidence:

• Time
• Resources
• Know-how

Home health nurses need time to think and research. Currently home health organizations set daily visit productivity and visit weights to ensure the nurse is spending time in the patient home "doing" patient care. However this current staffing model does not allow the nurse the ability to step back and formulate the questions to address the patient needs and advance nursing practice. EBP requires time to formulate the questions, time to research, time to move theory to application and then time to re-evaluate.

Resources are another key element to evidence based practice. Many home health organizations are independent entities with no affiliations to medical libraries and have limited technology. Home health nurses need access to articles, periodicals, studies and other evidenced based materials. Whether the resources are retrieved from an academic medical library or subscription to an online database, home health organizations need to provide both the affiliation and technology for access to evidence based materials.

Knowing how to implement evidence based practice is the other key element. If EBP is a priority to home health organizations then continuing nurse education activities are essential. Home health nurses need support in learning how to search and retrieve information, how to assess its validity and how to re-evaluate once the evidence has been put into practice. Sharing the knowledge through publication is important because it builds the evidence to support the practice. Home health nurses need continuing education activities which help the practitioner become a scholarly writer so that others can read what practice changes are effective for a given problem and the measurable outcomes associated to the change.

While I have only identified three elements to evidence based practice, I am sure there are other factors. I look forward to learning about them during the VNAA 28th Annual Meeting pre-conference with faculty Dr. Marcia Rachel and Rebecca Askew, both published authors of the recent Home Healthcare Nurse journal article Keeping It Real: Evidence Based Practice in Home HealthCare. Stay tuned for an updated blog, hopefully with additional strategies to help home health organizations successfully implement evidence based practice. In the mean time I am including additional resources to reference.

Evidence Based Practice Resources
Web Tutorials

Yale University
Nursing Library and Information Resources
Cushing/Whitney Medical Library

Information Services Department of the Library of the Health Sciences-Chicago, University of Illinois at Chicago.
Evidence-Based Practice in the Health Sciences: Evidence-Based Nursing Tutorial

Penn State University, University Park
Evidence Based Practice Tutorial for Nurses

University of Minnesota
Welcome to Evidence-Based Practice: An Interprofessional Tutorial

Web Resources
Virginia Commonwealth University
Evidence-Based Nursing Resource Guide

Agency for Healthcare Research and Quality

National Guideline Clearinghouse™ (NGC)

University of Iowa's 17th National Evidence-Based Practice Conference


Sunday, April 18, 2010

Battling Influenza: Doing My Part

I had the pleasure of attending the National Influenza Vaccine Summit (NIVS) in Dallas, June 29 – July 1, 2009, representing the VNAA. In addition, I also had the honor of moderating one of the summit breakout session panels: 2009 - 2010 Service Delivery, Late Season Vaccination and & Retrospective Coverage Data. This was an important session to participate in as VNAs are community immunizers providing 1.5 million vaccine doses annually. VNAs understand the importance of partnering with organizations like Center for Disease Control and Prevention (CDC), The Association of State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO) and collaborating in forums such as NIVS to expand the immunization coverage within the community.

Many do not realize the importance of vaccination for the prevention of influenza because many do not know the morbidity and mortality associated to the influenza disease. According to the CDC, approximately 5-20% of the U.S. population becomes ill with the influenza virus annually. Further, this highly contagious disease causes an estimated 36,000 deaths each year. Although 36,000 deaths annually may not sound like a lot, it is important to recognize that influenza and pneumonia were the eighth leading causes of death in the United States in 2006 (U.S. Department of Health and Human Services, 2009), just behind alzheimer’s, diabetes, accidents, chronic lower respiratory diseases, stroke, cancer, and heart disease. Yet many in the community continue to view influenza with an attitude of “it’s just the flu” with no life threatening consequences.

Having a family, I have personally experienced the consequences of young children contracting respiratory viruses. One of my children contracted a respiratory illness during the 2003 – 2004 year at the age of 4 months and we have been battling respiratory issues ever since. Diagnostic testing was not performed and therefore we never had a definitive diagnosis as to whether my child had contracted Respiratory Syncytial Virus (RSV) or influenza. Both illnesses are airborne diseases caused by a virus and both have similar signs and symptoms which I later read about in an article Influenza A In Young Children with Suspected Respiratory Syncytial virus Infection (Friedman, 2003). Friedman recommended that children presenting with fever and respiratory illness symptoms should be tested for both RSV and Influenza. I also learned at the NIVS that particular Influenza year 2003 – 2004 there was widespread activity that caused severe illness and deaths in children. Regardless of the cause of the respiratory illness my child experienced in 2004, he has remained highly susceptible to respiratory infections including croup and bronchitis since that time. In addition I have another child that has been recently diagnosed with asthma and therefore is also at risk for experiencing complications from influenza like bronchitis and pneumonia. And if that was not enough, at the NIVS, I learned that I too am highly susceptible to complications from influenza since I am in the high risk category – pregnancy during flu season.

Yes, I am entering my second trimester and I am due during the first week of January 2010. I must admit that as a nurse I had significant knowledge deficits related to influenza, vaccines and pregnancy. I was relieved to learn that I can get the vaccination while I am pregnant. This is noteworthy news since children under the age of 6 months are not recommended for vaccination against the influenza virus. However it has been found that vaccination during pregnancy does provide newborns with immunity against the influenza virus. I wish I would have known this during my pregnancy of 2003, as a study published in the October 2008 issue of the New England Journal of Medicine found that influenza vaccination in pregnancy "reduced proven influenza illness by 63% in infants up to 6 months of age and averted approximately a third of all febrile respiratory illnesses in mothers and young infants" (Zaman et.al,2008). This would have helped reduce the likelihood of my 4 month old son in 2003 from contracting a respiratory illness. This pregnancy will be different and by following a few vaccine recommendations by (CDC) and the American College of Obstetrics and Gynecology (ACOG) to ensure my health and safety and protect my unborn child’s well being, I will get vaccinated. These guidelines can be found on the National Women’s Health Resource Center (NWHRC) at the Flu-Free and a Mom-to-Be pages a joint campaign initiative between the National Women’s Health Resource Center and the Association of Women’s Health Obstetric and Neonatal Nurses (AWHONN).

So it should become no surprise that I have professional and personal concerns related to the recent pandemic H1N1 Flu virus outbreak. This will be an added challenge as we enter the 2009 – 2010 seasonal Influenza year. However I am not panicking and will continue to follow the Advisory Committee on Immunization Practices (ACIP) recommendations. It will be interesting to learn about the results of the highly anticipated special ACIP meeting on Novel Influenza A (H1N1) scheduled Wednesday, July 29, 2009. There are many questions that need to be answered related to the vaccine that is under current development by the pharmaceutical manufacturers including when it will be released for distribution to the general public, how will the government release it, how many doses will be needed, will commercial insurers pay for the vaccine and what is the vaccine’s potential efficacy against the current H1N1 virus. In addition I will be following the World Health Organization (WHO) tracking of the pandemic and to see if there are changes in the H1N1 Flu virus virulence.

I intend to do all that I can to keep my family healthy and plan to have everyone vaccinated in September 2009 to not only protect me and my children but also to keep from spreading this highly contagious illness to others in my community that are at risk in developing complications from influenza including seniors over the age of 65. In addition practicing general health etiquette will ensure prevention and protection against current and future influenza strains. Although these techniques are simple in nature and everyone knows about them, it is amazing to me how forgetful individuals become regarding health etiquette in public environments. I was quickly reminded of others disregard to public health as I was traveling back home from the NIVS and was trapped in an airplane for three hours in front of a young couple that apparently had active respiratory illnesses. I knew this because the young women had a deep chest cough that would occur every 15 – 30 minutes during the flight and had intervals of sneezing and nose blowing. After the first coughing spell she took a cough drop but it was troubling to learn that she never covered her mouth when she coughed and the airline stewardess had to give her tissues. Her husband was not as ill and only would cough about every hour but still it was a deep chest cough that was beyond a “smoker’s cough.” Realizing that I may be just a tad over zealous since I just spent three days at the vaccine summit, I tried to tread lightly but did voice my concerns to the flight attendant. Apparently I was not the only one to complain, however the flight attendant stated there was not much she could do and only hoped that whatever they had was not contagious.

In closing, I am asking that everyone one do their part to stay healthy and get immunized against influenza. You can go as early as September or as late as March. Many do not realize that you can get the influenza virus as late as May, so it is never to late to get vaccinated. And as the H1N1 virus has shown it can be contracted during the summer months as well. But if you are still not convinced about the seriousness of the influenza illness and/or the safety and efficacy of vaccines, I would ask that you practice the following health habits to not only keep yourself healthy but also out of respect for public health.

1. Wash your hands, wash your hands, wash your hands. 20 – 30 seconds to the tune of Happy Birthday twice is all that it takes. If soap and water is unavailable please use alcohol based hand sanitizer.

2. Cover your mouth and nose when you sneeze or cough with a tissue and throw the tissue away after use. Try and keep a travel pack readily available instead of reusing the same old tissue. If a tissue is unavailable then use the inside of your elbow to cough into rather than into your hands.

3. Social distancing- stay home from work/school/church/mall or other public places when you are sick and seek treatment from a healthcare professional as soon as possible. The flu usually includes a high temperature fever with chills, with aches, pains, dry cough and extreme tiredness. There are medications that can help treat the flu called Anti-virals. Can’t tell if it is the cold or flu then use this resource to help tell the difference Cold or Flu.

4. Avoid close contact with others that are sick. If you cannot avoid contact due to caretaking please ensure hands are washed after every encounter and do your part to stay healthy.

5. Avoid touching your eyes, nose or mouth during the influenza season as this is how the virus is transmitted.

6. Practice health habits – get plenty of sleep, eat nutritious meals, exercise and reduce stress. Take vitamins, minerals and supplements as needed but ensure that you advise your healthcare professional that you are taking them in addition to any other prescription medication you may be on.


U.S. Department of Health and Human Services (2009). Center for Disease Control and Prevention. National Vital Statistics Reports: Deaths Final Data for 2006. (Volume 57, Number 14) Retrieved July 7, 2009 from http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf.

Friedman MJ and Attia MW. Influenza A in Young Children with Suspected Respiratory Syncytial Virus Infection. Acad Emerg Med 2003 Dec; 10:1400-3.

Zaman, K., Roy, Eliza, Arifeen, Shams E., Rahman, Mahbubur, Raqib, Rubhana, Wilson, Emily, Omer, Saad B., Shahid, Nigar S., Breiman, Robert F., Steinhoff, Mark C. Effectiveness of Maternal Influenza Immunization in Mothers and Infants N Engl J Med 2008 359: 1555-1564.