Identification of Patients for Referral to Home Care Services
Guidelines for Home Care Assessment
The following qualifiers can help determine those patients appropriate for home care services:
- Patients requiring assessments/education relating to:
- New diagnosis
- New medications or change in medications
- Change in patient’s physical environment and/or new assistive device.
- Patients with unstable disease process; cardio/pulmonary, diabetes, neurological, neuromuscular, metabolic, cerebrovascular, cardiovascular, renal, cancer, pediatric/including asthma, premature infants, psychiatric
- Patients with open wounds, VAC wound care, pressure ulcers
- Patients with ostomies, trachs, feeding tubes
- Patients with drainage tubes and catheters
- Patients requiring I.V. and injectable drug therapies
- Patients with recent change in functional status including but not limited to: falls, paralysis, fractures, amputation or other physical impairment, change in custodial needs, ortho, neuro and/or deconditioned diagnosis
- Patients with pain control management
- Patients with end-stage disease and palliative care needs
- Patients with new oxygen and/or nebulizer treatments
- Patients receiving any type of home care services, i.e., CHHA, LTHHCP, PCA, private care, at time of hospital admission
- Patients re-hospitalized within 60 days and/or known history of repeated hospital readmissions.
- Patients requiring expedited discharges (EHD/Bridge Program)
The above guidelines can be utilized at:
- Admission
- Patient care rounds
- Individual case conference with members of the health care team
- Inquiry from patient/family/physicians
- eview of medical records
HOMEBOUND STATUS
– CMS Pub 100-02
For a patient to be eligible to receive covered home health services, the law requires that a physician certify in all cases that the patient is confined to his/her home. For purposes of the statute, an individual shall be considered "confined to the home" (homebound) if the following two criteria are met:
1. Criteria-One:
The patient must either:
- Because of illness or injury, need the aid of supportive devices such as crutches, canes,
wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence
OR
- Have a condition such that leaving his or her home is medically contraindicated.
If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional requirements defined in Criteria-Two below.
2. Criteria-Two:
- There must exist a normal inability to leave home;
AND
- Leaving home must require a considerable and taxing effort.
For the complete definition please refer to http://www.cms.gov/
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REFERRALS TO POST-ACUTE CARE |
Benchmark |
Target |
Month |
Month |
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Home w No Services (as % of Discharges) |
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Home Care (as % of discharges) |
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Acute Rehab (as % of discharges) |
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Sub-acute Rehab (as % of discharges) |
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Long Term Care (as % of discharges) |
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Other (as % of discharges) |
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