Rural Home Health

A young, stay-at-home mother needs assistance and training in learning how to administer parenteral nutrition to her chronically ill baby.

A young child, recuperating at home after a serious illness, needs physical therapy.

A teenager, with a terminal illness, is too sick to travel to his doctor to receive pain medication.

An elderly woman, living alone on a farm, needs assistance with her household tasks as well as a friendly face to talk to.

Home health care is for people of all ages, in cities and rural areas. Home health services range from helping the smallest baby to helping the elderly who choose to live independently in their own home. Most people want to recover and rehabilitate from an illness or injury at home, where they have both comfort and security.

Home health care is an essential part of health care today. It encompasses a wide range of health and social services that may not easily or effectively be provided solely by family and friends. Services range from highly skilled and technical nursing care to assistance with the essential activities of daily living. These services are delivered at home to recovering, disabled, chronically, or terminally ill persons in need of medical, nursing, social, or therapeutic treatment.

In rural areas, home health services face their own issues such as keeping a fully trained staff, transportation issues such as distance, and keeping enough patients to support a home health agency.

Contacts

For questions about CMS regulations
CMS Regional Office Rural Health Coordinators

To find home care associations in your area
Listing of state home care associations

There are more organizations related to Home Health in the organizations section.

Frequently Asked Questions


What is Home Health Care?

The term "home health care" goes back as far as the first century when a group of women known as deaconesses developed a program to care for the ill in their homes. When Medicare and Medicaid began in 1965, home health care became a growing industry.

Home health services are initiated when a loved one is no longer able to care for him or herself due to failing health or recent changes to their health. Home care offers a wide range of health and social services delivered at home to those recovering from an illness or injury, or for those who are disabled and/or chronically ill. Often a physician, nurse, hospital discharge planner or case manager suggests obtaining professional help at home to assist with your health care needs.

Home care is one of the oldest forms of health care. Home care is a term that describes a wide variety of services provided in the home setting. These services include:

  • Skilled nursing care
  • Physical therapy
  • Occupational therapy
  • Speech-language therapy
  • Medical social services

These services are provided by a number of different types of organizations and agencies, such as home health agencies, hospice care, Meals On Wheels, respite care, private duty nursing agencies and others.

The need for home health care has grown for several reasons. Medical science and technology have improved, making many treatments that could once be done only in a hospital now can be done at home. Home health care is usually less expensive and can often be just as effective as care in a hospital or skilled nursing facility. Most important is the fact that most patients and their families prefer to stay at home rather than be in a hospital or a nursing home.


Why is Home Health Care an issue in rural areas?

Hospitals stays are decreasing, thus increasing the number of patients who need skilled services in their home. Unfortunately, rural caregivers are often at a disadvantage due to being isolated from social support, resources, financial assistance, training, respite options, community programs and information on caregiving.

In many rural areas, low population is combined with a lack of health services, poverty, underserved areas and geographic isolation. The need for home health care in rural America continues to grow, but lack of financial support has hampered the ability of many rural counties to meet the needs of their residents. Home Health Care can provide some health services to those in need.

Despite this, home health services face their own issues in rural areas. Keeping fully staffed in rural areas, with qualified nurses and therapists, can be a problem. Keeping the critical mass of patients to support having a home health agency, particularly a visiting nurse association, can be a problem. Transportation issues such as distance and topography, even paying for gas, can also add to the difficulties associated with providing service in rural areas.


How can technology be used in providing Home Health Care in rural areas?

Technology can provide the means to overcome geographical distances that often hinder access to health care. Health technology and telehealth are powerful tools to improve access to home health care in rural, remote, and other underserved areas. By using computers and video cameras, sending e-mail reminders, transmitting results by telephone, and assisting provider follow-up; underserved, rural, and remote communities could improve care for individuals of all ages who have chronic health conditions or disabilities.

Video conferencing, together with computer communications and resource management, is a possibility in some rural areas. Broadband wireless communications networks now offer a significant opportunity to increase the productivity of rural home health care providing higher quality care at lower cost. Digital technologies can be used to train health care professionals, link remote health care providers, provide telemedicine and telehealth consultations using video conferencing, serve people with disabilities, and provide direct patient care to those in rural areas.

There are barriers to using these technologies. These barriers include restrictive licensure and scope-of-practice restrictions that can impede development of technology-based services. In addition, public and private payers of health care costs often do not cover or reimburse for electronic health and telehealth services. To take full advantage of technology in the provision of home health services, reimbursement must become flexible enough to allow evidence-based practices to be implemented, coordinating both traditional clinical care and electronic health visits and ensuring services delivered through technology are sustained. Changing policies and supports in all sectors of the health care industry will be required.

Electronic health records improve the quality, accountability, and cost-effectiveness of health care services. Communication between informed consumers and health care professionals improve discussions regarding treatment options and more knowledgeable decisions.


Who provides Home Health Care?

Home health services can be provided by a variety of trained individuals. Providers may be for-profit, non-profit, or hospital based. Examples of providers are:

  • Companions - Provide comfort and companionship to individuals who, for medical and/or safety reasons, may not be left at home alone. They may also assist with household tasks.
  • Family Caregivers - Provide emotional, physical, and spiritual comfort to loved ones.
  • Home Health Aides - Assist patients with activities of daily living such as getting in and out of bed, walking, bathing, toileting, and dressing.
  • Homemakers/Chore Workers - Perform light household duties such as laundry, meal preparation, general housekeeping, and shopping.
  • Medical Social Workers – Evaluate the social and emotional factors affecting ill and disabled individuals; provide counseling; assist patients and their family members identify available community resources; serve as case managers; and coordinate a variety of services.
  • Occupational Therapists - Help individuals who have physical, developmental, social, or emotional problems. They also instruct patients on using rehabilitation techniques and equipment to improve function in basic household tasks such as eating, bathing, and dressing.
  • Physical Therapists – Work to restore the mobility and strength of patients who are limited or disabled by physical injuries through the use of exercise, massage and other techniques; help to alleviate pain and restore injured muscles with specialized equipment; teach patients and caregivers special techniques for walking and transfer. Walkers, wheelchairs, and other medical equipment may be provided.
  • Physicians - Work with home care providers to determine services that are needed by patients, which specialists are most suitable to provide these services, and the frequency of services to be provided. They also prescribe and oversee patient plans of care.
  • Registered Nurses/Licensed Practical Nurses – Provide skilled nursing services, such as injections and intravenous therapy, wound care, education on disease treatment and prevention, and patient assessments. RNs may also provide case management services.
  • Respiratory Therapists - Provide oxygen therapy to those in need.
  • Speech Language Pathologists - Work to develop and restore the speech of individuals with communication disorders, usually as a result of surgery or stroke. They also retrain patients in breathing, swallowing, and muscle control.
  • Volunteers - Assist with a variety of patient needs. Depending on their level of training and experience, volunteers may provide companionship, emotional support, counseling and helping with personal care, paperwork, and transportation. Volunteers may provide respite care for family caregivers.

Who pays for Home Health Care?

In most parts of the country, home health services are paid for by some third party. All third party payors have specific eligibility and coverage requirements. It is important that caregivers be aware of the coverage requirements of the patient's third party payor because without third party payment for needed services, the patient may be unable to afford these services. Third party payors may include:

Medicare
Home health visits may be paid by Medicare if certain requirements are met. The Medicare program covers the elderly, those 65 and over, and individuals who have been disabled for two or more years. Medicare has the most restrictive requirements for payment of home health services, however, it is frequently the only resource the elderly have for needed care. Medicare Home Health Benefit is a federal program that has two parts - Part A and Part B. All home health services can be covered under either Part A or Part B while other forms of health care are only covered under one of the parts. Hospitals and short term nursing home care are covered only under Part A, while doctor's visits, durable medical equipment, ambulance and outpatient services are covered under Part B. The patient must meet the following four conditions:

  • A doctor must decide that the patient needs skilled care in the home and prescribe or order home care, and
  • Must need at least one of the following services: part-time or intermittent skilled nursing care or physical therapy, speech-language services, and
  • Must be homebound, and
  • Must receive services from a home health agency that is "certified" (or approved) by Medicare.
If all four of the conditions above are met, Medicare will help cover:
  • Skilled nursing
  • Home health aide services
  • Therapy
  • Medical social services
  • Certain medical supplies
  • Certain durable medical equipment

Medicare does not pay for:

  • 24-hour per day care in the home
  • Prescription drugs (with a few exceptions — consult your physician)
  • Meals delivered to the home
  • Homemaker services like cleaning, laundry and shopping.

For further information about Medicare enrollment, or the Medicare Home Health Benefit, call 1-800-MEDICARE. Also, see the Centers for Medicare and Medicaid's documents Medicare and Home Health.

Medicaid
Medicaid is a state program designed to provide necessary health care to low income citizens. Eligibility to receive services under the program is determined based on financial information, which is periodically reviewed. The reimbursement criteria differs from state to state and each state has its own process and criteria for participation.

In all states, Medicaid pays for basic home health care: part-time skilled nursing; home health aide services; and medical supplies and equipment. Medicaid may pay for homemaker, personal care and other services not paid for by Medicare. For information about how to apply for Medicaid, including waiver and demonstration programs in your state, please contact your state Medicaid agency. For state policy officials and others who develop and/or operate the state waiver and demonstration programs, please see the CMS searchable state map website.

For information on what is available under Medicaid in each state, the Kaiser Family Foundation provides the following:

For further information on Medicaid benefits, see the Centers for Medicare & Medicaid Services website.

Older Americans Act
This program provides services for those 60 years and older who have the greatest financial and social need. Federal funds for state and local social service programs enable frail and disabled older persons to remain independent. For further information, see the Administration on Aging Older Americans Act website.

Social Services Block Grant Programs
Each year, states receive federal social services block grants for state-identified service needs. These funds are allocated by the government on the basis of the state's population and within a federal limit. Portions of the funding often are directed into programs providing home health care and homemaker or chore worker services. Contact your state health department or ACF Social Services Block Grant Program.

Veterans Administration
The Veterans Administration will cover Home Health Services for specific groups of individuals. These services, to those Veterans who are at least 50% disabled because of a service-related condition, must be authorized by a doctor. The individual must be under the care of a physician and in need of intermittent nursing, physical therapy, speech therapy or occupational therapy services. The services must be provided through the VA's network of hospital-based home health providers. TRICARE/CHAMPUS and CHAMPVA are two additional programs under the Veterans Administration that reimburse for home health care. These programs have essentially the same eligibility requirements as VA Benefits although the program participants are civilians rather than veterans or active military personnel.

Worker's Compensation
In most states, this is a limited source for home health care. Worker's compensation is a special state program developed under each state's worker's compensation laws to provide payment for health care needs of an employee who has an illness or injury that arose from his employment. Funding for the program is basically from employer contributions. See your employer or place of business for further information.

Health Insurance Companies
Many commercial insurance companies include home health benefits as part of their health insurance policies. Requirements for coverage vary greatly. Check with your insurance company for further information.

Private/Self-Pay
Home health services can be purchased privately by a patient using his or her own funds. Home health services which do not meet the criteria of a third-party payor must be paid for "out of pocket" by the patient or family.


Where can one find a listing of state home health care associations?

The National Association for Home Care provides a website which lists individual state home health care associations. The U.S. Department of Health and Human Services provides Medicare's Home Health Compare, which contains information on how well the home health agencies in your area care for their patients. The Visiting Nurses Associations of America provides a list of VNAs that service a particular state.

People often receive home health care services following a hospitalization or during an illness. Often the hospital discharge planner or social worker provides information on home health agencies to the patient or family. Ask the hospital for a list of home health care agencies in your community. Physicians, friends, and family often recommend home health agencies.


Where are Visiting Nurse Association's located?

The Visiting Nurse Associations of America represents exclusively the non-profit, community-based home health agencies. The association has a website with a map that allows you to view a list of VNAs that service a particular state. Visiting nurses bring compassionate, high-quality and cost-effective home care to individuals in their communities. They care for patients of all ages from infants needing maternal/child health programs to the elderly needing hospice care.


What is the Home Health Face-to-Face Encounter?

As a condition for payment, the Affordable Care Act requires that, prior to certifying a patient’s eligibility for the home health benefit, the physician must document that the physician himself or herself or an allowed nonphysician practitioner (NPP), has had a face-to-face encounter with the patient.

Information on the face-to-face encounter is available on Page 67106, Section D of the November 8, 2012 Federal Register Final Rule titled Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2013, Hospice Quality Reporting Requirements, and Survey and Enforcement Requirements for Home Health Agencies."

On March 1, 2013, CMS released updated information regarding the face-to-face encounter in Home Health Face-to-Face Encounter Question & Answers, revised February 28, 2013.


What is the Medicare Home Health Rural Add-on?

This creates a 3% add-on to payments made for home health services to patients in rural areas. For further information, see Medicare Home Health Rural Add-on. Information on the add-on is also available on Page 67103, Section 6 of the November 8, 2012 Federal Register Final Rule titled Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2013, Hospice Quality Reporting Requirements, and Survey and Enforcement Requirements for Home Health Agencies."