Identification of Patients for Referral to Home Care Services
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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