Post 40: Five Key Differences Between Home Health Care and Home (Provider/Caregiver) Care
Updated: Dec 24, 2021
"Are you here to evaluate my mom for provider services? She needs someone to help her clean the house, do the laundry, and cook. She can't even step into the tub by herself. She needs physical therapy too. Can she get a therapist?"
Medical illness or health decline often results in a person requiring assistance in some area of self care or daily living, whether it be a temporary or long term need. For this reason, palliative care specialists (read Post 1: What Exactly Does a Palliative Care Specialist Do?) frequently get asked about different types of care at home.
This post specifically talks about the differences between home health care and home (provider/caregiver) care.
1. Home health care consists of services that require the skill of a formally trained and certified/licensed healthcare professional, such as a physical therapist, occupational therapist, speech therapist, nurse, medical social worker, home health aide and/or certified nursing assistant.
The following are common scenarios that describe a small fraction of the skilled services each home health medical professional provides.
An elderly woman has completed her rehab stay after surgery for hip fracture from a fall. She may be discharged home with home health physical therapy if she is evaluated to have realistic potential to further improve strength, balance, and mobility. She may also be discharged home with a home health nurse to receive education on which medications to take, when, and how to minimize the risk of a serious event due to confusion over medications.
A middle aged man coming home from rehab after a big stroke may be discharged home with physical therapy (to work on increasing strength, movement, and balance) and occupational therapy (to work on fine motor skills necessary for self care such as dressing, shaving, and using utensils to feed himself). He may also work with a home health speech therapist if his ability to speak or swallow was affected by the stroke.
A man experiencing worsening dementia at home may be ordered physical therapy due to increased imbalance and risk of falls. He may be ordered speech therapy due to increased difficulty swallowing foods of certain textures, coughing and gasping whenever he attempts to eat solids. During this time period, a home health aide could go to the home twice weekly to assist the gentleman with stepping into and out of the shower and with the showering process itself (shampooing, soaping, scrubbing, rinsing, toweling, dressing) if needed.
Home (provider/caregiver) care refers to providers who assist with non-medical day to day living that do not require formal training nor certification, such as cleaning the house, obtaining groceries, and meal prepping.
Home care could refer to any type of non-medical assistance, such as collecting mail from the mailbox, pulling the trash bin to the curb, driving a disabled person to the grocery store or doctor's appointment, making the bed, doing laundry, cooking dinner, setting up the pillbox, and coordinating rides to multiple doctors' appointments.
2. Home health care is covered by Medicare Part A and/or B and usually by private insurance. Veterans may be covered through the Veterans Affairs (VA).
If more details were needed about coverage, this is when speaking with your own insurance would be helpful.
Home care providers are covered by Medicaid. For those not financially eligible for Medicaid, home care is usually provided by family and close friends (i.e. unpaid caregivers) or by privately paid providers. Long term insurance cover some home care if specific criteria are met, depending on the insurance plan.
Most long term insurance plans state that a person must require help in at least two areas of "activities of daily living" - bathing, using the toilet (including cleaning themself after using the toilet ), dressing (which may include grooming such as brushing the hair, brushing the teeth, and shaving), eating (which may include being able to cut their own steak), and being able to stand up from a chair and walk (I give more detailed examples of potential changes in activities of daily living in Post 24: A Cloudy Crystal Ball - Predictors of Prognosis Part 1 of 3).
In addition, most long term insurance policies require a person to pay for help for 30, 60, or 90 days before the insurance start reimbursing for that care.
So if an elderly woman with worsening knee arthritis required help only with stepping into and out of the tub, she would likely not be eligible for benefits from her long term insurance plan.
If a man with worsening Parkinson's disease needed another person to pull him up from a chair any time he wanted to walk, assist with stepping into the tub and shampooing his hair any time he were ready to shower, and help with cutting his food into fine pieces, this man would have to pay a provider himself for up to three months (depending on the terms of his long term insurance policy) to assist with personal care before being eligible for reimbursement.
More commonly, I see family providing hours of unpaid caregiving or making arrangements to pay providers out of pocket to help their loved one. Sometimes the hours of unpaid caregiving may still not be enough assistance for the person with worsening stamina, strength, balance, or alertness (read Post 36: A Nursing Home for Dad? - Six Practical Steps to Making a Difficult Decision).
3. Home health services are meant to be temporary, until a patient improves to their previous baseline or new baseline, and sometimes long term if home health professionals are able to document that their skilled service is necessary long term.
The following are example scenarios that certainly do not include all potential cases.
A woman in her 70s has become essentially bedbound due to "excruciating" sciatica back pain. With both carefully titrated pain medications (read Post 31: Three Common Misconceptions about Opioid "Pain Pills") and home health physical therapy, she is able to get out of bed and walk with a walker to the bathroom on her own.
An elderly father is discharged home from the hospital after a big stroke. His son declines rehab, stating his father would receive more attentive 24/7 care at home. The elderly man returns home with a long term feeding tube inserted in his stomach due to his difficulty swallowing as an effect of his stroke. The son notices after several months that his father is comfortably eating by mouth and that his father is no longer using the feeding tube. A home health speech therapist may evaluate this man's swallowing ability and offer tips and techniques to maximize swallowing safely by mouth. After passing his swallow evaluation, the elderly man may end up having his long term feeding tube removed.
An elderly man whose prostate is so enlarged that it is obstructing the passage of urine through the urethra ends up requiring an indwelling (i.e. long term) foley catheter (tube in the urethra that runs from the bladder to a urine bag so urine can flow out from the bladder). The home health nurse returns every month to exchange the foley catheter for a new one.
A young woman who is quadriplegic since being involved in a motor vehicle accident a year ago has recurrent, difficult to heal bedsores on her bottom ("sacral area"). The home health nurse comes daily to three times weekly, depending on the severity of the bedsore ulcer, for months to clean and dress the wounds (i.e. ulcers).
Home (provider/caregiver) care may be required short term during a recovery or long term for irreversibly declining strength.
A man may need help with chores around the house as he recuperates from a long hospitalization or a fractured foot. He may then no longer need home care assistance after he fully recovers.
Or a woman may require help with increasingly more activities as her COPD (chronic obstructive pulmonary disease, a disease of the lungs caused by years of damage in which inflammation and excess mucous production cause blockage of the airways) worsens. She may start out requiring help with bringing in the mail and getting rides to the grocery store and require more and more assistance in other areas of her life such as bathing or getting dressed.
4. Home health services are provided to "homebound" patients for whom leaving their home is taxing and infrequently done. There must be documentation that a patient is homebound.
The homebound patient may be the person who takes significantly more time than it used to take to visit the doctor's office. Perhaps they require assistance to stand up from their wheelchair and slowly step into the car. This person may visit doctors' appointments, attend church most Sundays, and leave for a rare outing to a restaurant and still be considered "homebound."
A patient is not considered homebound if they are attending their grandson's baseball games or taking their walker with them as they go out to eat three times per week.
Home (provider/caregiver) care assistance can be provided to homebound or non-homebound people.
For example, a person could ask their trusted privately paid provider to continue cleaning the house and checking the mail while they are out of town for a week for a family reunion.
5. Home health services require a doctor's order. However, Medicare and insurance will not cover a home health service if home health professionals and doctors are not able to provide sufficient evidence that the home health service is medically reasonable and necessary (i.e. the skilled medical professional does not think they are making a difference in the patient's ability to function) and if they are unable to document that the patient is homebound.
Sometimes a patient tells me, "The physical therapist said that I'm done with my sessions. They said to ask you for a doctor's order if I want more sessions." When I read the home health physical therapist's note, I see that the physical therapist has documented that the patient has not been able to progress over multiple sessions and has now plateaued at a new baseline. Or I read that the patient with dementia is unable to comprehend and therefore follow any instructions for physical therapy exercise. Or I read that the patient has not been home the multiple times that the home health physical therapist has attempted to see them in their home.
In these instances, I would reply, "I could write an order. However, insurance will likely not cover this home health service."
Home (provider/caregiver) care can be obtained at any time the person or their family feel like they need assistance with day to day tasks. This type of care does not require a doctor's order to obtain.
For example, a person may have their niece administer their medications without ever informing or involving their doctor.
I hope the above information and examples clarify common misconceptions about home health care and home (provider/caregiver) care, which people frequently use interchangeably in error. Understanding the differences between the two will hopefully better enable a person or family member to advocate for the particular help they need most as they make requests to their healthcare providers; communicate with the hospital's/rehab's/primary care physician's/palliative care team's social worker; obtain information by word of mouth; and google available local agencies.