Myths About Home Care: Home care is only for the homebound

By: Edward Ratner, MD

As a teacher of home care to both students and practicing physicians, I frequently encounter myths about home care. As in all fields of medicine, staying current in home care medicine has become increasingly difficult. To optimally serve patients who might benefit from care at home, physicians must keep track of an increasing array of diagnostics and therapeutic interventions that can be offered at home. In addition, an understanding of which types of care at home are reimbursed by which insurers is required. Many of the current myths about home care are based upon obsolete practice or policy. A few, like the myth that home care is only the homebound, were never true.

It is easy to see how such a myth could arise. The dominant payer of home health agency services, Medicare, has a longstanding requirement that patients receiving services under Part A (the Hospital Trust Fund) must be homebound. Although the definition of homebound has always remained a little vague, it is clear that a patient who leaves home alone without difficulty is not homebound. Physicians are typically most familiar with this type of home care. Some have come to believe that this Medicare payment policy applies to all services for all patients, or at least to all patients covered by Medicare.

It is a challenge to describe, even briefly, all the ways that this myth is false. First, Medicare explicitly stated in 2001 that physician home visits to patients are covered even if the patient is not homebound. Justification for a home visit must be documented, but the patient being homebound is only one of many reasons a home visit may be appropriate. Patient convenience and patient request are not the types of justifications Medicare is looking for, however. (I begin each home visit with a sentence describing the reason for the home visit. Reasons I use include immobility, need to assess the home situation, need to involve home based care givers, and cognitive, psychiatric, or emotional inability to go to the office.)

Medicare also covers selected home health agency services for patients who are not homebound. These include physical, occupational, and speech therapy. Coverage is by Medicare Part B (which also covers physician services). Coinsurance and deductibles may apply if the patient lacks supplemental insurance.

Another Medicare-reimbursed program serving patients at home, even if they are not homebound, is hospice. It is a strange twist of Medicare policy that a dying patient who is able to get out of the house has coverage for home nursing, but not if recovering from the same illness.

Other types of home care provided to patients who are not homebound include infusion therapy, pediatric home care, obstetric (pre- and post-natal) home care, and custodial or long-term nursing services. These types of services are commonly reimbursed by private health and long-term care insurers and/or Medicaid programs.

Home care is not right for every patient, but it is not just for the homebound!