Education
Home Health Care Overview & Process
Everything you need to know about starting home health care and what to expect.
Getting Started
When to start home health care
- After a recent hospitalization or healthcare facility stay
- New disease diagnosis
- New medications prescribed
- Exacerbation of existing illness
- Recent fall or near fall
- Daily activities like bathing and dressing are difficult
- Frequent visits to your doctor or emergency room
- To avoid decline from existing illness
Benefits
Benefits to you
✓Greater independence and freedom
✓Help you feel better, recover from your illness or injury and slow decline
✓Relief for family caregivers
✓Prevent trips to the hospital or a nursing facility
Did You Know?
Medicare Part A covers 100% of home health care with no out-of-pocket cost and no limit on visits.
Hospital-to-Home
Role of the Intake Nurse Navigator
Successful transition from hospital to home starts with planning on the day of hospital admission. Our Nurse Navigator is your contact from the beginning of the hospital stay to develop your plan for recovery and independence at home. Nurse Navigator is included with all hospital discharges at no additional charge.
✓Coordinate complex care in the transition back home
✓Setup and plan home health for advanced nursing & therapy
✓Arrange personal care assistance
✓Wound vac coordination with vendor
✓Infusion coordination
✓Ostomy management teaching
✓Post-Op surgery care
✓Medication management plan
✓Setup travel home with CNA escort
✓Logistics for home medical equipment
✓Coordination with community doctors
✓Recommend services that are needed
✓Help you understand what is covered by your insurance
Coverage
Medicare Part A covers 100% of home health care if:
1
You are homebound, meaning it's difficult to leave the home without help (homebound doesn't mean bedbound)2
Your care needs can only be done by skilled nurses and therapists3
Your primary care physician agrees to supervise our care plan and sign orders4
Your care can be safely delivered in your home5
We must demonstrate an ability to maintain or improve your health conditionGetting Started
The typical process to start care
1
We determine your payor and review with you what is covered and out-of-pocket costs (if any).
2
Your primary care physician or hospitalist writes an order for home health care.
3
The home health order must document the primary diagnosis we are treating and in-home services needed.
4
Your primary care physician must agree to review, approve and sign the plan of care we develop for you.
5
You must have a face-to-face encounter (video telehealth ok) with your PCP 90 days prior or 30 days after we start care.
6
If you have regular Medicare Part A, we typically start care the day after you contact us.
7
If you have Medicare Advantage or commercial insurance, we may need to obtain prior authorization before we can start.
Services
What we do in your home
Patient teaching on self-management of chronic diseases
Dementia care navigation with GUIDE program
Treat non-healing wounds
Guidance on living with heart and lung diseases
Assist with tubes, drains or special medical equipment in the home
Reconcile medications with prescribers and teach about the medications
Counseling assistance for community resources, such as Veteran benefits
After-surgery ortho care, such as hip, knee or back
Maintenance care
Intravenous therapy
Treat an infection
Post-stroke care
Pain management
Get in Touch
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