One of the most meaningful developments for Medicaid recipients in recent years has been the drive to increase the accessibility and coordination of care between providers when chronic conditions require multiple clinics or physicians. To this end, The Centers for Medicare & Medicaid Services (CMS) has created and promoted three similar but distinct programs that make a wide array of options available to Medicaid seniors who are dealing with increasing medical issues and costs. These three programs are known as Health Home, Home Health, and Home Care. As these names are quite similar and easy to confuse, we will address the three programs individually and provide distinguishing characteristics of each to help you understand their differences and how they can be used together to maximize care.
Since the creation of Health Home as an optional benefit in 2010, 21 states have created 32 different Health Home models. At the heart of all these models is the “whole-person” philosophy, treating patients in ways that coordinate across the continuum of care with various providers to ensure that the patient receives the best primary, acute, behavioral health, and long-term services needed to treat their whole person.
Health Home refers specifically to providers who work in coordination with other healthcare professionals to provide specific services to high-risk and high-cost patients. Working together, they can focus on a variety of services for the patient, such as one-on-one care management to coordinate the efforts of multiple physicians, transitional and follow-up care, and recommendations and referrals to community and social support services. Additional services included in Health Homes are:
- Comprehensive care management
- Health promotion
- Comprehensive transitional care/follow-up
- Patient & family support
For Medicaid recipients in particular, Health Homes targets those with two or more chronic conditions, have one chronic condition and are at risk for a second, or who have one serious and persistent mental health condition. Chronic conditions include mental or behavioral health issues, substance abuse, asthma, diabetes, heart disease, or obesity. Other chronic conditions, such as HIV/AIDS, can be considered for approval by CMS. Additionally, states can create Health Home programs that target services geographically, though they cannot exclude people with both Medicaid and Medicare.
During 2017, Washington’s Health Home program was among the most effective. Through individualized care and interaction, they were able to save money by reducing preventable hospital readmissions, emergency room visits, and service duplication. In a focus group of individuals using Health Home services, more than half reported significant improvement in their health and quality of life. Many also reported that their Health Home Care Coordinator offered valuable assistance in planning and achieving their health goals.
States can create unique guidelines for determining Health Home providers. According to recommendations from Medicaid.gov, potential providers can be:
- Designated providers – this can include a physician, clinical/group practice, rural health clinic, community health center, mental health centers or agencies, home health agencies, pediatricians, OB/GYNs, or other providers
- Teams of health professionals – teams can include physicians, nurse care coordinators, nutritionists, social workers, behavioral health professionals, and can be free-standing, virtual, hospital-based, or a community mental health center
- Health team – must include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers, chiropractors, licensed complementary and alternative practitioners
As states create and implement Health Home services, they must also provide reporting guidelines to the service providers who must report back to the state to help ensure quality measures are met. States, in turn, are required to report utilization, expenditure, and quality data for regular surveys and independent evaluations for effectiveness.
In addition to the increased emphasis in recent years by CMS to promote care coordination and convenience, they have also emphasized their similarly-named Home Health program. A quick reading of both Home Health and Health Home program titles can easily cause confusion, as both use the same two words but in a different order. When researching these programs, it is important to pay close attention to not confuse the two.
Home Health has been in the news more frequently in recent months, particularly with the passage of a new federal spending bill that includes some wins and losses for Home Health Care. Most notably, the bill provides a new payment model for home health care providers, changing the current 60-day unit of payment to a 30-day model.
Another modification welcomed by most is the rural add-on. The add-on helps ensures providers can continue services to patients by covering the additional transportation and staffing costs required in remote areas. Additional changes include:
- Face-to-face: Home health care providers may see some relief when it comes to the burdensome face-to-face requirement
- Independence at Home: The bill also extends Independence at Home for seven years, a program from CMS that incentivizes primary care at home. The program originally began as a three-year pilot, and it was floated to become permanent in 2016. While a money-saver, it has been found to save less than originally projected, about $746 per beneficiary in 2016
- Telehealth: Accountable Care Organizations (ACOs) have an ability to expand the use of telehealth services under the bill
- Chronic Care Act: Lawmakers also solidified the Chronic Care Act within the spending bill, ensuring emphasis placed on improving chronic care for those with physical or behavioral chronic conditions
Home Health was also in headlines recently due to CMS refusing to delay the 2018 Conditions of Participation (CoPs) despite not having issued a final version of their Interpretive Guidelines. CMS had previously provided a draft of the guidelines and indicated there would be little change from the draft. A copy of the draft guidelines was available upon request. They also indicated that they would not impose any Civil Monetary Penalties (CMPs) on organizations making a good faith effort to adhere to the guidelines they anticipated receiving. Only if there is an identified immediate jeopardy situation would they consider CMPs. CMS indicated agencies should continue making full implementation steps according to the draft guidelines until the finalized ones are distributed.
An easy distinction to help distinguish Home Health from the other outlined programs is to remember that Home Health is clinical care that takes place in a patient’s home. As such, additional services covered under Home Health could include:
- Therapy and skilled nursing services
- Administration of medications, including injections
- Medical tests
- Monitoring of health status
- Wound care
Some specific situations when Home Health should be considered are:
- After an inpatient hospitalization, rehabilitation, or a stay at a skilled nursing facility. This can help the senior transition back to independence
- When a senior has had a recent medication change, to monitor for side effects and evaluate the effectiveness of the new medication
- When seniors experience an overall decline in functioning. Home Health can be used to help them regain independence through therapy or learning new skills to compensate for their deficit
An additional program that CMS provides is Home Care. This program is more specifically targeted towards Medicaid recipients. Home Care is similar to the previously discussed Home Health program but is distinct in that it provides non-clinical care. Health and Home Care are not mutually exclusive services, many families find that utilizing these services in tandem may best help a senior who, for example, is recovering after hospitalization. The Home Health staff address clinical and rehabilitative needs during the transition home, while a Home Care aide can help with personal caregiving and household chores that the senior requires assistance with during his or her recovery.
As of last year, all 50 states and D.C. had at least one program that provided assistance to elderly individuals living outside of nursing homes that required some degree of care that can be covered by Home Care.
Home Care and Home Health are distinct types of care, although both are provided in a home setting. Most people are not aware of the differences and use these terms interchangeably. While Home Health is exclusively clinical care, examples of non-clinical care covered under Home Care could include:
- Meal preparation
- House cleaning
- Help dressing, bathing and grooming
- Reminders to take medicine
- Help with bill paying
Home Care is generally provided by caregivers, usually home care aides, who are trained to understand the unique circumstances of senior care. Home care aides can help seniors with activities of daily living, and in the process also offer some friendly companionship, which can offer measurable improvements to their emotional and behavioral health. An additional benefit could be transportation to medical appointments for those who are no longer able to drive.
Home Care is classified as personal care or companion care and is considered unskilled or non-clinical. As such, family members can often be the ones paid by Medicaid to provide this unskilled care. Applying for a waiver to make this possible is different in each state. It is worth noting that in all but eight states, legal guardians and spouses cannot be hired as a personal caregiver, but Medicaid does not prohibit adult children or ex-spouses from being hired and compensated.
The Health Home, Home Health, and Home Care programs increase the accessibility and coordination of care for seniors when chronic conditions require multiple types of clinical and non-clinical care. Armed with knowledge, care coordinators can help them navigate the maze of healthcare options available to them, and provide them with the information they need to chart the best course.