Selecting and Working with a Home Health Agency: A Guide for Medicare/Medicaid Beneficiaries

Mission Statement of the Health Facilities and Emergency Medical Services Division:

We are responsible for establishing and enforcing standards for the operation of health care facilities. Through education, inspection, investigation and enforcement, we assure that the public receives care from providers that promotes their health and enhances the quality of their lives, their dignity and their autonomy.

Introduction:

This brochure is limited to information about "certified" home health agencies, i.e. those who have received "certification" from the federal government to participate in Medicare and Medicaid.

What is Home Care?

Home care is a wide range of health and social services delivered at home to persons recovering form an illness or injury, or persons who are disabled and/or chronically ill. Agencies who deliver such care are generally known as "home health agencies."

They provide "skilled services" such as nursing, social services and therapeutic treatments (physical, speech and occupational therapy). They also provide non-skilled services like help with bathing, dressing and eating. Medical equipment such as wheelchairs, walkers and oxygen may also be provided.

Home health services can be purchased privately by an individual expending his/her own funds; private health insurance may cover home health services; they can be paid for by Medicare and Medicaid. As with any insurance, coverage of certain benefits will vary and it is best to check your benefits when deciding on care options.

  Who Operates Home Health Agencies?

Home health agencies can be for-profit or not-for-profit. They may be operated by hospitals or even local health agencies, such as county nursing services or local health departments.

Certified Home Health Agencies

We recommend you consider choosing a "certified" home health agency, even if you are not eligible for Medicare or Medicaid. If you are on Medicare or Medicaid, you can only use a certified agency. Certified agencies provide safeguards because they meet specific standards established by the federal government and are monitored by the state through the Colorado Department of Public Health and Environment's Health Facilities and Emergency Medical Services Division.

Medicare/Medicaid Recipients: Eligibility for Home Health Services

Medicare and Medicaid's home health benefit allows people with restricted mobility to receive needed care at home. Services and supplies are provided by nurses, aides and therapists under a physician's plan of care.

Medicare will pay for home health services if your physician certifies that you:

• Are homebound -- i.e. confined to home except for infrequent or short absences or trips for medical care, and

• Require one or more of the following services: physical therapy, speech-language pathology, or skilled nursing.

If you need only personal or custodial (non-skilled) care, you do not qualify for the Medicare home health benefit.

If you have Medicaid, you may be eligible for both skilled and non-skilled services. To find out more about Medicaid home health benefits, phone your local county department of Social Services or the Colorado Department of Health Care Policy and Financing at 303-866-3864.

Information About Home Health Agencies

Hospital Discharge Planners or Health Plans: If you are leaving the hospital and need home care, your doctor, the hospital discharge planner or a social worker can help you choose an appropriate agency. Your health plan may require you to use certain agencies.

Health Department Information: The Health Facilities and Emergency Medical Services Division has complete lists of all certified home health agencies in Colorado. The department's files, which contain survey results and summaries of complaint investigations, are available  for your review at the division at 4300 Cherry Creek Drive South, Denver, second floor.

Questions to Ask When Choosing An Agency:

1. Is the agency certified?

2. How long has it provided care in your area?

3. Has it provided care for people with needs similar to yours?

4. Can you contact the agency after hours?

5. Will it provide references from others who are familiar with its services?

6. Does it provide the client with a care plan that specifies what services will be provided and by whom?

7. Are the people who provide services licensed to do so?

8. Does it check references and do criminal background checks before hiring employees?

What to Expect With a Certified Home Agency

• Anyone from the agency is a guest in your home. You and your property should be treated with respect.

• On the first visit, you should received, as part of your admissions packet, a written notice of your rights. The state's Home Health Hotline number should also be disclosed at that time.

• On the first visit, a registered nurse will evaluate you and develop a care plan. You have the right to participate in planning your care and to be informed in advance when changes to your care plan are made.

• Before services start, you should be advised about the extent to which Medicare and Medicaid will pay for services and which services you may likely have to pay for yourself.

• The agency should inform you about advance directives and your right to specify how you want medical decisions to be made, should you become ill and unable to make such decisions.

• The agency must observe confidentiality regarding your medical records.

• Remember, the agency is responsible for all of the care that you receive, from their employees, or from others they may contract with to provide your care.

Resolving Care Problems

Federal laws give you the right to complain to home health agency staff or outside sources without fear of discrimination or retaliation.

If you or a relative are receiving home health services, it is possible that problems may arise. To prevent problems, the best tool is open communication with your direct care givers and other agency staff.

• Develop and maintain good relationships with the nurses, aides and others who are providing you with services. Do not hesitate to ask questions.

• Bring issues to the attention of the staff as soon as they arise.

• Work up the chain of command: if you have a care problem, talk to the direct care giver first. If that doesn't work, ask to speak to that person's supervisor.

• If visits are missed or staff is very late for an appointment, call the agency.

• If problems persist, contact the agency's administrator. If this doesn't help, contact the agency's governing body.

• The agency should have written policies explaining how to file a complaint or grievance by contacting the governing body. This information is included in the packet you receive.

• It is best to put your complaint in writing; you can later show others that you gave the agency an opportunity to address your concerns.

Filing a Formal Complaint

If previous steps fail, you may file a complaint with the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Services Division by calling 303-692-2800 (Denver Metro Area) or the Home Health Hotline at 1-800-842-8826. A complaint may also be filed in writing or by fax. Write to Colorado Department of Public Health and Environment, HFEMSD A-2, 4300 Cherry Creek Drive South, Denver CO 80246 or FAX to 303-782-4883.

The Health Facilities and Emergency Medical Services Division will investigate all complaints related to patient care, abuse and violation of patient rights. Complaints about billing and insurance coverage are not addressed by the health department. You should call your insurance carrier.

Provide the Following Information:

• Dates, times, names, and the people involved.

• Your name, address, and daytime phone number where you can be reached.

• If there are witnesses or other parties who can provide additional information, include their names, addresses, and daytime phone numbers.

• At the end of the investigation, you will receive a letter containing a summary of the investigation and findings.

• You can also file a complaint without giving your name.

To Check On a Nurse or Nurse Aid

If you wish to check on the license or certification status of a nurse or nurse aide who is providing care to you, the Colorado Board of Nursing operates "ALIS", a 24-hour state-sponsored Automated Licensing Information System at 303-894-7888. All you need provide is that person's name or their nursing license number.

Other Resources About Home Health Care

The Colorado Department of Health Care Policy and Financing, Medicaid Home Health -- 303-866-3864

The Colorado Foundation for Medical Care -- 1-800-727-7086 (Medicare Hot-line and Questions); 303-695-3333 (Medicare questions -- metro area); 303-695-3300, ext. 3112 (Medicaid Home Health)

Home Care Association of Colorado -- 303-694-4728

http://www.cdphe.state.co.us/hf/broch/hha.htm