Rural Home Health Services
Access to home health services is important for people with chronic conditions or disabilities, and those who need short-term medical help after being discharged from the hospital. Many rural people depend on home health services in order to retain a degree of independence, and to avoid or delay hospitalization or a move to a nursing home or assisted living facility. This type of care is less costly than hospitalization, improves recovery and well-being, and eliminates the need to travel for appropriate services. However, rural populations are at risk of having inadequate access to affordable home health services.
Frequently Asked Questions
- What is included in home health services and what is the difference between home health services and home care services?
- Why are home health services especially important for rural populations?
- To what extent are home health services available in rural communities?
- Who can order skilled home health services for Medicare beneficiaries and what is required of them?
- Who qualifies for Medicaid and Medicare reimbursement of rural home health services?
- Who provides rural home health services, and where can they occur?
- Where can rural home health agencies find additional financial support?
- What are some challenges faced by rural home health agencies?
- Can telehealth visits fulfill the Medicare face-to-face requirement?
- What effect do recent federal policy changes have on rural home health agencies (HHAs)?
- What effect does the COVID-19 public health emergency have on home health agencies?
What is included in home health services and what is the difference between home health services and home care services?
Home health services involve medical care, and must be provided by medical professionals, such as registered nurses (RNs) and occupational or physical therapists. It can be prescribed following:
- An inpatient hospitalization, or a stay at a rehabilitation center or a skilled nursing facility when continued care at home is needed
- A medication change, so that a medical professional can check for possible side effects and make sure the medicine is effective
- A decline in health, necessitating therapy or acquisition of different skills and coping mechanisms
Additionally, home health services can be used to maintain the patient's condition, prevent or slow
deterioration of the condition, or improve the condition. Unlike skilled nursing facilities, a patient does not
need to be hospitalized prior to receiving home health services. WWAMI Rural Health Research Center published two briefs describing the differences in
characteristics of patients who receive home health services in rural areas after a hospitalization and those
who do not (
Home health services can include:
- Wound care
- Injections and administration of medicine
- Medical tests
- Skilled nursing care, furnished by, or under supervision of, an RN
- Physical, speech-language, and occupational therapy
- Monitoring health status
- Provision of medical supplies (other than drugs) and medical equipment
- Medical social services
- Limited home health aide services for routine health-related tasks that do not require the skills of a nurse or therapist, as well as for assistance with activities of daily living
Home care services, however, are not medical in nature, and are provided by home care aides who usually do not have medical training. Medicare does not reimburse for these services except when provided in conjunction with skilled nursing or therapy. Home care aides offer help with activities of daily living, such as:
- Dressing, grooming, and bathing
- House cleaning
- Grocery shopping and meal preparation
- Help with bill paying
- Medication reminders
Why are home health services especially important for rural populations?
According to the 2014 study Differences in Case-Mix between Rural and Urban Recipients of Home Health Care, rural home health patients are more likely than their urban counterparts to:
- Be severely ill or in fragile condition
- Have more risk factors for hospitalization
- Need respiratory treatments and therapies
- Have a surgical wound requiring treatment
It is important for people to have access to home health services, both as a post-acute care option and for longer-term treatment. With this type of medical care, they may be able to delay hospitalization, keep costs down, and remain in their homes as long as possible.
To what extent are home health services available in rural communities?
The Medicare Payment Advisory Commission's March 2020 chapter on home health care services states that 98% of Medicare beneficiaries live in a ZIP code with at least one home health agency, 96.5% of beneficiaries live in a ZIP code where two or more home health agencies operate, and 83% lived in a ZIP code where five or more agencies operate. However, it is important to consider that the 2% of Medicare beneficiaries who live in a ZIP code that is not served by at least one home health agency are more likely to live in rural areas. Additionally, a February 2020 WWAMI Rural Health Research Center brief notes that while the utilization of home health services among Medicare beneficiaries in 2013 decreased as rurality increased, there was not a significant difference when the number of home health visits and episodes were adjusted by population.
Rural Health Clinics (RHCs) can be certified to provide home health services if there is no functioning home health agency in their service area. According to the Medicare Learning Network's Rural Health Clinic fact sheet, RHCs can supply visiting nurse services to homebound patients in areas where CMS has certified a shortage of home health agencies.
Medicare.gov's Care Compare tool allows users to find and compare home health agencies in their area in terms of services offered and quality of care compared to national and state averages.
Who can order skilled home health services for Medicare beneficiaries and what is required of them?
Medicare regulations specified prior to March 2020 that services must be ordered by a physician, defined as a doctor of medicine, a doctor of osteopathy, or a podiatrist. In response to the COVID-19 pandemic, Section 3708 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act extended this authority to nurse practitioners, clinical nurse specialists, and physician assistants. The certifying provider, or a practitioner working with the provider, must have a face-to-face encounter with the patient related to the reason the patient needs home care within 90 days before the start of care or within 30 days after the start of care. The home health provider, working with the patient's certifying provider, must then create an individualized plan of care and review it with the physician no less frequently than every 60 days. The plan should include:
- All pertinent diagnoses
- Patient's mental, psychosocial, and cognitive status
- Services, supplies, and equipment required for treatment
- Frequency and duration of home visits
- Prognosis and potential for rehabilitation
- Functional limitations and permitted activities
- Prescribed medicines and treatments, and nutritional needs
- Recommended safety measures, to avoid injury
- Measurable outcomes and goals
- Any additional orders the provider wishes to include
For more information, visit Medicare's home health services webpage.
Who qualifies for Medicaid and Medicare reimbursement of rural home health services?
Home health services are considered a mandatory benefit for states to provide under the Medicaid program. However, coverage and eligibility for home health services vary by state and type of Medicaid coverage.
Medicare covers the cost of home health services for homebound beneficiaries who need intermittent, short-term, episodic skilled care, provided by a Medicare-certified home health agency (HHA) or visiting nurse service. The term homebound does not refer to people who can literally never leave their homes. Instead, it signifies people who are unable to leave home without assistance or great effort, or who have a condition that would preclude their safely leaving home alone. Patients who leave their homes for medical appointments may still be considered homebound.
CMS implemented regulations in 2018 intended to improve the quality of services and strengthen the rights of home health patients and their caregivers. As a result, home health agencies must take into consideration whether informal caregivers are willing, able, and available. Patients can also select personal representatives who can aid in making decisions about the patient's care, even if that person does not have legal status as guardian.
Who provides rural home health services, and where can they occur?
Home health agencies (HHAs) are certified by Medicare and/or Medicaid, are licensed by their state, and provide skilled medical care. Rural HHAs can be for-profit, nonprofit, or government-run. Access to Rural Home Health Services: Views from the Field reports that freestanding or facility-based HHAs are most common in rural areas. According to the Medicare Payment Advisory Committee's March 2019 analysis of CMS claims data, 17% of the nation's freestanding home health agencies provided more than half of their services to Medicare beneficiaries in rural areas in 2017.
Facility-based HHAs may be operated by a hospital, skilled nursing facility, or other facility. Rural Health Clinics and Federally Qualified Health Centers can provide visiting nurse services in Home Health Shortage Areas, as noted in Section 190.1 of the Medicare Benefit Policy Manual. In some instances, rural hospitals will operate HHAs because it is a necessary service that is not being provided by others in the community, regardless of whether it is financially advantageous to provide the services. The Financial Importance of Medicare Post-Acute and Hospice Care to Rural Hospitals notes that about a third of rural PPS hospitals and less than a quarter of Critical Access Hospitals reported Medicare income for home health services in 2015.
Care usually takes place in the patient's home. However, if necessary equipment is too large or cumbersome to bring to a home, care can take place in a hospital, skilled nursing facility, or rehabilitation center.
Medicare.gov provides a list of approved Home Health Care Agencies, including contact information, type of ownership, lists of services provided, and quality ratings.
Where can rural home health agencies find additional financial support?
According to the policy brief Home is Where the Heart Is: Insights on the Coordination and Delivery of Home Health Services in Rural America, many rural home health agencies must rely in part on financial support from outside sources in order to remain in operation. Some report receiving money from mill levies, county health-specific or general funds, or local foundation grants. Home health agencies affiliated with or owned by hospitals may also receive funding directly from that source.
Additional funds for home health services may be available from:
- Community nonprofit organizations
- Local Area Agencies on Aging
- State-level elder affairs or aging departments
- Federal social services block grant programs
- The Veterans Health Administration (for veterans who are at least 50% disabled, due to a service-related condition)
What are some challenges faced by rural home health agencies?
Access to Rural Home Health Services: Views from the Field outlines the following challenges rural home health agencies face:
- Compliance with Medicare's regulations and reimbursement policies
- A prospective payment model that is not well-suited to low-volume agencies
- Equipment procurement regulations that may be impractical in rural areas
- High turnover rates among rural healthcare workers
- High poverty rates, population loss, and healthcare facility closures, all of which affect home health care
Home is Where the Heart Is: Insights on the Coordination and Delivery of Home Health Services in Rural America cites other barriers to providing home health services, including:
- Insufficient reimbursement from Medicare
- High costs of implementing and maintaining electronic health records systems
- Limitations in insurance coverage affecting service provision
- Different interpretations in the definition of homebound status
Home health workers in rural areas face other difficulties, such as traveling long distances on poor roads or in inclement weather. In addition, as rural areas become more ethnically diverse, providers may experience challenges in serving people from different cultures and those who may not speak the same language.
Some communities actively foster partnerships that allow home health professionals to maximize their time and provide the highest possible level of service. The Rural Monitor article Rural Post-Acute Care: Healthcare Leaders Offer Practical Solutions to Workforce Challenges describes creative ways in which one home health agency in Maine reaches patients in remote areas who might not otherwise receive needed care.
Can telehealth visits fulfill the Medicare face-to-face requirement?
Telehealth visits can fulfill the requirement, as long as they originate at an approved site. This means that the patient can be located in a doctor's office, a hospital, or a skilled nursing facility to receive the telehealth service, but not the patient's home.
What effect do recent federal policy changes have on rural home health agencies (HHAs)?
In 2016, CMS implemented the Home Health Value-Based Purchasing (HHVBP) Model in nine states across the country. This program is designed to promote increased efficiency and better patient outcomes, linking payments to performance while moving away from a volume-based payment model.
The Bipartisan Budget Act of 2018 established new requirements for home health payment reform. These new requirements include eliminating therapy thresholds for case-mix adjustment and changing units of payments from 60-day periods to 30-day periods. The Patient-Driven Groupings Model (PDGM), the result of these changes, took effect on January 1, 2020, and intends to realign Medicare payments for home health services with a patient's clinical characteristics and needs. Home Health Agencies may need to have increased contact with each patient's physician in order to complete the documentation required to bill for each 30-day period of care.
Since 2000, Congress has repeatedly passed legislation providing an increased payment to rural home health agencies above the base reimbursement rate. The Bipartisan Budget Act of 2018 extended a 3% payment increase for all home health episodes provided in rural areas through calendar year 2019. The Act also divided rural counties into three categories, which will determine the rate and duration of the supplemental payment, with all additional payments phased-out after 2022. For more information, read the March 2019 Medicare Payment Advisory Commission's chapter on home health care services.
What effect does the COVID-19 public health emergency have on home health agencies?
In response to the declared public health emergency regarding the COVID-19 pandemic, U.S. Department of Health and Human Services Secretary Azar can issue waivers that modify regulatory requirements so that providers can continue to meet the needs of patients during the emergency. Home Health Agencies: CMS Flexibilities to Fight COVID-19 outlines both temporary waivers and new regulations that apply to home health agencies as a result of the COVID-19 pandemic and public health emergency, including:
- Increasing the permitted use of telehealth services, including for face-to-face encounters.
- Expanding who can order home health services and certify/recertify patient eligibility.
- Updating the definition of homebound to include Medicare beneficiaries advised by their healthcare providers to not leave the home because of a confirmed or suspected COVID-19 diagnosis or if the patient has an underlying condition that makes them more vulnerable to contracting COVID-19.
- Modifying Quality Assurance and Performance Improvement (QAPI) and other reporting requirements.
Last Reviewed: 5/14/2020