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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


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 avoid or delay hospitalization, keep costs down, and remain in their homes as long as possible.


Who can order skilled home health services for Medicare beneficiaries and what is required of them?

Medicare regulations specify that services must be ordered by a physician, defined as a doctor of medicine, a doctor of osteopathy, or a podiatrist. A doctor or a practitioner working with a doctor must have a face-to-face encounter with the patient within 90 days before the start of care, and this visit must be related to the reason the patient needs home care. The home health 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 the CMS document Home Health Services.


To what extent are home health services available in rural communities?

According to the 2014 publication Home Health Care Agency Availability in Rural Counties:

  • As of 2008, home health services were available in most U.S. counties, but rural counties were more likely to have just one agency
  • Specialized home health services were not as readily available as skilled nursing or home health aide services
  • Facility-level quality of care was on average slightly lower in rural counties

Rural Health Clinics (RHCs) can also 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 document Rural Health Clinic, RHCs can supply visiting nurse services to homebound patients in areas where CMS has certified a shortage of home health agencies.

Medicare.gov's Home Health Compare tool allows users to find and compare HHAs in their area.


What is the difference between home health 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
  • 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

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

Home care services are not medical in nature, and are provided by home care aides who usually do not have medical training. They offer help with activities of daily living, such as:

  • Dressing, grooming, and bathing
  • House cleaning
  • Grocery shopping and meal preparation
  • Transportation
  • Help with bill paying
  • Medication reminders

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.

In 2013, CMS also clarified that home health services can be used to:

  • Maintain the patient's condition
  • Prevent or slow deterioration of the condition, or
  • Improve the condition

For more information about this, see the Jimmo v. Sebelius Settlement Agreement Fact Sheet.


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. 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 Medicare Benefit Policy Manual.

Hospital-based HHAs are fairly common in rural areas. 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 2017 findings brief The Financial Importance of Medicare Post-Acute and Hospice Care to Rural Hospitals noted that about a third of rural PPS hospitals and less than a quarter of Critical Access Hospitals surveyed reported Medicare income for home health services during the study period of 2012 through 2016.

Medicare.gov provides a list of approved Home Health Care Agencies, including contact information, type of ownership, lists of services provided, and quality ratings.

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.


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?

According to the 2016 publication Access to Rural Home Health Services: Views from the Field, challenges faced by rural home health agencies include:

  • 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

The policy brief 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 cultures other than their own and who may or 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 the Eastern Maine Health System's VNA Home Health Hospice reaches patients in remote areas who might not otherwise receive needed care.


Can telehealth visits fulfill the face-to-face requirement?

Telehealth visits can fulfill the requirement, as long as they originate at an approved site. This means that the patient receiving the service could be located in a doctor's office, a hospital, or a skilled nursing facility, but not the patient's home.

For further information about requirements for the face-to-face encounter, see the CMS document Home Health Face-to-Face Encounter Questions and Answers.


What effect do the January 2018 federal rules have on rural home health agencies (HHAs)?

The January 2018 CMS regulations revise the home health conditions of participation for Medicare and Medicaid. The changes are intended to improve the quality of services and strengthen the rights of home health patients and their caregivers.

Under the new regulations, HHAs must take into consideration whether informal caregivers are willing, able, and available to help provide care. 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.


Last Reviewed: 7/12/2018