Home Health: Patient Rights and Responsibilities

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Home health is a complex care system that requires nurses to be knowledgeable about the care and interventions the patient needs, as well as many business—and legislative-related aspects of home health. This course will review home health patient rights and responsibilities, outline guidelines for billing and reimbursement in the home health setting and summarize current and proposed legislation and quality guidelines that impact reimbursement. 

Introduction

Home health has become a focus of discussion in the increasingly complex United States healthcare system. While quality standards are necessary for patient safety, added administrative needs increase the cost of providing this type of care. Home health nurses can benefit from being knowledgeable regarding home health rights and responsibilities, billing and reimbursement guidelines, legislation changes, and quality guidelines, as they affect everyday nursing practice. Clinic and hospital nurses should also be aware of these aspects of healthcare as they plan for discharge care and ongoing follow-up needs. Nurses in all settings can use current knowledge of home health practices to promote optimal outcomes.

What is Home Health?

Home health, also known as in-home care, allows an individual with acute or chronic medical needs to receive care in their home. There are several types of home health, and people may receive more than one type of service. Personal care services are when a trained home health aide or certified nurse’s assistant helps with activities of daily living, such as bathing, washing hair, and getting dressed. Some states may allow household care, including essential yard work, laundry, and cleaning. Meal preparation or delivery may be considered part of these services. Transportation services may be provided for some patients as part of in-home care (1).

Home health visits by a registered nurse (RN) or licensed practical/vocational nurse (LPN/LVN) may be intermittent or hourly. Intermittent visits may include wound care, patient and caregiver education, intravenous therapy for medications or parenteral nutrition, injections, monitoring, and assessment. Hourly home care, or private duty nursing, is for medically fragile individuals with needs that cannot be met through intermittent visits and who would otherwise require nursing home care due to their medical needs. Care for private-duty nursing patients is often, though not always, total care with complex medication regimens and requires specialized equipment, such as a feeding pump or ventilator.

Home health services can also provide physical therapy, occupational therapy, and speech-language pathology services. Medical social services may be necessary for some individuals. Durable medical equipment (DME) and other medical supplies needed to provide care at home are considered part of home health. To receive home health services, a physician or other healthcare provider must assess the patient and determine the need for in-home care (2). Often, insurance companies determine the amount of care that can be provided in the home and who is eligible. Home visits from a physician or other medical provider may be available in some areas.

Home health agencies must be licensed and abide by specific regulations. To bill for Medicare services, they must meet specific guidelines determined by the Center for Medicare and Medicaid Services (CMS). Ninety-four percent of home health agencies comply with CMS guidelines (3). The agency’s primary work is to provide home health services, and organization policies must be guided by at least one physician and one RN. A physician or RN must supervise the services that are provided. Clinical records must be maintained.

All licensing and certification standards must be adhered to by the organization’s state. Federal requirements must be met, and the organization must utilize a budget. Home health agencies may be non-profit or for-profit or be a division of an entity (4). Over 80% of home care agencies are for-profit organizations (3). Employees who provide care must be qualified per their scope of practice to give the patient the required care (4). Medicaid may cover private-duty nursing services and often has similar guidelines to Medicare services. Private duty services covered through insurance have varied requirements but typically follow many Medicare guidelines.

History

Home health originated in ancient times when family members were cared for at home by other family members. In the early 19th century, those who could afford it received medical services in their home. In 1813, in Charleston, SC, a group of wealthy women of the Ladies Benevolent Society (LBS) worked to provide medical care for individuals who could not afford it. In the early 1900s, home care was popularized in the United States due to the influence of Florence Nightingale and the English model of care. Trained nurses were becoming more numerous, allowing nearly 600 home healthcare organizations to care for patients in the US by 1909 (5).

As nurses strove for recognition as a profession, home healthcare facilitated the acknowledgment of the importance of these healthcare workers in society (5). In 1893, Lillian Wald, a nurse in New York City instrumental in establishing the profession of visiting nurses, coined the term “public health nurse,” which was used to refer to visiting nurses who worked outside the hospital to provide care for those who may not otherwise be able to afford it (6). With the onset of insurance coverage came a change in the model of providing home nursing services.

A more business-like approach was necessary for documentation, billing, and reimbursement. After the Great Depression in the 1920s, hospital-based medical care became more popular, though home care was still used to care for the poor and chronically ill. In the mid-1950s, a resurgence of home care became available when institutions, physicians, and insurance companies realized the cost-saving benefits of this type of care. With the passage of Medicare legislation in 1965, the vitality of home care was secured. By the 1990s, home care was able to meet the needs of many acute and chronically ill (5). Home health agencies exist to facilitate this complex care model.

Patient Rights and Responsibilities

Patient rights are considered part of human rights and outline the minimum standards that patients should expect for their medical care. They generally outline that patients should be treated with dignity and respect and maintain autonomy (7). The American Hospital Association (AHA) established a patient Bill of Rights in 1973.

In 1990, the Patient Self-Determination Act required home health agencies to notify patients of their rights and responsibilities (8). Home health agencies use the patient rights and responsibilities statement to comply with federal regulations and inform patients of their rights. It must be updated periodically when the client’s level of care or amount of services changes. The Patient Bill of Rights has led to healthcare quality improvement and further legislation (7).

Case Study

Mrs. Phillips is a geriatric client of Tamara, LPN. Mrs. Phillips states that she is supposed to receive medications at night, but the night shift nurses have not been giving them. Mrs. Phillips also informed Tamara that her insurance coverage would change at the end of the month. Tamara assumes since the insurance change doesn’t impact the doctor’s orders, she does not need to worry about it. She also assured Mrs. Phillips that she would give her the necessary medications during her shift, but she is not on the night shift, so she is not responsible for those medications. Tamara does not report these issues to other agency staff.

Why is this a problem?

Mrs. Phillips’s right to receive the medications that have been prescribed is being violated. Even though the medication issue does not occur on Tamara’s shift, Tamara must report the complaint to the agency supervisor. Mrs. Phillips is adhering to the agreed-upon patient responsibilities by notifying an employee of the change in insurance. Still, if Tamara doesn’t understand the Impact of this change, it could cause a delay in the ability to provide services or a denial of reimbursement from the insurance company. This could impact Mrs. Phillips’s care and possibly result in hospitalization.

Billing and Reimbursement Guidelines

Billing and reimbursement guidelines describe how an agency or business is paid to provide home health services. Various payor sources, such as Medicare or private insurance, may use different reimbursement models. Other states may also have diverse requirements for documentation and provider scope of practice that can impact reimbursement.

The reimbursement model implemented can affect patient care (10). While many may have their home health services covered by private insurance, veteran benefits, or Medicaid, many home health care patients have Medicare as their primary payor source. As a result, Medicare reimbursement changes substantially impact all home health areas.

Medicare currently uses a prospective payment system. Since 2020, a value-based model called the Patient-Driven Groupings Model (PDGM) has been used. Instead of reimbursement based on a specific number of visits, reimbursement is now based on the patient’s condition, whether they have been recently hospitalized, and the market rates of the geographical area where the patient lives (11).

Home health value-based purchasing models have been associated with improved outcomes, fewer hospitalizations, and lower healthcare costs (12). Medicare sets a base payment that is adjusted for the patient’s condition and geographical market. The fee is adjusted again if the patient requires more or less care than expected. The base payment is adjusted annually (11). Billing is also consolidated so that the reimbursement covers all necessary care services, with a few exceptions, like durable medical equipment (13).

Current and Proposed Legislation

In November 2024, the Centers for Medicaid and Medicare Services (CMS) payment guidelines were finalized for 2025. An increase in the reimbursement rate was proposed but then offset with adjustments. Challenged with increased expenditures using the PDGM system, Medicare needed to cut costs. A significant decrease in spending was proposed, but home health agencies stated that such a significant decrease at one time would be detrimental to the sustainability of agencies.

Medicare agreed to decrease the reimbursement slower, with only a partial reduction for 2025 and an expected repeated decrease for 2026. Instead of the 2.7% increase in payments, the adjustments needed for the spending decrease resulted in an overall rise of 0.5% in costs to home health agencies for 2025. The requirements of the Bipartisan Budget Act were implemented with the allowance for CMS to adjust rates based on behavior or how the agencies are using the funds to provide services (14).

Proposed changes to the quality reporting model, scheduled to begin in 2027, include changes to the social determinants of health portion of the assessment, including one living situation element, two food elements, and one item related to utilities. Initiatives are also underway to emphasize functional status at discharge and health equity (14).

Quality Guidelines

Quality guidelines guide home care agencies, not only to maintain licensure but also for billing purposes. One way CMS is working to increase the quality of patient care is by tying reimbursement to the quality of care being delivered. Home care agencies with Medicare must submit Outcome and Assessment Information Set (OASIS) reports.

These include time requirements for care plans, start-of-care and resumption-of-care assessments, and end-of-care assessments. Home health quality measures are categorized by outcome, process, and patient-reported outcome measures. Outcome measures include four measures based on OASIS assessments and Medicare claims (15).

1. Improvement measures describe how patients have improved their mobility, self-care abilities, and overall health.
2. Measures of potentially avoidable events describe whether the patient could avoid preventable complications, which can indicate potential problems in their care.
3. Utilization of care measures describes efficiency measures. This quantifies the need for other types of healthcare the patient has had to access while receiving home care, such as emergency department visits, hospitalizations, and avoidable physician visits.
4. Cost/Resource measures describe whether the agency’s home care use has been cost-effective for CMS.

(15).

Medicare is not the only payor source that requires quality assurance, but it substantially impacts how home health agencies conduct their businesses and provide care. Medicare assigns a star rating based on quality to help patients when selecting a home health agency to meet their needs (15). While not all home health agencies provide Medicare services, those accredited tend to achieve higher quality measures in the same way the Joint Commission accredits hospitals (16).

Impact of Nurses

Nurses provide over 73% of home health services worldwide, and RNs lead most home health administration. With this extent of global Impact, nurses are a vital part of the home health system. Home-based services improve patient compliance with medications, patient satisfaction, and health-related quality of life. Due to reduced hospital admissions, home health also has a cost-saving value (17).

Nurses must be knowledgeable about patient rights and responsibilities to ensure they do not violate any rights and to facilitate the patient’s access to those rights. Nurses are often the in-person representatives of the home health agency, so the patient may voice complaints, notify the nurse of changes in insurance, or inform the nurse of scheduling needs, which will need to be communicated to the appropriate persons within the agency.

While nurses who provide care in the home are usually not directly involved in billing and reimbursement, nurses need to understand the process. This allows them to utilize better the resources provided to the patient through their insurance and help their employer be more financially viable. This can impact pay rates for nurses who provide care in the home. Nurses aware of how services are billed and reimbursed are better prepared to document the care they provide to meet the standards of the payor source. They also validate their profession when they recognize their service is valuable to the payor.

Quality initiatives are critical for home health nursing staff to understand. Quality improvement initiatives are created in response to shortcomings in the delivery of home health care. Nurses impact the overall quality patients receive by incorporating interventions into the patient’s care plan that will facilitate optimal outcomes and promote quality in the care they receive. Quality initiatives are not meant to burden nurses in the home but rather an opportunity to improve the quality of care their patients receive through evidence-based initiatives. Home care quality can only improve when the nurses who deliver the care know current initiatives and recommendations and their rationale.

Conclusion

Home health nurses provide a valuable service to their patients and community that impacts health outcomes and healthcare spending. While the world of home health nursing can be complex, with varying patient needs, different levels of skilled care, multiple payor sources, agencies that provide oversight, and the need for specialized documentation, it is also rewarding as nurses can impact the health of their patient and the patient can remain in the comfort of their own home with their family. Nurses who are knowledgeable of patient rights and responsibilities, billing and reimbursement guidelines, legislative changes, and quality indicators can provide more efficient and effective care, resulting in optimal outcomes for the patients they care for.

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