Care in the home lets clients recover, manage chronic illness, or die in familiar surroundings with their families. In the home, the client and family control the environment; the nurse is a guest who must adapt care to the household's routines, resources, and culture.
| Term | Meaning |
|---|
| Home health care | Skilled, intermittent nursing and therapy services delivered at home by a home health agency, usually after hospitalization or during an exacerbation, to restore function or teach self-management. Most is paid by Medicare or Medicaid under a provider-certified plan of care |
| Home care (private duty, personal care) | Non-skilled help with ADLs, homemaking, and companionship, often paid privately or through Medicaid home and community-based services — not covered by Medicare as a stand-alone service |
| Palliative care | Interdisciplinary relief of symptoms and suffering for anyone with serious illness, at any stage, alongside curative treatment |
| Hospice | Palliative care for clients with a limited prognosis who choose comfort-focused care instead of curative treatment of the terminal illness; delivered mostly at home and in nursing homes, with bereavement support for the family |
| Interdisciplinary team | Home health: nurse, physical, occupational, and speech therapists, medical social worker, home health aide. Hospice: physician, registered nurse, social worker, and pastoral or other counselor as the core group, plus aides, therapists, dietitian, and trained volunteers |
Why home-based care matters: it supports safe transitions from hospital to home, reduces avoidable readmissions, lets clients remain in their communities, and in hospice allows a death that reflects the client's values.
Medicare home health benefit — eligibility (all required)
- The client is homebound — both criteria apply: (a) needs help (a person, a device such as a cane, walker, or wheelchair, or special transportation) to leave home or leaving home is medically inadvisable, and (b) normally cannot leave home, and leaving takes considerable and taxing effort. Short, infrequent absences for medical care, religious services, or adult day care are allowed.
- The client needs skilled services on an intermittent (part-time) basis: skilled nursing, physical therapy, or speech-language pathology (occupational therapy can continue eligibility once it has started).
- The client is under the care of a physician or allowed practitioner who certifies eligibility and establishes and reviews a plan of care.
- A face-to-face encounter related to the main reason for home care occurred within 90 days before or 30 days after the start of care (telehealth allowed in some circumstances).
- Care is provided by a Medicare-certified home health agency.
What Medicare home health covers: skilled nursing (for example, wound care, injections, teaching, assessment of an unstable condition), therapy, medical social services, part-time home health aide care only when the client also receives skilled care, and medical supplies. The client pays nothing for covered home health services; durable medical equipment carries 20% coinsurance after the Part B deductible. Not covered: 24-hour care, meal delivery, homemaker services unrelated to the plan, and custodial care when it is the only need.
Medicare hospice benefit (Part A)
- The client's attending physician (if any) and the hospice medical director certify a terminal illness with a life expectancy of 6 months or less if the illness runs its normal course.
- The client signs an election statement choosing comfort care instead of Medicare-covered curative treatment for the terminal illness and related conditions. Conditions unrelated to the terminal illness remain covered by regular Medicare.
- Benefit periods: two 90-day periods, then an unlimited number of 60-day periods. A hospice physician or nurse practitioner must have a face-to-face encounter before recertification for the third benefit period and each one after.
- Clients may revoke hospice at any time and return to regular Medicare coverage, and may elect hospice again later if still eligible. Living longer than 6 months is not a reason for discharge if the prognosis is still limited.
- Costs: no charge for covered hospice services; up to $5 per prescription for symptom-control drugs; up to 5% of the Medicare-approved amount for inpatient respite care. Room and board in a nursing home is not covered by the hospice benefit.
Four levels of hospice care
| Level | When used |
|---|
| Routine home care | Most days; care wherever the client lives |
| Continuous home care | A crisis of uncontrolled symptoms; at least 8 hours of care in a 24-hour day, mostly nursing, at home |
| General inpatient care | Pain or symptoms that cannot be managed at home |
| Inpatient respite care | Short stay (up to 5 consecutive days) to give the family caregiver a rest |
Phases of a home visit
- Initiation — clarify the referral source and purpose, and obtain the client's agreement to the visit.
- Pre-visit — review records, call to schedule, plan goals, supplies, and route, and check safety information.
- In-home — introduce yourself with identification, build rapport, assess the client, family, and home, give care and teaching, and set mutual goals.
- Termination — summarize, confirm teaching with teach-back, plan the next visit, leave written instructions and contact numbers.
- Post-visit — document promptly, communicate with the provider and team, and update the plan.
Home health nursing
- Start-of-care comprehensive assessment (Medicare-certified agencies use the standardized OASIS data set): health status, function, home environment, medications, caregiver ability, and risk of hospitalization.
- Medication reconciliation at every transition; many post-discharge problems are medication errors.
- Skilled teaching: heart failure self-care (daily weights, symptoms to report), diabetes and insulin, anticoagulants, inhalers, ostomy and wound care, infusion therapy.
- Home safety: fall hazards, fire and oxygen safety (no smoking or open flames near oxygen), safe medication storage, working smoke and carbon monoxide alarms.
- Infection control in the home: hand hygiene before and after care, a clean work surface, a nursing bag kept on a clean barrier and opened only after hand hygiene, sharps in a puncture-resistant container, and teaching the family about waste disposal.
- Telehealth and remote monitoring (weights, blood pressure, oxygen saturation) can extend visits but do not replace in-person skilled assessment when needed.
- Discharge when goals are met, the client is no longer homebound, or skilled needs end; plan follow-up in the community.
Hospice nursing
- Symptom management: pain (scheduled opioids with a bowel regimen), dyspnea (opioids, fan, positioning), nausea, anxiety, terminal delirium, and respiratory secretions near death.
- Family teaching: expected signs of approaching death (sleeping more, reduced intake, mottling, breathing changes), who to call instead of 911 for an expected death, and how to give comfort medications.
- Psychosocial and spiritual care, including anticipatory grief.
- After death: support the family, follow state rules for pronouncement and notification, and arrange removal of controlled substances per agency policy and law.
- Bereavement care continues for the family after the death (federal rules require bereavement services for up to 1 year).
- Case manager and coordinator: the registered nurse usually coordinates the plan of care, communicates with the certifying provider, and arranges therapy, social work, aide services, and equipment.
- Direct care provider and educator: performs skilled procedures and teaches the client and family to manage care between visits.
- Supervisor of aides: assigns and supervises home health and hospice aides within state Nurse Practice Act delegation rules; federal rules require regular registered nurse supervisory visits (for example, at least every 14 days for hospice aides).
- Advocate: supports the client's goals, including the choice to stay home or to stop curative treatment.
- Documenter: records the findings that justify homebound status, skilled need, and (in hospice) continuing terminal prognosis — Medicare payment and legal accountability depend on it.
- Safety manager for the client and for self.
Nurse safety on home visits: know the address and route, share the schedule with the agency, keep a charged phone, visit in daylight when possible, park where you can leave easily, and leave immediately if you feel threatened (weapons, violence, intoxicated people) — return later with an escort or reschedule.
- Scope and delegation: tasks follow the state Nurse Practice Act; aides do not perform assessment, teaching, or clinical judgment.
- Documentation and fraud: document objective evidence of homebound status and skilled need. Billing for services that are not medically necessary or not provided is Medicare fraud.
- Advance directives: the Patient Self-Determination Act applies to Medicare- and Medicaid-certified home health agencies and hospices — clients must be informed of their rights. Out-of-hospital do-not-resuscitate orders and POLST-type forms vary by state; confirm they are in the home and visible.
- Hospice election is a voluntary, informed choice; the client can revoke it at any time. Children under 21 enrolled in Medicaid or CHIP may receive hospice and curative treatment at the same time (concurrent care, ACA Section 2302).
- Confidentiality: protect health information in the home, in the car, and on mobile devices (HIPAA).
- Abuse and neglect: report suspected abuse of children or vulnerable adults per state law.
- Ethical tensions: autonomy versus safety in the home, family disagreement about goals, requests for hastened death. Respond with open communication, the interdisciplinary team, and the ethics resources of the agency.
Case 1 — Homebound or not? A client with heart failure walks with a walker and needs his daughter's help to leave the house. He goes out only for medical appointments and church on Sundays. Correct judgment: he meets the homebound criteria. Why: leaving home takes considerable effort and help, and absences for medical care and religious services are allowed.
Case 2 — Aide-only request. A family asks the home health agency to send an aide three times a week for bathing only. The client has no skilled need. Correct action: explain that Medicare home health covers aide services only alongside skilled care, and refer the family to the Area Agency on Aging, Medicaid home and community-based services, or private home care. Why: custodial care alone is not a Medicare home health benefit.
Case 3 — Hospice client outliving 6 months. A client with advanced COPD has been in hospice for 7 months and is still declining. Correct action: the hospice physician recertifies after a face-to-face encounter documenting continued limited prognosis. Why: eligibility is based on prognosis at each recertification, not on a fixed time limit.
Case 4 — Expected death at home. At 0200 the wife of a hospice client calls because his breathing has stopped. Correct action: the family calls the hospice agency, not 911; the hospice nurse visits, supports the family, and follows state pronouncement procedures. Why: calling 911 may trigger resuscitation the client did not want.
- Thinking Medicare home health is for anyone who wants help at home — it requires homebound status plus intermittent skilled need and a certified plan of care.
- Believing Medicare pays for a home health aide alone or for 24-hour care — it does not.
- Believing hospice means "giving up all treatment" — treatment for comfort, and for unrelated conditions, continues.
- Believing hospice ends at 6 months — recertification continues as long as the prognosis remains limited.
- Believing hospice is only for cancer — heart failure, COPD, dementia, and kidney and liver failure are common hospice diagnoses.
- Confusing palliative care (any stage, with cure-focused treatment) with hospice (limited prognosis, comfort focus).
- Opening the nursing bag before hand hygiene or placing it on the floor.
- Staying in an unsafe home to finish the visit.
- Medicare home health: homebound + intermittent skilled need + provider-certified plan of care + face-to-face encounter (90 days before or 30 days after start)
- Aide services covered only with skilled care; no 24-hour or custodial-only care
- Hospice: prognosis 6 months or less if the illness runs its normal course, certified by physicians; client elects comfort care
- Hospice benefit periods: 90 + 90 days, then unlimited 60-day periods; face-to-face before the third period
- Four hospice levels: routine home, continuous home, general inpatient, respite (up to 5 days)
- Client can revoke hospice any time; unrelated conditions stay covered
- Palliative care = any stage; hospice = limited prognosis, comfort focus
- Home visit phases: initiation, pre-visit, in-home, termination, post-visit
- Registered nurse coordinates the plan and supervises aides within the state Nurse Practice Act
- Nurse safety: leave if threatened; share your schedule
- Bereavement support for families continues after the death