A month or two ago, I wrote an article for my blog titled "Misunderstanding Homecare." I received a great deal of positive response, with many of those e-mails or messages letting me know they were unaware of the specific types of homecare before they read the article, and were thankful to now understand the types, and when they may be appropriate.

Patient and consumer education is the basis for everything I write, because it empowers families to make educated, and more appropriate decisions for their current or future situations. Uneducated decisions cause a lot of stress, and anxiety, so I am posting a version of my original article again here, hoping to reduce the stress and anxiety families are facing or will face.

There is so much misunderstanding about homecare that I want to help clarify the misunderstandings. Many refer to homecare as home health or just homecare without ever realizing there are three types of homecare. This isn't a just a misunderstanding in the lay community, but there is an enormous lack of understanding among medical professionals and those working in the medical field. Even websites that provide health information can be very wrong in their description of home care. They use home health and homecare interchangeably as if it were one in the same.

The lack of knowledge, particularly in the medical community, is a huge disservice to patients. Because of the changes we have witnessed in healthcare in the last several years, patients are being left to their own accord to educate themselves, and advocate for the best care. If doctors, nurses, social workers, and discharge planners don't understand homecare or teach their patients about home care options, how are patients supposed to find the resources that would best suit their needs?

I have spent most of my career working as a nurse in Home Health Care, hospice and, for the last eight years, owning Visiting Angels (www.visitingangels.com/annarbor), a private duty homecare agency in Ann Arbor. I speak about this from years of experience and caring for countless families in all three types of home care.

There are three types of home care as I mentioned. Home health care, private duty homecare and hospice care.

The most confusion comes between home health and private duty. There is also a need for hospice education, but that is specifically related to hospice services, and when hospice is appropriate. I will briefly touch on hospice care in this article.

HOME HEALTH CARE

Home health care is medical care in the home for homebound patients. It is a benefit of Medicare, Medicaid and most private health insurances if the patient meets very specific criteria. Home health provides nursing, physical therapy, occupational therapy, speech therapy, social work, and home health aides.

To qualify, a patient typically has had an acute health change requiring hospitalization, and home health is initiated upon hospital discharge. The patient must be homebound, meaning they only leave the home for medical appointments. Qualifications don't require hospitalization, but that is the most common qualifier for home health. A patient can also qualify if there is a significant change in health status, such as an acute illness or injury not requiring hospitalization. For example, if a patient went to ER for trouble breathing, and was having a hard time controlling congestive heart failure, they would most likely qualify, but again, would have to be homebound, and home health would have to be physician ordered. If a patient was physically debilitated due to an illness or injury and needed therapy to regain strength and balance, they could qualify.

Patients also can qualify based on a new and life altering diagnosis, such as insulin-dependent diabetes. Diabetics are at risk for a multitude of problems from uncontrolled blood sugar so education and monitoring is essential to prevent complications.

Home health is always set up on a short, temporary basis. It must include either nursing or physical therapy to obtain services. Home health must be ordered by a physician to be covered by insurance. Visits are determined based on the nurse’s initial assessment, or the therapist’s assessment. The nurse typically determines which of the services available will be initiated and how often they and the home health aide will visit. Therapists either initiating care or being initiated by the nurse provide their own evaluation to determine the frequency and length of their visits, which are physician ordered.

The goal of home health is to improve health outcomes. Their services are guided by Medicare guidelines. Medicare expects the home health team to educate the patient and family specific to the ordering diagnosis and discharge as soon as possible. Medical procedures that were once done by nurses, such as dressing changes on wounds, daily catheterization and injections, are now being taught to patients and families, with the expectation that a responsible party within that patient's family or friends will provide those medical procedures after being taught by the nurse.

Home health aides can only provide personal care according to Medicare guidelines. This includes bathing and grooming but does not include providing meals, housekeeping or any type of tasks that aren't directly related to personal care.

Therapists provide therapy, but their main job is to educate the patient how to perform the therapy, and all the work is up to the patient. No one really improves if they don't follow the therapist’s directions to follow the exercise plan when the therapist is not there.

There is always a care plan that is followed by the team, with the inclusion of the patient, and family if applicable. Home health is set up on a 60-day basis. The professionals who visit will typically be in the home for 45 minutes to an hour. As weeks go on in the 60 -ay certification period, visits decrease, unless the patient’s health status declines. If the team determines the patient improves to the point they no longer qualify for services, or they do not remain homebound, discharge will be before the 60-day certification period ends. If the patient continues to have significant health needs that cannot be improved in the 60 day period, home health can recertify the patient beyond the 60 days.

PRIVATE DUTY HOMECARE

Private duty homecare is non medical. The services are provided by caregiver's and/or certified home health aides (may be dependent on individual state regulations). Michigan is an unlicensed state, so there are no requirement's for caregivers to be certified. The services provided are considered custodial care and do not require a physician's order. Services are designed to help the care recipient remain in the home as independent as possible by providing hygiene, meals, light housekeeping, companionship, errands and medication reminders. Some agencies or individuals providing services transporting clients, some do not.

Private duty homecare is most often provided in a person's private residence, but services are also provided in assisted living, long term care facilities and even in hospitals. Residents in assisted living may decline, or have an acute illness or injury that leaves them less independent and unable to remain in assisted living because they need more assistance than the facility can offer. Most residents no longer drive but continue to like to get out to shop, go out to eat, or go to another outside event or activity. Private duty is able to provide the companionship and transportation services these clients prefer.

Families have private duty agencies provide service in nursing homes for companionship, meal assistance or outings. There has been a growth in families contacting private duty agencies to relieve families from sitting and attending to their loved one who is hospitalized. Although the hospital guides what a private duty caregiver can do with a patient, families feel more comfortable with someone there at the bedside with their loved one for companionship and monitoring. Visiting Angels often provides this service on the midnight shift so family members feel comfortable leaving for the night to get some much needed sleep.

The amount of services are determined by the care recipient, and/or family -- because private duty is not covered by health insurance -- with the help of the agency. Most private duty homecare services are paid out of pocket but may be covered in part or whole by long term care insurance or veterans benefits. Individual states may have programs providing limited private duty services for low income residents, but my experience is they are very limited in the number of residents that can qualify for services.

There is typically a waiting list for these programs, or they are closed to new applicants. They provide a very little amount of services from agencies that contract with them. Michigan's program for low income senior's is called MI Choice. It is a Medicaid waiver program. You can find specifics on the program here http://www.aaa1c.org/consumers/docs/MIChoiceWaiver.pdf or contact the Area Agency on Aging for more information. To find which AAA is in your region go to http://www.michigan.gov/mdch/0,1607,7-132-2943_4857_5045-16263--,00.html#map The agency for Washtenaw County is Area Agency on Aging 1B http://www.aaa1b.com/

My Visiting Angels private duty home care agency in Ann Arbor does not contract with the state of Michigan for the MI Choice Medicaid waiver program because their reimbursement rate is so low I would personally have to cover a portion of care for the care recipients. Agencies that contract for these services typically pay their caregivers a very low wage and therefore don't attract or retain the best staff. We choose to pay a higher wage to attract, hire, and retain the best caregivers possible. I have advocated on a government level for a higher reimbursement rate so Michigan's waiver clients will have more options in their care selection. Veterans Administration, also a government program, pays for homecare services for qualifying veterans at the agency rate, giving them a selection of higher quality agencies.

Private duty often works in collaboration with home health agencies, because the services are very different in nature and, typically, if someone needs home health, they also need assistance with activities of daily living (ADLs). Because I am a nurse and geriatric care manager, I always assess the need for home health care if our client comes to us before home health. I make referrals so our clients can improve and have the best quality of life possible. Many private duty agencies do not involve themselves with health care at all because of the lack of knowledge in understanding health care needs.

Private duty homecare is available 24 hours a day, 365 days a year. Clients can obtain services long term or short term. Some agencies require a minimum amount of hours either per shift, per day or per week, some do not. This varies by the agency, as well as the rates, so check around. Don't base your decision on the particular costs the agency charges. Remember Michigan is an unlicensed state. Anyone can open a private duty agency in the state of Michigan. The lowest rates can mean poorly paid staff with a high turnover rate, and highest doesn't always mean best. Always take into consideration who will provide the best care for your needs, the reputation of the agency, years in business, and how they obtain and train their staff. Families can interview agencies, and ask for references to decide who would best suit their needs, and who they feel most comfortable with.

Every state has their own decision to license or not. I believe seniors and their families are at a much greater safety risk in unlicensed states. For $20, anyone can open a registered business and call it a private duty homecare agency. No criteria for experience, no background check, no mandates on the services they perform, or who they emplo, and no criteria for training. Ethical, legitimate agencies, like my own, are pushing for regulation for the protection of the elderly.

Private duty agencies are never certified by Medicare, because Medicare does not cover these services. Long term care insurance companies have been difficult to deal with in the recent years because the language in their policies states the home care agency must be licensed or Medicare certified. They are beginning to understand this varies by state, and private duty homecare is never certified by Medicare, paying claims they tried to deny in the past.

Some home health agencies also operate private duty, but they are run as separate companies. Even when their home health division is Medicare certified, their private duty is not. Very few companies that offer both home health and private duty do both well. The focus tends to be on the home health division with little attention to providing excellent private duty.

I've always believed that if a company diversifies itself too much they typically don't do it all well.

I would rather contract a company whose sole concentration and expertise is in private duty, or home health than one that tries to do it all.

HOSPICE

Hospice , as most know, is care for the dying. The perception of what hospice is or what it provides is usually not accurate. Hospice can be provided in homes, hospice facilities, long term care facilities and in hospitals. Some hosipice companies have their own hospice facility, while others contract beds in non-owned facilities so they have facility care for family respite or other patient needs. Medicare, Medicaid and most private insurances cover hospice care. This also requires a physicians order, but does not require the patient to be homebound. It is initiated based on a terminal diagnosis. The old rule of thumb used to be that hospice was for patients given six months or less to live. That is no longer the case, although it is expected that death is impending from a terminal diagnosis. Medicare pays for hospice care based on specific criteria.

Hospice consists of nurses, home health aides, social work, spiritual care and volunteers, as well as a bereavement counselor. Patients may use all or some of the services based on their needs and preferences. Visits are short, typically between 45 minutes and 1.5 hours. Volunteers may be scheduled longer, and the staff may be in the home much longer than a typical visit if the patient is in need of pain control or other comfort measures.

Although hospice operates under a primary physician or medical director who is a physician, hospice nurses direct care. Nurses case manage the care and work as a team with other hospice professionals, as well as the family and even friends of the patient.

Some home health companies have hospice as well, and often have a transitional program. Patients may start out with home health, and as they decline decide to transition to hospice services. Patients never have both. The focus of home health and hospice are very different. Home health concentrates on improvement, and hospice concentrates on comfort, support and the best quality of life possible for however long the patient will live. They specialize in pain control and the process of dying. They address physical, emotional, and spiritual needs, not only with the patient, but with their loved ones.

Patients and families often call hospice much too late. Hospice is most beneficial when they are contacted soon after a terminal diagnosis. Hospice covers all equipment and medications related to the terminal diagnosis, saving families hundreds, if not thousands of dollars. Because their focus is not curative, and they are focused on palliative care, or comfort care, they will provide better pain control than any individual physician or facility.

Physicians and nurses approach care from an improvement or cure perspective. This is a very different mindset than assisting someone in the dying process. I have heard physicians tell patients they did not want to prescribe a particular pain medication or dosage because they had concerns about addiction with a dying patient. There are no concerns about addiction from a hospice team. A patient who is in pain and terminal will require pain control for the rest of his or her life, and often at higher dosages than physicians are willing to order. This is why perspective is important. Living the best quality of life possible as someone is nearing end of life is what hospice focuses on.

Private duty will often work in collaboration with hospice, to provide care when families are unable or need respite. Private duty follows the direction of the hospice team to maintain comfort and support for the patient. Rather than contacting EMS or the client's physician for help with changing status, private duty caregivers contact the hospice nurse for instruction.

I hope this clarifies the misunderstand of home care. There is no charge for most hospice or private duty companies to meet with you to assess your needs, and provide information. Home Health is a bit different in the fact that it is physician ordered. The physician initiates home health, or based on a referral or phone call to a home health agency, the agency may contact the physician asking for an order. Home health then makes the appointment to assess, and plan the start of care. Hospice and private duty are more optional. Understanding your health status, or your loved one's status, and what your needs are can help you obtain the best services for your situation. Most companies are very receptive to calls for information.

My suggestion is to always check out the company before beginning services. Most consumers don't realize they have a choice. You have the right to choose a home health, hospice or private duty company. Just because a hospital or care facility owns their own home care companies doesn't always mean they are good or the best for you or your loved one. Keep in mind some health care companies want to provide it all and keep their patients in their system for financial reasons. Their financial goals will not benefit your care.

Ask the tough questions, ask for references and Google the company you are interested in. Know the owners' names and Google them as well. Many consumers are now voicing their dissatisfaction with providers that are all over the web. Just realize one person's dissatisfaction isn't verifiable to exclude a company. A few dissatisfied consumers can be a red flag to exclude a particular company from your options.

If you feel this article was of benefit to you, please comment and share with your physicians or others you feel may benefit. Education helps medical professionals direct the most appropriate care for patients and families, improving outcomes, and helps reduce the stress and anxiety families face when the unexpected happens.

I wish you the best care for your needs, and the needs of your loved ones!

Angil Tarach can be reached for questions or comments at visitingangelswc@comcast.net, or call Visiting Angels at 734-929-9201. To learn more about Visiting Angels Ann Arbor go to www.visitingangels.com/annarbor.