Home Care & Community Based Nursing
questions and answers 2025/2026
What is Homecare? - answer•Has community health (health promotion) and community-based (illness
treatment) components
•Emphasis on pt and family independence, capability
•Not only nursing, but includes the interdisciplinary team
Mind Set for Home Care - answer•Empowers patient in their own environment to maximize health and
minimize disability = Patient Centered!
•Family members contribute/part of care network
•Nurse is a guest
•Nurse maintains safety for patient, family and self
•Requires creative problem solving; nurse on patient's turf = sensitive negotiations!
•Charting justifies each visit and associated skilled care
Medicare home care eligibility criteria: - answer•Health services provided in the patient's home
-(can be in family's home, assisted living, homeless shelter, hotel, jail or prison )
•Medicare certified agency
-St. Joseph Homecare, Sutter at Home, AccentCare, Kaiser
,•Physician's orders required
•Skilled service of Nursing, PT, OT, MSW or ST
•Expected to improve in a reasonable and predictable time
•Intermittent visits only (not round the clock care)
•Patient must be homebound
Private Duty Care Not Paid for by Medicare - answer•Custodial care, not skilled service, not intermittent,
patient doesn't have to be homebound
-Cooking and feeding
-Trips to doctor, church, hair done, shopping
-Companionship
-Safety at night
-Bathing, exercise review
•Paid entirely out of pocket or by long term care insurance (or VA if eligible)
•No physician order required
•Local examples are Visiting Angels, Hired Hands, At Your Service, Right at Home
What is homebound? - answer•Leaving home is not recommended by MD (provider appts for
assessment or care allowed)
- or -
, Must have help to leave home (device or person to transport)
- and -
•It's a major effort to leave home
Who's homecare eligible? - answer•A wide variety of Med/Surg type patients
•Especially those with multiple comorbidities
•High proportion of gerontology patients
Medicare Principal Diagnoses - answerCirculatory system dz
MS dz
Why Home Care? Comparison of Hospital, SNF and Home Health Medicare Cost Trends - answerHospital
(per day) 6200
Skilled Nursing Facility (SNF) per day 622
Home Health (per visit) 139
Improved Outcomes - answer•National study of patients after knee & hip replacements
•Compared 120 day post-op outcomes of pts discharged to SNF and inpt rehab vs. pts discharged to
home health care
•Home Health Care patients less likely to be institutionalized; achieved similar outcomes
Homecare Reimbursement- or - Who pays? - answer
Medicare Home Care Reimbursement - answer•Funded and monitored by the Federal Government
•Clinician (RN, PT or ST)who sees patient first puts together the Plan of Treatment (POT)
questions and answers 2025/2026
What is Homecare? - answer•Has community health (health promotion) and community-based (illness
treatment) components
•Emphasis on pt and family independence, capability
•Not only nursing, but includes the interdisciplinary team
Mind Set for Home Care - answer•Empowers patient in their own environment to maximize health and
minimize disability = Patient Centered!
•Family members contribute/part of care network
•Nurse is a guest
•Nurse maintains safety for patient, family and self
•Requires creative problem solving; nurse on patient's turf = sensitive negotiations!
•Charting justifies each visit and associated skilled care
Medicare home care eligibility criteria: - answer•Health services provided in the patient's home
-(can be in family's home, assisted living, homeless shelter, hotel, jail or prison )
•Medicare certified agency
-St. Joseph Homecare, Sutter at Home, AccentCare, Kaiser
,•Physician's orders required
•Skilled service of Nursing, PT, OT, MSW or ST
•Expected to improve in a reasonable and predictable time
•Intermittent visits only (not round the clock care)
•Patient must be homebound
Private Duty Care Not Paid for by Medicare - answer•Custodial care, not skilled service, not intermittent,
patient doesn't have to be homebound
-Cooking and feeding
-Trips to doctor, church, hair done, shopping
-Companionship
-Safety at night
-Bathing, exercise review
•Paid entirely out of pocket or by long term care insurance (or VA if eligible)
•No physician order required
•Local examples are Visiting Angels, Hired Hands, At Your Service, Right at Home
What is homebound? - answer•Leaving home is not recommended by MD (provider appts for
assessment or care allowed)
- or -
, Must have help to leave home (device or person to transport)
- and -
•It's a major effort to leave home
Who's homecare eligible? - answer•A wide variety of Med/Surg type patients
•Especially those with multiple comorbidities
•High proportion of gerontology patients
Medicare Principal Diagnoses - answerCirculatory system dz
MS dz
Why Home Care? Comparison of Hospital, SNF and Home Health Medicare Cost Trends - answerHospital
(per day) 6200
Skilled Nursing Facility (SNF) per day 622
Home Health (per visit) 139
Improved Outcomes - answer•National study of patients after knee & hip replacements
•Compared 120 day post-op outcomes of pts discharged to SNF and inpt rehab vs. pts discharged to
home health care
•Home Health Care patients less likely to be institutionalized; achieved similar outcomes
Homecare Reimbursement- or - Who pays? - answer
Medicare Home Care Reimbursement - answer•Funded and monitored by the Federal Government
•Clinician (RN, PT or ST)who sees patient first puts together the Plan of Treatment (POT)
