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What Are the Medicare Guidelines for Home Health Care Discharge Planning?
Date Updated: December 13, 2024
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The Medicare guidelines for home health care discharge planning are flexible, with agencies free to set their own procedures. Providers must notify patients of any changes to their Medicare status. Ideally, agencies should ensure individuals can cope with self-care routines. Conversely, discharge planning when leaving a hospital has stricter requirements.
Starting Home Health Care After Leaving a Hospital
Different procedures exist depending on whether a person arranges home health care while in an inpatient or a residential setting. For example, doctors or caregivers usually contact home health care agencies for those in private homes, assisted living communities or nursing facilities. However, specialized discharge planners — typically hospital-employed social workers or nurses — work with those returning home after hospital stays. Hospital staff evaluates whether an individual needs a discharge plan. If they do, the staff creates and implements such a plan, including details of:
- Medications, including timings, doses and instructions
- Ongoing care needs and regimes
- Follow-up appointments
- Caregiver details
- Residence following discharge
Staff ensures individuals have post-hospital support in place before leaving. This plan includes referring individuals to home health care agencies for continuation of medically essential support. Discharge planning considers:
- Care requirements
- Physical, emotional and social needs
- Local service availability
- Availability of informal family support
- Desired health outcomes
Discontinuing Home Health Care
Doctors must reassess individuals’ ongoing needs for home health care. Every 60 days, they must recertify the medical necessity of qualifying services and an individual’s homebound status for Medicare funding to continue. Home health care agencies can’t bill Medicare for services without such certification. However, Medicare doesn’t have stringent home health care discharge rules. Providers must notify patients using a home health advanced beneficiary notice if Medicare will cover services and if any change occurs.
Home health discharge occurs when individuals no longer need in-home medical care, don’t meet homebound criteria or fulfill their care plan goals. Although not mandated by Medicare, home health agencies should provide patients and their caregivers the necessary training and education to continue self-care measures following their discharge. If possible, they should also ensure arrangements for vital medical equipment and community support services.