Home Health Aides (HHAs)

Members recently discharged from the hospital and/or those diagnosed with certain medical conditions may require short-term skilled care in the home for rehabilitation. When medically necessary, such services can be used to restore or improve functional independence, and also to help train caregivers and family members in ongoing care of the member.

Home health aides (HHAs) assist skilled providers by caring for members who cannot leave the home.HHAs provide assistance with activities of daily living such as bathing and mobility. An HHA may also provide routine care of prosthetic/orthotic devices, record vital signs or other health monitoring values such as blood glucose, assist with a prescribed home exercise program, assist with elimination, or assist in feeding and providing a prescribed diet. The services of home health aides are typically considered medically necessary only when they are part of a skilled treatment plan and when the services fall under many of the same criteria.

This guideline provides clinical criteria regarding the indications, exclusions, and benefit details for home health aides.Information about coverage and benefit limitations can be found in the member’s plan contract at hioscar.com/forms.

Definitions

"Homebound" refers to members who have a normal inability to leave home without considerable and taxing effort (i.e. requires an assistive device or the assistance of another person to leave home) AND one of the following:

• Members who cannot leave home due to a medical condition, chronic disease, or injury; or
• Members advised by a treating provider not to leave home for various reasons (e.g. safety, ongoing medical treatment needs, etc); or
• Members who need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, special transportation (when the member is unable to use common transportation such as private automobile, bus, taxi due to medical condition), or the assistance of others to leave their place of residence.

When the member does leave home, the absence of the member from the home is infrequent or for short periods of time, such as to receive health treatment or adult daycare (non-residential program providing services during the day).

"Home Health Aide (HHA)" is a provider who assists a homebound member with ADLs and other non-skilled needs to facilitate function in the home environment. Some home health aides may be able to perform specific non-skilled services (e.g., glucometer test, ostomy or foley care, tube feeding, monitor adherence of medications, etc.,) and more advanced delegated tasks from nurses depending on the scope of practice within the state. HHAs are trained and certified personnel, but do not fall under the realm of "skilled" professionals because their level of training is general. Home health aides who are personally employed by the consumer are typically permitted to provide additional or more expansive services than home health aides employed by an organization. Home health aides provide intermittent care.

"Activities of Daily Living (ADLs)" are defined as routine activities that most healthy persons perform daily without requiring assistance: These include, but are not limited to: bathing, communication, dressing, feeding, grooming, mobility, personal hygiene, self-maintenance, skin management, and toileting.

"Instrumental Activities of Daily Living (IADLs)" are defined as activities that may be performed daily but are not fundamental for daily functioning. These include, but are not limited to: the use of public transportation, balancing a checkbook, community living activities, meal preparation, laundry, leisure activities and sports, and motor vehicle operation.

"Custodial Care" or "Long-term Care" are non-skilled, personal care to maintain the member’s ADLs or IADLS over a long-term duration and do not require oversight or skilled services by trained health professionals or technical personnel. These services are not part of a medical treatment plan for recovery, rehabilitation, habilitation, or improvement in sickness or injury. Custodial services may be provided in the home, assisted living facilities, or nursing homes, etc. This type of custodial or long-term care typically does not apply for plan benefits, please see the member’s plan benefit.

Hospice Care / End-of-Life Care

- is interdisciplinary and holistic care provided when curative or life-prolonging treatments are no longer beneficial and services may focus on symptom control, psychosocial and spiritual care, nursing, or short-term acute services. Trained clinicians and support staff support individual and family quality-of-life goals. Hospice care can be provided in the home, skilled nursing facility, or hospital setting (for acute symptom management and stabilization to return to previous level of hospice care).

Palliative Care

- are interdisciplinary and holistic care that focuses on symptom management, relieving suffering in all stages of disease, supporting communication, assessing psychosocial and spiritual resources, social and economic resources. Members may receive curative or life-prolonging treatment, and may not choose to receive hospice care or end-of-life care. Furthermore, palliative care provides support for individual and family quality-of-life goals.

Clinical Indications

Home Health Aide services are considered medically necessary for initial requests when ALL of the following criteria are met:

1. The treatment plan is prescribed by a licensed provider (MD, DO, NP, or PA) as per individual state law and must be provided by a licensed or certified HHA; and
2. The member meets the definition of homebound (see Definitions section); and
3. Medical necessity criteria in the appropriate MCG Home Care Optimal Recovery Guidelines or MCG Home Care General Recovery Guideline is met; and/or

For members requesting hospice care/end-of-life care or palliative care (please check plan benefits to verify hospice or palliative care benefit timeframes), the following criteria must be met to meet medical necessity:

1. The member is terminally ill, presenting with functional decline, and certified by a medical practitioner for life expectancy less than twelve months for palliative care and less than six months for hospice/end-of-life care; and
2. The home health aid is under supervision of a registered nurse and services are rendered as part of a hospice care program; and
3. The member may receive curative treatment while receiving palliative care; and/or
4. The member is not receiving curative treatment while in hospice care; and

5. A licensed clinician assesses and documents the medical necessity for HHA services; and

6. HHA services are a necessary and reasonable component of a care plan that exceeds the scope of custodial care, which include non-skilled services in addition to activities of daily living (see Definitions section); and

7. The written plan of care is sufficiently detailed to determine the medical necessity of treatment and includes the following elements:

1. A medical evaluation has been conducted within 30 days of the service dates; and
2. The diagnosis, the date of onset or exacerbation of the disorder/diagnosis, the duration, the severity, the anticipated course (stable, progressive or, improving), and the prognosis; and
3. Prior level of functioning and current level of functioning; and
4. Long-term and short-term goals that are specific, quantitative, objective, and provide a reasonable estimate of when the goals will be reached; and
5. The frequency and duration of treatment; and
6. The specific treatment services to be provided; and
7. Discharge plan; and

8. Documentation of medical necessity should be reviewed when ANY of the following occur:

• The plan of care exceeds the expected duration and/or estimated frequency of care; or
• There is a change in the member's condition that may impact the plan of care; or
• The specific goals are no longer expected to be achieved in a reasonable or expected duration of time.

Extension Requests

A Plan member who requires continued home health aide visits, beyond the original treatment plan of care, may receive extended treatment when the follow criteria are met:

1. A medical evaluation has been conducted within 30 days of the service dates; and
1. The appropriate MCG Home Care Optimal Recovery Guidelines with the Extended Visits criteria are met; or
2. The appropriate MCG Home Care General Recovery Guideline is reviewed and the member is still in General Treatment Course Stage 2 or has not met all of the milestones in Stage 3; or
2. For an extension request/recertification for hospice or palliative care, please see plan benefits and requirements. The member meets medical necessity when the member continues to meet criteria as listed under Clinical Indications above in criterion 4.

Experimental or Investigational / Not Medically Necessary

Skilled care, and thus home health aide services, should be discontinued when ONE of the following is present:

• Homebound status is no longer met; or
• The member reaches the predetermined goals or skilled treatment is no longer required; or
• The member has reached maximum rehabilitation potential; or
• The goals will not be met and there is no expectation of meeting them in reasonable time; or
• The member can safely and effectively continue their rehabilitation independently; or
• The member's medical condition prevents further need; or
• The member refuses treatment.

Home health aide services are NOT considered medically necessary for the following:

• The member does not meet the definition of homebound; or
• Skilled care is not medically necessary or is not provided for a specific illness or injury; or
• Chronic illness / chronic flare-ups or exacerbations that did not result in a decline in function or related to an acute exacerbation; or
• Home health aide services ordered solely for ADLs or IADL assistance; or
• Home health aide services for any of the following:
• Babysitting or childcare services
• Housekeeping, except for the member's immediate surrounding area
• Transportation
• Long-term maintenance therapy, as it is aimed to preserve the present level of function or preventing regression below an acceptable level of functioning; or
• Custodial care or Long-term care services, which may include:
• Personal Care Aides (PCAs) or Personal Care Workers (PCWs)
• If solely for long-term or non-skilled assistance with ADLs
• If solely for long-term or non-skilled assistance with IADLs
• Turning or positioning
• Application of skin creams or lotions
• Routine care for incontinence
• Routine administration of oral medications
• General maintenance of colostomy and ileostomy
• Routine indwelling bladder catheter care
• Routine supervision of exercises that have already been taught to the member or caregiver