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Introduction   

The global population is living longer due to the advancements in healthcare and technology. According to the World Health Organization (WHO), by 2050, there are estimated to be 2.1 billion people over 60 (2). These additional years come with potentially poor health and disability, thereby increasing healthcare expenses.  

Statistics show that 5% of emergency department patients account for 30 to 50% of emergency department visits, and these patients are often unsuccessful at meeting their own healthcare needs (1). Emergency department visits are often due to ineffective, overutilization or underutilization, and uncoordinated effective health care and social services. This has driven the increased interest in home care management and advocacy.  

Home care is a cost-effective means of care management that meets the needs of elderly adults who want to remain in their homes (3). Aging individuals experience challenges in self-care, including comorbidity, frailty, and functional decline. The physical challenges that come with aging can also lead to an increased risk of mental health difficulties such as depression or anxiety (3). In addition to elderly patients, home care also focuses on the needs and care of premature babies, children with chronic illnesses, and adults with multiple, chronic, and degenerative diseases.   

As you work through the section questions, I hope you will be able to recall patients you have cared for within home care or patients you have referred to home care. You may have personal experience with homecare with a family member or loved one. Regardless, I hope you better understand case management in home care and the importance of advocacy for those in home care. 

Case Management  

It is meaningful first to define case management, and then examine how it applies to and is essential in home care. Because it is integrated with other terms, such as care management, care coordination, and disease management, case management can have many overlapping definitions and identities.  

Next, we will examine each term’s definition.  

Case management – is a healthcare process in which healthcare professionals assist a patient and family in developing a plan with accessible support services. They help optimize and coordinate the patient’s healthcare goals and outcomes. Case managers help patients, and their family members navigate through the complex healthcare system for services and support that are available to them either in the community, organization, or institution. Case management tends to be more disease centered.  

Care management – is frequently used in the payer context and is considered an umbrella term to describe a program. It has become a primary means of managing the health of a defined population. The program comprises a broad set of activities and tasks that include the healthcare-related aspects of case management but also extends to a wide array of services, supports, benefits, healthy lifestyle programs, recreational activities, and social enrichment programs within a benefit plan (1). According to the Agency for Healthcare Research and Quality, care management is a team-based, patient-centered approach to care. It assists patients and their support systems in managing their medical conditions more effectively while encompassing a patient-specific program to reduce health risks and decrease the cost of care (4).  

Care coordination – includes the activities and tasks also covered in case management but are seen in a broader aspect of and associated with population health. It is typically a way for an organization or institution to implement population health strategies to manage the specific needs of a population. They often look at different sub-groups within a population to decide who should receive case management services. (1) 

Disease management – is a more specific form of case management. It is directed at patients who share a common diagnosis or condition. For example, patients with arthritis or patients after joint replacement surgery may be offered a distinct and/or specific disease management program for a certain time. In this regard, case managers can be described as service brokers, service coordinators, or system navigators. 

Role of Case Manager in Home Care 

Case Managers can be used by insurers/payers, hospitals, health systems, physician practices, and community healthcare organizations (1). They can also work in various settings, from hospitals to home health services in patient homes.  

For this learning module, we will be taking a closer look at their involvement and role in homecare. Case managers can be used for a broad population with various chronic conditions or a specific disease or disability, such as patients with brain injury (1).  

Case managers follow patients from the beginning to the end, meaning they identify proper patients and follow them through the assessment and care planning steps. They also continue to be involved by monitoring the care described in the care plan and assisting the patient in achieving the specified outcomes in a measurable time frame. The key to case management is the planning of care, which results in a care plan that essentially is the roadmap for a given patient to navigate through to manage their disease (1).  

Because case management is a broad term encompassing many different activities and tasks in health care, there are many different perspectives on what exactly case management is. Case management can include several different components.  

These core elements are not an all-inclusive list and may include other activities and duties (1).  

• Patient identification and eligibility determination (1) 

• • Identifying patients who are not receiving case management services 

• • Building a rapport with the patient.  

• Assessment (1) 

• • Developing a detailed and comprehensive understanding of the patient, including: 

• • • Health needs  

• • • Social needs 

• • • Capabilities  

• • Access to resources  

• Care planning and goal setting (1) 

• • A care plan that includes achievable patient-centered goals 

• • Tasks and actions to achieve established goals 

• • Access to services and support needed to achieve stated goals 

• • Help to guide patients to services and support while helping them overcome barriers (unexpected or expected)  

• Plan implementation (1) 

• • Care plan in action and includes different healthcare providers, settings, organizations, or institutions 

• • The patient should remain at the center and focus on various tasks and activities 

• Plan monitoring (1) 

• • Occurs throughout the entire process 

• • Reviewing ongoing feedback and conducting follow-up as necessary 

• • Evaluation of current goals and outcomes throughout  

• • Provide education and understanding of relevant health information 

• • Provide encouragement and emotional support  

• • Advocate and empower the patient to pursue services and support beneficial to their circumstance  

• • This also includes paperwork, report writing, data gathering, and analysis 

• Transition and discharge (1) 

• • Transition refers to the patient moving through the healthcare system depending on their need of services (moved home, transferred to different facility) 

• • Discharge is when the closure has been met, and there is no longer a need or gap in service.  

Speaking to the patient about their needs and why the doctor ordered home care services (7). Discuss with the patient and caregivers what services the doctor ordered. Ask questions related to the patient’s health.  

Develop a plan of care that outlines what kinds of services and care the patient should receive based on their current health condition. The care plan needs to be reviewed at least once every 60 days.  

The plan of care should include (7): 

• What services are being provided and how they will be provided 

• Which healthcare professionals are providing the specified services  

• How often the patient will need services  

• The visit schedule  

•  Needed medical equipment  

• Expect results from treatment (goals)  

• Any services provided over the phone or via video 

Teach the patient and or caregiver as appropriate in the ongoing care that may be needed. This can include wound care, therapy, or disease management to help in recovery or assist the patient to stay in their home. To ensure proper education is being provided to patients, they should be able to, for example, learn to recognize problems like infection or shortness of breath and know what to do or who to contact if they happen. Please speak with the doctor or healthcare provider and update them on the current plan of care as well as the progress of the patient.  

Advocacy in Home Healthcare  

Advocacy is a concept that has been widely acknowledged in all healthcare professions. Advocacy in homecare means speaking up for a patient or family when they have difficulties speaking up for themselves or are concerned that they are not being heard.  

This can include: 

• Helping ensure patients and families are heard 

• Ensuring wishes and preferences are taken into consideration 

• Patient rights and needs are met 

A case manager advocates for a patient or their family by helping them with their social and medical needs and making the right decisions with the options available to them. They help patients and caregivers find services and make sure patients are followed up with their healthcare providers. They help to protect the patient’s rights and play a critical role in patient safety. They are there to represent the patient’s interests and support them when needed.  

Improving Access to Healthcare  

Let us take a deeper dive into the current issue of adequate access to healthcare and how case managers can improve this through advocacy. Access to healthcare is still a significant problem within all healthcare systems worldwide. According to the World Health Organization (WHO), at least half the global population cannot obtain essential healthcare services due to poor access. Organizations, institutions, and communities use case managers to help patients locate and manage health resources and enhance communication between patients and their families within the healthcare system.  

Access to healthcare is defined as reaching a healthcare service/provider/institution to obtain appropriate services concerning their current level of care. It includes three distinct pieces: 

1. Patients have to be able to obtain services within a healthcare system  
2. Patients have to be able to locate proper healthcare services 
3. Patients have to be able to communicate with their healthcare providers 

Case managers utilize five interventions to improve access to healthcare regardless of the setting they are working in (5).  

• Bridging health systems in the community (5) 

• • Case managers are responsible for interpreting information from healthcare systems to patients and vice versa. Often, when working in home healthcare, especially, case managers are the only healthcare professionals in contact with a patient. It is essential to develop trust so treatment and care can be delivered, which will help decrease delays in these already vulnerable populations. To help establish this trust, case managers need to have strong collaboration skills with other healthcare professionals, institutions, and organizations.   

• Providing the care plan (5) 

• • Case managers need to develop a plan of care specific to each patient to meet their healthcare needs. This plan should include other family members or support people. It includes assessment, problem analysis, planning, implementation, and evaluation. 

• Delivering individually tailored health promotion and prevention (5) 

• • Case managers provide personalized health promotion and disease prevention strategies within care management. This includes education on managing medical equipment, medications, and disease processes. They also need to educate patients on preventative care to help empower them to be aware of their lifestyle and how it can affect their health. The goal is to improve their understanding of health and change their health-seeking behaviors.  

• Assisting in decision-making (5) 

• • Studies have shown that patients with access to a case manager communicate better with healthcare professionals and can better participate in their healthcare process. This includes improving their health and well-being while understanding the many different avenues of the healthcare system. Case managers should be articulate leaders who possess mediation skills when assisting in decision-making.  

• Providing holistic support (5) 

• • Case managers provide holistic support to patients and families through their healthcare knowledge and psychological support. It is important to show caring behaviors and be aware of any cultural or environmental barriers that might inhibit a patient from meeting their optimal level of health.  

Home Healthcare  

Now, let us take a look at what defines home healthcare. Many healthcare treatments offered only in a hospital, doctor’s office, or skilled nursing facility can now be done in the home. Many different types of services are available to help meet the needs of an older person living at home.  

Home healthcare is a wide range of services given in the patient’s home for illness or injury. Homecare services are available to help with all aspects of care; we will take a closer look at specific services. In home care, case managers assist with surgery recovery, accident, illness, or management of chronic conditions or disabilities. Home care is typically considered less expensive, more convenient, and just as effective as the care one would receive in a hospital or skilled nursing facility (SNF).  

Example of Home Health Services: 

• Wound care (pressure ulcers or surgical) 

• Patient and caregiver education  

• Intravenous or nutrition therapy  

• Injections 

• Monitoring serious illness and unstable health status  

• Physical therapy  

• Occupational therapy  

• Speech-language pathology services  

• Blood pressure readings 

• Range of motion exercises 

• Medical social services  

• Health aides (activities of daily living) 

• Durable medical equipment  

• Medical supplies for use in the home  

(6) 

Goals of Home Healthcare  

The main goal of home healthcare is to treat an illness or injury. Home healthcare can also help with: 

• Recover 

• Regain independence  

• Become more self-sufficient  

• Maintain current condition or level of function  

• Slow decline  

Coverage of Home Health Services  

Since most changes in insurance happen with Medicare, and a large majority of the patients seen in homecare have Medicare, we will focus on the current Medicare insurance requirements. Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) cover eligible health services as long as the patient needs part-time or intermittent skilled services and is considered to be “homebound.” 

Let us take a look at what classifies a person as being homebound.  

Homebound Status  

• Trouble leaving the home without help 

• • Using a cane, wheelchair, walker or crutches  

• • Need assistance from another person  

• • Need special transportation  

• • Due to illness or injury  

• Leaving the home is not recommended due to the condition  

• Unable to leave home because it takes a significant effort  

(6) 

Covered Home Health Services  

Medicare covers services if they are reasonable and necessary for treating the patient’s illness or injury. Medicare also covers skilled nursing and therapy services when the healthcare provider determines that the care the patient needs requires the specialized judgment, knowledge, and skills of a nurse or therapist (7).  

• Medically necessary part-time or intermittent skilled nursing care 

• • Requires the skill of a nurse (RN or LPN) 

• • • If an LPN gives care, an RN will supervise care  

• • Gives direct care and teaches caregivers about the care  

• • Manage, observe, and evaluate care 

• • Examples of care: 

• • • IV drugs  

• • • Injections 

• • • Tube feedings 

• • • Changing dressings  

• • • Teaching about prescription drugs  

• • • Teaching about chronic disease (diabetes, congestive heart failure, COPD) 

• Physical therapy 

• • Therapy to restore or improve functions affected by your illness or injury 

• Occupational therapy 

• • Therapy to restore or improve functions affected by your illness or injury 

• Speech-language pathology services 

• • Therapy to restore or improve functions affected by your illness or injury 

• Medical social services 

• • Assist with social or emotional concerns that may interfere with treatment or recovery  

• • Counseling  

• • Assist with finding community resources  

• • Also, they have to be receiving skilled care (nursing, physical therapy, speech-language pathology, or occupational therapy) 

• Part-time or intermittent home health aide care (only if you are also getting skilled nursing care at the same time) 

• • Have also to be receiving skilled care (nursing, physical therapy, speech-language pathology, or occupational therapy) 

• Injectable osteoporosis drugs for women 

• Durable medical equipment 

• • Must meet certain criteria  

• • Must be ordered by a doctor 

• • Medicare pays 80%  

• • Wheelchair, walker 

• Medical supplies for use at home 

• • Wound dressings  

Home Healthcare case managers must perform an initial assessment of all care needs and communicate those needs with the doctors or healthcare providers responsible for signing the plan of care (7). They are also responsible for routinely assessing the patient’s needs and adjusting the care plan. The case manager is responsible for making sure all the patient’s needs are met (medical, nursing, rehabilitative, social, and discharge planning) and are outlined in the plan of care (7).  

A doctor or nurse practitioner must visit the patient face-to-face before verifying that they need homecare services. The doctor or other healthcare provider also needs to write an order for homecare services and specify what services are needed (6). For Medicare, a Medicare-certified home health agency must provide the care.  

Some might wonder what “part-time or intermittent” care means. This means the patient can receive care and home health aide services for up to 8 hours a day with a maximum of 28 hours per week (6). Care must be less than seven days a week and up to 21 days. It can be extended to the 3-week limit or more frequent for a short period if a doctor or other healthcare provider deems it necessary (6). 

Medicare does not cover the following: 

• 24-hour-a-day care at home  

• Meals delivered to the home  

• Homemaker services (shopping, cleaning, laundry, etc.) that are not related to the established care plan by the case manager  

• Custodial or personal care that helps with daily living activities (bathing, dressing, or using the bathroom) when this is considered to be the only care the patient needs 

Patients are not eligible for home healthcare benefits if they need more than “part-time, intermittent” skilled nursing care. If the patient needs full-time skilled care over an extended period, they will not qualify for benefits (7).  

The patient is permitted to leave the home for medical treatment or short, infrequent trips for non-medical reasons: 

• Attending religious services 

• Barber or salon 

• Walk around the block 

• Attend a family reunion, funeral, graduation, or other infrequent or unique event  

Patients who attend adult day care are still eligible for home healthcare services.  

Costs in Original Medicare (6)  

• $0 for covered home healthcare service  

• After the patient meets the Part B deductible, 20% of the Medicare-approved amount for Medicare-covered medical equipment  

“Advanced Beneficiary Notice of Noncoverage” (ABN) 

Before starting services in the home, case managers must provide a notice to the patient called the Advance Beneficiary Notice (ABN) before providing services and supplies that Medicare does not cover for any of these reasons (7): 

• Care is not medically reasonable and necessary  

• Care is only nonskilled personal care (bathing, dressing, laundry) 

• The patient is not homebound 

• The patient does not need skilled care on an intermittent basis  

The ABN outlines the services or supplies not covered and why Medicare will not pay. It also gives detailed instructions on how the patient receives an official decision from Medicare about payment and supplies and how to file an appeal for what is not covered (7).  

“Home Health Change of Care Notice” (HHCCN) 

The case manager must give HHCCN before stopping or reducing any services or supplies provided to the patient in their home. Anytime the care plan is changed by the case manager, the patient must be notified in writing.  

Examples: 

• If a case manager reduces or stops giving some or all the home health services or supplies due to a business decision based on the organization, they are associated with  

• The doctor or healthcare provider has changed or has not renewed orders (signed current plan of care) 

If a patient receives services from a home health agency in Florida, Illinois, Massachusetts, Michigan, or Texas, they may be affected by a Medicare demonstration program. Under this demonstration, the home health agency or patient may submit a request for a pre-claim review of coverage for home health services to Medicare. This helps the patient and the home health agency know earlier if Medicare will likely cover the services. Medicare will review the information and cover the services if the services are medically necessary and meet Medicare requirements. 

Who’s Eligible  

If the patient has Medicare, they can receive home health benefits if:  

• They are under the care of a doctor or other health care provider (including a nurse practitioner, a clinical nurse specialist, and a physician assistant) 

• They receive it as part of a care plan your doctor or provider has established and reviews regularly.  

• The doctor or allowed provider certifies that the patient needs one or more of these: 

• Intermittent skilled nursing care (other than drawing blood)  

• Physical therapy 

• Speech-language pathology services  

• Continued occupational therapy 

• Home health aide services 

Medicare pays for the patient’s home health care services during 30 days of care. The patient can have more than one 30-day period of care. Payment for each 30-day period is based on the patient’s condition and care needs established by the case manager. Home healthcare agencies that are Medicare-certified are paid by Medicare and accept only the amount Medicare approves for services.  

Providing Patient and Family Education  

A significant part of being a case manager for homecare is setting up patients and caregivers for success by building independence and confidence through education. Since caregivers are not with patients 24/7, detailed education is pivotal. Often, teaching care requires a 3-day session or longer to set the patient up for success and ensure the education has been received. Education and teaching involved the utilization of the teach-back method to verify understanding. 

Case managers are often involved in a patient’s care until education has been provided, and the patient or caregiver understands. The extent of the education and teaching will vary according to the patient’s specific needs. For example, a patient requiring wound care may need 3-4 education sessions a week for several weeks. A patient with an infection treated with antibiotics may need one visit a week for 2-3 weeks for education.  

Case Study: Chronic Health Conditions  

Background/Referral 

Virginia was an eighty-five-year-old frail woman with multiple chronic health conditions, including one who was recently admitted for congestive heart failure. Virginia was recently hospitalized, and instead of going to a nursing home or rehab center, Virginia expressed a strong preference to stay at home. Virginia has a granddaughter who lives nearby and is very involved in health care. She requested homecare services for education and help in managing her diseases as well as her medications.  

Social History/Demographics 

An 85-year-old widowed woman who lives alone with her granddaughter nearby. She is a retired seamstress whose husband died 1.5 years ago. She has become less active and rarely gets out of the house. She does not do any cooking as it is only herself, and she mostly eats soup from a can, or frozen meals heated up. She has three grown children and six grandchildren, one of whom lives in the state and nearby. 

History 

• Type II diabetes 

• Myocardial infarction  

• Hypertension  

• Chronic systolic heart failure  

• Chronic obstructive pulmonary disease  

Summary of Inpatient Admission 

Virginia recently presented to the emergency room via ambulance with complaints of weakness, fatigue, decreased tolerance to activity, shortness of breath with exertion, weight gain, and a productive cough with blood-tinged sputum. A furosemide IV was administered to address the fluid volume access. Approximately 4500mL of fluid was removed before discharge, and the patient was discharged at 125 pounds.  

Diagnosis 

Exacerbation of congestive heart failure secondary to coronary artery disease  

Ejection Fraction 40%  

Home Assessment 

The patient lives alone in a clean but cluttered house. She states she avoids cooking because it is only her. Take-out food containers are noted on the table and trash can. Medication bottles are all over the house; some are expired, and some are discontinued. She says she takes her medications as prescribed but admits to sometimes forgetting.  

Patient Response 

The patient states she misses her husband and does not often see her children or other grandchildren because they all live out of state. She mostly eats ready-to-eat meals because they are easy to prepare, and her husband used to do all of the grocery shopping. She states she has been less active since he passed away and feels more depressed. Reports that she does not weigh herself often and cannot read the numbers on the scale due to vision problems. 

Care Plan 

• Dietary to teach about what and how to eat  

• • Education on meal shopping and preparing meals 

• Therapy for Depression  

• Physical therapy to increase activity  

• Ensure follow-up with medical providers  

• Education on medication 

• Education on daily weight and weight management  

• Education on signs and symptoms of pulmonary edema and heart failure  

Outcomes 

• Teaching on diet, exercise, taking medications on time as prescribed, and monitoring lung sounds, weights, intake, and output.  

• Advocacy to medical providers and follow-up reports to granddaughter to ensure proper care and monitoring.  

Conclusion

Patients often leave the hospital and return home, going from a highly supportive medical environment to a non-medical environment with potentially no support or caregivers. Patients often need help understanding their medical diagnoses, medications, navigation of the healthcare system, and information given to them by multiple medical professionals.  

Healthcare providers often need an understanding of a patient’s home environment and capabilities, leaving them to have increased hospitalizations and healthcare costs. This is why home healthcare case managers are so important. Their role is crucial in helping patients maintain independence in their homes. This is most often done through education and advocacy.  

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