This document provides an overview of the services provided by skilled home care agencies, including nursing, physical therapy, occupational therapy, speech therapy, and social work. It describes the clinical assessments, treatment planning, provision of care, education, health monitoring, and follow-up activities conducted by each discipline. The document also outlines the goals of restoring and maintaining a patient's health and independence at home. Finally, it discusses the licensing and standards of home care agencies and ways to provide quality oversight of their services.

1. Presentation by
Graciela Lange
Copyright March 2011

2. Skilled Home Care: In home services
provided by qualified personnel:
• Nursing
• Physical therapy
• Occupational therapy
• Speech therapy
• Social work

3. What do these disciplines provide?
• Clinical assessment
• Treatment planning
• Treatment provision
• Patient and/or family education
• Health status monitoring
• Reassessment, referral, and follow-up

4. Home care agencies will not accept
• Patients unwilling to participate in home plan
of care (non compliant or refuse care).
• Patients without an address or phone number
• Patients w/ hx active drug use - violence
• Patients whose scope of care exceeds what
VNS can safely provide and support.

5. Nursing
• Medication management
• Disease management (symptom management
etc.)
• Access line care e.g. PICC
• Patient/caregiver education related to disease
process
• Wound care
• Labs related to referral diagnosis

6. Occupational Therapist
• Functional assessment ADLs and iADLs
• Evaluation for adaptive equipment
• Evaluation for home safety modification
• Patient/caregiver teaching related to
equipment etc.

7. Physical Therapist
• Strengthening- conditioning
• Range of motion
• Gait-mobility training (balance, transfers)
• Evaluation of assistive mobility aids
• Home safety evaluation
• In-home rehab

8. Speech Therapist
• Cognitive evaluation
• Speech rehab
• Dysphagia evaluation

9. Medical Social Worker
• Patient-caregiver support
• Assist w/ fiscal – community resources
• Stress management
• Grief support
• Long range care planning

10. Goal:
• To support in restoring, improving their health
status and maintaining their independence

11. Home Care Agencies
• Provide short term intermittent skilled care
• Individual disciplines (not interdisciplinary
• RN or PT or ST is identified case manager
• OT and MSW can’t open a referral
– Agencies are state-licensed or
– CMS-certified for the level of care provided (SHC,
H/HHA),
– Must be in good standing with the state.

12. Home Care Agencies
• Agencies have catchment areas
• Not all agencies offer same disciplines e.g.
speech
• Not all agencies offer same services e.g.
Wound care specialist or falls prevention
program

13. • Some agencies have better outcomes with
specific skilled needs (Refer to OASIS Medicare
data – Medicare website (compare home health
agencies)
• Some agencies provide earlier start of care dates
• Not all offer weekend home visits for routine care
• Patient preference should be considered when
selecting the home care agency

14. Quality Oversight – Monitoring
• Service quality complaints should be reviewed
by referring agency –hospital.
• Create process for customer feedback
• Report suspected neglect- abuse involving
caregiver, family etc. (mandated reporting)
• Sustain and cultivate partnerships with home
care agencies - staff

15. Questions?
- Thank You
Graciela Lange | Presentation © 2011