Chapter VI.

Home Care: Information & Resources

Home care includes both 1) home health care which is primarily medical and health-related; and 2) personal care services or home-based care services which are essentially non-medical in nature. The term “home care” is used here to mean care and services provided to individuals in their own home or apartment, a family member’s home, or another community residence. The main purpose of home care is to provide enough support to people so that they can remain in their own homes and communities.

A. Home Health Care

Overview

Home health care is most typically “skilled care” provided under a doctor’s order through a home health agency. “Skilled care” is the level of care provided when an illness or an injury such as a hip fracture, requires nursing care or rehabilitation services after discharge from a hospital. Services are provided by licensed or certified professionals including nurses, physical therapists, occupational therapists, speech language pathologists, medical social workers, dietitians, and home health aides through a home health agency. Skilled care generally includes a full range of therapies and skilled nursing care. Examples of skilled nursing care are administration of intravenous medication, injections, tube feeding, oxygen to help you breathe, and changing sterile dressings on a wound.

Home health care is also usually a short-term service, although it can be ongoing under certain circumstances.

Regulation of Home Health Care Agencies

All home health agencies in Indiana must be licensed by the Indiana State Department of Health. To be licensed, the agency must comply with state regulations. To read these regulations, click here. Agencies that wish to receive funding from Medicare and/or Medicaid must also be "certified." To be certified, the agency must follow federal “conditions of participation” (standards). You can access these conditions of participation at www.access.gpo.gov/nara/cfr/waisidx_04/42cfr484_04.html/.

Client Rights

Consumers receiving care from a home health agency have rights required under both state and federal regulations.

To learn about state rights, click here.

To learn more about federal rights that apply to certified home health agencies, click here.

Listing of Home Health Agencies

The Indiana State Department of Health maintains a statewide directory of home health agencies.

Checklists and Guides For Choosing a Home Health Agency

Medicare and Home Health Care

Choosing a Home Health Agency

Choosing an Agency for In Home Care

CICOA's Guide For Shopping For Home Care

Comparing Different Home Health Care Agencies

A number of sources of information should be considered when comparing home health care agencies. These include inspection results (available through the Indiana State Department of Health), talking with your doctor, asking knowledgeable sources in the community, and asking people you know about their experience.

Home Health Agency Consumer Reports
www.in.gov/isdh/reports/QAMIS/acc/hharep

The Indiana State Department of Health developed this report to aid consumers in their choice of a home health agency. Consumers can evaluate and compare agencies in the following categories; available services, state and federal survey (inspection) results, substantiated complaints investigated by the Indiana State Department of Health, and ownership/administrator changes.

Home Health Compare
www.medicare.gov/HHCompare

This federal website offered through Medicare allows you to compare home health agencies in terms of “quality measures.” According to Medicare, the quality measures describe how well home health agencies provide care for some of their patients. The agencies provide information about patients’ physical and mental health and whether their ability to perform basic daily activities is maintained or improved.

Costs and Payments

Costs

In Indiana, a one hour visit from a licensed practical nurse costs approximately $55–$60, while a registered nurse for one hour costs approximately $75 (the actual amounts can vary widely throughout the state.)  The average cost of a home health aide provided through a licensed home health agency is $22 per hour provided.* The average cost for a homemaker/companion from an agency per hour is $19 (neither amount reflects what the aide actually receives). *

Payment

Home health care can by paid for by:

1. Medicare

Medicare will cover home health care expenses for your loved one only if the following conditions are met:

• Your loved one needs:

  
  

  • skilled nursing care on an “intermittent basis” (intermittent can range from every day to a period of 21 days—if there is a predictable end to the need for daily care, to as little as once every 60 days); or

  • physical, occupational or speech therapy.*

    
    

• A physician has signed or will sign a care plan for your loved one.
  

• Your loved one is “homebound.” Being homebound means that leaving home is a major effort and that your loved one is unable to leave without personal assistance or the help of a wheelchair, crutches, etc. If your loved one does leave home, it must be to get medical care, or for short, infrequent non-medical reasons such as a trip to get a haircut, or to attend religious services or adult day services.
  

• The home health agency caring for your loved one must be approved by the Medicare program.

*Source: Medicare Advocacy Center, www.medicareadvocacy.org/.

2. Medicaid

Medicaid is a health insurance program financed and run jointly by the federal and state governments for people who are 65 or older, blind or disabled and meet certain financial eligibility requirements. Medicaid is a state administered program, so guidelines and services vary by state. In Indiana, the program is operated by the Indiana Family and Social Services Administration.

3. CHOICE

CHOICE is Indiana’s state funded home care program. Any cost to the individual is based on a sliding fee scale—referred to as a "cost share". To qualify for CHOICE funding you must be limited in at least two activities of daily living. A person seeking services funded by the CHOICE program must also work with their local Area Agency on Aging (AAA). The process starts with an in-home assessment conducted by the AAA care manager from that person's local agency. Once a person is screened and their home care needs are determined, the AAA case manager works with the person and his or her family to design a care plan that is tailored to meet the person’s specific home care needs within the bounds of available funding. Care voluntarily provided by family members, friends, neighbors, and local service organizations is incorporated into the care plan in order to maintain their involvement and to control costs. People of any age may apply to enter the CHOICE program. For more information on CHOICE, click here.

4. Long Term Care Insurance

Long term care insurance policies cover long term care expenses once an individual has met a pre-defined set of qualifying criteria. Coverage will last for a certain number of years. Long term care insurance is not for everyone, and it is very important that consumers carefully evaluate the pros and cons and their own financial situation before purchasing a policy. One evaluation tool available to consumers is “The 2007 Self-Assessment Guide for Long Term Care Insurance,” which is produced by the Indiana Long Term Care Insurance Program. That guide, and "The Buyer's Guide to Long-Term Care Insurance," are useful resources for anyone looking into long term care insurance.

Check your insurance policy to see if home health care is covered. Not all policies include coverage of these services.

5. Veterans Aid and Attendance Benefit

The Aid and Attendance Pension Program provides financial assistance to a qualifying veteran, veteran and one dependent, or a surviving spouse. This benefit can cover care at home. To qualify, a veteran must be eligible for a VA pension, meet service requirements, meet certain disability requirements, and meet income and asset limitations. Aid and attendance is paid in addition to a veteran’s basic pension. It can take up to six months to process an application, so starting early is important. For more information, go to: www.veteranaid.org/.

6. Private Pay

Your loved one (or someone else) pays for the service out of their own pocket.

B. Personal Attendant Services

Overview

Personal attendant services (also referred to as "attendant care", "personal services" or "home-based care services") are services to help a person remain in their own home, and carry out functions of daily living and self care. These services are considered “non-medical,” that is, they do not need to be provided by a licensed health care professional. Instead the services are usually provided through arrangements with a home health care agency (home health aides, homemakers, and companions), personal services agency, or by hiring a private duty aide or personal services attendant (also called an "attendant" or "personal care attendant").

Examples of personal care attendant services include:

• Transporting and/or escorting a client to medical appointments.

• Help with bathing, oral hygiene, hair care, shaving, dressing, applying cosmetics, moving between bed and chair, meal planning, preparation and cleanup, toileting assistance, and other day-to-day activities.

Regulations of Personal Attendant Services

Personal services agencies that provide services to more than seven (7) people must be licensed by the State. You can access the state law governing personal services agencies by clicking here.

There are no state regulations for personal services agencies that provide services to fewer than seven (7) people at this time.

If services are furnished by an independent private duty aide or personal services attendant whom you or your loved one hires, there are no licensure requirements or regulations. However, if the services of an aide or personal services attendant are funded by the Medicaid Waiver or the CHOICE program, state law requires that the aide/personal services attendant must register with the Indiana Division of Aging by providing certain information including a resume, a limited criminal history check, and references.

Client Rights

Client rights for services provided through a personal services agency are spelled out in state law at IC 16-27-4-12.

Listing of Personal Services Agencies

The Indiana State Department of Health maintains a directory of all licensed personal services agencies in Indiana at www.in.gov/isdh/reports/QAMIS/acc/psadir/.

Costs and Payment

Costs

In Indiana, the average cost of a home health aide provided through a licensed home health agency is $22 per hour.* (Note: this is what it costs to the consumer, not what the aide actually receives.) The average cost for a homemaker/companion from an agency per hour is $19 (again, this is not what the homemaker receives).*

*Source: The MetLife Market Survey of Adult Day Services & Home Care Costs. September 2008.

Payment

Personal attendant services can be paid for through:

1. Medicaid Waiver

Federal law requires Medicaid to pay for long term care services only when they are delivered in a nursing home or other long term care facility. However, states may negotiate a "waiver" of that requirement in order to provide a full array of home and community based long term care services. To qualify for Medicaid Waiver services, a person must be eligible for Medicaid, and in need of the same level of care as those who qualify for Medicaid nursing home care. Eligibility for a Waiver is based on an in-home assessment done by a care manager from the local Area Agency on Aging, and then reviewed by a state Medicaid case manager.

There are a number of different kinds of waivers. The most common waiver for older adults is known as the Aged and Disabled Waiver. To access Medicaid Waiver services, you must work with your local Area Agency on Aging. For more information read this Consumer Waiver Guide.

2. CHOICE

CHOICE is Indiana’s state funded home care program. Any cost to the individual is based on a sliding fee scale—referred to as a "cost share." To qualify for CHOICE funding you must be limited in at least two activities of daily living. A person seeking services funded by the CHOICE program must also work with the local AAA. The process starts with an in-home assessment conducted by the AAA care manager from that person's local agency. Once a person is screened and their home care needs are determined, the AAA case manager works with the person and his or her family to design a care plan that is tailored to meet the person’s specific home care needs within the bounds of available funding. Care voluntarily provided by family members, friends, neighbors, and local service organizations is incorporated into the care plan in order to maintain their involvement and to control costs. People of any age may apply to enter the CHOICE program. For more information on CHOICE, click here.

3. Long Term Care Insurance (depending on policy)

Long term care insurance policies cover long term care expenses once an individual has met a pre-defined set of qualifying criteria. Coverage will last for a certain number of years. Long term care insurance is not for everyone, and it is very important that consumers carefully evaluate the pros and cons and their own financial situation before purchasing a policy. One evaluation tool available to consumers is “The 2007 Self-Assessment Guide for Long Term Care Insurance,” which is produced by the Indiana Long Term Care Insurance Program. That guide, and "The Buyer's Guide to Long-Term Care Insurance," are useful resources for anyone looking into long term care insurance.

Check your insurance policy to see if personal services are covered.

4. Veterans Aid and Attendance Benefit

The Aid and Attendance Pension Program provides financial assistance to a qualifying veteran, veteran and one dependent, or a surviving spouse. This benefit can cover care at home. To qualify, a veteran must be eligible for a VA pension; meet service requirements; meet certain disability requirements; and meet income and asset limitations. Aid and attendance is paid in addition to a veteran’s basic pension. It can take up to six months to process an application, so starting early is important. For more information, go to: www.veteranaid.org/.

5. Private Pay

Your loved one (or someone else) pays for the service out of their own pocket.

Using an Agency or Hiring a Caregiver?

The decision about which approach to take is very personal and depends on your loved one’s circumstances. Listed below are just a few benefits and drawbacks to consider. You can find more detailed information in the resources listed at the end of the Home Care section.

Agency

Advantages:

• You eliminate your responsibilities for most of the administrative tasks (hiring, training, paying, scheduling, etc.).

• The agency may be able to provide more services than you could obtain yourself.

Disadvantages:

• An agency is typically more expensive.

• You may have less flexibility in selecting and scheduling your worker(s).

Hiring privately

Advantages:

• You can pick the worker who is most compatible with you and your situation.

• You may have more flexibility in scheduling.

Disadvantages:

• You are responsible for hiring, training, and scheduling workers and finding replacements to cover illness and other time off.

• You are responsible for paying workers (unless you use a "fiscal intermediary”—an entity created by the state to take care of wages, payroll taxes, etc.).

• You may be liable for on-the-job injuries. 

Much of the material in this section is taken from, Help At Home, published by the Ohio Department of Aging.

Getting Good Care For A Loved One

The following are tips to help you get quality home care for a loved one (in no particular order):

1. Educate yourself. Learn what you have the right to expect!

Familiarize yourself with the regulations, your loved one’s rights as a patient/client, and your rights as a family member.

2. Share information about your loved one with home care staff.

The more staff know about your loved one, the better care they can provide to meet your loved one's needs. Make sure you tell them how your loved one likes care done, approaches that work, what distresses him or her, what calms him or her down, things he or she likes/dislikes, etc.

It’s a good idea to ask the home care team what information they need from you to help them care for your loved one.

3. Participate in the care planning process.

Care Planning

Care planning involves the development of a plan of care that describes the services, treatment, and care to be provided. Once a care plan is developed it is evaluated and revised periodically.

Care plan participation

Your loved one has the right to participate in the development of his or her care/service plan. If your loved one wishes, or if your loved one is unable to make health care decisions and you have the legal authority to do so, you can also participate.

Participation in the care planning process is very important because it shapes the care your loved one will receive and gives both you and your loved one a chance to ask questions and raise any issues.

4. Ask that the same caregivers be assigned to care for your loved one most of the time.

This is called consistent assignment and can improve your loved one's quality of care because the staff person gets to know well your loved one's needs and preferences.

5. Know what care your loved one is supposed to receive.

Getting a copy of the care/service plan will provide you with this information.

It is also a very good idea to know what medications your loved one is being given, the dose, and when it is supposed to be given. You should also ask why the medication is being given so you can know whether it is working.

6. Monitor your loved one’s care.

Once you know what services and treatments are to be given, you can oversee your loved one’s care to make sure the right care is given at the right time in the right way.

Monitoring includes:

• Observing your loved one, and if possible, periodically observing the care being provided.

• Talking with your loved one and staff about how things are going.

• Reviewing the records kept by the agency. Your loved one and you, if you have the legal authority or your loved one’s permission, have the right to look at the medical records. Ask the home health agency for its policy regarding accessing records. Look for:

  
  

  • Information about your loved one’s condition, progress, and status.

  • Any problems you are not aware of and what is being done about those problems.

  • Whether your loved one is getting the care and services outlined in the care plan.

7. Develop a positive working relationship with staff.

• Get to know staff.

The team member who often has the most personal and ongoing contact with a patient is the home health aide. Learning to speak and work effectively with that person and his/her supervisor is key to receiving the kind of care you desire for your loved one.

• Treat staff with respect.

• Show appreciation for good work! A "thank you" goes a long way.

8. Communicate effectively!!

• Find out the name of the person at the agency whom you should contact and the best time to do so when you have information to share or questions to ask. Usually the home care nurse is the main contact and the person to call should you question the type or quality of care being given.

• Establish a system of communicating with the nurses, aides and others who come into the home. Having a written communication log that remains in the home can be one effective method for assuring accurate, two-way transmission of information.

  
  

  • Consider a three-ring notebook that has a complete medical history of your loved one and can be used to record each doctor’s visit and medical procedures, such as blood tests and X-rays. Aides, nurses and other caregivers should record in the notebook all medical information, including symptoms and medication compliance. Make sure to add any information or forms that come from a medical appointment so you are sure to have all the information for your loved one in one place. This will help you answer questions from the doctor or other caregivers; provide continuity if a caregiver leaves; and make it easier to monitor care.

  • Tell home health staff about any changes in your loved one’s condition or medication.

  • Leave emergency contact information with your phone number(s) and that of another family member/friend.

  • State what you mean clearly, politely, respectfully and in language that is free of blame and judgment. Speak up nicely, if something isn't done, or if it isn’t done the right way. How you communicate is just as important as what you communicate.

  • Reinforce positives. Thank staff when a problem has been addressed or when good care has been provided.

9. Keep a journal.

Write down the names of people you contact or talk to; phone numbers; dates; and information you have obtained.

Make notes about:

• Your loved one’s condition and appearance.

• Any change in your loved one’s condition or incidents involving him or her.

• Answers to any questions you’ve asked staff.

• Any problems. Write down when the problem occurred, the people involved, what happened, where it happened, and indicate what staff said they would do about the problem. Include staff names if you know them.

10. Take action when there is a problem!

The sooner you address a concern, the better – problems that go unaddressed can build up over time and can become more difficult to resolve. Don’t be afraid to ask questions or voice concerns with the supervisor if you feel your loved one’s care needs are not being met.

Some of the material in this section has been adapted from Becoming An Effective Advocate for Care, published by the MetLife Mature Market Institute, in cooperation with the National Alliance for Caregiving.

Addressing Problems

Listed below are some approaches that you can take to address a problem with the care and services provided by a home health care agency or personal services agency. (These steps do not have to be followed in this order.)

Before trying to resolve a problem, check with your loved one—if possible, to make sure he or she wants action to be taken. In addition, try to involve your loved one as much as you can in problem resolution.

Working with the home health or personal services agency to resolve the problem

If at all possible, it is best to try to resolve any concern by working directly with agency staff. A home health agency or personal services agency is required to investigate any complaint made by the individual receiving services or by their family or representative. The agency must also document the complaint and the resolution of the complaint.

You can raise your concerns in a number of different ways.

1. Speak with staff.

Start by discussing the problem with the staff that are most directly involved to see if the problem can be corrected.

If that doesn’t work, go up the “chain of command” if necessary. Go to the:

• Supervisor.

• Home health agency administrator or personal services agency manager.

• Regional manager if the agency is part of a corporation.

• CEO if the agency is part of a corporation.

2. Put your complaint in writing and request a written response.

3. Raise your concerns the next time your care/service plan is reviewed. 

4. Request a special meeting to discuss your concern. When you voice your concerns it may help if you:

• Make sure you have details about the concern, such as the nature of the problem, when it occurs/occurred, and names of people involved.

• Report concerns and problems to staff as soon as they arise.

• Clearly state your concerns and the outcome you would like; state what you mean clearly, politely, respectfully and in language that is free of blame and judgment.

• Document your conversations with staff about the problem. Make copies of anything you submit in writing. Keep any letters you receive.

For guidance on communicating with and presenting a problem to staff, see:

• Guidelines for Presenting the Problem

• Coaching-based Communication

Seeking help outside the home health/personal services agency

If one or a combination of the approaches listed above does not resolve the problem, there are organizations, agencies and programs you can turn to for help outside the agency. (Note: these are not listed in any particular order.)

1. Consult a private geriatric care manager or your loved one’s CHOICE or Medicaid Waiver care manager.

Care managers can help resolve problems. A private geriatric care manager is usually either a nurse or a social worker and brings knowledge and expertise to the problem. Geriatric care managers charge a fee for their services and most will also bill for out-of-pocket expenses (mileage, long-distance calls, etc.). To learn more about private geriatric care managers and get a list of geriatric care managers in Indiana go to: caremanager.findlocation.com/.

If your services are funded through the Medicaid Waiver or CHOICE programs, you can ask your care manager to help solve the problem. The care manager can work with you and the agency to reach a solution.

2. File a complaint with the Indiana State Department Of Health.

The Indiana State Department of Health (ISDH) investigates all complaints about care or treatment provided (or not provided) by a home health agency or personal services agency.

When filing a complaint make sure to include the following information:

• Name of agency and city where it is located

• Date(s) the problem occurs/occurred or at least the time period involved

• The time of day the problem occurs/occurred or is most prevalent

• Names, and if possible, the job positions of the individuals involved

• Specifics of the problem, including examples of the problem you are reporting

You can file a complaint by writing, phone, email or by internet.

Indiana State Department of Health

Division of Acute Care

2 North Meridian Street, 4A

Indianapolis, IN 46204

800-227-6334

www.in.gov/isdh/20111.htm

complaints@isdh.in.gov

If you file a complaint by phone, you should follow up the call with a written letter that includes the details you described on the phone and requests that your letter be added to the complaint file.

If you want to learn what the results of the investigation are, you will need to provide your name and contact information to ISDH. ISDH does not reveal the name of the person filing the complaint to the agency. However, you can certainly file a complaint anonymously if you are not comfortable giving your name.

3. File a complaint with the Indiana Division of Aging.

If your services are funded through the Medicaid Waiver or CHOICE programs and working with the AAA or other care manager has not resolved the problem, contact the Division of Aging to report the problem.

Division of Aging

402 W. Washington Street

P.O. Box 7083, MS21

Indianapolis, IN 46207-7083

317-232-7132 or 800-545-7763, ext. 2-7132
www.in.gov/fssa/2329.htm

4. File a complaint with Health Care Excel.

Health Care Excel (HCE) is the Medicare Quality Improvement Organization for Indiana. Its job is to improve the quality of health care in Indiana. As part of this job, Health Care Excel is required to review care if a complaint is filed by a Medicare beneficiary regarding a Medicare-certified home health agency. HCE will review your medical records to determine if your care met professional standards.

When you file a complaint, you will be asked to provide information by phone and submit a letter about your concerns. Because HCE requests a copy of your medical record from the home health agency as part of its review process, you cannot remain anonymous.

Health Care Excel, Inc.
2901 Ohio Boulevard, Suite 112
Terre Haute, IN 47803
1-800-288-1499
www.hce.org/QIO/Indiana_Medicare/INQIO.html

Other Resources For Complaint Resolution

Adult Protective Services (APS)

Adult Protective Services investigators investigate reports of abuse, neglect or exploitation of endangered adults 18 years or older. If you do not know the address of your local APS investigator, you can contact the state office.

Adult Protective Services

Indiana Division of Aging

402 West Washington Street

P.O. Box 7083 MS 21

Indianapolis, IN 46207-7083

317-232-0135 or 1-800-992-6978
www.in.gov/fssa/da/3479.htm

Law Enforcement Agencies

Should you believe that your loved one has been the victim of a crime related to home health agency/personal services agency staff or a caregiver you have hired, contact a local law enforcement agency immediately.

Licensing Boards

There are a variety of boards that license health professionals such as nurses and physical therapists. These boards, under the auspices of the Office of the Indiana Attorney General, Consumer Protection Division, also investigate complaints filed against these health care professionals. To file a complaint, you must complete a complaint form. To get a copy of the form, call 800-382-5516 or 317-232-6330 or go to:

www.in.gov/attorneygeneral/consumer/onlineform.html/.

The form must be submitted to:

Consumer Protection Division

Office of the Indiana Attorney General

302 W. Washington St., 5th Floor

Indianapolis, IN 46204

Legal Assistance

Law firms

Private attorneys can often help resolve or assist you in seeking compensation and justice when your loved one has been harmed by a home health agency or personal services agency. It is important to get help from an attorney who is knowledgeable about home care laws and who is familiar with issues involving home care.

“Elder law” attorneys may be of particular assistance in resolving a concern since they focus their practice on issues frequently confronted by older adults and their families. In Indiana, certain attorneys have been certified as specialists in Elder Law. To locate an elder law attorney in your area, go to: www.naela.org/MemberDirectory/.

Indiana Legal Services, Inc.

Indiana Legal Services provides free assistance to those who meet certain financial criteria. For more information and to locate an office, go to:

www.indianajustice.org/Home/PublicWeb/LegalSvcs/.

Appeals Process: For CHOICE/Medicaid Waiver Clients Only

If your concern is related to a decision about services, there is an appeal process you can use to challenge the decision. Decisions that can be appealed include: your loved one being found ineligible for services, having services denied to your loved one, having services discontinued, or having services provided to your loved one that are not in his or her best interests. To learn more about appealing a decision about CHOICE in Marion and the 7 surrounding counties, see “Appeal Process for Client Services.” If your loved one lives outside of that area, contact his or her local AAA (see Chapter IV). For information about how to appeal a Medicaid Waiver decision, read “Your Appeal Right as an Applicant for HCBS Benefits.”

Additional Resources

Medicare and Home Health Care

Center for Medicare Advocacy: Home Health Care

Hiring in-home help

Hiring an Independent Caregiver