HOW DOES A PATIENT QUALIFY FOR HOME CARE?
The patient is homebound.
- Normal inability to leave home: leaving home would require a considerable and taxing effort.
- Absences from the home are infrequent or for periods of relatively short duration, i.e., to receive medical treatment; it is medically unsafe for the patient to leave their home.
- Restricted ability to leave place of residence must be evaluated on an individual basis but may include:
- the aid of supportive devices
- the use of special equipment
- the assistance of another person
- if leaving home is medically contraindicated
- Member lacks transportation.
- Member chooses not to leave home because it is inconvenient.
- Member drives to the store regularly.
- Member is able to leave home without significant effort.
- Member is instructed not to drive but can ride in a car.
Services are intermittent/part-time.
- To meet the requirement for "intermittent/part-time", an individual must have a medically predictable recurring need for skilled services. Daily visits (7 days a week) must be temporary, and in most instances, home care is considered short-term.
- In most instances, this definition will be met if a patient requires skilled service at least once every 60 days.
- Member is not currently a Home Health patient, yet needs lab draw, flu shot, house call, etc.
- Kaiser Health Plan benefits for Home Health services does not include providing long term or life time care.
The patient requires skilled care.
What is skilled care?
- A skilled service must be provided by a registered or licensed professional to be safe and effective. This may be due to the inherent complexity of the service, the condition of the patient or accepted standards of medical and nursing practice.
- Member needs a Home Health Aide yet does not need any higher level of care.
- Member needs respite.
- Member needs assistance with long-term planning but has no nursing needs.
- Member requiring a lab draw only does not qualify for skilled nursing visits.
Skilled services are medically reasonable and necessary.
Examples of reasonable and necessary:
- The skilled care shall be reasonable and necessary to the treatment of the beneficiary's illness or injury.
- When Home Health skilled services, as interventions, are necessary to, and contribute to a patient's progessing, then these services are considered reasonable and necessary.
Not reasonable and necessary examples:
- Member needs custodial care for range of motion.
- A member who shows "no progress", or is not compliant is an example of someone who is not able to benefit from skilled intervention.
Home Care is ordered by the doctor.
The patient must be under care of a Kaiser physician and Home Care must be ordered by the MD. Referrals must be complete.
* Diverted Services *
There are incidences when a patient requires services, which at the time of referral, may not be readily available, such as if the Case managers have full caseloads. At these times, Kaiser Home Health may divert the Member to a Community-Based Home Health Agency so that the Member's needs will be met.
For more information about Home Health Care, please call (510) 752-6295.
If you think you have a MEDICAL OR PSYCHIATRIC EMERGENCY, CALL 911 IMMEDIATELY or go to the nearest hospital. DO NOT attempt to access emergency care through this web site. An emergency medical condition is a medical or psychiatric condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that you could reasonably expect the absence of immediate medical attention to result in any of the following: serious jeopardy to your health, serious impairment to your bodily functions, or serious dysfunction of any bodily organ or part. An emergency medical condition is also "active labor," which means a labor when there is inadequate time for safe transfer to a Plan hospital (or designated hospital) before delivery or if a transfer poses a threat to the health of the member or unborn child.
This site may contain links to other web sites outside of www.permanente.net. Kaiser Permanente has no control over the content or the availability of these sites, and is not responsible for the privacy practices or the content of such Web sites. Web links are provided as an educational tool, and should not be relied upon for personal diagnosis or treatment. A link or reference to a web site should not be construed as an endorsement of the site or its contents. Any medical content that you feel may be important to your health should always be discussed with your Kaiser Permanente physician.