Whose Patient Is It? The Case for Medical Direction in Home Care

December 2001

By: Edward Ratner, MD

Home health care is unique among health care services because it is the only type in which seeing a physician is not a prerequisite to the receipt of other services.

Even among home care patients who have had recent medical care, ongoing care can be uncertain. A recent study by the Office of Inspector General of the Department of Health and Human Services found that as many as 40% of patients receiving Medicare-funded home care did not see a physician in the three months after admission. These are, by definition, homebound sick people with new diagnoses, medications, or exacerbations of existing illnesses requiring nursing or rehabilitation.

How does this happen? As a home health agency medical director, I am called on a regular basis regarding three types of undoctored patients. First, there are patients who move to a new state (e.g. to be with a relative). Such individuals may arrange for home care even before they arrive. The home care agency orders from needs a physician licensed in the state, but the patient has not arranged for one. The second type are patients being discharged from a hospital or emergency room (ER). Despite being referred to home care, some have no arrangements made for medical follow-up. The third group includes those who cannot leave their home because of acute or chronic illness. Some of these persons have not seen a physician in years and seek home health services for assistance with activities of daily living, while others have had a relationship with a clinic or physician but now cannot go to an office setting due to physical or mental disabilities.

Home health care without physician services has a number of consequences. The first is related to access. An inability to obtain services or delays in initiating them can occur when a physician is not available to verbally authorize the start of care. An ER visit or even hospitalization may be necessary if a physician cannot be found to authorize home care.

Another problem relates to regulations and reimbursement for home health agencies. Home care orders and certifications must be signed in a timely manner. Sometimes physicians referring patients from hospitals or ERs are unwilling to sign paperwork sent from the home health agency. Agencies may face loss of revenue for services already rendered or even sanctions for incomplete paperwork.

A third problem arises when home health nurses are pushed to diagnose medical problems. For example, a nurse may be asked to determine whether a patient's new shortness of breath is due to pneumonia or heart failure. Only in home care is treatment for shortness of breath initiated without a uniform expectation of hands-on assessment by a physician within hours or, at most, a couple of days.

There is a solution to these problems. Home health agencies can and should work with one or more physicians to ensure medical care for their patients. This may involve a formal medical directorship. A precedent exists for home health agencies employing primary care physicians to serve undoctored patients in a community. The relationship could also be one of informal, mutual cooperation with a physician practice.

The role of the physician in any of these relationships is to provide medical care and oversight of home care services for patients without a primary physician. Telephone consultation and completion of paperwork are necessary but not sufficient. The physician in such a role should be willing and able to visit persons in the home setting, alone or with a home health agency professional.

The American Academy of Home Care Physicians (AAHCP) supports the development of physicians to play these roles. The AAHCP works toward this end through advocacy with government and home health agencies and through education of physicians.