Home care

Home care, also known as domiciliary care, is health care provided in the patient's home by healthcare professionals (often referred to as home health care or formal care; in the United States, it is known as skilled care) or by family and friends (also known as caregivers, primary caregiver, or  voluntary caregivers who give informal care). Often, the term home care is used to distinguish non-medical care or custodial care, which is care that is provided by persons who are not nurses, doctors, or other licensed medical personnel, whereas the term home health care, refers to care that is provided by such licensed personnel.

Concept
(The following definition is applicable in United States and United Kingdom.)

Home Care and Home Health Care are phrases that are used interchangeably in the United States, by both laypersons and professionals, to mean any type of care given to a person in their own home. Both phrases are used interchangeably regardless of whether the person requires Skilled Care by professionals or not.

Home care aims to enable people to remain at home rather than use residential, long-term, or institutional-based nursing care. Care workers visit service users (patients) in the person's own home to help with daily tasks such as getting up, going to bed, dressing, toileting, personal hygiene, some household tasks, shopping, cooking and supervision of medication.

There may be differences in other countries about types of services delivered. In the United States, a Home Care Patient might receive care from Home Health Aide workers only; or a combination of Skilled Services by a Licensed Professional and Home Health Aide workers.

From the description of services for the United Kingdom, there are apparently large differences in the number of visits to a patient in the home (In the description below, care is given twice daily in the United Kingdom.) In the U.S., workers visit the home on a schedule determined in part by a Licensed Physician and in part by the type of insurance a patient has. Visits range from a few days a week, to every day. Visits are at minimum 2 hours' duration, but can range up to around-the-clock service in the U.S. (generally the longer hours are split between 2 or more workers).

In the United States
While there are differences in terms used in describing aspects of Home Care or Home Health Care in the United States and other areas of the world, for the most part the descriptions are very similar.

Estimates for the U.S. indicate that most home care is of the informal variety with families and friends providing substantial amounts of care, including very high tech kinds of care as well as simpler assistance with bathing or dressing. For formal care, the health care professionals most often involved are nurses followed by physical therapists and home care aides. Other health care providers include respiratory and occupational therapists, medical social workers and mental health workers. Physicians may perform home visits also. To find such a physician, contact the American Academy of Home Care Physicians (AAHCP). In the U.S., home health care is generally paid for by private employer-sponsored health insurance or public payers (Medicare and Medicaid), or by private-pay (paid with the family's or patient's own resources).

ADLs and IADLs
Activities of daily living (ADL) refers to six activities (bathing, dressing, transferring, using the toilet room, eating, and walking) that reflect the patient's capacity for self-care. The patient's need for assistance with these activities for the Study mentioned was measured by the receipt of help from agency staff at the time of the survey (for current patients) or the last time service was provided prior to discharge (for discharges). Help that a patient may receive from persons that are not staff of the agency (for example, family members, friends, or individuals employed directly by the patient and not by the agency) was not included in the Study.

Instrumental activities of daily living (IADL) refers to six daily tasks (light housework, preparing meals, taking medications, shopping for groceries or clothes, using the telephone, and managing money) that enables the patient to live independently in the community. The patient's need for assistance with these activities was measured in the Study by the receipt of help from agency staff at the time of the survey (for current patients) or the last time service was provided prior to discharge (for discharges). Help that a patient may have received from persons who are not staff of the agency (for example, family members, friends, or individuals employed directly by the patient and not by the agency) was not included in this Study.

Most agencies do not provide transportation, such as to doctor's offices. Workers can do errands for the patient though.

Licensure and providers in Florida
Florida is a Licensure State which requires different levels of licensing depending upon the services provided. Companion assistance is provided by a Home Maker Companion Agency whereas Nursing Services and assistance with ADL's can be provided by a Home Health Agency or Nurse Registry. The State licensing authority is the Agency for Health Care Administration (AHCA)AHCA.

Aide worker qualifications
Entry-level qualifications in the USA require workers to have a High School Education or GED and some agencies require 1 year experience, and must pass a competency test. Competency implies the worker has knowledge of home and patient safety, ability to safely deliver personal care, proper use of assistive equipment (wheelchair, walker, cane, crutches, mechanical lifts, etc.), food preparation, care of the home, sanitary conditions, etc. Workers need to also display the ability to observe and report to the nurse any changes in the patient's overall condition. Many of the duties of home care workers involve good common sense also.

Often workers have had experience in a Nursing Home (institutional care) prior to being hired in a home care agency. Workers can take an examination to become a State tested Certified Nursing Assistant (CNA) and be included in a State Registry. Other requirements in the U.S.A. include a background check (police check with finger-printing), drug testing, general references and applicant interview. There is no specialization of workers for particular types of patients, but employees receive individual instruction (usually by the Registered Nurse) as needed for specialized patient care.

Compensation
In the United States, registered nurses employed in the home care field receive on average around $22.00 to $30.00 per visit.

Payment / reimbursement of other Skilled Services vary according to the specific discipline.

Home Health Aides are paid between $5.15 (current minimum wage) to approximately $12.00 per hour. Wages vary considerably by geographic region. These workers do not usually have any kind of benefits offered. They do not receive paid vacations, nor sick days. Currently there is high turn-over and frequent call-offs or no-shows by workers in the home health care / home care field.

Obviously, the agencies' fees are substantially higher, but traditionally reimbursement by State, Federal, or private insurance is lower than the charges billed. Agencies must pay for office and overhead, office staff, professional and non-professional salaries and must pay into the Worker's Compensation fund, etc.

Recent Supreme Court case: Coke v. Long Island Home Care
For years, home care work has been selectively classified as a “companionship service” and exempted from federal overtime and minimum wage rules under the Fair Labor Standards Act (FSLA). This April, the Supreme Court considered arguments on the companionship exemption, which stems from a case brought by a home care worker represented by counsel provided by SEIU. The original 2003 case, Evelyn Coke v. Long Island Care at Home, Ltd. and Maryann Osborne, argues that agency-employed home caregivers should be covered under overtime and minimum wage regulations.

Evelyn Coke, a home care worker employed by a home care agency that was not paying her overtime, sued the agency in 2003, alleging that the regulation construing the “companionship services” exemption to apply to agency employees and exempt them from the federal minimum wage and overtime law is inconsistent with the law. The case has wound its way through the appeals process, and in January, the Supreme Court decided to hear the case this spring.

In the court decision, the court stated the Fair Labor Standards Amendments of 1974 exempted from the minimum wage and maximum hours rules of the FSLA persons "employed in domestic service employment to provide companionship services for individuals . . . unable to care for themselves." 29 U. S. C. §213(a)(15). The court found that the DOL's power to administer a congressionally created program necessarily requires the making of rules to fill any 'gap' left, implicitly or explicitly, by Congress, and when that agency fills that gap reasonably, it is binding. In this case, one of the gaps was whether to include workers paid by third parties in the exemption and the DOL has done that. Since the DOL has followed public notice procedure, and since there was gap left in the legislation, the DOL's regulation stands and home health care workers are not covered by either minimum wage or overtime pay requirements.

2004 Study by NIHS
In February 2004, the National Center for Health Statistics (NIHS) conducted the "National Home and Hospice Study," which was updated in 2005.

The data was collected on about approximately 1.3+ million (1,355,300) persons receiving home care in the USA. Of that total, almost 30% (29.5% or 400,100 persons) were under 65 years of age, while the majority, almost 70%, were over 65 years old (70.5% or 955,200 persons).

The 2005 chart data of estimates based on interviews with non-institutionalized citizens, however, shows a relatively stable number of about 6 to 7 percent of adults age 65 who needed help for personal care (ADLs) - this has remained about the same between 1997 and 2004. (Data has a 95% reliability.) Those aged 85 or older were at least 6 times more likely (20.6%) to need ADL assistance than those of age 65. Between age 65 and 85 years, more women than men needed help.

To review the 2005 Early Release data used, visit the NCHS-NHIS website to see the PDF files. [NOTE: * The 2005 data reflects data, still between 6 to 7%, is only based on interviews conducted between January to June 2005, so it remains to be seen whether the figure remained constant or changed through the end of 2005.] Again, the 1998-2005 data is specific for over 65 or older and does not include any data for adults under 65 years old.

In the 2004 data, just over 30% (30.2 % or 385,500) of the total 1.3+million persons lived alone, but the study did not break this down by age groups. A large portion, 1,094,900 or 80.8% had a primary caregiver, and almost 76% (75.9% or 831,100 lived with the primary caregiver, typically the spouse, child or child-in-law, other relative or parent, in that order. (Paid help and the category of neighbor/friend/ or unknown caregiver would be, for the majority, were living with non-family (4.3%) or unknown living arrangement .)  Most patients still need external help, even if the primary caregiver is a spouse.

A total of 600,900 persons received personal care.

Payment described in the 2004 study
Page 4 of the study describes the population break-down by type of payment used. Of the 1.3+ million:

710,000 paid by Medicare - Medicare often is the primary billing source, if this is the primary carrier between two types of insurance (like between Medicare and Medicaid). Also, if a patient has Medicare and that patient has a "skilled need" requiring nursing visits, the patient's case is typically billed under Medicare.

277,000 paid by Medicaid - This number seems low for Community Based Services (CBS) or Home Care (HC), especially as a nationwide statistic.

235,000 paid by private insurance, or self/family - Private insurance includes VA (Veterans Administration), some Railroad or Steelworkers health plans or other private insurance. "Self/family" indicates "private pay" status, when the patient or family pays 100% of all home care charges. Home care fees can be quite high; few patients & families can absorb these costs for a long period of time.

133,200 all other payments - including patients unable to pay, or who had no charge for care, or those whose payment "source not yet determined or approved." Sometimes after "opening a case" (the formal paperwork process of admitting a patient to home care services, there can be a short period of time when the office has not yet received approval by one of two or more insurances held by the patient. This is not unusual.  There can also be cases where the office must make phone calls to be sure a particular diagnosis is "covered" by the patient's primary insurance.  This is not unusual.  These delays explain, in part, a couple circumstances where payment source would be listed as "unknown."

CBLTC expenditures
Community-Based Long Term Care (CBLTC) is the newer name for Home Health Care Services paid by States' Medicaid programs. Most of these programs have a category called 'Medicaid Waiver' to define level of care being delivered.

The Study "Medicaid Home and Community-Based Long Term Care – Trends in the U.S. and Maryland" funded by the National Institute of Disability and Rehabilitation Research, Department of Education, Information Brokering for Long Term Care, The Robert Wood Johnson Foundation, focused on expenditures. In this study, the Medicaid Waiver Expenditures by Recipient Group in 2001 based on total expenditure of $14,218,236,802 was broken down in this manner of actual spending (presumably this is based on nationwide figures):


 * MR/DD 74%
 * Aged/Disabled 17%
 * Disabled/Phy. Disabled 4%
 * Aged 3%
 * Children 1%
 * TBI/Head Injury 1%
 * AIDS < 1%
 * Mental Health <1% (less than 1%)
 * Source: Kitchener, Ng & Harrington, 2003. Medicaid HCBS Program Data. SF: UCSF

But, the same report included figures on "Participants by Recipient Type" in 2001 based on a total number of 832,915. Participant types were broken down thus (presumably this is based on nationwide figures):


 * Aged/Disabled 41%
 * MR/DD 39%
 * Aged 11%
 * Disabled /Phy. Disabled 5%
 * AIDS 2%
 * Children 1%
 * TBI/Head Injury 1%
 * Mental Health <1% (less than 1%)
 * Source: Kitchener, Ng, and Harrington, 2003. Medicaid HCBS Program Data. SF: UCSF.

This data would be interpreted that the MR/DD population represents 39% of the study population of 832,915, and this population used 74% of the available resources of the total expenditure of $14,218,236,802. The aged/disabled population had a higher number of patients in need at 41%, but only had 17% of the total dollar expenditure. The Disabled/Physically Disabled Group (presumably minus the aged in the statistics given - but this group was not well defined in this study's report, as to age etc.), represented 5% of the population and used just 4% of allocated funding. Adding the Aged/Disabled with those of "Disabled/Physically Disabled," the total group would represent 45% in population which used just 22% of funding. Again, the 39% MR/DD used 74%, more than three times higher than the larger group of disabled citizens.

Home care providers
Homecare is purchased by the service user directly from independent home care agencies or as part of the statutory responsibility of social services departments of local authorities who either provide care by their own employees or commission services from independent agencies. Care is usually provided once or twice a day with the aim of keeping frail or disabled people healthy and independent though can extend to full-time help by a live-in nurse or carer.

United Kingdom Home Care Association
Domiciliary care providers in the UK are able to join the United Kingdom Homecare Association (UKHCA), which is the professional association of domiciliary care providers in the independent, voluntary, not for profit and statutory sectors. The Association represents the views of over 1,540 home care providers, each of which agrees to abide by the UKHCA Code of Practice. UKHCA is often a point of contact for members of the public who wish to contact home care providers in their local area.

Statutory Regulation
Home care agencies are regulated by statutory bodies in three of the four home nations. The regulator's function is to ensure that home care agencies work within the applicable legislation:

England

 * Regulator: The Commission for Social Care Inspection (CSCI)
 * The Care Standards Act 2000
 * The Domiciliary Care Agency Regulations 2002

Wales

 * Regulator: The Care Standards Inspectorate for Wales (CSIW)
 * The Care Standards Act 2000
 * The Domiciliary Care Agencies (Wales) Regulations 2004

Scotland

 * Regulator: The Care Commission
 * The Regulation of Care (Scotland) Act 2001

Northern Ireland

 * There is no statutory regulation of domiciliary care at the time of writing (July 2005) although draft legislation is currently under consideration.

Aids to daily living
An aids-to-daily-living (ADL) product is any product that helps persons with temporary or permanent disabilities perform everyday activities such as bathing, eating, and dressing. Some of the ADL product categories are:


 * Dressing aids
 * Reachers, grabbers, and knobs
 * Medicine dropper and spoons
 * Reading accessories
 * Bathroom products (raised toilet seats, shower stools, hand-held showers, etc.)
 * Transfer benches
 * Eating utensils
 * Grab bars and safety rails
 * Pill crushers and cutters
 * Playing cards and accessories
 * Bedroom products (beds, overbed tables, pads, etc.)
 * Step stools