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1. The patient is homebound. |
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Homebound examples:
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
Non-homebound examples:
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.
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2. Services are intermittent/part-time. |
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Intermittent/Part-time examples:
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.
Non-intermittent examples:
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.
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3. The patient requires skilled care. |
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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.
Non-skilled care:
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.
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4. Skilled services are medically reasonable and necessary. |
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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.
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5. Home Care is ordered by the doctor. |
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The patient must be under care of a Kaiser physician and Home Care must be ordered by the MD. Referrals must be complete.
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* Diverted Services * |
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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.
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