Definitions of terms in Home Care
The home care industry has a language all its own. Here is a glossary of terms used in the home care industry to assist you.
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Acute care is a branch of secondary health-care where necessary treatment of a disease for only a short period of time in which a patient is treated for a brief but severe episode of illness. Many hospitals are acute care facilities with the goal of discharging the patient as soon as the patient is deemed healthy and stable, with appropriate discharge instructions.
Adult and Social Day Care Facilities
An adult day care center, also commonly known as adult day services, is a non-residential facility providing activities for elderly and/or handicapped individuals. Most centers operate 10 – 12 hours per day and provide meals, social/recreational outings, and general supervision. Adult daycare centers operate under a social model and/or a health care model.
Ambulatory care is any medical care delivered on an outpatient basis. Increasing numbers of medical conditions do not require hospital admission and can be managed without admission to a hospital. Many medical investigations can be performed on an ambulatory basis, including blood tests, X-rays endoscopy and even biopsy procedures of superficial organs.
Assisted living residences or assisted living facilities (ALFs) provide supervision or assistance with activities of daily living (ADLs); coordination of services by outside health care providers; and monitoring of resident activities to help to ensure their health, safety, and well-being. Assistance may include the administration or supervision of medication, or personal care services provided by a trained staff person.
Case management is a procedure to plan, seek, and monitor services for different social agencies and staff on behalf of a client. Usually one agency takes primary responsibility for the client and assigns a case manager, who coordinates services, advocates for the client, and sometimes controls resources and purchases services for the client. The procedure allows many social workers in the agency, or in different agencies to coordinate their efforts to serve a given client through professional teamwork, thus expanding the range of needed services offered.
A nurse, doctor, or social worker who coordinates services for patients and providers.
Centers for Medicare and Medicaid (CMS)
The Centers for Medicare & Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards.
Certified Home Health Agencies (CHHA’s)
New York State licenses two types of organizations that provide home health care: Certified Home Health Agencies or CHHA’s and Licensed Home Care Services Agencies or LHCSA’s. Only the employees of such agencies are permitted to provide hands-on care to patients, from help with bathing to the administration of medications. Certified Home Health Care Agencies provide part-time, intermittent health care and support services to patients who need intermediate and skilled health care. Certified Home Health Care Agencies also provide long-term nursing and home health aide services and can either provide or arrange for other services including physical, occupational and speech therapy, medical supplies and equipment and social worker and nutrition services.
The difference between a Certified Home Health Care Agency (CHHA) and a Licensed Home Health Care Agency (LHCSA) is that a Certified Home Health Care Agency can bill Medicare and a Licensed Home Health Care Agency cannot. As a result, a Certified Home Health Care Agency has to abide by different regulations and guidelines than a Licensed Home Health Care Agency.
The main function of formularies today is to specify which medicines are approved to be prescribed under a particular contract. The development of formularies is based on evaluations of efficacy, safety, and cost-effectiveness of drugs.
Geriatrics is a sub-specialty of internal medicine that focuses on health care of elderly people. It aims to promote health by preventing and treating diseases and disabilities in older adults. There is no set age at which patients may be under the care of a geriatrician, or physician who specializes in the care of elderly people. Rather, this decision is determined by the individual patient’s needs, and the availability of a specialist.
Home Health Aide (HHA)
A home health aide provides health-related services to persons in the home and is certified by the New York State Department of Health. Home health aides receive careful training in such areas as working with immobile patients, monitoring a patient’s temperature and pulse rate and preventing infections. By law, HHA’s are not permitted to place a medication in a patient’s mouth, but they can count out and place medications in a patient’s hand. They can also help with household activities, such as grocery shopping and laundry.
Home Health Care
Home Care, (also referred to as domiciliary care or social care), is health care or supportive care provided in the patient’s home by healthcare professionals (often referred to as home health care or formal care.
Health Insurance Portability and Accountability (HIPAA)
HIPAA is a federal law designed to protect patients’ medical records and other health information that is provided to health plans, doctors, hospitals and other health care providers. Developed by the Department of Health and Human Services, these new standards give patients access to their medical records and more control over how their personal health information is used and disclosed.
Infusion therapy involves the administration of medication through a needle or catheter. It is prescribed when a patient’s condition is so severe that it cannot be treated effectively by oral medications. Typically, “infusion therapy” means that a drug is administered intravenously, but the term also may refer to situations where drugs are provided through other non-oral routes, such as intramuscular injections and epidural routes (into the membranes surrounding the spinal cord).
A vaccination that stimulates the immune system by creating resistance to a disease.
Managed Long Term Care Program
The Managed Long-Term Care program was created in 1997 specifically for seniors who are physically qualified to enter a nursing home, but who prefer to remain in their own homes. Under this program, members are eligible for all of the care that is available under the Lombardi program, but can also receive a wide range of additional services.
Medicare Part A
The Medicare component that provides insurance to cover the costs of home health care after hospitalization, hospice care, plus inpatient hospital services, nursing home care, or other extended facility care.
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. Medicare operates similar to a single-payer health care system
Medicare Part A
Part A covers inpatient hospital stays (at least overnight), including semiprivate room, food, tests, and doctor’s fees.
Part A covers brief stays for convalescence in a skilled nursing facility if certain criteria are met:
- A preceding hospital stay must be at least three days, three midnights, not counting the discharge date.
- The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay.
- If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision then the nursing home stay would be covered.
- The care being rendered by the nursing home must be skilled. Medicare part A does not pay for custodial, non-skilled, or long-term care activities, including activities of daily living (ADL) such as personal hygiene, cooking, cleaning, etc.
The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2010, $137.50 per day). Many insurance companies have a provision for skilled nursing care in the policies they sell.
If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 100-day clock is reset and the person qualifies for a new 100-day benefit period.
Medicare Part B
Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still working. There is a lifetime penalty (10% per year) imposed for not enrolling in Part B unless actively working. Part B coverage begins once a patient meets his or her deductible, then typically Medicare covers 80% of approved services, while the remaining 20% is paid by the patient.
Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments and other outpatient medical treatments administered in a doctor’s office. Medication administration is covered under Part B only if it is administered by the physician during an office visit.
Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered.
Complex rules are used to manage the benefit, and advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) only apply within the multi-state area managed by a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003. Coverage information is also located in the CMS Internet-Only Manuals (IOM), the Code of Federal Regulations (CFR), the Social Security Act, and the Federal Register.
Medicare Prescription Drug Plan (DPD or MPDP)
Medicare Part D went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D. It was made possible by the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to benzodiazepines, cough suppressant and barbiturates. Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases.
Medigap (Medicare Supplement) refers to various private supplemental health insurance plans sold to Medicare beneficiaries in the United States that provide coverage for medical expenses not or only partially covered by Medicare. Medigap’s name is derived from the notion that it exists to cover the difference or “gap” between the expenses reimbursed by Medicare and the total amount charged. As of 2006, 18% of Medicare beneficiaries were covered by a Medigap policy.
Medicaid is the United States health program for eligible individuals and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. Among the groups of people served by Medicaid are certain eligible U.S. citizens and resident aliens, including low-income adults and their children, and people with certain disabilities. Poverty alone does not necessarily qualify an individual for Medicaid. Medicaid is the largest source of funding for medical and health-related services for people with limited income in the United States. Because of the aging World War II/Korean War generation, the fastest growing aspect of Medicaid is nursing home coverage. As the Baby Boomer generation begins to reach nursing home age in 2020 to 2040, the nursing home aspect of Medicaid will boom, causing concerns for federal and state budgets.
A nurse is a healthcare professional who, in collaboration with other members of a health care team, is responsible for: treatment, safety, and recovery of acutely or chronically ill individuals; health promotion and maintenance within families, communities and populations; and, treatment of life-threatening emergencies in a wide range of health care settings. Nurses perform a wide range of clinical and non-clinical functions necessary to the delivery of health care, and may also be involved in medical and nursing research.
A Nurse Practitioner (NP) is an Advanced Practice Nurse (APN) who has completed graduate-level education (either a Master’s or a Doctoral degree). Additional APN roles include the Certified Registered Nurse Anesthetist (CRNA)s, CNMs, and CNSs. All Nurse Practitioners are Registered Nurses who have completed extensive additional education, training, and have a dramatically expanded scope of practice over the traditional RN role. To become licensed to practice, Nurse Practitioners hold national board certification in an area of specialty (such as family, women’s health, pediatrics, adult, acute care, etc.), and are licensed through the state nursing boards rather than medical boards. The core philosophy of the field is individualized care. Nurse practitioners focus on patients’ conditions as well as the effects of illness on the lives of the patients and their families.
Occupational Therapist (OT)
An occupational therapist (OT) is trained in the practice of occupational therapy. The role of an occupational therapist is to work with a client to help them achieve a fulfilled and satisfied state in life through the use of “purposeful activity or interventions designed to achieve functional outcomes which promote health, prevent iNYury or disability and which develop, improve, sustain or restore the highest possible level of independence.
Physical Therapist (PT)
Physical therapy (or physiotherapy), often abbreviated PT, is the art and science of physical care and rehabilitation. It is a primary care health profession, with physical therapists (or physiotherapists) providing services to individuals and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan. This includes providing services in circumstances where movement and function are threatened by aging, iNYury, disease or environmental factors. Functional movement is central to what it means to be healthy.
Patient Review Instrument (PRI)
Before a senior can be placed in a skilled nursing facility, it is mandated by law that a patient review instrument, or PRI, be performed by a registered nurse. PRI’s are valid for 30 days and are used to determine the level of care and the type of facility required. It includes medical condition, treatments and medications needed, special diets or therapies needed, physical and mental abilities and limitations, ability to perform acts of daily living such as eating moving and toileting, behaviors such as aggressiveness and disruptiveness.
A Registered Nurse (RN) is a nurse who has graduated from a college’s nursing program or from a school of nursing and has passed a national licensing exam. A registered nurse helps individuals, families, and groups to achieve health and prevent disease. They care for the sick and injured in hospitals and other health care facilities, physicians’ offices, private homes, public health agencies, schools, camps, and industry.
In the context of home care, social workers specialize in helping individuals cope with the medical, functional, emotional, psychological, personal relationship, environmental and financial challenges of living in their own homes. They are trained in counseling and accessing community services, whether those services are provided directly by the government or by community organizations.
Speech Therapist (ST)
Speech Therapists or Speech Language Pathologists help patients regain their ability to produce and understand speech as well as facilitate communication skills.
Skilled Nursing Facility
A nursing home, convalescent home, Skilled Nursing Unit (SNU), care home or rest home provides a type of care of residents: it is a place of residence for people who require constant nursing care and have significant deficiencies with activities of daily living]. Residents include the elderly and younger adults with physical or mental disabilities. Residents in a skilled nursing facility may also receive physical, occupational, and other rehabilitative therapies following an accident or illness.