CONSUMER ADVOCACY IN HOME CARE ISSUES

All this means that the initial contact to a company is made by:

• A hospital - usually by the nurse discharging you from the hospital.  But, instead of a nurse, a medical social worker or another person who has been hired as a "coordinator" may be the one to contact the company.

• A doctor or doctor's office.  All home care must have a "doctor's order" to begin service, BUT the actual calls to locate service from a company can be done from other places, as described in here.  *When a doctor writes an order for home care, the contact to a company can be made many different ways.  But, when a company is finally picked, the company then calls the doctor directly for "doctor's orders" to begin the home care AND specific orders about your care.

• A "coordinator" or a "facilitator" or "(medical) case manager", who often is an employee of a "coordinating company" which is working for a State or for a particular insurance company.  For example, Ohio contracts with "Care Star" as a "coordinating company" that has "coordinator" or a "facilitator" or "(medical) case manager" -- they keep changing their job title --  whose job it is to find the home care company who is best able to provide your care.

• NO Home Care Company makes "cold calls" or solicitation calls to citizens, to see if someone might need home care.  

• If a patient or family member calls a company directly, the company will want to speak to the doctor, especially where services are medical in nature, and where services will be paid by Medicare, Medicaid or private insurance.  If a patient is "private pay" (the patient is paying 100% of services rendered), a patient may initially call a company themselves to get general information, but the company must still contact your doctor and get "doctor's orders" to begin care.  (An exception is "private duty" with no "company" involved.  See below.)

• In some States for Medicaid patients (and under certain Medicaid Programs, like the "Waiver" program in Ohio), you may choose to hire an "Independent Contractor."  These Independents are under the umbrella of the State, since the State pays for the service.   I believe the State-contracted "coordinator" or a "facilitator" or "(medical) case manager," as well as the Independent Contractor, is still responsible to obtain doctor's orders for service.  

• EXCEPTION:  If finances permit, a patient may decide to hire a "private duty nurse" or "private duty Aide/companion/helper."   Private Duty Nurses, one who is a Registered Nurse (R.N.) or an Licensed Practical Nurse (L.P.N.) / Licensed Vocational Nurse (L.V.N.) are employed under their nursing license.  They do not have to have an "order" to provide general nursing care BUT THEY SHOULD be in contact with your doctor, who CAN then give specific "orders" about aspects of your care.   These nurses are always under and are limited by the "Professional Standards" of their individual License.  (LPN/LVN and RN have different Professional Standards.)  A patient can hire a "private duty Aide/companion/helper" without having a doctor write an order for these services.  If you hire private employees, you need to check references and be sure of the person's qualifications.  You would be that person's "employer" also, and you are technically responsible to pay the employee's worker's compensation, cover any on-site injury or accident, and withhold taxes.  You would also be responsible for hiring, disciplinary measures or "warnings," and for any firings that might be needed.  You alone or your family would be responsible financially. You should be very sure you can handle these additional responsibilities before hiring private employees.  Too many patients begin this kind of arrangement without putting the "terms of employment" in writing, but it is always a good idea to have some type of written contract.  Discuss this with your attorney, who may be able to design a simple contract for you to use.  Be sure your contract covers issues about pay amounts & pay schedule, time off, vacation or sick time (IF you provide these), and anything else which you or your attorney thinks should be included.  I am not an attorney so I can not advise on this.  Just be sure your contract is clear and covers "everything."  

• EXCEPTION: The hiring of a "house-keeper" or strictly "companion" is not considered to be "home care" and should not replace appropriate medical and personal care for ill patients.  But, if your doctor thinks you do not need a "home care company" and you can afford the personal expense, you may only need a house-keeper/companion.  

Usually, once a company is picked and calls are made to the company, the company will call the doctor for "orders" and then calls the patient to arrange a first visit.   This first visit is an "assessment" of the patient, along with filling out paperwork.  Because Medicare or Medicaid are usually the payers of service, there is often a thick set of necessary paperwork.  The patient or guardian will be asked questions (a zillion questions, it feels like), and will need to sign several different papers.

Patient (and Family, if family can be there) should ask ALL the questions you can think of during this first visit.   ASK questions BEFORE signing each paper -- AND be sure to READ what you are signing -- even if that means you take longer by reading the page.  A nurse is typically allotted 2 full hours to complete the visit -- but the visit CAN run longer.   (Overall, the nurse's pay works out in the nurse's favor in the long run, because maybe your visit takes 3 hours but another patient's first visit only takes an hour because they have less that needs written down.  So don't worry about taking up too much time!)

Make sure you understand ALL parts of any financial agreement that you are asked to sign.  NEVER sign a totally blank financial agreement - no matter how "nice" the nurse looks or sounds.  <smiling>   A financial agreement should have your full name, should be dated, should have EXACT COSTS that you are responsible for (NOT "approx. $__.00"), when you will be billed, when payment is expected and any other "terms."  I cannot say this srongly enough: Never sign blank forms.

The same goes for medical forms the nurse must fill out (and often are co-signed by the nurse).  Always make sure your own name is ON the form, and that the form is correctly filled in.  Never sign blank forms.

THINGS TO ASK ABOUT REGARDING SERVICES

• Will you be a "Skilled Nursing" case?

• How often will the Nurse visit?  What care will the nurse give?

• How often will an Aide come?  Get days and specific times.  Tell the nurse if you prefer certain times of the day, and if you need to take medications WITH your meals, so your help will be in your home when YOU need them there.

• How often does the nurse supervise the Aides?  It used to be that skilled nursing patients had supervisory visits every two weeks (to supervise the Aide) but this may have changed.   Currently, non-skilled care has supervisory visits once every 30 to 60 days - depending on insurance.  This may be different in different States.

• What care will the Aide give?  Get as much in detail as you can.  Again, ask a lot of questions.

• What are the qualifications of the people who will be caring for you?   Nurses will all be licensed, but you can ask what "kind" of nurse they are (RN, LPN, LVN); how long they have been a nurse; how long have they done home care nursing; and even what they like the most / the least about home care nursing.  Ask the Nurse if the company's Aides are State Certified; what kind / if they have a different certificate; how much experience new-hires have before coming to the company; how often are Aides given In-service training; how long YOUR Aide has worked for this company or how much experience does YOUR Aide have in home care duties.  

• Get phone numbers to the office.  Ask which person to call for specific things, like schedule changes are handled by someone other than the nurse usually.

• Make sure you are given a page describing your rights.

• Make sure you are given a page describing the "complaint process."  This should include actual names of certain persons, with their phone number and address if you choose to write a letter.  It should include the "steps" you should use. (*You do not HAVE to go in that order, but it is recommended.  However, you can choose to skip to a higher level to complain, especially if a problem is very serious, or if you have tried unsuccessfully to get problems resolved at any lower level in the complaint process.)

• The nurse should leave copies of any papers you have had to sign.

• The nurse should leave a "care plan" in your house before they leave.  The care plan tells the Aide what things they are to do -- or not do.  It should include special diet, frequency of care, and types of care the Aide is to do with or for you.  The care plan should say how much (or how little) help YOU need, and anything else specific to YOUR care.  A care plan should NEVER be blank, nor should the care plan just say "See patient's chart."

• Ask about dress code for employees.  You'd be surprised how many Aides come dressed in ripped or dirty clothes, who smell, etc.

Always indicate to the nurse if you have "house rules" you expect employees to follow.  For example, no employee should smoke IN your house, but you also don't want cigarette butts littering your yard around your front door.  

Give clear directions to your home, including what door the Aide should use.

Ask if the company pays to have the Aide do a day's worth of "orientation" in your home, especially if one Aide is replacing your current Aide.   Orientations are very helpful so the patient does not have to keep repeating themselves with every new Aide.

Commonly Used Abbreviations in Long Term Care (and Home Care) - external link