Home Care FAQs
  Professional's Guide

Professional's Guide to Home Care & Hospice Referrals

What is an Appropriate Referral…

…for In-Home Aide Services
In-home aide services may be required for individuals who are disabled or chronically ill and who have a safe living environment and want to remain at  home. Usually individuals need assistance with personal care and home management tasks related to a medical condition. Ideally individuals also have a strong support system of family and friends. In-home aide services may be covered by NC’s Medicaid Personal Care Program (PCS), long-term care insurance, private insurance, Veteran’s benefits or private pay. Criteria for NC’s Medicaid PCS program may be discussed with a PCS provider agency.

…for Home Health Services?
Home Health services can benefit an individual who is in need of skilled intervention such as skilled nursing or therapy. Medicare beneficiaries must meet specific eligibility and coverage criteria to receive home health services. Medicare requires that individuals meet their definition of homebound. It is also important that there are achievable goals that can be reached. Home health services are usually delivered over a short period of time – for example following a patient’s hospital discharge from an acute medical crisis. However, for a more detailed look into Medicare’s coverage criteria and other examples of when home health is appropriate, visit http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf .  The NC Medicaid program also covers home health services and closely mirrors Medicare’s coverage criteria with a few exceptions. Agencies providing Medicaid therapy services must seek prior approval for services. The NC Medicaid Community Care Manual may be found at http://www.dhhs.state.nc.us/dma/ for more detailed information regarding Medicaid’s covered services.   

…for Hospice Services?
Referrals to Hospice should be made for patients who have a life-limiting illness or injury. Hospice focuses on caring, not curing. Hospice can be provided in the patient’s home, free-standing hospice centers, hospitals and nursing homes. Hospice benefits the family as well as the patient and can be a great source of education and comfort during the difficult end-of-life process.

…for Community Alternative (CAP) Services?
CAP services are almost always only available to individuals who are Medicaid beneficiaries. North Carolina has four CAP programs: CAP-Children; CAP-Disabled Adults; and CAP-Mental Retardation/Developmental Disabilities. Individuals that are accepted to the CAP programs are at a high risk of going into institutional care but can stay at home with the CAP services. CAP is a case managed program and services must be approved by the CAP case manager. For more information on CAP, see the NC Medicaid Community Care Manual at http://www.dhhs.state.nc.us/dma/

…for Mental Health/Developmental Disabilities Services?
An appropriate referral for Mental Health/Developmental Disabilities would be someone who has special needs for home and community based services based on their disability. To receive MH/DD services an individual must work through their area Mental Health/Developmental Disabilities/Substance Abuse Services agency.

How Can I Locate a Home Care or Hospice Agency?

For a comprehensive listing – Visit AHHC's Home Care & Hospice Directory. There you will find agencies, and the services they provide, listed by the counties the agencies serve.

What Services Do Home Care Agencies Provide?

Home Health covers the following when they are medically necessary to help treat, restore, rehabilitate or sustain a patient in the home: Skilled Nursing, Physical Therapy, Speech-Language Pathology, Occupational Therapy, Medical Social Work, Home Health Aide and Medical Supplies.  Physician orders are required for these services and the patient must meet certain guidelines to qualify.  Medicare, Medicaid and Private Insurance cover these services when the appropriate criteria is met.

Home Infusion Therapy provides IV therapy and nutrition, such as chemotherapy, pain management and antibiotic therapy in the patient’s home.  Nurses and pharmacists work with the patient and family to teach them to administer the covered medication.  The patient should check with their specific insurance, or other payor, for coverage.

Home Medical Equipment/Durable Medical Equipment (HME/DME) are items that help the patient be more independent and improve their ability to function in the home.  Some of the equipment included in this category includes canes, walkers, wheelchairs, beds, respiratory equipment and oxygen, apnea monitors and safety equipment such as bathtub rails.

Hospice is a special way of caring for individuals who are in the final stages of their lives due to a life-limiting illness.  The hospice approach focuses on managing symptoms as opposed to curing an illness.  Hospice services help patients, who are no longer seeking aggressive treatment or a medical cure, manage their terminal illness at home or in a home like environment.  Hospice addresses the physical, psychosocial, and spiritual needs of the patient and family.

Personal Care Services (PCS) are in-home aide services (bathing, toileting, feeding dressing, home management tasks, etc) provided to qualified patients that have full Medicaid coverage (blue card).  These patients often need the same type of services that patients in an adult care home need.  Medicaid limits the number of PCS hours per day, and per month, that a patient may receive.

Private Duty Nursing (PDN) is medically necessary, continuous, substantial and complex nursing services provided by a licensed nurse in the patients’ home.  Most of the sickest PDN patients are children.  If a patient qualifies, Medicaid and some Private Insurance companies pay for this service. Medicare does not pay for this service.

The Community Alternatives Program for Disabled Adults (CAP/DA) provides an alternative to nursing facility care for disabled adults by allowing them to receive needed care in their homes.

The Community Alternatives Program for Persons with Mental Retardation/Developmental Disabilities (CAP/MRDD) provides services to individuals any age who normally would require care in an intermediate facility for the mentally retarded.

The Community Alternatives Program for Children (CAP/C) provides cost-effective care for medically fragile children who would otherwise require long-term hospital or nursing facility care.

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