Abuse* (personal): When another person does something on purpose that causes you mental or physical harm or pain.
Accessory Dwelling Unit* (ADU): A separate housing arrangement within a single-family home. The ADU is a complete living unit and includes a private kitchen and bath.
Activities of daily living (ADL): Self-care abilities related to personal care including bathing, dressing, eating, toileting, continence, transferring, and ambulating.
* Activities you usually do during a normal day such as getting in and out of bed, dressing, bathing, eating, and using the bathroom.
Adult Living Care Facility*: To be used when billing services rendered at a residential care facility that houses beneficiaries who cannot live alone but who do not need around-the-clock skilled medical services. The facility services do not include a medical component (Program Memo B-98-28).
APS (adult protective services): These services protect vulnerable adults by investigating allegations of abuse, neglect, abandonment, and financial exploitation. Based on the outcome of an investigation, APS may offer legal or social protective services. An adult maintains the right to refuse protective services. The vulnerable adult or the legal representative must give written consent for protective services and may end the services at any time. APS conducts an investigation at no charge and without regard to the income of the alleged victim. Some protective services may be provided without cost.
Assessment: The process by which a physician or another health care professional evaluates a person’s health status. Assessment is related to, but distinct from, diagnosis. It may involve the use of formal assessment instruments along with more informal interviews with the patient, the patient’s family, and other caregivers, and with observation of the patient’s behavior.
* The gathering of information to rate or evaluate your health and needs, such as in a nursing home.
Assessment instruments: Specific procedures, tests, and scales used to measure and evaluate cognitive and self-care abilities, problems, functional limitations, and other patient characteristics.
Assisted Living*: A type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available as needed to people who still live on their own in a residential facility. In most cases, the “assisted living” residents pay a regular monthly rent. Then they typically pay additional fees for the services they get.
Attending physician: The physician designated by the patient or his or her representative who has the most significant role in the determinations and delivery of the individual’s medical care.
* Number of the licensed physician who would normally be expected to certify and recertify the medical necessity of the number of services rendered and/or who has primary responsibility for the patient’s medical care and treatment.
Board and Care Home*: A type of group living arrangement designed to meet the needs of people who cannot live on their own. These homes offer help with some personal care services.
Care plan oversight (CPO): Ongoing oversight of home care services after the physician has referred a patient to a home care agency and developed and/or approved the care plan. CPO can be done by the referring or another physician, nurse practitioner, or physician assistant identified by the referring physician. Oversight includes collaboration and communication between the referring physician and a variety of other health care professionals participating in the care of the patient.
Care transition: Care involved when a patient/client leaves one care setting (e.g., hospital, nursing home, assisted living facility, skilled nursing facility, primary care physician, home health provider, or specialist) and moves to another. It involves a set of actions designed to ensure the coordination of care as patients transfer between different locations.
Case management: Those activities necessary to determine the patient’s needs, arrange for and coordinate the appropriate services, and monitor the effectiveness of services and reassess them as needed.
* A process used by a doctor, nurse, or other health professional to manage your health care. Case managers make sure that you get needed services, and track your use of facilities and resources.
CHAP (www.chapinc.org): Community Health Accreditation Program of the National League for Nursing (NLN). CHAP was granted “deeming authority” by the Centers for Medicare and Medicaid Services (CMS) in 1992 for home health and in 1999, for hospice. This means that instead of state surveys, CHAP has regulatory authorization to survey agencies providing home health and hospice services to determine whether they meet the Medicare Conditions of Participation (COPs). In 2006, CMS granted CHAP full deeming authority for home medical equipment (HME).
Childhelp USA (www.childhelp.org): A national organization that provides crisis assistance and other counseling and referral services.
CLIA (Clinical Laboratory Improvement Amendments) (www.cms.gov/clia): The Centers for Medicare and Medicaid Services program that regulates all clinical laboratory testing in the United States. Some states (e.g., California) and professional societies (e.g., College of American Pathologists) have stricter guidelines.
CMN (Certificate of Medical Necessity): Forms required by Medicare to authorize certain categories of durable medical equipment.
CMS (Centers for Medicare & Medicaid Services) (www.cms.gov): The branch of the Department of Health and Human Services that issues rules and regulations for the Medicare and Medicaid programs.
Community-based Care Transitions Program (CCTP): The CCTP, mandated by section 3026 of the PPACA (Patient Protection and Affordable Care Act), provides funding to test models for improving care transitions for high-risk Medicare beneficiaries. The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measureable savings to the Medicare program (www.cms.gov/demoprojectsevalrpts/md/itemdetail.asp?itemid=CMS1239313).
Conditions of participation (www.cms.gov/CFCsAndCOPs/): The regulations under which a home health agency may be allowed to participate in Medicare and Medicaid programs.
Continuous improvement: A philosophy or attitude of looking for methods to improve the quality of products or services as an ongoing part of the administration of a health care delivery system.
* A process which continually monitors program performance. When a quality problem is identified, CQI develops a revised approach to that problem and monitors implementation and success of the revised approach. The process includes involvement at all stages by all organizations, which are affected by the problem and/or involved in implementing the revised approach.
Custodial care: Treatments or services, regardless of who recommends them or where they are provided, that could be given safely and reasonably by a person not medically skilled and are mainly to help the patient with activities of daily living.
* Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving round, and using the bathroom. It may also include care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care.
Disability*: For Social Security purposes, the inability to engage in substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or to last for a continuous period of not less than 12 months. Special rules apply for workers aged 55 or older whose disability is based on blindness. The law generally requires that a person be disabled continuously for 5 months before he or she can qualify for a disabled worker cash benefit. An additional 24 months is necessary to qualify under Medicare.
Discharge Planning*: A process used to decide what a patient needs for a smooth move from one level of care to another. This is done by a social worker or other health care professional. It includes moves from a hospital to a nursing home or to home care. Discharge planning may also include the services of home health agencies to help with the patient’s home care.
Duplication of services: The same service being provided by two disciplines.
Durable medical equipment (DME): Defined by Medicare as equipment that can withstand repeated use, is primarily designed to serve a medical purpose, is generally not useful to a person in the absence of injury or illness, and is appropriate for use in the home. Examples of DME include oxygen concentrators, wheelchairs, walkers, hospital beds, and suction machines.
* Medical equipment that is ordered by a doctor (or, if Medicare allows, a nurse practitioner, physician assistant or clinical nurse specialist) for use in the home. A hospital or nursing home that mostly provides skilled care can’t qualify as a home in this situation. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.
Enteral nutrition therapy: Therapy that addresses the nutritional needs of patients who are unable to take food orally. A feeding tube, passed through the nose, stomach, or small intestine, supplies the patient with calories and vital nutrients. Home enteral nutrition supplies and equipment are reimbursable under Medicare Part B for patients with Medicare-specified diagnoses.
The Federal Child Abuse Prevention and Treatment Act (CAPTA): CAPTA, as amended by the Keeping Children and Families Safe Act of 2003, defines child abuse and neglect.
CMS Form-485: Formerly required for home health certification and plan of care, now may be used or the HHA may submit any document that is signed and dated by the physician that contains all the data elements in the 485.
Fraud: Intentional deception or misrepresentation that an individual knows to be false and untrue.
*The intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s).
Functional limitations: The limitations of performance and the impact of these limitations on the patient’s lifestyle caused by chronic disease, either the broad effects of a single condition on many activities of daily life, or the independent effects of several conditions, each of which affects only a few activities.
HHS (U.S. Department of Health and Human Services): The department under which the Medicare and Medicaid programs are administered.
HIPAA (Health Insurance Portability and Accountability Act of 1996, P.L. 104-191) (www.cms.gov/hipaageninfo/): Title II of HIPAA concerns “Administrative Simplification.” Title II is intended to improve the efficiency of the health care system by standardizing the electronic exchange of health care data and protecting the security and privacy of individuals’ health care information.
High-technology home care: The application of technology at home to patients with acute, subacute, or chronic organ system diseases, dysfunction, or failure.
Home Based Primary Care (VA HBPC) (www.va.gov/GERIATRICS/Home_Based_Primary_Care.asp): Provides comprehensive, interdisciplinary, primary care in the homes of veterans with serious chronic disease and disability. HBPC targets frail, chronically ill veterans for whom routine clinic-based care is not effective. By providing coordinated care and the integration of diverse services, HBPC assists in improving the quality of life for these vulnerable individuals.
Home health agency or organization (HHA): An organization that provides patients with skilled nursing and/or other therapeutic care in their homes, usually following the Medicare model of approved services (see home health care).
Home health aide: A trained individual who works under the supervision of a nurse or therapist, providing personal care and assistance with activities of daily living (ADL). Medicare requires that home health aides’ training and competency evaluation must be completed before the aide renders care in the home.
Homebound: The patient has a condition, caused by an illness or injury, that restricts the ability of the patient to leave his or her home except with the assistance of another individual, or the aid of a supportive device (e.g., crutches, a cane, a wheelchair, or a walker), or the patient has a condition such that leaving his or her home is medically contraindicated.
*Normally unable to leave home unassisted. To be homebound means that leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to the barber or to attend religious service. A need for adult day care doesn’t keep you from getting home health care.
Home care: Home care describes a vast array of services ranging from family members balancing the checkbook of a mildly demented parent, to nurse practitioners making post-natal visits to new parents, to skilled nurses, physical therapists, occupational therapists, speech therapists and social workers providing services to a recently discharged stroke patient, to physicians managing a ventilator-dependent patient in the patient’s living room. It can also apply to vocational services, social services, homemaker services, and home health aide services to disabled, sick, or convalescent persons in the home. Services can range from high-technology care (e.g., administration of intravenous drugs) to relatively simple supportive care (e.g., provision of home-delivered meals).
Home health care: As defined under the Medicare Part A benefit, covers skilled, medically necessary care provided on an intermittent, part-time basis, by registered nurses, physical therapists, or speech therapists. If the patient qualifies for one or more of these “skilled” services, he or she is then eligible to receive services, if needed, from home health aides, dietitians, occupational therapists, and social workers.
* Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.
Homemaker: A person paid to help in the home with personal care, light housekeeping, meal preparation, and shopping.
Home Patients*: Medically-able individuals, who have their own dialysis equipment at home and after proper training, perform their own dialysis treatment alone or with the assistance of a helper.
Hospital at Home: Hospital at Home is a care service delivery model that provides acute hospital-level care in the home as a substitute for care in a traditional acute hospital setting. It provides an intensity of care, including medical and nursing care, similar to that provided in the hospital, is appropriate to the severity of illness treated, and provides care that cannot be supplied by usual community-based home health care services. In the international literature, two general types of Hospital at Home models are described. “Substitutive” models usually divert patients from emergency department or ambulatory sites to the home. In this model, the patient is never admitted to the traditional hospital inpatient bed. In addition, “early discharge” models are described in which patients are initially admitted to the traditional acute hospital, and then later “transferred” to a Hospital at Home bed If the patient still requires acute hospital-level care.
Instrumental activities of daily living (IADL): Activities that facilitate independence, such as the management of finances, use of the telephone, use of public transportation, meal planning and preparation, shopping, and taking medications appropriately.
Intermediary: The organization handling claims from hospitals, nursing homes, home health agencies, and other health care providers under federal or state health coverage programs.
* A private company that has a contract with Medicare to pay Part A and some Part B bills.
Intermittent: A qualifying criterion for Medicare home health services, meaning that continuous 24-hour/day nursing services will not be covered, but only those services “either provided or needed on fewer than 7 days each week or less than 8 hours each day and 28 or fewer hours each week for periods of 21 days or less with extensions in exceptional circumstances when the need for additional care is finite and predictable.” Most Medicare home health patients do not require such intensive services.
Joint Commission (www.jointcommission.org) (formerly JCAHO: Joint Commission on Accreditation of Healthcare Organizations): An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 19,000 health care organizations and programs in the United States including hospitals, ambulatory health care, behavioral health care, nursing home care, as well as home health care and durable medical equipment organizations.
* An organization that accredits healthcare organizations. In the future, the JCAHO may play a role in certifying these organizations’ compliance with the HIPAA A/S requirements.
Long-term Care*: A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare doesn’t pay for this type of care if this is the only kind of care you need.
Management and evaluation of the care plan: Skilled nursing visits for management and evaluation of the patient’s care plan under the Medicare home health benefit are considered “reasonable and necessary where underlying conditions or complications require that only a registered nurse can ensure that essential nonskilled care is achieving its purpose. For skilled nursing care to be reasonable and necessary for management and evaluation of the patient’s plan of care, the complexity of the necessary unskilled services that are a necessary part of the medical treatment must require the involvement of licensed nurses to promote the patient’s recovery and medical safety in view of the patient’s overall condition”.
Medicaid (Title XIX): A state/federal program designed to provide medical benefits to indigent persons of all ages.
Medically necessary care (under Medicare): “To be considered reasonable and necessary, services must be consistent with the nature and severity of the patient’s illness or injury, his or her particular medical needs, and the accepted standards of medical and nursing practice, without regard as to whether the illness or injury is acute, chronic, terminal, or expected to last a long time.”
Medical necessity: Services required and medically appropriate for the treatment of an illness or injury. Such services must be consistent with recognized standards of care.
Medical social services: Social services in home care are directly related to the treatment of the patient’s medical condition. Medicare allows two to three visits for family intervention directly related to the patient’s health and safety.
Medicare: Public Law 89-97, which provides hospital and physician benefits for eligible persons (aged 65 years or older, permanently disabled after 24 consecutive months of disability, or those with chronic renal disease who require hemodialysis or kidney transplant after a three-month waiting period). Medicare Part A provides hospital and home health benefits; Medicare Part B provides benefits for professional services, durable medical equipment (DME), and supplies.
Medicare-certified: A home health agency or organization that is found by the Centers for Medicare & Medicaid Services (CMS) to meet Medicare’s Conditions of Participation, is certified by CMS, and is thus allowed to participate in the Medicare program.
Medicare criteria for skilled services: “To be considered a skilled service, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel.”
Medicare’s OASIS: See OASIS.
Mini-Mental State Examination (MMSE): A simple screening test to detect dementia; it assesses a range of cognitive abilities, such as memory, calculations, language, and spatial ability.
The National Center on Elder Abuse (NCEA) (www.ncea.aoa.gov): Useful national resource for elder rights, law enforcement and legal professionals, public policy leaders, researchers, and the public administered under the auspices of the National Association of State Units on Aging. Its Web site has links to state adult protective services web sites and other useful information on elder abuse.
NAHC: National Association for Home Care and Hospice (www.nahc.org) A membership organization of home health agencies, hospices and home care aide organizations
NCQA (National Committee for Quality Assurance) (www.ncqa.org): Founded in 1979, the NCQA performs external review of quality assurance programs in prepaid health plans.
NLN (CHAP): National League for Nursing’s Community Health Accreditation Program (see under CHAP above).
Nutritional services: The assessment, planning, and recommendations for a patient’s nutritional needs by a dietitian.
OASIS (Outcome and Assessment Information Set) (www.cms.gov/HomeHealthQualityInits/06_OASISC.asp): The instrument/data collection tool used to collect and report performance data by home health agencies. Since 1999, CMS has required Medicare-certified home health agencies to collect and transmit OASIS data for all adult patients whose care is reimbursed by Medicare and Medicaid with the exception of patients receiving pre- or postnatal services only. OASIS data are used for multiple purposes including calculating several types of quality reports which are provided to home health agencies to help guide quality and performance improvement efforts. Beginning in January 2010 the latest version OASIS-C includes data items supporting measurement of rates for use of specific evidence-based care processes. From a national policy perspective, CMS anticipates that these process measures will promote the use of best practices across the home health industry. Selected OASIS items are also used to define case-mix payments for the 60-day episode.
Occupational therapy services: Assist the patient to attain the maximum level of physical motor skills, sensory testing, adaptive or assistive devices, activities of daily living, and specialized upper extremity/hand therapies. While occupational therapy does not, in itself, constitute a basis for entitlement to Medicare reimbursement, a beneficiary of home health services (i.e., skilled nursing care, physical, and/or speech therapy) is also covered for occupational therapy.
Outcomes Based Quality Improvement (OBQI) : OBQI Reports include 37 risk-adjusted outcome measures from OASIS-C . These reports allow home health agencies to proceed into the second phase of OBQI, called outcome enhancement. It is the outcome enhancement activities that allow an agency to focus its quality (or performance) improvement activities on select target outcomes, to investigate the care processes that contributed to these outcomes, and to make changes in clinical actions that will lead to improved patient outcomes. If the agency carefully implements the steps in this process, this change in patient outcomes is expected to be evident when the next report is accessed. (www.cms.gov/HomeHealthQualityInits/Downloads/ HHQIOBQIManual.pdf)
PACE (Program of All Inclusive Care for the Elderly) (www.cms.gov/pace): PACE is an optional benefit under both Medicare and Medicaid in which dually eligible persons who are frail enough to meet state standards for nursing home care are offered an alternative to institutionalization. Under PACE, they are offered comprehensive medical and social services through adult day centers and home and/or inpatient facilities. PACE is available only in states that have chosen to offer it under Medicaid.
Parenteral nutrition therapy: Therapy to assist patients unable to digest food by the gastrointestinal tract. A catheter, usually centrally placed and attached to an infusion pump, supplies nutrients to the patient’s bloodstream. Supplies and equipment are reimbursable under Medicare Part B for patients with Medicare-specified diagnoses.
Patient Protection and Affordable Care Act (PPACA): Federal health care reform legislation enacted 2010.
PECOS (Provider Enrollment, Chain and Ownership System)– As of July 2010, physicians making referrals to home health agencies and durable medical equipment vendors are required to be enrolled in the CMS, Web-based database, PECOS.
Personal care: Assistance with activities of daily living, including bathing, toileting, dressing, grooming, transferring and feeding.
Physical therapy services: The treatment of neuromuscular and musculoskeletal dysfunctions through the application of physical agents (heat, cold, ultrasound, etc.) and neuromuscular procedures to alleviate pain, prevent disability, and rehabilitate function after disease or trauma. Services are based on patient need and should have a restorative function. This usually means that the patient has a fair or good rehabilitation potential. The physical therapy documentation must show progress toward established goals.
Primary family caregiver or care partner: Relative or significant other who assumes many of the tasks involved in caring for a home care patient that the patient is unable to perform.
Private-duty nursing: Nursing, chore service, housekeeping, and other types of patient care administered in a hospital, in a nursing home, or by a home health agency. Private-duty nursing is covered by some private-pay insurers or is self-pay.
Psychiatric nursing: The nurse must meet specific credentialing and training requirements to perform home health psychiatric nursing. Psychiatric nurses specialize in caring for home care patients with mental disorders but should also be able to perform other aspects of home health such as wound care.
Quality control: A management process where performance is measured against expectations and corrective actions are taken as needed.
Recertification: The attending physician certifies that the beneficiary requires continued skilled services after the expiration date of the initial certification, and then periodically thereafter.
Respiratory care services: Required by patients who suffer from a variety of chronic pulmonary or heart related problems. Home respiratory care treatment (oxygen therapy, intermittent positive-pressure breathing [IPPB] therapy, etc.) is covered under Medicare Part B, based on criteria of medical necessity.
Respite care: Services provided on a short-term basis to individuals unable to care for themselves. Respite care provides a relief (respite) for those persons normally providing care to the individual, allowing these caregivers time off to attend to their own needs or the needs of other family members.
Skilled nursing services: Occurs when a registered nurse uses knowledge as a professional nurse to execute skills, render judgments, and evaluate process and outcomes. The skills allowed in home health are assessment and observation, teaching and training, direct procedures, and management and evaluation of the care plan.
Speech therapy services: Provided by a speech and language therapist as part of the home rehabilitation program for patients with cerebrovascular accidents, tracheostomies, laryngectomies, and various neuromuscular diseases.
Telehealth: Technology that allows remote monitoring of a patient. It can include transmitting patient data, such as weight, vital signs, and blood sugar levels, to two-way video communication and listening devices (e.g., telestethoscopes) in order to conduct virtual health care visits.