The home health team, role by role

Home health can bring several people through the front door in the same week: a nurse on Monday, a therapist on Tuesday, an aide on Thursday. It helps to know who each one is and what they’re there to do. Medicare’s rules spell out the roles, who leads, and who checks on whom.^1,2 This note goes role by role, starting with the person who orders the care and ending with the family.

The short answer

• A doctor or allowed provider orders home health and signs the plan of care.³
• A registered nurse usually leads: the first assessment, the nursing care, the teaching and the plan.⁴
• Physical, occupational and speech therapists come when the plan calls for them.⁵
• A medical social worker helps with social and emotional problems that get in the way of recovery.⁶
• A home health aide helps with bathing, dressing and getting around, under a nurse’s or therapist’s written instructions.^2,6
• A clinical manager at the agency oversees all of it, and the family is part of the plan too.^7,8

The doctor or allowed provider

Home health starts with an order. The person ordering can be a doctor or an allowed provider, which includes a nurse practitioner, a clinical nurse specialist or a physician assistant.³ They certify that the person qualifies, sign the plan of care and review it regularly.³ The agency has to tell them promptly when the person’s condition changes in a way that means the plan isn’t working or needs to change.⁸

The doctor doesn’t usually come to the house. The nurse and therapists are their eyes there, and the calls between them are how the plan changes.

The registered nurse

A registered nurse makes the first visit, unless therapy is the only service ordered.⁴ The nurse assesses the person’s health, mood and thinking, how they move and care for themselves, their medicines and their caregivers, and that assessment becomes the base of the plan.⁴

After that, the nurse gives skilled nursing care. Medicare’s examples include caring for a pressure sore or a surgical wound, teaching the patient and caregiver, IV or nutrition therapy, injections, and watching a serious illness or unstable health.⁵ The nurse reviews every medicine for side effects, interactions, duplicates and missed doses,⁴ and calls the doctor when something changes. Nursing services are supervised by a registered nurse.¹

The therapists

Medicare covers physical therapy, occupational therapy and speech-language pathology at home when the person meets certain conditions.⁵ Each works on a different part of getting through the day:

• Physical therapists work on walking, strength, balance and getting in and out of a bed, a chair or a car safely. The science of physical therapy at home explains what the research shows.
• Occupational therapists work on everyday tasks like bathing, dressing and making a meal, and on setting up the home so those tasks are safer.
• Speech-language pathologists work on speech, language and swallowing, often after a stroke or with Parkinson’s disease.

Like the nurses, the therapists assess the person, help build the plan with the person and family, give the care the doctor ordered, teach, and keep the doctor informed.¹ Therapy is supervised by a physical or occupational therapist.¹

The medical social worker

A medical social worker helps with social or emotional problems that are getting in the way of treatment or recovery.⁶ Medicare can also cover short-term help for a family member or caregiver when the problem clearly and directly gets in the way of the person’s care.⁶ The social worker comes when it’s ordered as part of the plan of care.⁶

The home health aide

A home health aide gives hands-on personal care, such as bathing, dressing, grooming, eating, moving from bed to chair, and walking. Aides can also do simple dressing changes, help with medicines the person usually takes on their own, and help with exercises that support the therapy.⁶

Aides are trained for at least 75 hours, including at least 16 hours of supervised practical training.² They work from written care instructions a registered nurse or therapist prepares, and when the person is also getting skilled care, a nurse or therapist checks the aide’s care in the home at least every 14 days.²

Medicare covers aide visits only while the person is also getting skilled nursing or therapy.⁵ An aide isn’t a full-time caregiver, and Medicare doesn’t cover personal care when it’s the only care someone needs.⁵

The clinical manager

Behind the visits, a clinical manager at the agency oversees the patient care and the staff: making assignments, coordinating care and referrals, making sure the person’s needs keep getting assessed, and keeping the plan of care current.⁷ The agency gives the family the clinical manager’s name and contact information in writing.⁸ If something isn’t working and the visiting nurse can’t fix it, that’s the next call.

The family

The plan of care includes teaching the person and their caregivers, including what they’ll need to know to manage after home health ends.⁸ The assessment asks who helps the person, and when they’re able and willing to.⁴ Be honest about that. A plan built on help that isn’t there won’t hold up.

Keep a notebook by the door. Ask each person who visits to write down what they did and what to watch for. It helps the next visitor, and it helps the family keep track. The first home health visit covers what to have ready.