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Home Care’s Role in a Healthcare Continuum

Family caregivers, elderly individuals, and people with disabilities have more choices than ever when it comes to selecting a home care agency. Many agencies offer niche, boutique services like transportation to appointments or even dog-walking, aimed at accommodating ultra-specific, unique client needs. Finding an agency who can deliver service in a concierge manner is critical for some. For others, agencies who provide individualized care, but also participate in a holistic, continuums are more beneficial.

Facilities and organizations – like hospitals and visiting nurse associations – that serve the medical needs of their communities, benefit greatly from partnerships with home care agencies. When these organizations partner with home care agencies, they promote communication between silos of healthcare networks, improve patient outcomes, and ensure that familiar caregivers remain in place.

When a hospital discharges an individual, they are usually referred to a visiting nurse association to help transition from the hospital environment to the home environment.  From there, many visiting nurse associations will either utilize their own team of home care aides, or partner with a home care organization to deliver scheduled visits reimbursed by Medicare or Medicaid.  The visits performed by home care aides allow individuals are designed to help individuals remain at home. These frequent visits yield valuable information about changes to clients’ mental or physical health. When a home care agency has a partnership with a visiting nurse association, they can communicate changes in client status to a nurse, physical therapist, or occupation therapist. From there, the client’s care plan can be updated to reflect a change in status reported by the home care aide. In this way, both organizations are leveraging their respective expertise to prevent re-hospitalization.

After a client is no longer eligible for Medicare or Medicaid funded service, a visiting nurse association who partners with a home care agency may be able to refer the client to their home care partner to receive continued service focused on keeping the client at home. Although the client may have to pay privately for the service, they have assurance that if a major event (fall, chronic condition, etc.) occurs, the home care agency can immediately enlist the services of the VNA to assess the client and determine eligibility for Medicare or Medicaid funded care. If so, the VNA can intervene. This is an example of how agencies and visiting nurse associations can work together to prevent unnecessary client hospitalizations.

Perhaps the greatest benefit of the care continuum presented in the VNA/home care arrangement is the continuity of caregivers. The one constant in the situations described in this article is the home care aide. When a VNA calls on a home care agency to deliver service, the goal is for the agency to supply an aide who will develop a therapeutic relationship with the client. If the client chooses to pay privately after the VNA is no longer involved they can keep their home care aide in place and maintain a positive relationship. Lastly, if an event occurs that requires the VNA to resume skilled care, the client and their family can keep the same aide.

Home care aides are a familiar face who understand the client’s needs, recognize daily or weekly changes in behavior or condition, and communicate effectively with their employers. This ground-floor role is the core of a successful care continuum.


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