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Eligibility and Referral for Home Health Care Services

Palomar Home Health Care follows Medicare criteria for admission to our services. This criterion is as follows:

  1. We accept patients for services based on an expectation that the patient needs can be met and that continuity of care can be provided. Patients may be self referred or referred by physician, discharge planner, friend or family member.
  2. The patient/client and if necessary, a competent caregiver, must be willing to be trained and able to participate in the plan of care, comply with the therapeutic regimen and agree that the patient/client should receive care at home. If the patient requires shift care, there needs to be a family member or a trained and competent caregiver to assume care in the event the agency is unable to staff a shift.
  3. Both the patient/client and the physician (if applicable) must understand the scope of home care services and agree to work cooperatively with the agency. The agency must have adequate and qualified personnel and resources to provide the services required; this includes the ability to provide care to patients in all age groups and nationalities with language needs considered.
  4. The physical facilities and resources in the patient’s residence, school and/or community environments must be adequate for proper and safe care. For a private duty shift case:
    • Physical facilities and resources in the patient’s home, school, and/or community environments will be adequate for proper and safe care to the client and staff member.
    • The patient has a family member or significant other trained and competent to assume care in the event the agency is unable to staff a shift.
    • The patient/family member agrees to keep privately owned medical and emergency equipment appropriately calibrated and maintained for safe and accurate delivery of nursing care.
  5. There must be a plan to meet medical emergencies.

     
  6. There is a reasonable expectation that payment will be received, or there is a payment source (private pay, insurance, MediCal, Medicare, etc.)
  7. Authorization number (if applicable) must be obtained by us before initiating services.
  8. The patient resides in the geographical area served by the agency.
  9. If all parties agree that the patient is an acceptable candidate for services a more complete evaluation will occur. The subsequent evaluation will intensively consider the following admission criteria.
    1.  Current medical status including:
      • Patient’s current diagnosis(es) and medical problems.
      • Patient’s current medical history.
      • Patient’s past medical history.
      • Pertinent physical findings, including any physical limitations.
      • Pertinent laboratory test results.
    2.  For infusion cases:
      • Appropriateness of the choice of drug(s) chosen for the patient.
      • Appropriateness of the dose, route, and frequency of administration for the patient.
      • Availability of suitable venous access, where appropriate.
  10. Criteria for admission under Medicare home health services also includes:
    • The patient must be homebound as required by the payer.
    • The patient must require skilled qualifying services.
    • The care needed must be intermittent (part time.)
    • The care must be a medical necessity (must be under the care of a physician.)
    • The care must be reasonable and necessary.
    • There is no duplication of services.
  11. We cannot accept for service any patient known to be in an unsafe environment (either for patient/client or agency staff) or any case in which specialized care is required and specialty-prepared staff are not available. If the patient/client does not meet admission criteria, the patient/client is referred to alternate services and the referral source and the physician (if applicable) are notified.
     

Contact or call us for any Home Health related questions at 760.739.2299 or 800.525.3010 .