Caring for people in their own homes plays a significant role in the delivery of healthcare. Studies show that providing care at home as opposed to in a clinical setting enhances a patient's quality of life and independence. It is also much more cost effective than long hospital or nursing home stays. The variety and scope of services now available makes home care not only more possible than before, but more practical and comfortable as well. As a result of all that is now being offered, home care has become the fastest-growing service industry in the United States in recent years. According to the National Association for Home Care & Hospice, approximately 20,000 providers currently deliver home care services to 7.6 million individuals. In 2003 alone, the annual expenditures for home healthcare services amounted to around $38.3 billion. A Brief History of Home Care The concept of home care is as old as time. Before the rise of the modern hospital during the last century or so, inpatient care was rare. So the only place the sick and elderly could receive care was at home. On the other hand, the concept of organized home care is fairly new. In the late 1800s when infectious diseases and high death rates dominated the American healthcare scene, the demand grew for trained nurses who could visit homes and ease the burden of care for families. In those days, homes, not hospitals or other clinical settings, were the workplaces for most nurses. Not only did they care for the sick, they also provided prenatal care, assisted with home deliveries and helped new mothers learn how to care for their babies. In the early years of the 20th century, hospital-based care became the more trusted method of care, and home-based services suffered a decline. But beginning in the mid-1950s, rising medical costs, an increase of chronic illnesses and a growing elderly population triggered a renewed interest in home care. Then in the 1960s, Medicare and Medicaid came along, both offering coverage for certain home care services, which further spurred growth in the home healthcare industry. Boosted by the healthcare policy trends of the 1970s and 80s favoring home care, the growth of the industry continues today. Defining Home Care The American Medical Association defines home care as "the provision of equipment and services to the patient in the home for the purpose of restoring and maintaining his or her maximal level of comfort, function and health." Providers include home health agencies, hospices, home care aide agencies, private-duty agencies, and companies specializing in medical equipment and supplies. The functions in some organizations overlap, and some may merge in order to provide a wider variety of services through one entity. The ideal home care scenario involves a collaborative effort of patient, family and professionals, and the needs that can be met in the home are many. Home care services range from light housekeeping to hospice with clients ranging from pediatric to geriatric. In addition to physicians and nurses, other professionals, including speech therapists, physical therapists, occupational therapists and social workers, may be involved in the plan of care. Reasons for home care may include helping a physically frail elderly person remain at home, facilitating recovery and rehabilitation from surgery, or caring for those with permanent disabilities or terminal illnesses. The Role of the Physician in Home Care Over the years, home care has become increasingly sophisticated. Services traditionally provided in a hospital, such as drug infusion therapy and respiratory support, are now routinely being moved into the home, posing new challenges for physicians as far as supervising care. Complicating matters is that other caregivers are usually separate from the physician's practice. In those cases, coordinating a patient's care is difficult, yet it is critical to the welfare of the patient that coordination occurs. It is also critical to doctors since the legal responsibility for supervising medically necessary care falls to them. In its publication "Medical Management of the Home Care Patient: Guidelines for Physicians," the American Medical Association specifically addresses the role physicians should play in home care (see sidebar). Equipping the Home Care Patient An important component of the home care industry is the equipment that may be needed to improve a patient's quality of life. Whether it's a cane, bathroom equipment, oxygen or sleep disorder monitors, there are usually certain items that can help a patient become more mobile, more comfortable or even less prone to infection or other complications. For example, says Joe Bryant of Happy Home Heath Care in Alabaster, a patient may be suffering from a condition that requires him or her to be in bed more time than not. In such a case, a hospital bed would be more practical than a regular bed. "A nurse is often not there 24/7, and many doctors are not aware of what a home medical equipment agency could provide," says Bryant. "A lot of times a doctor will order a nursing assessment or evaluation, but not an equipment evaluation." A good home equipment agency, he says, will offer a free assessment of equipment needs. A representative will often meet with family members, nurses or both to determine needs and make recommendations. "This is a component that's really being missed by the medical community," Bryant says. "The right equipment goes a long way toward making a patient's stay at home a much more quality option." Non-medical Home Care But people in need of home care services may not always be in need of medical care. For example, an elderly person living alone may only require help with personal care or meals. Younger people recovering from surgeries or debilitating illnesses may need only temporary help with errands or laundry. These are situations where a non-medical home care service can help. "Events may change clients' circumstances, or they may just need some help getting over a hump, "says Dan Pahos, director of Home Instead Senior Care in Birmingham. "We also work with other entities to ensure a continuum of care. It's just a matter of choosing who can deliver the right care." In regard to helping physicians address non-medical issues with their patients, Pahos has found that many doctors don't even know such services exist. Thus, Pahos and others in the non-medical home care industry are now trying to get the word out. "It's certainly under the radar," Pahos explains. "We often get a surprised, 'Wow! I didn't know there was such a thing.' Our biggest battle is just letting doctors know we exist." Other non-medical services include medication reminders, shopping, and light housekeeping. These services are also available to those in nursing homes and assisted living facilities who may need help beyond what is routinely provided. Medicare Considerations Regarding Home Care In considering home care for a patient, physicians should be aware of insurance issues or in the case of the elderly patient, Medicare requirements. Medicare will not pay home care services unless a beneficiary meets four specific conditions. First, a doctor must decide the care is needed and prescribe it. The home health agency makes an assessment and develops a plan of care, which the doctor must then approve and sign. Second, the patient must need either part-time or intermittent skilled nursing care, physical therapy or speech-language services. Third, the patient must be homebound, and fourth, services must come from a Medicare-approved agency. If all four conditions are met, Medicare will help cover skilled nursing, home health aide services, therapy, medical social services, certain medical supplies and durable medical equipment. Medicare does not pay for 24-hour home care, prescription drugs (certain exceptions apply), meal delivery, or homemaker (cleaning, laundry, shopping, etc.) services.