Home Health Care Today

Home Health Care Today

Cold Winds Blowing From Capitol Hill

By Michael E. Donnellan, MBA, RRT

In a magical land called Oz, far, far away, home health care is provided by Munchkins under the watchful eye of a wizard. The elderly are contented, healthy, and cohesive as they travel the Yellow Brick Road. With excellent family values and unlimited funding, Ozlings enjoy the benefits of a perfect home health care environment. After all, explained one Ozling, “Society is ultimately judged by how well it treats its most vulnerable members.”

Over the rainbow, a far different reality exists in Kansas. In the United States, more than 20,000 separate providers deliver home care services to some 8 million individuals with long-term or permanent health disabilities or terminal illnesses. And the bean counters are crunching the numbers hard to keep down expenses.

Home care costs, estimated at $40 billion in 1997, rose to $42 billion in 1998, when the average cost per Medicare home health care visit was estimated to be $67. The numbers have been steadily climbing since. Such statistics cannot be taken at face value because of variables across the spectrum of the entire data-collection system. The statistics do, however, indicate spending trends of a system under siege and possible outcomes based on demographics, reimbursement policies and attitudes. Translation: There are more people seeking services than ever before, and more caregivers are needed to provide the services.

As of September 1998, there were approximately 500,000 people employed in home health care (representing 372,453 FTEs). The largest subsets were health care aides and RNs. Respiratory therapists represent only a small percentage of the total number. But as the number of potential patients grows annually, it is a normal progression for RTs to move into home health care to watch over the infirm, most of them tranfers from acute care facilities where they needed the services of RTs and continue to need them in a new setting.

Therapists looking to beef up employment numbers today need to take heed of the changing economic and political climates influencing home health care financing today. RTs choosing to practice in home health care must gird themselves against cold winds blowing in from Capitol Hill. Home care reimbursement is being slashed to hold down costs and the federal government is asking home care providers to do more with less. In turn, third-party insurers are adopting the same philosophy.

The American Association for Respiratory Care (AARC) has become politically active on home health care issues in a major effort to preserve safe clinical standards for patients and to save respiratory therapy jobs. Although the AARC’s efforts are noble, the tide of cost-conscious care continues to swell.


There are problems beyond reimbursement in the home care field. It’s important for RTs to know up-front that DMEs often have their own hidden agendas. So before RTs commit their time, reputation and license to these agencies, they need to investigate the firm thoroughly. Some therapists have been caught up in Medicare fraud and abuse cases because they were not as wary as they should have been. Beware the superficial and look beneath the surface veneers.

While there are pitfalls, there are also rewards. Home care agencies can provide a great opportunity for therapists to practice their clinical, patient assessment, in-services and interventional medicine skills. There are other perks too. Agencies often provide CEU opportunities, liability insurance, automobiles and even auto insurance coverage.

Still, there are no universal practices in the industry. Some agencies use drivers to deliver and set up oxygen equipment and then rely on RTs to follow through with the care. The agency may even assign clinical duties to non-caregiver drivers, in violation of clinical practice guidelines and the law. Watch out for the such situations.

Some DMEs rely on RTs to do it all–delivering equipment and providing 24-hour a day coverage seven days a week. This is tolerable if there is a large staff. However, if staffing levels declines, RTs may find their caseloads swelling.

As in acute care hospitals, RTs cannot provide direct, hands-on patient care unless a physician has ordered specific treatments. If treatments are part of the normal DME procedures, therapists must be certain there is a system in place to link therapists to the physicians so therapy beyond approved responsibilities, like basic spirometry, oxygen saturation, breath sounds and patient assessment, can be discussed.


Despite its current under-funded status, the home health care industry is destined for growth because it will be servicing a greater number of senior citizens as the baby boomers age. RTs with their skills will probably survive in the arena because of their keen understanding of equipment technology and the disease processes. In fact, few can match their skills and abilities in the entire health care spectrum.

Escalating costs and lower reimbursements will probably impact RT roles for the short term. Even with current cutbacks, it is inevitable there will be a need for RTs to serve as consultants as a minimum. But this will probably be only short term until the cost-efficiency of therapists can be assessed fully against overall health care costs.

There are, of course, good and bad apples in home care, just as there are at every level of health care. Most home health care agencies and DMEs require a minimum of two years of hospital acute care as a prerequisite for RTs. If you do encounter companies that are simply looking for a breathing individual who will not ask many questions, your radar screen should be up and buzzing and you should take off running.

Before you ever agree to work for a home care agency, check its references and business reputation carefully. Check the qualifications of those who work there. Remember, too, that equipment maintenance is important. A simple visit to the firm’s warehouse can reveal much about the quality of care the company claims to represent. Request a copy of the company’s liability insurance for scope of coverage. The insurer should have an excellent track record, as well.

There is a future for RTs beyond acute hospital care, and home care–one potential option–can be satisfying. After all, most patients would rather get their care at home than in a facility, so they do appreciate the efforts of their caregivers. But in such a setting, therapists need to remember they will be working alone in the individual’s sanctuary and act accordingly. And if you want to work in home care, select an agency that believes the same thing.

While home health care must be grounded in reality, it is just as vital to remember it can be a magical kingdom of Oz only a few “heal” clicks removed from Kansas.

Michael Donnellan is a perinatal/pediatric specialist at Sutter-Alta Bates Medical Center, Berkeley, Calif.