Back in the Hospital During Home Health: What Next

Your mom or dad was on home health. The nurse came twice a week, the therapist was working on walking, and things were settling into a routine. Then a fall, or a fever, or trouble breathing, and now your parent is in the hospital again.

I'm an occupational therapist, and I've picked up a lot of patients after a hospital stay. The smoothest returns were in families who knew what happens to home health in the meantime, and what to ask before coming home.

ER Visit, Observation, or Admission: It Makes a Difference

From home health's side, what matters is whether your parent was admitted as an inpatient. CMS's OASIS manual, which agencies follow when they assess patients, defines it. An agency records a transfer when the patient is admitted to an inpatient facility "for 24 hours or longer (for reasons other than diagnostic tests)". And it says plainly what doesn't count:

"Short stay observation periods in a hospital OR time spent in the ER, regardless of duration, do not meet the definition for transfer to an inpatient facility."

So an ER visit, or a night "under observation", is not a transfer, even a long one. And because a resumption of care is for a patient who "Resumes care following an inpatient stay of 24 hours or longer for reasons other than diagnostic tests," no resumption visit is required either. In my experience, home health just keeps going after one of those. Call the agency anyway. It must "promptly alert" the doctor to changes in your parent's condition that suggest the plan of care should change (42 CFR §484.60(c)(1)), and it can't if it doesn't know about the ER trip.

If your parent stays overnight, ask the hospital staff: "Is my parent admitted as an inpatient, or under observation?" The agency will want that answer.

What Happens to Home Health During the Hospital Stay

Visits at home stop, because your parent isn't home. Behind the scenes, the agency records one of two kinds of transfer:

Transfer, not discharged. The patient "is admitted to an inpatient facility for 24 hours or longer (for reasons other than diagnostic tests), with the expectation that home health care will be resumed following inpatient discharge." In the manual's words, "The patient is not discharged from the agency."
Transfer and discharged. The agency "does NOT anticipate the patient will be returning to care." The manual's examples include "The patient needs a higher level of care and is no longer appropriate for home health care." and "The patient’s family plans on moving the patient out of the service area."

If the agency isn't sure your parent will come back, the manual says to use the first one. Nobody has to visit the hospital for this: "A telephone call may provide the information necessary to complete the required data items."

One more case: if your parent goes on to a skilled nursing facility, an inpatient rehab facility, a long-term care hospital or a psychiatric hospital during the 30-day period of home health care, the manual says CMS "expects and recommends (but does not require) the HHA to discharge the patient" and start over with a new start of care when your parent comes home.

Tell the Agency the Same Day

This is my suggestion, not a rule, and it's the most useful thing you can do. Call the agency the day your parent is admitted, or as soon as you know.

The agency has its own deadline. When a patient lands in the hospital unplanned, the agency must send a transfer summary "within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer" (42 CFR §484.110(a)(6)(iii)). The clock starts when the agency becomes aware, so your phone call can be what starts it. That summary tells the hospital team what home health was doing.

Tell them which hospital, the admission date and the reason if you know it, and ask them to let your parent's nurse or therapist know.

Coming Home: Does the Same Agency Come Back?

If the agency did not discharge your parent, it plans to pick up where it left off. The visit that does this is called the resumption of care. Even then, the agency needs the doctor's go-ahead. The OASIS manual tracks the date the agency received "authorization to begin or resume home care".

If the agency did discharge your parent, home health starts again as a new start of care, the way it did the first time. Medicare's benefit manual says a new certification happens "anytime that a Start of Care OASIS is completed to initiate care." In plain words, a doctor or allowed practitioner signs off on home health again, as if for the first time, and a new plan of care is written. Usually the hospital's discharge planner is the person who sends that new referral.

Either way, you get a say. Medicare's booklet on home health says "You have a say in which agency you use, and your doctor (or allowed provider), hospital discharge planner, or other referring agency should honor your choice." The hospital's own discharge planning rule says it must tell you about your "freedom to choose among participating Medicare providers and suppliers of post-discharge services" (42 CFR §482.43(d)(2)).

If the first agency was a good fit, name it to the discharge planner before your parent leaves. If it wasn't, this is a natural time to ask for another. Our guide on how to choose a home health agency covers how to compare them. Whichever agency it is, the hospital must send it "all necessary medical information pertaining to the patient's current course of illness and treatment" at discharge (42 CFR §482.43(b)).

The Resumption of Care Visit

This visit is a full reassessment, not a quick check-in. The federal rule for home health says the comprehensive assessment must be updated:

"Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner-ordered resumption date" (42 CFR §484.55(d)(2))

If the doctor didn't give a specific resumption date, the manual says the visit "must be conducted within 48 hours of the referral or within 48 hours of the patient’s return home from the inpatient facility." The full assessment itself, in the manual's words, "must be completed within 2 calendar days of the facility discharge date, the agency’s knowledge of the patient’s return home, or a physician-ordered ROC date."

Who comes? The manual says "The ROC assessment must be completed by an RN, PT, OT, or SLP." This is the return visit; the rules for the very first visit are different. That's a registered nurse, or a physical, occupational or speech therapist. It also says a licensed practical nurse, a therapy assistant or a home health aide "may not be responsible for completing the comprehensive assessment and OASIS." Which clinician comes depends on what your parent's orders are for.

Care that can't wait, like an injection, "may be provided before the ROC comprehensive assessment is completed," in the manual's words. Part of every comprehensive assessment is "A review of all medications the patient is currently using" (42 CFR §484.55(c)(5)). After a hospital stay, that's the part I'd pay the most attention to.

Bring the New Papers, Sort Out the Medicines

None of this is a rule. It's what I've seen help.

The new discharge papers. Not the ones from last time. Put the old ones away so nobody reads from them by mistake.
The new medication list. Hospitals often stop, start or change doses. In my experience, medication mix-ups after a second hospital stay are common, because the old bottles are still in the kitchen.
Every bottle in the house, old and new, in one bag for the nurse. Don't throw anything out until the nurse or the pharmacist has gone through it with you. Then follow their advice on what to set aside.
The names of any new doctors your parent saw in the hospital, and the follow-up appointments.

If the bottles and the new list don't match and the nurse hasn't come yet, call the doctor's office or the pharmacist. Don't guess.

New Orders, New Visit Schedule

Expect the plan to change. The rule says the plan of care must be reviewed and revised "as frequently as the patient's condition or needs require, but no less frequently than once every 60 days" (42 CFR §484.60(c)(1)). Any revision due to a change in health status "must be communicated to the patient, representative (if any), caregiver" and the doctors on the plan (42 CFR §484.60(c)(3)(i)).

Visits per week might go up, or a new discipline might be added. If you haven't heard about a new schedule a few days after the resumption visit, ask.

Does the 60-Day Period Start Over?

Usually not. The OASIS manual says: "Unless the patient has been discharged, the due dates for Follow-Up (recertification) assessments are calculated from the original Start of Care date rather than from the Resumption of Care date." In plain words, the resumption doesn't reset the clock.

There are two exceptions in the manual. If your parent was discharged, care starts over. And "If a Medicare patient returns to the HHA after an inpatient stay that spans the end of the 60-day certification period, Medicare requires a new start of care assessment."

What to Ask the Discharge Planner Before You Leave

This is my list, not a rule:

Was my parent admitted as an inpatient, or under observation?
Has the home health agency been told my parent is coming home, and when?
Did the doctor write a date for home health to resume?
Which medicines are new, which stopped, and which changed doses?
Who is the follow-up doctor, and when is the appointment?

Write the answers down. If the agency calls before the papers reach it, you'll have what it needs.

When to Call the Doctor, and When to Call 911

This is general safety, not medical advice.

If it's an emergency, call 911. Don't wait for the agency or the doctor.
If something seems wrong but isn't an emergency, call the doctor's office, and call the agency so the nurse knows.
Follow the hospital's discharge instructions. If they don't say which signs mean "call the doctor" and which mean "go to the ER," ask before you leave.

The First Days Back

For the general picture, our guide to leaving the hospital with home health covers what to have ready and who to call if nobody comes. If the stay changed what your parent can do, getting your home ready for home health goes room by room.

If you want the agency's side, our resumption of care guide is written for clinicians and goes through the rules in more detail.

Frequently Asked Questions

Does home health stop if my parent goes to the ER?

Not by itself. CMS's OASIS manual says time spent in the ER, or an observation stay, does not count as a transfer to an inpatient facility, however long it lasts. A transfer is an inpatient admission of 24 hours or longer for reasons other than diagnostic tests. Call the agency the same day either way, so the nurse and the doctor know what happened.

Will the same home health agency come back after the hospital?

If the agency did not discharge your parent, it plans to resume care with a resumption of care visit. If it did discharge your parent, home health starts over with a new start of care. Either way, you have a say in which agency you use. Tell the hospital discharge planner which agency you want before your parent leaves.

How soon should home health come back after a hospital stay?

Medicare's rule says the assessment must be updated within 48 hours of your parent's return home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on the resumption date the doctor or allowed practitioner ordered. Call the agency the day your parent is coming home.

Does the 60-day home health period start over after a hospital stay?

Not when care resumes. CMS's OASIS manual says that unless the patient has been discharged, the next recertification is counted from the original start of care date, not the resumption date. If the hospital stay runs past the end of the 60-day period, Medicare requires a new start of care.

Sources

Want a different agency this time?

See the Medicare-certified home health agencies that serve your ZIP code, from Medicare's Care Compare data, with phone numbers and star ratings.

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Back in the Hospital During Home Health: What Happens to Care, and How It Picks Up Again