Who's Who on the Home Health Team, and Why the Assistant Came Instead of the Therapist

Home health has started, and people keep coming to the house. A nurse on Monday. A physical therapist on Tuesday. Then someone who says she's the PTA, and an aide on Thursday. You're not sure who is who, and you wonder why the therapist stopped coming and sent an assistant.

I'm an occupational therapist, and I've worked in home health. This guide lists who may come, what each person does, and the Medicare rule behind each role. Two kinds of rules are here. The agency rules (42 CFR Part 484), like who does the first visit and how aides are supervised, apply to every patient of a Medicare-certified agency. The coverage rules (42 CFR Part 409), like the 30-day therapist visit, are Original Medicare's. If your parent has Medicare Advantage, Medicaid or private insurance, ask the plan how it handles them.

The Short Version

The third column is my plain summary. The rule column is where to read the actual text.

Nurses: RN and LPN

A registered nurse usually comes first. The rule says "A registered nurse must conduct an initial assessment visit", and when therapy is the only service ordered, a therapist may do it instead. For Medicare, an occupational therapist may do it only when OT is ordered along with physical therapy or speech (42 CFR §484.55(a)(1) and (a)(2)). Our guide to the first home health visit covers that visit.

A licensed practical nurse (called a licensed vocational nurse in some states) also gives skilled nursing care. Medicare defines skilled nursing as services performed by "a registered nurse, or practical (vocational) nurse" (42 CFR §409.44(b)(1)), and the LPN works "under the supervision of a qualified registered nurse" (42 CFR §484.115(e)).

For the longer comprehensive assessment, the rule names a registered nurse, or a therapist on a therapy-only case (42 CFR §484.55(b)(2) and (b)(3)). It doesn't name an LPN or an assistant.

Therapists: PT, OT and Speech

Families mix up PT and OT more than anything else. Here's how I explain it, as my shorthand, not a Medicare definition:

• Physical therapy works on walking, getting in and out of a bed or chair, strength and balance.
• Occupational therapy works on the daily activities of living: bathing, dressing, using the toilet, getting around the kitchen, and setting up the home so those things are safer.

Many patients get both.

A speech-language pathologist works on speech, language and swallowing. Medicare's home health rules don't define a speech-language pathology assistant. The personnel rule sets standards for occupational therapy, physical therapist and social work assistants, and none for a speech assistant (42 CFR §484.115). The coverage rule names PT and OT assistants but only "a qualified speech-language pathologist" for speech (42 CFR §409.44(c)(2)(ii)). So for Medicare home health, expect the speech therapist to make the speech visits.

Why Did the Assistant Come Instead of the Therapist?

The plain answer: the doctor ordered a service, not a person. Orders must specify the treatments, "the type of home health discipline that will furnish the ordered services and at what frequency" (42 CFR §409.43(b)). Physical therapy twice a week is an order for physical therapy. It doesn't say whether a PT or a PTA makes each visit.

Medicare's coverage rule says therapy must be something that can be done safely and effectively only "by a qualified physical therapist or by a qualified physical therapy assistant under the supervision of a qualified physical therapist", and the same sentence names the occupational therapy assistant under an occupational therapist (42 CFR §409.44(c)(2)(ii)). So a PTA visit is a physical therapy visit. A COTA visit is an occupational therapy visit. An LPN visit is a nursing visit. Each assistant works under a licensed clinician of their own discipline.

Two rules limit what the assistant does:

1. The therapist goes first. "The patient's function must be initially assessed and periodically reassessed by a qualified therapist, of the corresponding discipline for the type of therapy being provided" (42 CFR §409.44(c)(2)(i)(A)). The therapy goals must be set by a qualified therapist with the doctor (§409.44(c)(1)(i)). The assistant's treatment visits come after that.
2. The therapist comes back at least every 30 days. The rule: "At least every 30 calendar days a qualified therapist (instead of an assistant) must provide the needed therapy service and functionally reassess the patient" (42 CFR §409.44(c)(2)(i)(B)). If that's missed, Medicare doesn't cover that discipline's therapy visits until the therapist has reassessed (§409.44(c)(2)(i)(C)).

The assistant is supervised by a therapist (42 CFR §484.75(c)(2)). Beyond that 30-day therapist visit, I couldn't find a Medicare home health rule that sets how often the supervising therapist must come out. State licensing rules for assistants may say more.

If something worries you, ask to talk to the supervising therapist. You have the right to take part in decisions about which disciplines will provide care (42 CFR §484.50(c)(4)(iv)). The rule's word is "disciplines", like nursing or physical therapy, not therapist versus assistant. You can still ask. Medicare's surveyor guidance says the agency "should make all reasonable attempts to respect the preferences of the patient regarding the services that will be delivered" (State Operations Manual, Appendix B, G428).

The Home Health Aide

An aide is assigned to your parent "by a registered nurse or other appropriate skilled professional", such as a therapist, who also writes the aide's care instructions (42 CFR §484.80(g)(1)). Aide services must be ordered by the doctor, included in the plan of care, permitted under state law, and consistent with the aide's training (§484.80(g)(2)).

The rule lists the aide's duties (42 CFR §484.80(g)(3)):

• Hands-on personal care
• Simple procedures as an extension of therapy or nursing services
• Help with walking or exercises
• "Assistance in administering medications ordinarily self-administered"

Medicare's coverage rule adds the limit. The aide can help with simple dressing changes and medicines only when they "do not require the skills of a licensed nurse" (42 CFR §409.45(b)(1)(ii) and (iii)). If a task needs a nurse's skill, it's the nurse's job.

The aide doesn't work alone. Aides must report changes in your parent's condition to the nurse or therapist (§484.80(g)(4)). When your parent is also getting nursing or therapy, a nurse or other skilled professional who knows your parent must do a "supervisory assessment of the aide services being provided no less frequently than every 14 days" (42 CFR §484.80(h)(1)(i)(A)). The aide doesn't have to be there for it. Once a year, a registered nurse or other skilled professional must also watch each aide at work on-site (§484.80(h)(1)(iv)). And if the supervisor notes a concern about the aide, they must make an on-site visit "to observe and assess the aide while he or she is performing care" (§484.80(h)(1)(iii)).

Medicare covers an aide only when your parent also needs skilled nursing, physical therapy, speech therapy, or continuing occupational therapy (42 CFR §409.45(a)). Our guide to what home health does not cover explains the limits.

The Medical Social Worker

Medical social work is its own service: "ordered by a physician or allowed practitioner and included in the plan of care", to help with "social or emotional problems" that get in the way of treatment or recovery (42 CFR §409.45(c)(1) and (c)(2)(i)). Medicare's booklet says this might include "counseling or help finding resources in your community."

A social work assistant may help, "under the supervision of a qualified social worker" (42 CFR §484.115(l)).

Who Is in Charge

The doctor or allowed practitioner. The plan of care is "established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry or allowed practitioner" (42 CFR §484.60(a)(1)). Medicare's booklet says an allowed provider includes a nurse practitioner, a clinical nurse specialist or a physician assistant. In my experience, the ordering doctor isn't part of the agency's staff and doesn't come to the house. The booklet says the agency will talk to your doctor and "keep your doctor updated about your progress."

The clinical manager. Inside the agency, one or more qualified people "must provide oversight of all patient care services and personnel", including making assignments and "Coordinating patient care" (42 CFR §484.105(c)). The agency must give you the clinical manager's name and contact information in writing (42 CFR §484.60(e)(5)).

"Supervisor" and "case manager." You'll hear both. Whatever title the agency uses, these are duties on your parent's chart. The case manager is usually the nurse or therapist who keeps track of one patient's care. A "supervisor" is whoever is responsible for an assistant's or aide's work on that patient. The same nurse may be your parent's case manager and the aide's supervisor at once.

How to Tell Who Is Who

• Ask each person for their name and credential, like RN, PTA or aide, and write it in a notebook with the date.
• Keep the written visit schedule. The agency must give you written instructions that include the visit schedule, "including frequency of visits by HHA personnel" (42 CFR §484.60(e)(1)).
• Ask to see a badge. I couldn't find a Medicare home health rule about ID badges, but in my experience most agencies give their staff one, and it's fair to ask.

Who to Call About What

This list is my suggestion, not a rule.

Frequently Asked Questions

Why did a physical therapist assistant come instead of the physical therapist?

Under Original Medicare, a physical therapist assistant may provide physical therapy under a physical therapist's supervision. The therapist must assess your parent first and set the goals, and at least every 30 days a therapist, not the assistant, must treat and reassess your parent. The visits in between can be the assistant's.

What is the difference between a PT and an OT in home health?

This is how I explain it, not a Medicare definition. A physical therapist works on walking, getting in and out of a bed or chair, strength and balance. An occupational therapist works on daily activities like bathing, dressing, using the toilet, the kitchen and setting up the home. Many patients get both.

What can a home health aide do?

Hands-on personal care like bathing and dressing, help with walking and exercises, simple tasks as an extension of the nurse's or therapist's care, and help with medicines your parent normally takes on their own. A nurse or therapist assigns the aide, writes the instructions, and reviews the aide's services at least every 14 days when skilled care is also being given.

Who is in charge of my parent's home health care?

The doctor or allowed practitioner orders the care and signs the plan of care. Inside the agency, the clinical manager oversees patient care, makes assignments and coordinates care. The agency must give you the clinical manager's name and contact information in writing.

Sources

• 42 CFR §409.43, Plan of care requirements (Cornell LII)
• 42 CFR §409.44, Skilled services requirements (Cornell LII)
• 42 CFR §409.45, Dependent services requirements (Cornell LII)
• 42 CFR §484.50, Patient rights (Cornell LII)
• 42 CFR §484.55, Comprehensive assessment of patients (Cornell LII)
• 42 CFR §484.60, Care planning, coordination of services, and quality of care (Cornell LII)
• 42 CFR §484.75, Skilled professional services (Cornell LII)
• 42 CFR §484.80, Home health aide services (Cornell LII)
• 42 CFR §484.105, Organization and administration of services (Cornell LII)
• 42 CFR §484.115, Personnel qualifications (Cornell LII)
• Medicare & Home Health Care, CMS Product No. 10969, July 2025 (Medicare.gov)