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HEAL AT HOME

April 2022  |Provider & Referral Resources

Home Health & Hospices Services

Home health and hospice services are an extension of your care. Our agencies are staffed with highly skilled home care professionals to deliver quality, compassionate care in the least restrictive and most supportive setting possible; home. Many patients also benefit from families and caregivers being incorporated in the care process, By working together, we can design a specific plan to help our shared patients achieve their best possible health – in the comfort of home.


Indicators for home health

Your patients are different – so are their medical conditions, treatments, and needs. Home health professionals are specially trained to deliver high-quality care to patients that helps them recover and regain strength, health, and independence. Our professional nurses, therapists, and social workers treat a wide range of medical conditions, allowing patients to rest and recover in the comfort of home. If you are treating patients who might benefit from healthcare in the privacy of their home – for whom one-on-one instruction will help better manage their condition, symptoms, and recovery – consider referring them to home health. Home health may be indicated if a patient:

  • Has a new diagnosis or an exacerbation of an existing diagnosis
  • Has a new medication
  • Requires teaching on a disease process or medication
  • Is at risk for or experiencing complications requiring labs
  • Requires other skilled nursing services (wound care, teaching, observation, and assessment)
  • Requires frequent follow-up from a physician’s office
  • Has frequent re-hospitalizations
  • Contacts a physician’s office frequently
  • Exhibits behaviors that indicate he or she is at risk for falls
  • Needs physical therapy, occupational therapy, speech therapy, or medical social services, due to:
    • - Mobility problems
    • - Bowel or bladder incontinence
    • - Vision problems
    • - ADL needs
    • - New DME training

If the answer is “yes” to any of the above indicators, the patient may be a candidate for a home health evaluation.

Keep in mind, patients with both acute and chronic conditions can benefit from in home care, including but not limited to the following:

  • Alzheimer's Disease
  • Chronic kidney disease
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes
  • Heart disease
  • Recovery from illness or surgery
  • Chronic conditions or injuries

In addition to providing medically necessary services for the treatment of the above conditions, home health care professionals act as a liaison between the patient, the patient's family, and the patient's doctor. Home health care professionals keep a log for each visit and provide updates on the patient's condition to the doctor as needed. This helps to ensure continuity of care.

Find a New Hampshire agency.

How do I talk to my patients about home health care?

When you enlist the services of home health professionals, we become part of your team – a team dedicated to achieving the best possible outcome for your patient. We teach patients to better understand their disease or condition, and how to manage things like medications and nutrition for the best quality of life. It’s important that your patients know that a skilled team of home health clinicians will help them more effectively manage their condition in the comfort of their own home. We will be their on-site healthcare champion – available 24/7 to address whatever symptoms or concerns they may encounter. The emotional support, camaraderie, and expertise of our clinicians helps reassure patients as they progress through their recovery or manage their chronic condition. With home health, they can trust that the plan of care you prescribe will be followed thoroughly and accurately, and that they will receive the high-quality, compassionate care they deserve.

Home health services include:

  • Managing medications
    • We can teach patients to safely take the right dosage at the right time and frequency.
  • Understanding a disease or condition
    • Our clinicians thoroughly educate patients about their disease or condition.
  • Making healthy food choices
    • We provide nutrition management through clinical guidance and dietary education.
  • Monitoring treatment progress
    • Using a multidisciplinary approach, our team monitors and documents patient compliance with your treatment orders.
  • Managing risk for falls
    • We help your patients understand physical risks and limitations and coach them to be safe at home.

Contact your local provider today for more information.

Find an Agency

Criteria for Homebound Status

Homebound Status should be reaffirmed at every visit.
CMS advises that an individual shall be considered “confined to the home” (homebound) if the following two criteria are met:

Criteria One:

The patient must either:

  • Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence or
  • Have a condition such that leaving his or her home is medically contraindicated.
  • If the patient meets one of the Criteria-One conditions, then the patient must also meet two additional requirements defined in Criteria-Two below.

Criteria-Two: 

  • There must exist a normal inability to leave home and leaving home must require a considerable and taxing effort.

Background and Further Clarification on Homebound



To be eligible for Medicare home health services a patient must have Medicare Part A and/or Part B per Section1814(a)(2)(C) and Section 1835(a)(2)(A) of the Social Security Act (the Act):

Physicians should also note that in accordance with the Patient Protection Affordable Care Act, CMS issued a Final Regulation that went into effect January 1, 2011 whereby Medicare will pay for home health services only when a physician certifies in the home health plan of care that the patient has had a face-to-face encounter (see below) with their physician in the 90 days prior to or within 30 days of the start of services. The primary reason for home health services must be addressed during this encounter.

If a physician works in collaboration with a nurse practitioner or clinical nurse specialist, or supervises a physician’s assistant, the face-to-face encounter may be carried out by that non-physician practitioner who must have documented their clinical findings and communicated those findings to you. However, only a physician may order home health services, certify that a face-to-face encounter occurred, and certify that other eligibility criteria are met (medical necessity and home bound status).

Medicare and Home Care Booklet from CMS

Certifying Patients for the Medicare Home Health Benefit

  • The patient must be homebound.
  • Need skilled services;
  • Be under the care of a physician;
  • Receive services under a plan of care established and reviewed by a physician; and
  • Have had a face-to-face encounter with a physician or allowed Non-Physician Practitioner (NPP)

The face to face physician encounter must be documented on the home health plan of care, or an addendum to that plan of care. Documentation of the certification of a face-to-face encounter must include:

  • The date of the encounter.
  • Indication that the encounter was related to the primary reason for home health.
  • An explanation of how the clinical findings of the encounter support the need for skilled nursing or therapy services.
  • An explanation of why the clinical findings of the encounter support that the patient is homebound.
  • Your signature and the date of that signature.

Many agencies also provide Medicare-eligible home health aide and medical social worker services in conjunction with nursing, physical therapy or occupational therapy services.

To qualify for the Medicare benefit, a face to face patient/ physician encounter must be made by the physician responsible for certifying home health.  If a physician works in collaboration with a nurse practitioner or clinical nurse specialist, or supervises a physician’s assistant, the face-to-face encounter may be carried out by that non-physician practitioner who must have documented their clinical findings and communicated those findings to you. However, only a physician may order home health services, certify that a face-to-face encounter occurred, and certify that other eligibility criteria are met (medical necessity and home bound status).

  • Related to the primary reason for which the patient requires home health services.
  • Made within 90 days prior to, or within 30 days of, the start of home health.

Certification for home health is already required by physicians. The face-to-face encounter for home health care can be included in the certification documentation or on a separate form. More information on the home health FTF encounter requirement can be found on the CMS' Home Health Agency (HHA) Center website.

For items on the Required Face-to-Face Encounter and Written Order Prior to Delivery List, a complete order is required prior to the item’s delivery. (For all other DMEPOS items, the order is required prior to claim submission.)

CMS may suspend the face-to-face encounter and written order prior to delivery requirements generally, or for a particular item or items, at any time and without creating a new rule--except for items included on the Master List (PDF).

Home Health Face to Face Documentation Requirements

MD Tools

Item Name Posted By Date Posted
1369_0514_Home_Health_Face-to-Face_Encounters_.pdf PDF (535.02 KB) Administration 3/31/2022
Skilled_care-Homebound_Narrative.pdf PDF (12.34 KB) Administration 3/31/2022
Phys_Attest_Form_F2F_2-9_FINAL.pdf PDF (53.04 KB) Administration 3/31/2022
NAHC_F2F_Fact_Sheet._7.13.17.pdf PDF (78.08 KB) Administration 3/31/2022
HH_F2F_Encounter_Fact_Sheet.FINAL.pdf PDF (57.12 KB) Administration 3/31/2022
HH_F2F_Documentation_Guide_FINAL.pdf PDF (51.01 KB) Administration 3/31/2022