What’s a Home Health Care Plan? Reviewing a Plan


Certified Care Manager, Aging Life Care Professional, and National Master Guardian Emeritus

Home health care is a valuable and critical service for anyone who has suffered from an illness, accident, or surgery. Medicare pays for home health care, and as a result, they make the rules regarding criteria for admission and eventual discharge.

The rules, regulations, and paperwork are enormously complicated, but the goal is straightforward: to help you or your loved one recover and return to your previous level of functioning.

Jump ahead to these sections:

When you are admitted to home health, the entire process might seem confusing and overwhelming. Everything that happens in home health occurs due to the care plan, or the driving force behind the service. The more you understand about the plan, the more you can focus on recovery.

What’s a Home Health Care Plan?

Any home health care plan must meet the Centers for Medicare and Medicaid Services (CMS) guidelines. The rules for reimbursement by Medicare for home health services change every year. For example, as a result of the pandemic, patients can opt to receive some services via telehealth. However, in order for a home health company to receive adequate reimbursement, some face-to-face visits are required. 

CMS requires a care plan to guide and identify the areas of care needed by the patient to recover from an accident or illness. The plan of care is called the 485 and every home health agency is required to use the same one.

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Who gets one?

Every patient who qualifies for home health must have a care plan. Patients must meet the following requirements in order to receive home health:

  • You must be under a doctor’s care, and your physician has to write an order for home health.
  • A doctor certifies that you need skilled nursing and skilled therapies such as physical, occupational, or speech therapy to address your physical impairments.
  • You must be homebound but can leave for doctor’s appointments, church services, or adult daycare.
  • There has to be some expectation of improvement within a reasonable amount of time.
  • The agency you choose must be Medicare certified.


The care plan’s purpose is to guide the medical disciplines needed toward your recovery. Each discipline has concrete goals related to your expected improvement. CMS changes the care plan requirements frequently, so home health companies must stay on top of any new requirements for treatment.

An example of a physical therapy goal might be to increase the number of steps you can take following hip surgery. Reimbursement for the home health company is inextricably tied to set goals as part of a physician's orders for care. 

Note: If you have a Medicare Advantage plan, you may only be able to choose home health companies that are within the care network provided by your insurance.


A home health care plan has a lot of moving parts, with nurses at the core of it all, reviewing your progress toward the ultimate goal of rehabilitation. You’ll also have other folks as part of your home health care team, each focused on specific portions of your care.

For example, you can have a physical therapist, respiratory therapist, and an aide coming in to provide “skilled” medical care. It should be noted that not every home health care plan will be the same, even if the disciplines required may be similar to others.


Nurses generally come to visit a patient about three times a week, but they can come more often if needed. Nurses are considered the hub of the wheel, so to speak, as they report to the physician about any changes and new problems. They also provide the initial assessment and admission to home health. Once the care plan is established, nurses also do the following:

  • Wound Care. Wound care might be the only medical need or in conjunction with other mobility/physical issues. Patients with diabetes, a sustained injury, or who are recovering from surgery need wound care.
  • Vital Signs. Nurses check your heart, lungs, blood pressure, and oxygen levels. Depending on the diagnosis, these measurements assess your progression and whether you have pneumonia.
  • Drawing Labs. A physician can order labs to evaluate how you are doing and any new medical problems. Drawing labs might entail getting a urine sample to see if there is a urinary tract infection.
  • Administering Medications. In some cases, a nurse might have to administer some IV medications. Otherwise, the nurse ensures that medicines are set up and taken correctly.
  • Physical Assessment. The nurse will perform a head-to-toe physical assessment. One reason for this is to look for pressure ulcers, which can quickly get out of control.
Physical therapy

Physical therapy is almost always part of a home health care plan. Any illness or surgery can result in loss of mobility, so physical therapists work with you to regain your strength and endurance. In the care plan, they may have specific mobility goals related to your individual situation. You may start very slowly with very small improvements, with the physical therapy care plan goals changing with your progress.

Occupational therapists

The word “occupational” refers to any activities that allow you to function independently. If you think about all of the tasks you do in a day, you will get some idea of everything that makes up a fully functioning and pleasurable life. 

Occupational therapists help you re-learn activities that are adversely affected as a result of your accident or illness. Examples might be learning to cook or clean by adapting to your disability through specific strategies. Occupational therapists also work with patients who may have cognitive difficulties and need some training to function better.

Speech therapy

If you or someone you know has had a stroke that affects their speech, you know how valuable a speech therapist is. Speech therapists are not always part of the home health care plan because they are not always needed. 

Speech therapists help patients learn to speak again. They also assist with swallowing problems by recommending special diets and eating techniques. 

Respiratory therapy

Respiratory therapists deal with airway or breathing problems that result from various conditions. These therapists help people with chronic obstructive pulmonary disease (COPD), asthma, pneumonia, lung cancer, or complications from a COVID-19 infection.


Medicare only pays for a home health aide if another skilled service is required. In other words, Medicare will not pay for just an aide without another discipline coming into the home. An aide typically comes to help patients about three times a week for bathing, exercises, toileting, and dressing. Medicare does not pay for “custodial” services like transportation, cooking, or cleaning.

Social work

The social worker on the home health team connects patients and families to resources and provides emotional support. Social workers can also help families plan for any future care once home health services are completed. 

Home Health Care Plan Example

The home health care certification and care plan can be quite extensive, depending upon your loved one’s medical condition and needs. A care plan includes all diagnoses, medications, surgeries, and mental status.

At the heart of the plan are the disciplines assigned to your care and specifics regarding what and how often they need to see you. These are the two sections of the care plan that require the most detail:

  • Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)
  • Goals/Rehabilitation Potential/Discharge Plans

The physician then needs to sign and “certify/recertify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy, and/or speech therapy or continues to need occupational therapy. The patient is under my care, and I have authorized services on this plan of care and will periodically review the plan.” Each of the above orders can take up several pages on the care plan. 

Tips for Reviewing Your or a Loved One’s Home Health Care Plan

Continued home health services used to be recertified every 60 days, but it is now 30 days. Generally speaking, a patient must show progress towards goals with a continued need for services.

If you or your loved one does not show improvement, that could be a reason leading to being discharged from home health services. As a result, make it a point to review and participate in the creation of your care plan.

Ask to see the care plan

At the beginning of service, ask to see the care plan and discuss each goal in regards to the appropriate discipline. If you don’t know what is expected of you, it is hard to make progress. For physical therapy, in particular, you will want to know specifics. Think of the care plan as a motivator to work hard and improve.

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Participate in the review

Home health staff are busy seeing and recertifying lots of patients. To know what progress you are making and if you qualify for recertification, you need to be a part of the review.

Talk with the nurse and physical therapist about any concerns with continuing home health services. As the loved one of a patient, advocate for continued services by offering your support to keep your family member on track towards improvement.


Medicare will not pay for home health indefinitely, and services tend to become more restrictive. With that said, you or your loved one will be discharged from home health eventually.

A discharge does not mean that you are entirely recovered. It simply means that you no longer meet the Medicare criteria for continued services. 

So that you aren’t left scrambling to get the care you need, try and get an idea of when home health will be discontinued. At that point, ask for a referral to services for in-home care through a private pay agency if you need one.

Compile a list of questions and most importantly, ask for training and education for any tasks you might need to do on your own.

Reviewing Your Home Health Care Plan

As you and your loved one go through the stressful journey of recovery, home health care can help you regain your independence and function. The more actively you can be a part of the care plan, the greater your success will be.

  1. “Home Health Certification and Plan of Care.” Centers for Medicare and Medicaid Services, www.cdc.gov/wtc/pdfs/policies/CMS-485-P.pdf
  2. “What’s a Home Health Care Plan?” Medicare.gov, U.S. Centers for Medicare and Medicaid Services, www.medicare.gov/whats-a-home-health-care-plan
  3. “Plan of Care.” Medicare Interactive.org, Medicare Rights Center, www.medicareinteractive.org/get-answers/medicare-covered-services/home-health-services/plan-of-care
  4. “Medicare and Home Health Care.” Centers for Medicare and Medicaid Services, www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Downloads/HHQIHHBenefits.pdf

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