Home Health Care: What to Look For in a Quality Agency

Home health agencies provide medically necessary care in a patient's home, ordered by a physician and delivered by licensed clinical professionals. It is important to distinguish between home health care (skilled, medical) and home care (non-medical, custodial) — they are fundamentally different services with very different coverage rules.

Medicare-certified home health agencies provide skilled services including:

• Skilled nursing visits — Wound care and dressing changes, medication management, IV infusion therapy, catheter care, post-surgical monitoring, and patient and family education on managing chronic conditions like diabetes or heart failure.
• Physical therapy (PT) — Restoring mobility, strength, balance, and function after surgery, stroke, or injury. Often the primary reason for a home health referral following a hospital discharge or orthopedic procedure.
• Occupational therapy (OT) — Helping patients regain the ability to perform activities of daily living (ADLs) such as dressing, bathing, and cooking safely in the home environment.
• Speech-language pathology — Treating swallowing disorders (dysphagia), communication deficits following stroke or neurological injury, and cognitive-communication challenges.
• Medical social work — Connecting patients with community resources, insurance navigation, and discharge planning coordination.
• Home health aide services — Personal care assistance (bathing, dressing, grooming) provided alongside skilled services — not as a standalone service under Medicare.

What home health does NOT typically include: Housekeeping, cooking, companionship, grocery shopping, or transportation. These non-medical services are provided by separate home care agencies and are generally not covered by Medicare or Medicaid.

CMS assigns home health agencies a quality star rating — separate from the nursing home 5-star system — based on clinical outcome data submitted through the Outcome and Assessment Information Set (OASIS), a standardized patient assessment tool completed at the start, resumption, and discharge of care.

The quality star rating measures how well an agency's patients improve during care. Core measures include:

• Improvement in ambulation and movement — The percentage of patients who improved in their ability to walk and move around.
• Improvement in bathing — How many patients can bathe more independently by discharge than at admission.
• Improvement in dyspnea — Reduction in shortness of breath during the care episode.
• Acute care hospitalization rate — How often the agency's patients end up in the hospital during their home health episode — a measure of care quality and deterioration prevention.
• Emergency department use without hospitalization — Visits to the ER that don't result in admission, suggesting gaps in care management between scheduled visits.

Quality stars range from 1 to 5. A 5-star agency consistently produces better patient outcomes than average for its market and patient complexity mix. A 1-star agency underperforms on multiple clinical dimensions.

One important caveat: CMS updates the Home Health Compare star ratings annually, and agencies that are newly certified or have insufficient case volume may not yet have a calculated rating. The absence of a quality star rating does not mean a new agency provides poor care — it means there isn't enough data to rate them yet.

Medicare covers home health services — but only when specific eligibility criteria are met. Many families are surprised to discover that services they assumed were covered are actually private pay.

Medicare Part A or Part B coverage requirements:

• The patient must be homebound. Homebound means that leaving home requires considerable effort — due to illness, injury, or a condition that makes leaving unsafe or exhausting. A patient doesn't have to be bedridden; someone with severe shortness of breath, a recent hip replacement, or significant cognitive decline can qualify as homebound even if they occasionally leave for medical appointments or religious services.
• A physician or allowed practitioner must order the services. Home health care cannot be self-referred. A doctor, nurse practitioner, clinical nurse specialist, or physician assistant must certify that skilled care is medically necessary.
• The services must be skilled. Personal care alone (bathing, dressing) is not covered unless it is provided alongside a covered skilled service such as skilled nursing or therapy during the same episode.
• The agency must be Medicare-certified. Only agencies with Medicare certification can bill Medicare. All agencies in our database meet this requirement.

When all criteria are met, Medicare pays 100% of covered home health services — there is no deductible or copay for Medicare beneficiaries receiving home health care.

Medicaid: Many states cover home health and personal care services through Medicaid Home and Community-Based Services (HCBS) waiver programs. Eligibility and covered services vary significantly by state. For individuals who meet Medicaid eligibility requirements, these programs can fund services well beyond what Medicare covers, including non-medical personal care and home modification assistance.

Private pay: Individuals who do not meet Medicare or Medicaid eligibility criteria pay out-of-pocket at hourly rates that vary by geography, service type, and agency. Skilled nursing visits typically range from $80–$200+ per visit; home health aide services typically range from $20–$40 per hour depending on the region.

Before choosing an agency, use these questions to probe beyond the quality star rating and understand what your day-to-day experience will actually look like:

• "What is your nurse-to-patient ratio, and will I have a consistent primary nurse?" Continuity of care is associated with better outcomes. Agencies that reassign staff frequently make it harder to catch subtle changes in patient condition.
• "How do you handle after-hours emergencies?" Medicare requires home health agencies to be available 24/7 for urgent clinical needs. Ask specifically: Is there a licensed nurse on call after hours, or does a call service take messages until morning?
• "How are care plans developed and updated?" Quality agencies conduct a thorough initial assessment, develop an individualized care plan in coordination with the physician, and formally reassess the plan when the patient's condition changes.
• "What is your average response time for a visit request?" After a hospital discharge, the first nursing visit within 24–48 hours is critical for preventing readmission. Ask how quickly they can typically begin care.
• "What is your staff's clinical training in my condition?" A patient recovering from cardiac surgery has different needs than a patient with a healing wound. Ask whether the agency has staff specifically experienced in managing your or your family member's diagnosis.
• "What is your agency's hospitalization rate?" A quality agency should be able to tell you their acute care hospitalization rate — one of the core measures in the CMS quality star rating — and explain how it compares to local averages.
• "Are your staff employees or independent contractors?" Employees are subject to agency supervision, ongoing training requirements, and liability coverage. Agencies using independent contractors may have less oversight over care quality and clinical practices.