Home health care

Review the claim information and determine whether the medical reports support this type of care. Confirm the need for home health care is related to the compensable injury. The services, level of care and duration are approved based on the worker’s confirmed needs. 

Home health care can be provided on a short-term or long-term basis depending on the worker’s needs. Consider whether a third-party assessmentA third-party assessment is an assessment completed by a nurse practitioner. The assessment is required when a worker’s injury or wound care is complex, or home health care is expected to be long-term (1 year) or permanent. is needed. If unsure, contact the third-party assessor to discuss.

Short term home health care or wound care is provided during the acute phase of a worker’s recovery (that is, up to three months), regardless of the complexity of the care, when their condition is expected to improve, and the amount of care is temporary and expected to decrease. A third-party assessment is not required for short-term care, unless the worker has complex medical needs and would benefit from a care plan or the care extends beyond one-year. Simple wound care or dressing changes can be managed by a home health care provider. A wound care assessment by the third-party assessor is not needed for these.

Long term home health care or wound care is provided when a worker has sustained a more severe injury,Severe brain injury, severe burn, amputation, paralysis. or their condition requires long-term or permanent carePermanent long-term care may be required for workers with injuries such as burns, amputations, paralysis, severe and disabling brain, heart or lung conditions, organ transplants or palliative care.. A third-party provider assessment is required for long term home health care. Referrals for additional assessments, such as a wound care assessment may also be required.

Consider if other referrals are needed (e.g., Occupational therapy assessment An Occupational therapy assessment can help determine the worker's functional needs and the types of aids and equipment that will help the worker maintain or improve their level of independence as well as eligibility for daily living allowances.).

Note: An assessment is not required when home health care is requested for only 48 hours or less. However, if it goes beyond 48 hours, an assessment is then required. 

When the worker is not eligible for home health care, discuss your decision and rationale with the worker and send the appropriate letter. Do not continue with this procedure.

Call the worker to discuss their need for home health care or wound care services, the reason for it being recommended and confirm what supports are needed. Gather relevant information for the referral, such as:

• What type of residence do they live in (i.e., apartment, condo, house, split-level, mobile home, other)?
• Who lives with them (i.e., do they live alone, with a spouse, minor or adult children, other family, friend, or roommate)?
• Do they receive any support or assistance from family or friends? What are they getting help with? Did they require this support before their work injury/illness?
• Are there any environmental hazards in their home (e.g., smoking, pets, uneven sidewalks, clutter, etc.)?
• Are they receiving any other allowances or supports from WCB (e.g., housekeeping allowance, home maintenance allowance)?
• What is their preferred language (when English is not their first language)?

Advise the worker that a referral for the required assessment(s) will be made:

• A home health care assessment to determine the level of support needed, anticipated timeframe for care and a care plan. 
• A third-party assessment when the home health care is expected to be long term (i.e., one year or more) or the worker’s injury and/or care is complex. The assessment will determine services needed and develop a care plan for the home health care provider to follow. If home health care starts first, the type and level of service may be adjusted after the third-party assessment report is received.
• Wound care assessment to develop a plan for supporting complex wound care.

Note: Home health care providers must be contracted with WCB.

At times a worker may not want a home care agency to assess them and/or provide services while they recover. If this is the case, discuss that an assessment is needed to determine the type of care they require. Ask the worker to consult with their physician to develop an alternative plan that addresses their recovery needs. Once a plan has been established, consider paying a short-term personal care allowance (PCA) for the required recovery period.

Send a referral to an authorized home health provider, wound care assessor or third-party assessor. 

Depending on the nature of the injury, more than one assessment may be required. For example, a referral may be needed for a home health care assessment as well as a third-party assessment. In other cases, a referral may be needed for both home health care and wound care assessments. The home health care plan is adjusted as needed once the third-party assessment report is received.

To determine the worker’s needs and whether a third-party assessment is required, consider: 

• Is care expected to go beyond one year? 
• Does the worker have complex medical needs for which a care plan developed by a nurse practitioner would be beneficial? 
• Does the worker require complex wound care (e.g., experiencing complications or wound is not healing as expected)?

If unsure, contact the third-party assessment provider to discuss. 

Note: If care started without an assessment (e.g., when immediate care was required) and is continuing beyond 48 hours, refer for an assessment.

Review the assessment reports and recommended care plan submitted by the home health care provider or third-party/wound care assessor.

Confirm the recommended type and level of care meets the worker's needs based on the compensable injury (e.g., the worker's needs based on the compensable injury are a match to the amount and type of care recommended). Contact the assessment provider to resolve questions or concerns with the assessment(s) and/or care plan(s).

Decide whether to approve home care services. Call the worker to discuss the decision. When the care is approved, discuss the care plan recommendations and authorize any other benefits and expenses. Communicate the decision in writing and send a copy to the home care provider within two days of receiving the assessment reports. 

When a third-party assessment was completed, send their reports to the home health care provider so they can adjust their care plan to include the recommendations.

Review the monthly status reports, any other medical reporting, and confirm the invoices are consistent with the authorized services.

Consider whether: 

• The worker’s recovery is on track according to the latest assessment.
• The approved care plan is still appropriate and meeting the worker’s needs. 
• The anticipated resolution of care date has been reached, and if an extension is required.
• The authorization period is nearing the one-year point (long-term care) and a third-party assessmentA third-party assessment is an assessment completed by a nurse practitioner. The assessment is required when a worker’s injury or wound care is complex, or home health care is expected to be long-term (1 year) or permanent. is required. 
• There is a plan to wean the worker from relying on home health care service and build their independence, if applicable.

When care is needed beyond the anticipated care resolution date, the provider indicates a new end-of-care date in the health care services extension report. Additional authorization is not required.

Stay in regular contact with the worker and the provider. Discuss any questions or concerns about the worker's recovery and whether the care plan or extension of care is meeting the worker's needs, and when the reduction of services is not consistent with the approved care plan. Resolve the concerns (e.g., revise the care plan, request a third-party assessment or new assessment, etc.). 

When the level of care changes, the provider submits a new assessment/reassessment report. Return to step 4 and repeat the authorization process.

Proactively address any conflictsAddress personality conflicts, aggression or abuse between the worker and the home care provider. or issues between the worker and provider as soon as possible. Collaborate with the worker, their family (when appropriate) and the provider to resolve the issues. Contact the health care consultant for assistance when necessary. If the home health care provider communicates that the worker has been verbally or physically aggressive, advise them to notify Health Care Strategy and submit an incident report within 72 hours of an incident.

In some cases, where a conflict cannot be resolved, it may be necessary to arrange for a new home health care provider, or to provide the worker with a self-managed personal care allowance instead of home health care services. 

Review the reports for long term care annually and confirm whether the level of care is meeting the worker’s needs. Determine the type of assessment needed for the annual review:

• Consider a third-party assessment when the worker’s needs have changed significantly, or you have concerns the current level of care is not meeting their needs. 
• Consider reassessment from the home health provider when the worker’s needs have not changed and the level of care provided is meeting their needs.

The provider will send in a new assessment report and authorization care form. Return to step 3 and repeat the process.