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Home healthcare and home care considerations during the COVID-19 pandemic

COVID 19 Coronavirus

By Doris Fischer-Sanchez | May 1, 2020

COVID-19 is creating challenging scenarios for healthcare. One area that is positioned to see an increase in demand is home healthcare and home care.

The COVID-19 pandemic is creating challenging scenarios for healthcare on many levels. One area of healthcare that is positioned to see an increase in demand for services is home healthcare and home care. With shelter in place orders in almost every state, more elderly patients and patients with underlying health conditions are staying home to lessen their exposure risk to COVID-19.1

In advance of looking at the various considerations to home healthcare and home care during the COVID-19 pandemic, it is important to understand the distinction between home healthcare and home care.

According to Medicare, home healthcare is a wide range of clinical medical services that can be provided by a registered nurse, physical therapist or other skilled medical professional in the home.2 Home healthcare is often prescribed as part of a discharge plan post hospitalization or part of a plan to keep more fragile patients out of the inpatient setting. Home healthcare usually requires the patient to be homebound in order to qualify for services and is time limited. Hospice services fall under the category of home healthcare.3 Alternatively, home care is provided by caregivers, known as home care aides, trained to understand the needs of primarily senior care. Home care aides help older adults with activities of daily living, companionship and light housekeeping. Services can include 24 hour a day, live in care. Home care is considered non-clinical and not a skilled service.4

Frequently, home healthcare and home care agencies are utilized during the same episode and one service or the other may remain involved based on the patient’s rate of recovery or ability to independently care for themselves. This table illustrates the general differences between the types of care.5

Differences between types of care
Service typically offered Home health Home care
Therapy towards rehabilitation Yes No
Administers medications Yes No
Performs medical tests Yes No
Formally monitors health status Yes No
Meal preparation or delivery No Yes
House cleaning No Yes
Help with bathing, dress and grooming No Yes
Transportation NoYes
Reminders to take medicine Yes Yes
Skilled nursing Yes No
Pain management Yes No
Wound care Yes No
Prescription medication management Yes No
IV therapy / injections Yes No
Incontinence care NoYes
Toileting help NoYes
Companionship NoYes

On April 3, 2020, the Center for Medicare and Medicaid Services (CMS) released a synopsis of the 1135 blanket waivers that are in effect during the COVID-19 pandemic and have a retroactive date to March 1, 2020 through the end of the emergency declaration.6 Home health agencies (HHA) have some very specific relaxation of criteria within the 1135 blanket waiver period:

Home health agencies (HHA)

  1. 01

    Requests for Anticipated Payment (RAPs):

    CMS is allowing Medicare Administrative Contractors (MACs) to extend the auto-cancellation date of RAPs during emergencies; this allows for a retroactive date to March 1, 2020 for final bill submission prior to auto-cancellation of the claim.

  2. 02


    CMS is providing relief to HHAs on the timeframes related to Outcome Assessment Information Set (OASIS) Transmission through the following actions below:

    • Extending the 5-day completion requirement for the comprehensive assessment to 30 days
    • Waiving the 30-day OASIS submission requirement. Delayed submission is permitted during the PHE. 13
  3. 03

    Initial Assessments:

    CMS is waiving the requirements at 42 CFR §484.55(a) to allow HHAs to perform Medicare-covered initial assessments and determine patients’ homebound status remotely or by record review. This will allow patients to be cared for in the best environment for them while supporting infection control and reducing impact on acute care and long-term care facilities. This will allow for maximizing coverage by already scarce physician and advanced practice clinicians and allow those clinicians to focus on caring for patients with the greatest acuity.

  4. 04

    Waive onsite visits for HHA aide supervision:

    CMS is waiving the requirements at 42 CFR §484.80(h), which require a nurse to conduct an onsite visit every two weeks. This would include waiving the requirements for a nurse or other professional to conduct an onsite visit every two weeks to evaluate if aides are providing care consistent with the care plan, as this may not be physically possible for a period. This waiver is also suspending the two week aide supervision by a registered nurse for home health agencies requirement at §484.80(h)(1), but virtual supervision is encouraged during the period of the waiver.7

As the 1135 blanket waiver supports the home healthcare industry to be able to provide expanded services, it is important to remember the real concerns for healthcare professionals and aides when caring for patients in their home setting. The availability of personal protective equipment (PPE) and proper training of staff on how to maximize use of PPE is essential.

Home healthcare and home care agencies require a comprehensive infection prevention education program for all staff but especially for field staff. Infection prevention training needs to include the appropriate use of PPE and universal/standard precautions. Staff need to know how to put on (don) and take off (doff) PPE without contaminating themselves. This includes knowing the proper sequence of donning and doffing gloves, masks, gowns and face shields. Hand washing continues to remain the first and most effective preventative measure. Staff should be brought into the office for demonstrations, return demonstrations and documentation of training.8

The Centers for Disease Control (CDC) has made the following recommendations for the suitability of care for someone in the home with COVID-19:

In consultation with state or local health department staff, a healthcare professional should assess whether the residential setting is appropriate for home care. Considerations for care at home include whether:

  • The patient is stable enough to receive care at home.
  • Appropriate caregivers are available at home.
  • There is a separate bedroom where the patient can recover without sharing immediate space with others.
  • Resources for access to food and other necessities are available.
  • The patient and other household members have access to appropriate, recommended personal protective equipment (at a minimum, gloves and facemask) and can adhere to precautions recommended as part of home care or isolation (e.g., respiratory hygiene and cough etiquette, hand hygiene).
  • There are household members who may be at increased risk of complications from COVID-19 infection (e.g., people >65 years old, young children, pregnant women, people who are immunocompromised or who have chronic heart, lung or kidney conditions).9

Per CMS, all HHAs should have the following considerations when initiating and making a home visit. HHAs should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home.

HHAs should ask patients about the following:

  1. international travel within the last 14 days to countries with sustained community transmission
  2. signs or symptoms of a respiratory infection, such as a fever, cough and sore throat
  3. in the last 14 days, has had contact with someone with or under investigation for COVID19, or are ill with respiratory illness
  4. residing in a community where community-based spread of COVID-19 is occurring.

For ill patients, implement source control measures (i.e., placing a facemask over the patient’s nose and mouth if that has not already been done). Inform the HHA clinical manager, local and state public health authorities about the presence of a person under investigation (PUI) for COVID-19.

CMS regulations requires that HHAs provide the types of services, supplies and equipment required by the individualized plan of care. HHAs are normally expected to provide supplies for respiratory hygiene and cough etiquette, including 60%-95% alcohol-based hand sanitizer (ABHS). State and federal surveyors should not cite home health agencies for not providing certain supplies (e.g., personal protective equipment (PPE) such as gowns, respirators, surgical masks and alcohol-based hand rubs (ABHR)) if they are having difficulty obtaining these supplies for reasons outside of their control. However, we do expect providers/suppliers to take actions to mitigate any resource shortages and show they are taking all appropriate steps to obtain the necessary supplies as soon as possible.10

Telehealth HHA services are also able to be expanded during the pandemic period. HHAs can provide more services to beneficiaries using telehealth within the 30-day episode of care, so long as it’s part of the patient’s plan of care and does not replace needed in-person visits as ordered on the plan of care. There is acknowledgment that the use of such technology may result in changes to the frequency or types of in-persons visits outlined on existing or new plans of care.11

Home healthcare and home care services are essential to helping the elderly and medically fragile patients to maintain their community independence. COVID-19 has created a potential surge in clients for HHAs. It is important for HHAs to implement their surge policies, understand the 1135 blanket waiver as it applies to them, train their staff to comply with infection control as recommended by the CDC and to know that when the 1135 waiver expires post pandemic that regulations likely will revert to the pre- COVID-19 pandemic state.


1 Ross-Johnson, S.(2020). Home healthcare looks to step in to care for COVID-19 patients. Modern Healthcare. Accessed at:

2 What’s Home Healthcare? Retrieved at:


4 Ibid.

5 Ibid.

6 Updated list of blanket waivers from CMS 4/3/2020 retrieved at:

7 Ibid.

8 Covid-19 Personal Protective Equipment (PPE) for Healthcare Personnel. Retrieved at:

9 Interim Guidance for Implementing Home Care of People not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19) retrieved at:

10 Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHAs) retrieved from:

11 Home Health Agencies: CMS Flexibilities to Fight COVID-19. (3/30/2020). Retrieved at:


Each applicable policy of insurance must be reviewed to determine the extent, if any, of coverage for COVID-19. Coverage may vary depending on the jurisdiction and circumstances. For global client programs it is critical to consider all local operations and how policies may or may not include COVID-19 coverage. The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal and/or other professional advisors. Some of the information in this publication may be compiled by third party sources we consider to be reliable, however we do not guarantee and are not responsible for the accuracy of such information. We assume no duty in contract, tort, or otherwise in connection with this publication and expressly disclaim, to the fullest extent permitted by law, any liability in connection with this publication. Willis Towers Watson offers insurance-related services through its appropriately licensed entities in each jurisdiction in which it operates. COVID-19 is a rapidly evolving situation and changes are occurring frequently. Willis Towers Watson does not undertake to update the information included herein after the date of publication. Accordingly, readers should be aware that certain content may have changed since the date of this publication. Please reach out to the author or your Willis Towers Watson contact for more information.


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