Social Work in Psychiatric Home Care:Regulations, Roles, and Realities

Home health care for psychiatric patients is one of the fastest-growing service delivery systems in the home health industry (Home Psychiatric Care Growing," 1996). Many home health agencies are developing and implementing psychiatric programs in response to consumer demand and interest from managed care companies. Home health care for psychiatric patients is attractive to providers, consumers, and insurance companies for several reasons: * It allows providers to expand their patient base and to diversify their services. * Consumers like the comfort and convenience of receiving services in their homes. * Managed care companies can reduce their costs for patient care by providing psychiatric services at home, when appropriate, rather than in hospitals or day treatment programs ("Psychiatric Home Care a Successful National Niche," 1995). * Preliminary outcome studies indicate that psychiatric home health services can reduce the number of future inpatient admissions for people with chronic mental illnesses and increase patient compliance with medication regimens ("Home Psychiatric Care Growing," 1996; Mayo, 1997). Psychiatric home health services were first approved by the Health Care Financing Administration (HCFA) for Medicare Part A reimbursement in 1979 (HCFA, 1979). In 1996 HCFA issued regulations that define psychiatric home care nursing services as "the evaluation, psychotherapy, and teaching activities needed by a patient suffering from a diagnosed disorder that requires active treatment by a psychiatrically trained nurse . . . to be provided under a plan of care established by a physician" (HCFA, 1996a, p. 18). This regulation is significant for three reasons. First, it requires that the patient have a preexisting psychiatric diagnosis. Psychiatric home care services are not appropriate for patients who are merely forgetful, noncompliant, or otherwise troublesome to staff. Second, the patient's condition must require active treatment. A patient must be displaying acute symptoms of his or her illness. Third, any physician may order psychiatric home health services. Previously, HCFA had required that orders come from a psychiatrist. This change in the regulations is also an acknowledgment that many general practice physicians treat patients for problems such depression and anxiety, particularly in rural areas where psychiatrists may be difficult to reach. A long-standing HCFA requirement for home health services is that the patient be homebound. In 1996 for the first time, HCFA acknowledged that a patient may be homebound for purely psychiatric reasons: "a patient with a psychiatric problem is [is considered homebound] if the illness is manifested in part by a refusal to leave home, or is of such a nature that it would not be considered safe to leave home unattended, even if he/she has no physical limitations" (HCFA, 1996b). Originally designed as a service for elderly homebound people with serious medical and mental health needs, psychiatric home health care has gradually expanded its role in the services continuum. An increasing number of psychiatric home health care patients do not have medical diagnoses, and clients range from school-age children to senior citizens. Many psychiatric hospitals now routinely refer patients to home care at discharge to help ensure compliance with follow-up outpatient treatment. Some managed behavioral health programs make referrals to psychiatric home care as an adjunct service for ambulatory psychiatric outpatients. Social work has been an integral part of home health care since the Medicare benefit was established in 1965. But, despite the considerable presence of social workers in other mental health settings, recognition and approval of social workers as providers of psychiatric home health care services has not yet been realized. Some reasons for this can be found in HCFA social work regulations and in recent actions taken by Medicare fiscal intermediaries against home health social workers. …