Key takeaway
Medicare home health after hospital discharge usually requires a physician order, a documented face-to-face visit when applicable, confirmation that you are homebound and need skilled care, and admission to a Medicare-certified agency such as Holistat.
1. Start during discharge planning
Before you leave the hospital, the discharge planner or case manager should review whether you need skilled nursing, wound care, physical therapy, or other home health services. Ask specifically about Medicare home health if you have Part A or Part B.
- Confirm your home address is within the agency’s service area.
- Ask which physician will sign home health orders after discharge.
- Request education on medications, wound care, or mobility equipment you will use at home.
2. Physician orders and the face-to-face requirement
Medicare requires a physician or allowed practitioner to order home health and certify that you need skilled services. For Medicare benefit periods, a face-to-face encounter documenting the need for home health is typically required within required timeframes before or after the start of care.
Hospitalists, primary care physicians, and specialists can coordinate these orders. Referral partners can also use Holistat’s digital face-to-face referral form or fax a completed referral to (682) 200-7472.
3. Confirm Medicare eligibility
Medicare generally covers skilled home health when all of the following apply:
- You are under the care of a physician or practitioner who establishes and reviews the plan of care.
- You are homebound (leaving home requires considerable effort and is medically contraindicated or you need help to leave).
- You need intermittent skilled nursing care, skilled therapy, or skilled services from a home health aide under certain conditions.
- Care is provided by a Medicare-certified home health agency.
Holistat’s intake team verifies coverage and service-area eligibility across Tarrant, Dallas, Collin, and Denton counties. See our overview of Medicare home health at Holistat.
4. Choose a Medicare-certified agency
You are not required to use the agency suggested by the hospital if another Medicare-certified provider serves your area and can meet your clinical needs. Compare agencies on responsiveness, nursing specialty support (such as wound care), therapy availability, and communication with your physician.
Holistat Home Health is licensed by the Texas HHSC and certified by CMS. We serve the Dallas–Fort Worth Metroplex from our Pantego office. View service areas for your city or ZIP code.
5. What happens on the first home health visit
A registered nurse or therapist performs the initial assessment, reviews hospital instructions, evaluates safety in the home, and begins implementing the physician’s plan of care. You should receive a visit schedule, emergency instructions, and contact numbers for the agency.
Skilled visits are intermittent—not 24-hour care. If you need ongoing personal care only, that may be home care rather than home health and is usually paid differently.
6. Stay connected with your doctor
Home health agencies communicate changes in condition, vital signs, wound progress, and therapy goals with the ordering physician. Keep follow-up appointments and notify your nurse if symptoms worsen or new problems develop after discharge.
Medical disclaimer: This guide is for educational purposes and does not replace advice from your physician or practitioner. Medicare coverage depends on individual eligibility, medical necessity, and current CMS rules.