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Care of Older People in the Home


Debra Bakerjian

, PhD, APRN, University of California Davis

Reviewed/Revised Oct 2022
Topic Resources

Older people may need care in their home when they are frail or weak, particularly after they have been discharged from the hospital or a rehabilitation facility. Simple care is usually provided by family members, friends, or both. More complex care may require health care practitioners (such as registered nurses and therapists) and others (such as home health aides and social workers) to come to the home. Such care is usually coordinated by a home health care agency and supervised by a doctor. Care may be needed only briefly or for a long time. Medicare provides services for people who are considered homebound, which typically means that they are able to leave their home only for doctors appointments or emergencies.

A nurse may be needed to change dressings or give injections of medications.

A physical therapist may be needed to help people regain strength and balance or recover from a stroke.

A home health aide may be needed to help people with shopping, preparing meals, going out in a wheelchair, taking a walk, or bathing.

A social worker can determine whether people are receiving the services they need and recommend additional services if needed. A social worker may also help arrange for rides to and from medical appointments.

With home health care, communication between all of the people involved is important. Any changes in the person's condition should be promptly reported to the person's nurse or doctor.


Sometimes the primary care practitioner coordinates a team of health care practitioners who work together to provide better care for people who live at home and have a chronic disorder or disability. This arrangement is called a patient-centered home. In some situations, a care manager of another member of the team may be responsible for coordination of care.

Care in the home can reduce placement in a nursing home by 23% and is less expensive when visits by home health aides and nurses are scheduled appropriately.

Financial issues

Medicare covers home health care services that are classified as skilled nursing care, including wound care and monitoring of disorders such as heart failure or diabetes. However, the amount of and time frame for such coverage is limited. When people no longer need skilled care, they are usually responsible for the costs of any further nursing care. Long-term care insurance or Medicaid (for people who qualify) may cover home care services. Veterans may also qualify for home care services depending on their needs and disability rating.

For home health care to be covered by insurance, a doctor must certify that home health care is required and, for Medicare, that people meet Medicare's requirements for home care.


The Programs for All-Inclusive Care for the Elderly (PACE) is a benefit provided under Medicare and Medicaid. PACE is available only in certain areas of the United States to people who are 55 years old or older and who meet their state’s standards for requiring care in a nursing home. Services provided by the PACE program allow nearly all participants to live at home, although nursing home care is provided if needed.

PACE involves an interdisciplinary team including doctors, nurses, physical and occupational therapists, social workers, dietitians, and drivers. The services are typically provided in an adult day health center and are available every day. The program provides transportation to the center. Some services may be provided in the home.

See PACE plan search for a list of participating states and available plans.

Other models of home health care

In the past few years, several new health care models have been developed as a way for people to receive home-based health care. The goal is to provide a higher quality of care and management that keeps older adults out of hospitals and nursing homes and allow older adults to remain in their home and community. Overall, these models involve traditional at-home health services that have been expanded to include other services. Some of these are being tested in various parts of the United States and are known as demonstration projects.

The Independence at Home Demonstration (IAH) model is sponsored by the Centers for Medicare and Medicaid Services (CMS). In this model, frail older adults who cannot easily leave their home receive care in their home from a doctor or other health care practitioner such as a nurse practitioner or physician assistant. The goal of this model is to keep older adults in their home and out of the hospital. To be eligible for this model of care, older adults must be unable to leave their home and have two or more chronic conditions.

The Hospital at Home (HAH) model enables organizations to provide hospital-level care in the person's home. Most of the participants are very ill older adults. The goal of this model is to decrease the number of days a person spends in the hospital, reduce hospital costs, improve patient satisfaction, and improve outcomes. In most cases, these people are generally stable but require extended hospital-level skilled care, such as daily visits from a doctor or nurse practitioner or physician assistant, and daily monitoring of their medical condition.

The Emergency Triage, Treat, and Transport (ET3) model developed by CMS allows ambulance care teams to have greater flexibility in deciding where a person should receive care. Instead of transporting a person to a hospital emergency department, the ambulance care team, often in consultation with a nurse practitioner or physician assistant, can transport the person to an urgent care center or doctor's office or can begin treatment in the person's home as directed by the nurse practitioner or physician assistant. The nurse practitioner or physician assistant may be in the ambulance or accessible via telehealth.

More Information

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

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