What does Medicare mean by "Monitoring serious illness and unstable health status?"

Go to

Medicare.gov compare

and you will find a welcome page and on it a list of service providers on the left side of your screen. Go down to Home Health Care and click on this.

A page will come up where you will input your city, state, zip code and an alphabetical list will come up of home health agencies that cover that area.

Click on one of those and you will see the services that particular agency offers. Not all of them offer all of the services Medicare might be willing to pay them for. They are private companies and can and do offer the ones they choose.

Look at a few of these, read their ratings. Notice they may have medicare ratings and also patient ratings.

Their phone number will be listed. You can call them and discuss your patient needs. Call several to see the differences.

Some doctors have certain agencies they work with.

I chose one for my mom based on the fact that a relative worked for them who was a nurse I had known all her life. I ended up working with them for two loved ones for years in two different small towns. Some support large geographic areas.

The one I worked with worked very well with all my LOs doctors. They need a doctors orders before they can provide services. Some will do an evaluation and then contact the doctor for the patient for the orders.

The doctor has to have seen the patient within a certain time frame to get started. So if there was a recent visit, they might just fax over to the doctor the orders they need to get started.

My mom’s cardiologist wanted her to have HH but didn’t want his office to manage the relationship. That’s how we found her primary care doctor who we saw once a year on average, same day we saw her cardiologist. if she needed blood work, home health nurse took care of it. If she needed a urine test, the home health took care of it. X-rays were done at home, etc. I was 3 hours away from my mom. It was a huge help.

The one I worked with had a hospice devision which worked out well for me when that time came as I already had a working relationship with their staff.

Many people are familiar with home health services after a hospital or rehab stay. These are ones who usually only come for six weeks or so after a discharge. They might come for wound care, etc. Some only do this type care and don’t offer continuous long term intermittent care. (Regardless the patient has to recertify on a regular basis).

When I first came to the forum, there where a few posters who had in the past or who were then working for home health agencies and they would declare that intermittent services were not available. I knew they were because I was using them. I finally realized that not all agencies offered that level of service. Because theirs didn’t, they thought no one’s did. So, just be aware, Medicare is huge and geographic areas have different practices and different numbers of care givers in the area to choose from. For example “Haveyourback” gave a list that included IVs. My particular home health did not offer that. They might teach a family member how to do a needed service but they didn’t provide that one.

Some posters here on the forum don’t find the services adequate for their LOs needs. My LOs fell within a sweet spot where it worked very well. Both mine had Original Medicare parts A&B. I’ve observed a friends sister who has an Advantage plan and during her cancer treatment she has found it difficult to receive the level of care through them that I experienced. So, it will depend on your friends insurance and her personal advocates ability/stamina to deal with them. It can be difficult. The forum has posters from all over so sometimes we don’t realize that things are done differently in other areas.

To be clear this is “home health”I am referring to, not “home care”.

https://www.agingcare.com/articles/difference-between-home-health-and-non-medical-home-care-services-426685.htm

ravensdottir: Contact Medicare directly.

Understanding “Monitoring Serious Illness and Unstable Health Status” in Medicare Home Health Services
What It Means in Practice
Here’s what “monitoring serious illness and unstable health status” implies:

• A person has a serious illness (could be acute illness, or worsening of chronic disease) or medical condition that can worsen quickly without close oversight.
• The person’s health condition is unstable — i.e. symptoms, lab values, vital signs, etc. may be changing or at risk of deterioration, or the patient is at risk of complications. For example, someone with congestive heart failure that decompensates, or someone with diabetes whose blood sugar swings dangerously, or someone recovering from surgery but with risk of infection or other complications.
• Skilled nursing or other professional medical care is needed to monitor how the illness is progressing, to catch changes early, adjust treatments, give medications or IV, adjust wound dressings, etc. This isn’t just routine personal care; it requires clinical judgment, training, skills.
Why It Matters for Eligibility and What Is Covered
Because such monitoring is explicitly included in the list of skilled nursing care services that are covered under Medicare’s home health benefit, if a patient meets the criteria (homebound, need for skilled care, under a plan of care, etc.), Medicare covers:

• Regular nursing visits to check on vital signs, wound healing, infection risk, medication effects, etc.
• Interventions by skilled nurses like giving IVs or nutrition therapy, injections, changing dressings, etc., when medically indicated.
• Education for patient/caregiver about how to recognize warning signs and when to contact the doctor.

If the illness is not serious, or the patient’s health status is stable (meaning no high risk of rapid change or complication), then some of the monitoring might not qualify for Medicare coverage.

I hope this summary helps clarify how Medicare defines and covers monitoring of serious illness and unstable health status under home health services.

What type of service are you looking for? This phrase sounds like "in home care" or "intermittant care" both have to be ordered by a Doctor. With these two, a nurse may come to the house one or more times a week and check vitals and look for any changes. An aide may come 2 or 3x a week to bathe the person. No services, like doing laundry or light housekeeping are done.

If you looking for Hospice care, your friend will need to stop their dialysis and any lifegiving meds. Hospice is end of life care. A nurse will come about 1x a week for vitals. An aide 2 or 3x. The family will be the caregivers. They will be taught how do give meds like Morphine and anxiety meds. Equipment needed is supplied and things like Depends, wipes, etc.

I would call Medicare to discuss this. Monitoring often involves coverage for checkin my medical staff for a patient who requires periodic checkups for chronic conditions that can become unstable. It is a nebulous "catch-phrase" sometimes used in qualifying a patient for in home visits at time, and requires letters from the patients' MDs explain just WHY the patient requires coverage for periodic checkin-checkup.

Those sound like words that would qualify someone for palliative care. I'm quite sure your friend would qualify if they are interested and it's available in your area.

This will not cover full time caregivers at home, only medical professional visits.

That phrase usually means that Medicare covers home health when a person has a serious illness or health condition that requires close, ongoing observation by medical professionals. In other words, if someone’s health status is unstable — for example, they’re at risk of complications, their condition changes quickly, or they need frequent adjustments to their care — then skilled nursing visits may be considered medically necessary.

For your friend on dialysis with multiple health issues, this wording is likely pointing to the idea that Medicare can cover skilled nursing to monitor things like vital signs, lab results, medication responses, or other changes that could become serious if left unchecked.

It might help to call the home health agency or Medicare directly to ask how this applies to your friend’s specific situation, since they can give examples of what qualifies and what documentation is needed