When a loved one in the Milwaukee area needs support to continue living safely at home, navigating the world of in-home care can feel overwhelming. You might hear terms like “skilled care” and “personal care” used interchangeably, but they represent very different services with distinct qualifications and payment methods.
At Professional Home Care Services (PHCS), we believe that an informed family is an empowered family. As a leading provider of in-home care in Milwaukee, West Allis, and surrounding Wisconsin communities, we want to clear up the confusion. This guide will explain the crucial differences between Skilled Home Health Care and Personal Care Services to help you find the right support for your needs.
What is Skilled Home Health Care?
Skilled Home Health Care is clinical, medical care prescribed by a physician. This type of care is designed to help a patient recover from an illness, injury, or surgery, or to manage a serious health condition. The key word is “skilled”—the services must be performed by a licensed medical professional.
For residents in West Allis or the greater Milwaukee County area, this often follows a discharge from local hospitals like Aurora West Allis Medical Center or Froedtert.
Services Include:
- Skilled Nursing (RNs/LPNs): Wound care, IV therapy, injections, medication management and education, monitoring of vital signs, and patient assessment.
- Physical Therapy (PT): Helping patients regain strength, mobility, and balance after an injury or operation (e.g., knee replacement recovery).
- Occupational Therapy (OT): Assisting patients in safely resuming daily activities like dressing, cooking, and bathing.
- Speech Therapy (ST): Helping patients with communication or swallowing disorders, often after a stroke.
How to Qualify for Skilled Care in Wisconsin:
To qualify for skilled home health, especially under Medicare, a patient typically must:
- Have a doctor’s order for the care.
- Require intermittent skilled services from a nurse or therapist.
- Be certified by a doctor as “homebound.” This doesn’t mean you can never leave the house, but that leaving requires a considerable and taxing effort (e.g., needing a walker, wheelchair, or the assistance of another person).
Who Pays for Skilled Home Health?
- Medicare: This is the primary payer for skilled home health care for eligible seniors, provided all criteria are met. Learn more about Medicare Home Health Services coverage.
- Medicaid: Covers skilled care for those who meet financial and medical eligibility rules.
- Private Health Insurance / VA Benefits: Many traditional insurance plans and Veterans’ benefits cover skilled home health, though coverage details vary.
What are Personal Care Services?
Personal Care Services are non-medical and focus on helping individuals with their Activities of Daily Living (ADLs). The goal is to provide assistance and support so a person can remain safe, comfortable, and independent in their own home.
In the industry, you might hear this referred to as “custodial care” or “private duty” care. While non-medical, this care also requires a doctor’s order in Wisconsin to ensure it is part of a comprehensive care plan.
Services Include:
- Personal Care Workers (PCWs): Assistance with bathing, dressing, grooming, and toileting.
- Homemaker/Companion Services: Help with meal preparation, light housekeeping, laundry, grocery shopping, and providing companionship.
- Mobility Assistance: Help with transferring from a bed to a chair or moving safely around the home to prevent falls.
How to Qualify for Personal Care:
Qualification is based on a person’s need for assistance with ADLs. For Wisconsin Medicaid-funded programs, a functional assessment is always required to determine the level of need. You must discuss your need for Personal Care Services with your doctor; this discussion and your specific needs must be clearly noted in your medical record.
Who Pays for Personal Care?
- Private Pay: This is the most common payment method. Families pay directly out-of-pocket.
- Medicaid: Wisconsin Medicaid is a primary source of funding for personal care for financially eligible individuals.
- Long-Term Care Insurance: Policies specifically designed for this type of care can be a great resource.
- Important Medicare Note: Medicare typically does not pay for long-term personal care services if that is the only care you need.
Real-Life Scenarios: Qualifying for Both Types of Care
Often, a person’s needs are complex, requiring a blend of both skilled and non-skilled support. Here is how that looks for our clients in Milwaukee and West Allis.
Example 1: The Hip Replacement Recovery
Situation: Mrs. Davis, 78, is discharged home after a successful hip replacement surgery. She is homebound and needs help to recover safely.
- Skilled Home Health: A Physical Therapist visits three times a week for strengthening exercises. A Skilled Nurse visits weekly to check her incision and manage pain medication.
- Personal Care: A Personal Care Worker (PCW) comes for two hours each morning to help Mrs. Davis get out of bed, bathe, and dress.
- How it Was Paid: Medicare covered the skilled nursing and PT because she met the homebound/skilled need requirements. Her family used a Long-Term Care Insurance policy to pay for the PCW services.
Example 2: Stroke Recovery
Situation: Mr. Chen, 68, returns home after hospitalization for a stroke. He has weakness on his right side and difficulty swallowing.
- Skilled Home Health: A Speech Therapist works on swallowing exercises. An Occupational Therapist helps him re-learn using his right hand.
- Personal Care: A PCW assists him with feeding and safe transfers from bed to recliner.
- How it Was Paid: Medicare paid for the skilled therapy. Mr. Chen also qualified for Wisconsin Medicaid, which covered the costs of his Personal Care Worker.
Example 3: Managing Chronic Illness (COPD & Diabetes)
Situation: Ms. Rodriguez, 82, lives with advanced COPD and diabetes. A recent bout of pneumonia has left her weak.
- Skilled Home Health: A Skilled Nurse visits to manage oxygen levels and provide diabetic care/insulin education.
- Personal Care: A Homemaker/Companion comes daily to prepare diabetic-friendly meals and do light housekeeping.
- How it Was Paid: Private health insurance covered the skilled nursing. The family pays privately (out-of-pocket) for the homemaker services.
When You Might Not Qualify (And What Your Options Are)
It can be frustrating when you need help but don’t meet the strict criteria for certain programs. Here is how Professional Home Care Services helps you navigate these gaps.
Situation 1: Needs Help, But Not a “Skilled” Need.
- Scenario: Mr. Smith has Alzheimer’s. He is physically healthy but needs supervision. He does not qualify for Medicare Home Health because he has no “intermittent skilled nursing” need.
- Solution: His family explores private pay or applies for WI Medicaid via Access Wisconsin to qualify for a Personal Care Worker.
Situation 2: Needs Therapy, But Is Not “Homebound.”
- Scenario: Mrs. Jones sprained her knee but can still drive to appointments. She does not qualify for home-based PT under Medicare because she is not “homebound.”
- Solution: Her doctor refers her to an outpatient physical therapy clinic.
Situation 3: Needs Personal Care, But Over Income Limits.
- Scenario: The Williams family needs a PCW for their father, but his assets are above the Medicaid threshold.
- Solution: They pay privately for personal care services or utilize long-term care insurance.
The Right Care is a Phone Call Away
Navigating your in-home care options doesn’t have to be a journey you take alone. At Professional Home Care Services (PHCS), we provide a full spectrum of care, from skilled nursing and therapy to personal care and companionship. Our expert team can help you understand your eligibility, coordinate with your doctor, and create a care plan that fits your life in Southeast Wisconsin.
Are you or a loved one in need of compassionate, professional care at home? Visit our website at www.phcsonline.com to learn more about our services or call us directly for a no-obligation consultation at (414) 541-6010.
Join Our Team Are you a caring and dedicated professional looking for a rewarding career in Milwaukee or West Allis? We are always seeking talented Skilled Nurses, Therapists, and Personal Care Workers to join our team. Visit the jobs page of our website https://www.phcsonline.com/blog1/home-care-jobs to learn about current opportunities.
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