When a loved one 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, Inc., 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.
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.
- 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:
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.
Who Pays for It?
- Medicare: This is the primary payer for skilled home health care for eligible seniors, provided all criteria are met. https://www.medicare.gov/coverage/home-health-services
- Medicaid: Also covers skilled care for those who meet its 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. This is sometimes called “custodial care” or “private duty” care. This care also requires a doctor’s order for care.
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.
How to Qualify:
Qualification is based on a person’s need for assistance with ADLs. For 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 and this discussion and your need must be clearly noted in your medical record with your doctor.
Who Pays for It?
- 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.
- Medicare: Important Note: Medicare does not typically 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.
Example 1: The Hip Replacement
- Situation: Mrs. Davis, 78, is discharged home after a successful hip replacement surgery. She is homebound and needs help to recover safely.
- Services Received:
- Skilled Home Health: A Physical Therapist visits three times a week to help her with strengthening exercises and learning to use her walker. A Skilled Nurse visits weekly to check her incision, manage her pain medication, and monitor for signs of infection.
- Personal Care: A Personal Care Worker (PCW) comes for two hours each morning to help Mrs. Davis get out of bed, bathe, and dress, as she cannot bend or bear full weight. The PCW also prepares her breakfast and lunch.
- How it Was Paid: Medicare covered the skilled nursing and physical therapy because she met the homebound and 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 being hospitalized for a stroke. He has some weakness on his right side and difficulty swallowing.
- Services Received:
- Skilled Home Health: A Speech Therapist works with him on swallowing exercises and communication. An Occupational Therapist helps him re-learn how to use his right hand for tasks like brushing his teeth.
- Personal Care: A PCW assists him with feeding, ensures he is positioned correctly, and helps him transfer safely from his bed to his recliner.
- How it Was Paid: Medicare paid for the skilled therapy services. Mr. Chen also qualified for the Wisconsin Medicaid (https://access.wi.gov/) which covered the costs of his Personal Care Worker.
Example 3: Managing a Chronic Illness
- Situation: Ms. Rodriguez, 82, lives with advanced COPD and diabetes. A recent bout of pneumonia has left her very weak.
- Services Received:
- Skilled Home Health: A Skilled Nurse visits to manage her oxygen levels, provide diabetic care including insulin injections, and educate her on new medications.
- Personal Care: A Homemaker/Companion comes daily to prepare diabetic-friendly meals, do light housekeeping that Ms. Rodriguez can no longer handle, and provide companionship.
- How it Was Paid: Her physician ordered the skilled nursing, which was covered by her private health insurance plan. The family pays privately (out-of-pocket) for the homemaker services to ensure she has the daily support she needs.
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.
- Situation 1: Needs Help, But Not a “Skilled” Need. Mr. Smith has Alzheimer’s. He is physically healthy but needs supervision and help with meals and dressing. He does not qualify for Medicare Home Health because he has no specific, intermittent skilled nursing or therapy need. His care is considered “custodial.”
- Solution: His family explores options like private pay or applying for WI Medicaid (https://access.wi.gov/) to get a Personal Care Worker.
- Situation 2: Needs Therapy, But Is Not “Homebound.” Mrs. Jones sprained her knee but is still able to get out of the house and drive to her doctor’s appointments with some effort. She does not qualify for Medicare Home Health for her physical therapy because she is not considered “homebound.”
- Solution: Her doctor refers her to an outpatient physical therapy clinic.
- Situation 3: Needs Personal Care, But Doesn’t Meet Financial Rules. The Williams family needs a PCW to help their father with daily activities. However, their father’s income and assets are above the threshold to qualify for Medicaid.
- Solution: They must pay privately for personal care services or investigate if a long-term care insurance policy is in place.
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, Inc., 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.
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.
Are you a caring and dedicated professional looking for a rewarding career? We are always seeking talented Skilled Nurses, Therapists, and Personal Care Workers to join our team. Visit our website at www.phcsonline.com or call (414) 541-6010 to learn about current opportunities.
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