Module 1, Topic 1
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Day 4: Home Health Care Structure

Petria September 3, 2020

Organizational Structure in a Home Health Care Business

The aging baby boom generation will propel the demand for in-home care to new heights. Running a home health care agency can combine a profitable business with meaningful opportunities to help clients maintain quality of life. How you structure your staff contributes to how well your business operates and how efficiently, effectively and thoroughly it serves the needs of those who rely on your assistance to help maintain their autonomy.

Independent or Franchised Provider

If you start your agency as an independent operation, you hold full responsibility for the way you structure and adapt your organization to the needs of your client base. If you opted to associate yourself with a franchised system, departing from the setup it mandates may violate the terms of your agreement. As an independent or as a franchisee, your principal supervisory needs center around nursing assessments, medication management and care-plan development; caregiver scheduling and oversight; Medicare and insurance paperwork; and accounting and payroll. If you introduce too many intermediate levels of bureaucracy in an attempt to spare your top supervisors from work overload, you run the risk of fragmenting responsibility in ways that can let critical details fall by the wayside

Home Health Agency Structure

Home health agencies utilize a wide variety of medical professionals to provide short-and long-term services to patients who are elderly, disabled or too ill to care for themselves. Home health care is often the difference between institutionalizing sick loved ones and allowing them to continue to live in their own home while they convalesce. These agencies are structured to help build a collaborative relationship between patients and their physicians, which helps patients and their families retain optimum control over their treatment

The Frontline

Nurses, home health aides and physical therapists typically make up the caregiving staff of home health care agencies and are the front-line service providers. These highly trained and licensed professionals work directly with patients and serve as the liaison between them, their family members and the agency. They are responsible for all patient care and have regular contact with patients and their families once services are contracted


Home health agencies must know whom they are employing. This involves checking regularly to ensure your clinicians have active and discipline-free licenses in their state of practice. CMS also requires that every home health agency have an administrator and a clinical supervisor. The clinical supervisor must be a nurse of more than one year of experience who is available in person or by phone at all times the agency is performing services. An administrator must be licensed or certified per the regulations of her state. These roles can be filled by the same person if the administrator is an experienced nurse.

Director of Nursing (DON)

The Director of Nursing (DON) is typically responsible for direct supervision of the caregiving staff, and resolves scheduling issues, answers caregiver questions, ensures patient visits are made on schedule and mitigates staffing problems as they a rise. This position is the first in the management chain of command. The Assistant Director of Nursing is responsible for immediate clinical supervision and is the bridge between the Quality Assurance RN and the Director of Nursing in some agencies. The DON is in the first tier of upper management and is ultimately responsible for all clinical operations within a home health agency.


An executive administrator, who is often also the agency owner, typically runs the home health agency. Ensuring the businesses functionality, including inspection readiness, marketing, knowledge of new and/or updated legislation and mitigating consumer complaints are among the executive administrator’s primary responsibilities. The administrator works closely with both the nursing administrator and/or the director of nursing to ensure that all facets of the agency are operating efficiently and in compliance with all municipal, state and federal laws. They must also pay close attention and oversee the Operational departments of the agency.

Employee Supervision

Home health agencies rely on the efforts of a field staff of certified nurse assistants, home health aides and homemakers to implement the terms of individual care plans and respond to clients’ or their families’ requests for changes in those plans. Too much supervision leaves no room for experienced, capable personnel to do their jobs without feeling as if they lack administrators’ trust. Too little supervision leaves room for lapses in care and judgment, overlooked treatment needs and unmonitored declines in patients’ condition. Verify that you have enough personnel with supervisory authority to respond to the size of your in-home work force, especially when your client base grows

Scheduling Managers

Because your clients’ needs require attention at all times of day, your daily schedule can become a challenging balance between patient care and employee availability. Some clients may respond better to certain caregivers than to other individuals you send in to provide service. How–and how well–you manage your agency schedule can make the difference between a smooth-running operation and daily chaos, as you juggle available caregivers to fill in for missing personnel. Examining the organizational structure for ways that can improve the scheduling function and scale it to match your level of client activity is key.

Service Delivery

I feel the most important aspect of a well-designed home health care agency’s organizational structure lies in its contribution to timely and appropriate care. Clear lines of communication between supervisors and field staff help assure that all information about changes in a client’s condition reaches those personnel charged with overseeing care plans, communicating with clients’ physicians and screening staff/client interactions for potential liabilities. These three aspects of oversight lie at the heart of an agency’s mission to preserve and extend quality of life for their clients. Examining an agency’s hierarchy for signs that it impedes the free flow of these kinds of crucial observations from care sites to the home office, and listen to the suggestions their employees offer based on their direct interaction with clients is crucial to the agency’s success.

Appropriate Patients

CMS requires that patient be appropriate to home care. This means that they must have come from an acute care hospital or the community and received a physician’s order for home care. Home health clinicians must routinely document their patients’ conditions, treatments and progress. Clinicians must have a plan of care in place and be comparing progress against the plan of care. Agencies should review documentation there documentation and policy and procedures regularly as state health agencies survey home health agencies’ for quality and safety compliance on a regular basis and in case of a complaint.

Safe Conditions

Every state has its own regulations regarding the standards of safety and health a home health agency to which a home health agency must adhere. However, commonalities include protection of patients against abuse by providers, clean instruments and needles, clinicians being free from the influence of alcohol and drugs, patient care being safe and clinically appropriate to the patient, and proper handling of drugs and controlled substances. CMS regulations support states by stating that Medicare participating agencies must remain in full compliance with their state regulations.

Regulatory Requirements

Health care is a highly regulated industry full of rules and compliance requirements, which literally fill volumes. Although home health care can be a lucrative business, you have to know what you’re doing to keep the company operating legally and eligible to receive payments from Medicare and insurance companies. Home health agencies are subject to regulations from their state departments of health as well as the federal Center for Medicare Services (CMS). However, within all the many regulations, a few basic categories are your most important guidelines.

Operational Department

In addition to the front-line medical professionals, it takes an extensive support staff to ensure that a home health agency runs efficiently. The human resource department is responsible for ensuring that agencies are staffed with talented customer service professionals like receptionists and secretaries as well as qualified medical technology specialists, coders and billers. Human resources is the bridge between caregivers, support staff and management