Home health and in-home palliative care services

In the Puget Sound region (excluding Olympia), the Kaiser Permanente Continuing Care Division provides home health services. In Olympia, Northwest Washington, and East of the Cascades, these services are available from contracted agencies.

Admission criteria

Kaiser Permanente's criteria for admission to home health services are based on the federal regulations for the Medicare home health benefit and MCG guidelines.

Arranging for services

If the member is in the hospital or skilled nursing facility, discharge planners in your area will arrange for home health services.

If the member is in your office, contact:

Puget Sound region:
Please submit a Home Health or Hospice referral via EPIC Order Entry.

Home Health and Hospice Referral Intake Office
Toll-free: 1-800-332-5735

Olympia, Northwest Washington, and East of the Cascades:
Send a request for authorization using the Referral Request tool.
Or, contact Review Services
Toll-free: 1-888-289-1363
Fax: 1-888-282-2685

Contracted providers

Find home health and home infusion therapy providers in our provider directory.

Scope of Services

The home health provider supplies covered interdisciplinary home care services to members twenty-four (24) hours a day, seven (7) days a week. Home health covered services include:

  • Skilled nursing services
  • Physical, occupational and speech therapy services
  • Medical social work services
  • Home health aide services

A. Admission

  1. The home health provider must accept all Kaiser Permanente referrals for covered services to members or notify the referring provider as soon as possible, and no later than two (2) hours after receiving the referral request that the home health provider is unable to accept the referral. Upon receipt of the referral, the home health provider will enter referral information into One Health Port to ensure authorization for services.
  2. Once the referral information is entered and authorization is secured, contact the member within twenty-four (24) hours of pre-authorization to perform triage assessment and schedule initial visit according to the member’s need and condition. Initial assessment should occur within 48 hours of referral acceptance, unless it is the member’s preference to complete the assessment on another day. If the assessment occurs outside of the 48 hours, the provider must be notified of new assessment date.

B. Member Assessment

  1. Perform complete physical assessment of member at initial visit. Perform ongoing assessment as appropriate to member’s condition and progress as required by federal and state home health regulations and other applicable voluntary accrediting body standards and guidelines.
  2. Communicate results of assessment plan of care to Kaiser Permanente and the Kaiser Permanente physician according to federal and state home health agency regulations and as needed based on the member’s condition.
  3. Secure appropriate consents for care as required by applicable federal and state home health agency regulations and other applicable voluntary accrediting body standards or guidelines.

C. Plan of Care

  1. Develop and submit a plan of care to Kaiser Permanente for approval and authorization within one business day following the initial visit or when the assessment warrants a request for modification to the original authorized plan of care.
  2. Assure the plan of care meets Medicare Conditions of Participation and all applicable federal and state home health regulations and any applicable voluntary accrediting body standards.
  3. Submit all forms requiring physician signature directly to the Kaiser Permanente physician.

D. Coordination, Supervision, and Evaluation of Care

  1. Make every reasonable effort to furnish the same personnel to each member throughout his or her episode of care.
  2. Assure that all ordered lab specimens are delivered to the closest Kaiser Permanente or Kaiser Permanente contracted laboratory facility. Utilize other facilities only when specifically authorized by Kaiser Permanente.
  3. Provide at no cost to Kaiser Permanente or the member, supplies that are commonly used by the home health provider’s employees during the delivery of patient care.
  4. Supervise and evaluate all care and services provided by the home health provider’s staff.
  5. Assure coordination of care with all other Kaiser Permanente providers, including supervision or participation in patient care conferences.

E. Scheduling of Visits or Hours

  1. Provide after hours and on-call availability for member visits as needed. On-call or as-needed (PRN) visits must occur within four (4) hours of the request.
  2. Provide visits seven (7) days per week, twenty-four (24) hours per day as required by member’s condition and at times mutually agreed upon by the home health provider’s staff and Members.

F. Discharge Planning from Home Health Services

  1. Notify Kaiser Permanente within one (1) business day when a member is discharged from the home health provider’s service and within one (1) business day following notification to the home health provider of member’s hospitalization.
  2. Coordinate discharge or transfer planning with the appropriate Kaiser Permanente providers, including the physician, family members and other resources as needed.

Documentation Requirements

  1. Provide Kaiser Permanente with a discharge summary, any interim summaries, re-certifications and Plans of Care at time of discharge.
  2. Submit copies of the member’s Plan of Treatment (Form CMS-485), any modifications or revisions to the Plan of Treatment and re-certifications of care to Kaiser Permanente.

Organizational Policies and Procedures

  1. The home health provider agrees to adhere to all applicable Kaiser Permanente organizational policies and procedures, including those necessary to meet federal and state home health agency regulations, as well as the standards of the Joint Commission on the Accreditation of Health Care Organizations or other applicable regulatory and voluntary accrediting bodies. These policies must include, but are not limited to:
    • Employee competency and performance appraisal
    • Employee education and training
    • Health requirements, including TB and Hepatitis B vaccination
    • Infection control
  2. At Kaiser Permanente’s request, the home health provider must provide Kaiser Permanente with a current copy of the following reports:
    • The home health provider’s fee schedule, including per visit services, hourly services, and supply schedule
    • Medicare Home Health Cost per Visit and per Beneficiary Cost Limits (i.e., Medicare Cost Caps)
    • Medicare Cost Report(s)
  3. The home health provider must supply Kaiser Permanente any requested utilization information on the home health provider’s activity, including but not limited to:
    • Annual average number of visits per patient
    • Annual number of visits per patient by selected ICD-10 diagnostic and/or procedure codes as mutually defined by Kaiser Permanente and the home health provider
    • Annual duration of service per patient
    • Total annual average patient census and number of visits
  4. Kaiser Permanente will routinely conduct a utilization review and quality assurance programs for home health services provided to members, including a review of all the associated documentation. If Kaiser Permanente’s utilization or quality assurance review finds that the care provided, even if medically necessary, does not meet Kaiser Permanente guidelines, including but not limited to, any Medicare regulations or guidelines, or does not meet authorized care as specified by Kaiser Permanente, the home health provider agrees to return all payments that have been made by Kaiser Permanente for such identified services and must not seek subsequent reimbursement from the member for such denied services. Kaiser Permanente agrees to provide written notice of such determination to the home health provider within six (6) months of the completion of service to the members.