Home Healthcare, Hospice and Telehealth Best Practices

01Purpose and scope

This manual supports the course Home Healthcare, Hospice and Telehealth. It describes how care is actually delivered when patients are treated in their homes, when they are receiving end-of-life care, and when clinicians use video, audio or secure messaging to evaluate, monitor or follow up with patients. It is written for nurses, therapists, social workers, aides, care coordinators, intake staff, hospice admissions teams and clinicians who supervise remote services.
The three areas share a common problem: the care team does not control the environment. A home may lack reliable power or a clean surface for a dressing change, a caregiver may be the only person available at night, and a telehealth visit may depend on a patient's cell signal. The manual covers the main activities, decisions, deliverables, stakeholders, standards and indicators in each area, and it notes where practice changes between agencies, states and payers.
This guidance does not replace qualified professional judgment, approved agency procedures, medical orders or required authorization. Coverage rules, licensure requirements, scope of practice and privacy obligations depend on jurisdiction and payer. Check the current requirements with your state licensing board, your state health department, the Centers for Medicare and Medicaid Services where applicable, and your organization's compliance office before changing any procedure.

02Core principles

Care in the home is organized around the person and the household, not the building. A plan that works in a clinic may fail at a farmhouse where the nearest pharmacy is forty minutes away and the patient lives alone. Start every episode by asking what the patient and family can realistically do, what they want to avoid, and who will be present when problems occur.
Hospice adds a second principle: the goal is comfort, dignity and support for the family, and the plan should follow the patient's stated goals and the prognosis documented by the attending physician or hospice medical director. Hospice staff do not treat the disease in the usual sense. They manage symptoms, prepare the family for changes and coordinate with the interdisciplinary group, which typically includes a physician, registered nurse, social worker, chaplain or spiritual care provider, aide and volunteer coordinator.
Telehealth is a delivery method, not a different standard of care. The same clinical judgment, consent, documentation and follow-up expectations apply. What changes is the information available to the clinician. Video shows posture, skin color, breathing effort and the home environment, but it does not replace a hands-on examination, and audio alone limits what can be assessed. Clinicians should decide in advance which conditions are suitable for remote care and which require an in-person visit or a referral to urgent services.
Safety is shared. Patients, caregivers and staff each hold part of the risk, and each should know what to do when something goes wrong. Teach emergency steps early, write them down in plain language, and confirm that the caregiver can find the phone number and the medication list without help.

03Planning and preparation

Intake begins with a referral, a physician order or a plan of care, and an eligibility check. For home health, the agency generally needs a face-to-face encounter documented by a practitioner and a plan of care signed by a certifying physician or allowed practitioner. For hospice, the patient usually needs a terminal prognosis certified by a physician and, in many cases, a hospice election statement. Requirements differ by payer and program, so confirm them against current federal and state guidance and your agency's policy.
Before the first visit, gather the diagnosis list, medication reconciliation from the referring provider, allergies, code status or advance directives, insurance information, recent hospitalizations and the names of the primary caregiver and any health care agent. Review the home environment through a phone call or a pre-visit checklist when possible. Ask about stairs, bathroom access, oxygen equipment, pets, firearms, water supply, cleanliness and whether anyone else lives in the home. These details shape the plan more than any single diagnosis.
For telehealth, prepare the technology and the consent process before the visit. Confirm the patient's identity and location, because a clinician may need to send emergency services to the correct address. Verify that the platform is one your organization has approved for protected health information, that the patient has a private place to talk, and that a backup number is on file. Document the patient's consent to telehealth, including the fact that they were told about its limits and how to get in-person care.
Staffing and supply planning matter as much as clinical planning. Home visits are scheduled around travel time, so a poorly built route can leave a patient waiting for hours. Hospice teams need on-call coverage and a supply process for comfort kits, which typically include medications approved under the prescriber's orders and local protocol. Confirm who can authorize after-hours medication and how caregivers reach that person.

04Recommended workflow

1
: Confirm the referral, eligibility and consent. Review the order, diagnosis, payer requirements and goals of care. Record who gave consent and whether a health care agent or surrogate is involved. If the patient lacks capacity and no surrogate is identified, escalate to the supervising clinician before proceeding.
2
: Complete the first visit or first video encounter with a focused assessment. Check vital signs when they can be measured safely, review medications with the bottles in the home, screen for falls, skin breakdown, nutrition, pain, mood, cognition and caregiver strain, and observe the home for hazards. In telehealth, ask the patient to show the medication containers and walk through the room if the clinical question requires it.
3
: Build the plan of care or care plan with the patient and caregiver. Set measurable goals, such as walking to the bathroom without assistance by a specified date, or keeping pain at or below an agreed score on a standard scale. Assign responsibilities to each discipline and to the caregiver. Keep the plan short enough that the caregiver can actually follow it.
4
: Deliver visits according to the schedule and the plan. Start each visit by reviewing the last visit's open items, then address the new concerns. Teach with the caregiver present, use teach-back to confirm understanding, and leave written instructions at the bedside. For hospice, schedule regular interdisciplinary reviews and bereavement contact after death according to agency policy.
5
: Escalate changes early. Define the thresholds that trigger a call to the physician or nurse practitioner, such as a fever above a set number, new confusion, uncontrolled pain, a fall with injury or a drop in oral intake for more than a day. In hospice, changes in breathing pattern, mottling or decreased responsiveness often signal the need for a family call and a visit, and the team should follow its documented guidance on comfort medications.
6
: Close the episode or transfer the patient. Summarize the course, goals met or not met, medications at discharge, equipment returned, and follow-up appointments. Send the summary to the next provider. For hospice discharge due to revocation or live discharge, follow the notification and documentation rules that apply in your jurisdiction.
7
: Review the episode for quality. Check the record for missing signatures, unsupported diagnoses, incomplete medication lists and late notes. Share what worked and what did not with the team. This step is often skipped, and it is where most repeated errors get caught.

05Quality checks, risk controls and compliance

Quality checks should be built into the workflow rather than added at the end. Use a short daily or weekly review of open orders, pending lab results, overdue visits, unsigned plans of care and incomplete consents. Keep a list of high-risk patients, such as those on anticoagulants, opioids or insulin, and check that their medication reconciliation is current after every change.
Medication safety is the most common source of serious harm in home care. Reconcile medications at intake and after every hospital or emergency visit. Ask the caregiver to bring every bottle, patch, inhaler and injectable to the visit, and note any duplicates or expired items. Use the medication management process approved by your agency. Clinicians should not change dosing outside their scope or without an order.
Infection control, fall prevention and equipment safety also belong in the risk plan. Clinicians should follow standard precautions, hand hygiene and sharps disposal, and they should document how they assessed the home for hazards such as loose rugs, unsecured oxygen tubing near open flame, or electrical cords across walking paths. Equipment vendors should be contacted for repairs, and the team should not attempt repairs themselves.
Privacy and security rules apply in every setting. In the United States, the HIPAA Privacy and Security Rules govern protected health information, including telehealth platforms and mobile devices. Use approved devices, avoid personal messaging apps for clinical content, lock devices in the vehicle, and verify who is in the room before discussing diagnoses. Home health and hospice providers also must follow Medicare Conditions of Participation where they participate in Medicare, including requirements for patient rights, clinical records, governing body oversight and quality assessment. Telehealth may involve state licensure, cross-state practice rules, prescribing limits and payer-specific documentation requirements, so check each state and payer before offering services across a border.
Telehealth carries specific risks. Video calls fail, audio drops, and patients can misread instructions on a small screen. Build a failover plan: a telephone backup, a rule for when to convert the visit to in-person care, and a process for emergency response when the clinician cannot confirm the patient's location or condition. Document the reason for any change in visit mode.

06Collaboration and documentation

Home and hospice care depend on communication across several people who rarely work in the same room. The physician or advanced practice provider sets the orders, the nurse manages the clinical plan, the therapists assess function, the social worker addresses finances and family dynamics, and the aide supports personal care. Each discipline should document its own findings, and the shared plan should reflect the decisions made together. A common failure is a plan that lists goals no one owns.
Documentation should be specific enough that another clinician could act on it without calling. Describe what was observed, what was done, what the patient or caregiver said, and what was planned next. Avoid vague phrases such as patient doing well or no concerns unless you state the basis for that conclusion. For telehealth visits, record the modality, the participants, the location of the patient, the start and end times, any technical problems, and whether the visit was completed as planned.
Caregiver communication requires a written path. Give the caregiver a phone number for routine questions, a different number for urgent issues, and a clear statement of what to do first when a problem occurs. In hospice, the family should know how to reach the on-call nurse at any hour and what to expect in the final days. Record the conversations that shaped these decisions.
Coordination with outside providers is part of the job. Send the plan of care to the physician, confirm that orders are signed, and call the pharmacy when a medication cannot be obtained. When a patient moves from hospital to home, obtain the discharge summary and medication list before the first visit, and confirm that the patient understands what changed in the hospital.

07Measures and continuous improvement

Choose a small number of indicators that reflect the purpose of the service and that your team can measure consistently. For home health, common indicators include timeliness of the start of care, rates of unplanned hospitalization, medication reconciliation completion, fall rates, pressure injury rates, and patient-reported measures of pain or function where the agency collects them. For hospice, indicators often include the proportion of patients receiving a visit within an agreed window after an urgent call, pain and symptom assessment completion, caregiver support contacts, and bereavement follow-up completion. For telehealth, track completion rates, technical failure rates, visits converted to in-person care, and patient-reported satisfaction with clarity and access.
Interpret indicators carefully. A low hospitalization rate may reflect a patient population with different needs rather than better care, and small teams can see large swings from a few cases. Use run charts or trend review over time, and look at individual cases behind each change. Define each measure in writing, including the numerator, denominator and data source, so the team uses the same method.
Improvement projects work best when they are small and time-limited. Choose one problem, such as late medication reconciliation after hospital discharge, write a specific change, test it with a few patients or clinicians, and review the result before expanding it. Record what was tried, what happened, and what will be done next. Share results with the staff who do the work, not only with leadership.
Tools and standards help but do not decide the question. Agencies may use accreditation standards, state licensure rules, payer quality programs and internal policy. Know which requirements are mandatory and which are voluntary. Where published quality measures exist, use their current definitions and confirm them with the source before reporting results.

08Common mistakes and how to prevent them

The most frequent mistake is treating the visit as the whole job. Care happens between visits, when caregivers decide whether to call, whether to give a dose, or whether to wait until morning. Prevent this by building a caregiver teaching plan into every episode and by checking, at each visit, what happened since the last one.
Another mistake is relying on a medication list from memory or from the referral. Patients take drugs that are not on any list, and caregivers often stop or split medications on their own. Prevent this by reconciling against physical containers and asking about over-the-counter products, supplements and medications from other prescribers.
In telehealth, clinicians sometimes continue a video visit when the picture or sound is poor and the clinical question needs a physical examination. Prevent this by setting a rule that poor connection during a symptom assessment means the visit is paused or converted, and by documenting the decision.
In hospice, teams sometimes wait too long to call the family when a patient is declining, or they overuse crisis calls at night without a plan for comfort. Prevent this by reviewing expected changes with the family early, using a written guide, and confirming who will respond after hours.
Documentation drift is also common. Notes are written at the end of a long day, copied forward from earlier visits, or left unsigned. Prevent this by completing notes before leaving the home or by the end of the visit window set by policy, and by auditing a sample of charts each month.

09Practical checklist

Confirm referral, order, eligibility, consent and identity before the first visit or video encounter.
Record the home environment, including access, hazards, equipment and who is present.
Reconcile medications using physical containers and document discrepancies with the prescriber.
Set measurable goals with the patient and caregiver, and assign each goal to a named person.
Give the caregiver written instructions, emergency steps and a phone number for urgent and routine questions.
Confirm telehealth platform approval, patient location, backup contact and the failover plan before each video visit.
Document the modality, participants, times, technical problems and any conversion to in-person care.
Define escalation thresholds for each patient and review them at each visit.
Send the summary and medication list to the next provider at transfer or discharge.
Review open items, unsigned notes and overdue visits weekly, and track two or three agreed indicators over time.

★Learning sources

Micro Degree: Home Healthcare, Hospice and Telehealth
Micro Degree: Healthcare Administration Practice
Micro Degree: Physiotherapy Assistant Operations
Micro Degree: Cardiac Care Support

?Frequently asked questions

Do I need a physician order before starting home health or hospice services?

Yes, in general, both services depend on a physician or other allowed practitioner documenting eligibility and a plan of care or hospice certification. The exact documents, timing and signature rules depend on the payer and current federal and state requirements. Check with your agency's compliance office and the current guidance from the Centers for Medicare and Medicaid Services or your state health department.

Can a nurse start a telehealth visit with a new patient without a prior in-person exam?

That depends on state licensure, the clinical situation, the practitioner's scope, and payer rules for initial telehealth encounters. Many organizations limit telehealth for new patients to conditions where the clinician can assess safely by video. Follow your organization's telehealth policy and the rules in the state where the patient is located.

What should I do if a hospice patient's family calls at night with a sudden change?

Follow the after-hours process your hospice has written and approved. Ask the family to describe the change, check the patient's comfort orders and symptom plan, and decide whether a nurse visit or phone guidance is needed. Document the call, the advice given and any follow-up. This guidance does not replace the judgment of the on-call clinician or the medical director's orders.

How do I keep patient information private in a home where other people are present?

Ask the patient whether they want others present for each discussion, and move to a private area when sensitive topics come up. For telehealth, confirm the patient is alone or has agreed to others being present before starting. Use only approved devices and platforms, and avoid leaving protected information on screens or paper in the home.