Introduction: The Medicare Payment Advisory Commission (MedPAC) has documented a significant increase in the number of Medicare beneficiaries opting for Medicare Advantage, also referred to as Medicare (Part C) plans. As a result, there also has been an increase in Medicare home health beneficiaries receiving their home health through Medicare Advantage Plans. A literature review indicates there is only one quantitative study and no qualitative studies on the impact of this shift on home health on patient care, and none on home care nurses’ views on the impact on patient care. Methods: The current study is a qualitative study based on in-person interviews of a convenience sample of 48 home care nurses from 9 different home health agencies in New York City between January 15, 2026 and March 25, 2026. Results and Conclusions: Five major themes emerged, with nurses perceiving: (1) the Medicare Advantage prior authorization process denials are frequent and adversely impact patient care; (2) Medicare Advantage plans use of home health decreases the amount of home health visits; (3) decreased Medicare Advantage home health visits per patient adversely affects nurses’ ability to deliver appropriate care; (4) decreased Medicare Advantage home health visits per patient increases the likelihood of health care readmissions; and (5) decreased Medicare Advantage home health visits per patient increase the likelihood of patients developing further medical complications. Recommendations are made for further government actions based on the study findings.

Objective: To determine if there is agreement—between a systematic literature review and home care social worker interviews—that current low utilization of Medicare home health social work services has an adverse impacts impact on patient care. Methods: This is a qualitative study based on in-person interviews of a convenience sample of 36 home care social workers from 6 different home health agencies in New York City between April 9, 2026, and May 29, 2026. It is a follow-up to a similar study on home care nurses view in this Journal, published online in June 2026. Results: Four major themes emerged, with social workers feeling, like nurses: (1) the Medicare Advantage prior authorization process denials are frequent and adversely impact patient care; (2) Medicare Advantage Plans use of home health decreases the amount of home health visits; (3) decreased Medicare Advantage home health visits disproportionately affect social work, which is the lowest volume service in traditional Medicare home health and (4) decreased Medicare Advantage home health visits per patient increase the likelihood of patients developing further psychosocial and medical complications. Conclusions: The current study reinforces the need for: (a) government sponsored robust research to have a more valid and reliable idea of where relevant policy changes should be made, and (b) statutory and regulatory action to address the low utilization of Medicare home health social work services and its adverse impacts on patient care.

In its 2025 final payment rule for Medicare Home Health published November 7, 2024, the Centers for Medicare and Medicaid Services added 5 questions to the outcome and Assessment Information Set (OASIS) needing to be addressed: 4 new (i.e., 1 on living situation; 2 on food insecurity; 1 on utilities) and 1 that revised transportation. The rule states that the changes are responsive to issues in the social determinants of health category and take effect with the calendar year 2027 Home Health Quality Reporting Program. A literature review indicates no studies on the potential impact of these OASIS revisions on Medicare home health social work services, the service for social needs. This article summarizes an initial, exploratory study to address the literature gap, based on interviews of 31 Medicare home health social workers between January 6, 2025, and February 9, 2025, in the New York City metropolitan area. Three themes emerged, including: social workers believe the new requirements (1) are overdue, needed, and provide the potential to increase services to deal with many unmet social needs; (2) Medicare continues to neglect the expansion of social work coverage and payment to home health agencies for supplemental social needs necessary to make the new requirements effective for Medicare home health patients; and (3) Medicare still does not mandate that any Social Determinants of Health need detected through the new OASIS requirements must receive follow-up care with appropriate, covered interventions and the OASIS questions do not affect scoring for episode payment.

There is significant literature on the existence and adverse effects of social isolation and depression among the elderly, exacerbated by the recent COVID-19 pandemic. A literature review indicates no studies of how the Medicare home health benefit addresses social isolation and depression, including no studies of home care social workers' perceptions of the nature and consequences of Medicare coverage. This article summarizes an initial, exploratory study to address the literature gap, based on interviews of a convenience sample of 44 home care social workers from 5 different home health agencies in the New York City metropolitan area between November 1, 2021 and May 31, 2022. Six themes emerged from the study. Social workers believe: (1) extensive social isolation and depression exist among Medicare home health beneficiaries; (2) Medicare home health policy provides no systematic measure to detect or monitor social isolation and a limited measure for depression among the homebound elderly; (3) Medicare home health policy provides no coverage to treat either depression or social isolation; (4) effective interventions are available to prevent and treat depression and social isolation. Social workers also believe that: (5) the lack of social isolation and depression coverage results in additional mental and physical health conditions; (6) lack of social isolation and depression coverage exacerbates existing mental and physical health conditions. Policymakers are urged to modify the Medicare home health benefit to improve detection and monitoring of social isolation and depression as well as coverage of appropriate evidence-based preventative and treatment interventions.

Alzheimer's disease is a major and increasing cause of illness and death in the United States, imposing significant social, economic, and psychological burdens on patients and their caregivers. This article explores the perceptions of Medicare home health nurses as to the impact of Medicare home health requirements on their decisions to admit, treat, cope with, and meet patient care needs of Alzheimer's disease patients. It presents an exploratory study, which resulted from a gap in the literature review that found only 3 studies and 1 article since 1965. The study is based on interviews of a convenience sample of 37 home care nurses from 5 home health agencies in the New York City metropolitan area. Analysis followed the grounded theory 3-stage coding of interview data: open, axial, and selective coding. This research methodology was used because it was developed for interpreting qualitative data in the absence of a pre-existing theory. Five themes emerged from interviews: (1) Most Medicare home health patients have some level of Alzheimer's disease (AD). Medicare home care regulations: (2) restrict nurses' admissions of persons with AD and lack a mandatory evidence-based assessment for AD; (3) restrict the care that nurses can order for persons with AD; (4) do not cover evidence-based non-pharmacological interventions for AD patients ; and (5) nurses use 3 coping strategies to deal with the restrictions: most as conformists, others as innovators, some as rebels. Policymakers are urged to consider legislation expanding coverage of home-based, evidence-based non-pharmacological interventions for persons with Alzheimer's disease; expanding Medicare home care social work services to allow delivery of appropriate services; requiring an evidence-based Alzheimer's disease assessment at intake and as part of the OASIS; additional reimbursement for home health agencies treating Medicare homebound persons with Alzheimer's disease.

There is significant literature on social determinants of health (SDOH) to improve health outcomes. In response, Congress and the Centers for Medicare and Medicaid Services (CMS) have expanded Medicare Advantage Plans’ ability to cover SDOH-related services through supplemental benefits and Special Needs Plans (SNPs). Congress has not authorized Traditional Medicare to cover such services. A literature review indicates no studies of Medicare home health social worker awareness of this dichotomy and their resulting perceptions of the impacts of the lack of such coverage. This article summarizes an initial, exploratory study to address the literature gap, based on interviews of a convenience sample of 44 home care social workers from 5 different home health agencies in the New York City metropolitan area between November 1, 2021, and May 31, 2022. Results indicate social workers lacked awareness of the dichotomy in coverage of SNPs and supplemental benefits in Medicare Advantage Plans and traditional Medicare. Once made aware of the dichotomy, 4 additional themes emerged from the interviews: documented patient needs were being ignored; the supplemental needs coverage permitted for Medicare Advantage plans should be extended to beneficiaries receiving traditional Medicare; and the lack of such coverage increased the risk of onset of mental and physical health conditions, and revolving door-admissions and costs. Policymakers are urged to consider adding coverage of special needs and supplemental benefits covered in Medicare Advantage to traditional Medicare, through Medicare home health.

This study addresses the lack of research on the perceptions of home care social workers as to how the Medicare home health benefit addresses anxiety. The findings are based on interviews of 44 home care social workers from five home health agencies in the New York City area. Four themes emerged. Social workers believe: (1) there is extensive anxiety among Medicare home health beneficiaries; (2) Medicare home health’s mandatory assessment for anxiety is limited and not done by social workers; (3) Medicare home health does not require treatment or coverage of anxiety; (4) the lack of coverage for patients assessed with anxiety creates and exacerbates mental and physical health conditions. Policymakers should modify the Medicare home health benefit to cover anxiety.

There is extensive literature on the significance of financial incentives in the Hospice Medicare Benefit (HMB) and the growth of proprietary ownership of hospices in the United States. A literature review indicates a paucity of information on hospice nurses’ perceptions of the impact of the HMB’s financial structure on care planning and delivery decisions. This article presents background on the topic and an initial, exploratory study to address the literature gap, based on interviews of a convenience sample of 48 hospice nurses from 6 different hospices between December 1, 2018, and January 31, 2020, in the New York City metropolitan area. Six themes emerged from the interviews: finances are the guiding principle in care planning and service delivery decisions; appropriate patient selection allows hospices to maximize profit by maximizing length of stay (LOS) and minimizing service utilization; balancing patient care needs, cost, and LOS is a challenge; live discharge decisions save money, but can compromise care; the Interdisciplinary Team (IDT) is where most major decisions are made regarding patient care and finances; and money drives patient care decisions, regardless of ownership type.

There is significant literature about the Medicare Outcome and Information Assessment (OASIS). A new OASIS Version E, effective January 2023, makes significant changes in assessing patient mental health. However, a literature review indicates no studies of the anticipated effectiveness of the OASIS-E on improving psychosocial care of Medicare home health beneficiaries. This article summarizes an initial, exploratory study to address the literature gap, based on interviews of a convenience sample of 36 home care social workers from 5 different home health agencies in the New York City metropolitan area between August 1, 2022, and November 30, 2022. Four themes emerged from the study, namely that social workers believe the OASIS-E revisions: are an improvement over prior OASIS versions; are cumbersome and do not require administration by a social worker; do not impose specific guidance requirements on using new measures scoring results in making care decisions; and do not address coverage of specific interventions that address patients with significant mental health issues. Policymakers are urged to modify the OASIS-E guidance manual to require use of new mental health assessment scores in care planning and to expand coverage of evidence-based treatment interventions for patients with significant assessed mental health conditions.

There is extensive literature on the significance of financial incentives in the Hospice Medicare Benefit (HMB) and the growth of proprietary ownership of hospices in the United States. A literature review indicates a paucity of information on hospice nurses' and hospice social workers' perceptions of the impact of the HMB's financial structure on care planning and delivery decisions. In a previous issue of this journal, the author addressed the literature gap by presenting a study on hospice nurses' perceptions of the impact of financial factors on their decision-making regarding care for Medicare hospice beneficiaries. The study presented in this article is a companion qualitative study to the nurses' study. This article presents background on the topic and an initial, exploratory study to address the literature gap, based on interviews of a convenience sample of 37 hospice social workers from 6 different hospices between December 1, 2018 and January 31, 2020, in the New York City metropolitan area. Six themes emerged from the interviews: finances are the guiding principle in care planning and service delivery decisions; balancing patient care needs, cost, and finance-related length of stay (LOS) is a challenge; the emphasis on finance diminishes the social workers' ability to address hospice patient needs; the emphasis on finance diminishes the social workers' ability to address hospice caregiver needs; the social work role is diminished because of the role of nurses in developing and implementing the plan of treatment, which influences finances; and the Interdisciplinary Team (IDT) is the crucial clinical and financial decision-making setting, but gives limited weight to social work input.

This article is a reaction paper to the article in this journal issue entitled Human Service Cartels: The Soft Repression of the Mediocracy by David Stoesz. As such, it addresses two significant questions about the Stoesz article. One question is as follows: Are we really talking about a cartel? The other question is as follows: Isn’t it the power elite that promotes societal control and repression?

This article is a reaction paper to the article in this issue of Research on Social Work Practice entitled Research to Consider While Effectively Redesigning Child Welfare Services by Richard P. Barth and colleagues. As such, it addresses two significant questions about the article. One question is: What are the methodological limitations? The second question is: What are the implications on the methodological limitations?

There is significant data on the adverse impact of COVID-19 on persons who were poor, minorities, had compromised physical or mental health, or other vulnerabilities prior to the COVID-19 pandemic. A significant portion of the overall Medicare population has such vulnerabilities. The Medicare home health beneficiary population is even more vulnerable than the overall Medicare population based on gender, race, income level, living alone status, and number of chronic conditions. A literature review indicates there is only 1 study on the impact of COVID-19 in Medicare home health on home care workers and none on the impact on home health beneficiaries. The current study is a qualitative study based on interviews of a convenience sample of 48 home care nurses from 9 different home health agencies in New York City between April 1 and August 31, 2020. Six major themes emerged: need for social service supports increased; loneliness and depression increased among patients; physical and mental health conditions became exacerbated; substance use and abuse increased; evidence of domestic violence against patients increased; and there was a limited amount of staff and equipment to care for patients.

There is extensive literature on the significance of substance use, misuse, and abuse among the elderly in the United States. A literature review indicates a paucity of information on the nature, significance, or impacts of the lack of substance use and abuse coverage in Medicare home health. This article presents background on the topic and an initial, exploratory study to address the literature gap, based on interviews of a convenience sample of 48 home care social workers between January 2013 and May 2015 in the New York City metropolitan area. Results indicate social workers believe substance use and abuse occurs frequently among Medicare home health patients; substance use and abuse is not assessed and treated professionally in Medicare home health; the lack of coverage in Medicare home health results in exacerbation of existing patient physical and mental health conditions, which, in turn, worsen substance use and abuse conditions; the homebound requirement and lack of coverage of transportation and personal care assistants limits home care patients ability to obtain outpatient substance use and abuse treatment; and lack of home-based assessment and treatment contributes to increased home care readmissions, re-hospitalizations, and increased caregiver burden.

TheJimmocase involved a 2011 lawsuit against the Centers for Medicare and Medicaid Services (CMS) alleging they illegally used an improvement standard instead of a need standard to make coverage decisions for Medicare home health and other Medicare beneficiaries. In 2013 CMS and the plaintiffs reached a settlement with CMS agreeing to replace the improvement standard with a need standard and conduct an education campaign to ensure its proper implementation. A literature review indicates no studies on the nature, significance, or impacts of theJimmo casein Medicare home health. The current study is an initial, exploratory study to address the literature gap, based on interviews of a convenience sample of 28 home care nurses between January 2019 and May 2019 in the New York City metropolitan area. Results indicate nurses believe they had little to no knowledge of theJimmo case; there was limited communication about the case from their agencies; they lacked guidance on the implications of the case on intake and eligibility decisions; they received no guidance on the impact of the case on documentation; and that their lack of knowledge and guidance had adverse impacts on patients.

There has been a 75% decline in home health aide visits between 2000 and 2016, the only Medicare home health nonskilled service. A literature review indicates no studies addressing reasons for the decrease. This study summarizes interviews of nine executives from three for-profit chain-owned Medicare-certified home health agencies. Results indicate agreement on three themes: Medicare home health uses a medical model, focusing on intermittent skilled care; the Medicare home health prospective payment system exacerbated the focus on skilled care by rewarding higher reimbursement for skilled care–based episodes; and a “less is better” synergy has evolved regarding utilization of home health aide services and reimbursement. Policymakers are urged to use the forthcoming Medicare home health Patient-Driven Groupings Model Reform and recent Medicare Advantage changes covering nonmedical services to encourage greater utilization of home health aides and other nonmedical services addressing patient and caregiver social needs affecting care.