Entry and Exit Criteria Home Care

Admission/Entry, Exclusion, Continued Stay, and Discharge/Transition/
Exit Criteria – HOME CARE

1. Purpose

Individuals seeking home care services (physician consultation, physiotherapy, speech therapy, care assistance, and nursing services) will be considered candidates when defined admission criteria are met. Services are provided in the home environment to maintain or improve health, safety, functional independence, and quality of life.

2. Admission or Entry Criteria for Home Care Services (Physician, Physiotherapy, Speech Therapy, Care Assistance, Nursing):

1. There is a valid physician order or authorized referral for home care services.
2. The requested services (physician, physiotherapy, speech therapy, care assistance, nursing) are reasonable, necessary, and can be safely delivered in the home.
3. The person’s needs fall within the documented home‑care scope of services.
4. The person served must:

• Be clinically stable enough for care to be safely provided at home.
• Have identified needs that require physician, nursing, therapy, or care assistance staff.
• Have a home environment that is, or can be made, reasonably safe for the person and staff.
• Have a willing caregiver/support person when required to implement the plan of care.
• Provide informed consent (or have consent from a legal representative).

3. Exclusion Criteria for Admission:

The criteria for excluding a person from receiving home care services include, but are not limited to, the following:

• Home environment presents safety risks that cannot be reasonably mitigated.
• Required level of monitoring/intervention exceeds what can safely be provided at home (needs higher level of care).
• Aggressive or abusive behaviors pose a serious threat to safety despite attempts at risk‑
• Physician or authorized prescriber instructs that services be withheld.

Persons ineligible for home care services are referred to an appropriate provider (e.g., hospital, OPD, other agency), and the rationale and referral are documented and communicated to the person served/family.

4. Continuing Stay Criteria

Each of the following conditions must be met in order to justify continuation of home care services.

• Services remain reasonable, necessary, and safely deliverable in the home.
• The person’s condition and plan of care still require physician/physiotherapy/speech therapy/nursing/care assistance.
• The person and/or caregiver is participating in the plan and able to follow agreed interventions.
• There is evidence of improvement, stabilization, or prevention of avoidable decline consistent with goals or wound care prevention.
• Progress, barriers, and plan changes are reviewed and documented at defined intervals as per condition of person served.
• Progress to be documented and communicated to the person served or authorized representative through Continuum of care report (Add number of document)

5. Discharge/Exit Criteria

Patients receiving home care services will be discharged from services when certain criteria are met. The discharge criteria include, but are not limited to, the following:

1. Goals in the home care plan have been achieved, or maximum benefit has been reached at home care level.
2. The person’s condition no longer requires home care; needs can be managed independently or by caregiver.
3. The person’s condition has deteriorated or become unstable and needs a higher level of care (ER, inpatient, rehab).
4. Persistent non participation or safety concerns remain despite efforts to resolve them, and risk outweighs benefit.
5. The person served declines or requests discontinuation of services.
6. Care is transferred to another provider (e.g., OPD physiotherapy, palliative care, another agency) with a written or verbal summary provided to the person and receiving provider (with consent).

6. Transition Criteria

1. Transition to higher level of care (Hospital/In-Patient)
2. Transition to lower or different level of care (Clinic follow-up, community services)
3. Emergency transfer process (Home to Emergency department of hospital)
4. Service required is not served within scope of service of the Home care program.

7. Review of Entry and Exit Criteria:

Entry and Exit Criteria shall be reviewed at least on an annual basis or if scope of service served changes.