Understanding the Medicare Skilled Home Health Benefit

When your Medicare patients are ready to leave the hospital or your office, they often still need skilled support to stay safe and stable at home. The Medicare Skilled Home Health Benefit is designed to bridge that gap—bringing nursing and therapy services directly to the patient’s home.

At Equilibrio Home Health, we partner with hospitals, physicians, and care coordinators across Hampton Roads to help eligible Medicare patients access this benefit and receive the right level of care where they live.

How Home Health Supports Your Patients and Your Practice

The Medicare Skilled Home Health Benefit is more than a list of covered services—it’s a key tool to support continuity of care and reduce avoidable readmissions.

Partnering with Equilibrio can help you:

Promote safer discharges
Ensure high-risk patients have skilled support in the critical days and weeks after leaving the hospital or clinic.
Reduce readmissions and ED visits
Early identification of changes in condition, medication issues, or functional decline allows for timely intervention.
Extend your care plan into the home
Our clinicians reinforce your treatment goals, provide education, and report back on progress and barriers.
Support caregivers
We equip families with the knowledge and skills they need to safely support their loved one at home.

Let Us Know if You'd Like to Partner with Equilibrio

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Your Role in Initiating Home Health

Referring a Medicare patient to home health is straightforward, and our intake team is available to guide you through each step.

Typical referral steps include:

Identify appropriate patients
- Recent hospitalization or surgery
- New or worsening diagnosis
- Complex medication regimen
- Functional decline or fall risk
- Need for ongoing skilled nursing or therapy at home
Order home health services
- Provide a face-to-face encounter note related to the need for home health
- Specify skilled services needed (nursing, PT, OT, speech)
- Outline key goals and any special instructions
Coordinate with Equilibrio
- Send referral documents via your preferred method (fax, secure email, or EMR—adjust to your actual process)
- Our team verifies eligibility, contacts the patient, and schedules the start of care
Ongoing communication
- We provide updates on patient progress, changes in condition, and any recommended modifications to the plan of care.