A group of healthcare professionals, including doctors and nurses, gathered around a tablet, looking at data together in a bright, airy clinic or hospital setting.
A group of healthcare professionals, including doctors and nurses, gathered around a tablet, looking at data together in a bright, airy clinic or hospital setting.

Partnering to Support Your Patients at Home

Thank you for considering Mount Desert Nursing Association as a trusted partner in your patients' care. This page is designed to help providers and clinics navigate our referral process, understand eligibility requirements for Medicare home health services, and ensure a smooth transition of care to the home setting.

For Providers & Clinics

Medicare eligibility for home health requires:

  • A face-to-face visit with a Maine-based provider within the last 60 days

  • The patient must be homebound (see definition below)

  • A skilled need such as nursing, physical therapy, or occupational therapy

  • Services must be intermittent and medically necessary

Homebound Status – Medicare Definition: The patient requires assistance (from a person or device) to leave home, and absences from home are infrequent or short in duration (e.g., medical appointments, church).

Read more on Medicare.gov – Homebound Status

An elderly man using a walker, assisted by a caregiver wearing a face mask, in a home setting.

Who Qualifies for Home Health Services Under Medicare?

A female doctor in a white coat examining an X-ray of a skull, with an older male patient sitting nearby in a medical office.

Understanding Our
Services

✅ Examples:

  • Stroke (CVA)

  • Congestive Heart Failure (CHF)

  • Chronic Obstructive Pulmonary Disease (COPD)

  • Recent orthopedic surgery (e.g., hip or knee replacement)

  • Post-fall with injury or mobility decline

  • Wound care needs (e.g., diabetic ulcers)

  • Exacerbation of chronic conditions requiring skilled intervention

Home Health vs. Caregivers: What’s the Difference?

- Essentially, we need the primary diagnosis - not the symptoms. COPD is a useable primary diagnosis, which may have weakness as a symptom. Parkinson’s is a useable diagnosis with frequent falls as a possible symptom.

- If patient is suspected of a primary diagnosis (i.e. osteoarthritis) but waiting for imaging or labs to confirm, we do need the imaging/lab reports confirming before referral can be sent and accepted.

Note: A referral for nursing or physical therapy can stand alone but occupational therapy services can only be provided when accompanying a PT or Nursing referral.

*This is not a complete list but primary examples. We are happy to check any code for viability if needed. Please do not hesitate to call us at 207-276-5184 with any questions.

Useable Diagnoses for Medicare Home Health

Patients must have a skilled need tied to a medical diagnosis. Below are some common, usable diagnoses that support home health eligibility under Medicare:

Our goal is to restore the patient's independence and reduce rehospitalizations.

Our home health care is intermittent, meaning care is provided for short durations, typically:

  • 1-hour visits

  • Up to 3 times per week, depending on patient need

  • Focused on returning the patient to their prior level of function

We offer:

    • post-operational monitoring

    • IV therapy

    • pain management

    • complex wound & incision care

    • mobility training

    • balance improvement

    • strength & flexibility exercises

    • fall prevention techniques

    • daily activity training (bathing, dressing, etc.)

    • strengthening & balance

A white house with black shutters and a grey roof, with dormer windows, is surrounded by a green lawn. To the right, there is a sign with a blue puzzle piece and a heart shape, indicating it is related to a medical or support organization.

Home Health (what we provide):

  • Licensed clinical services (nursing, PT, OT)

  • Ordered by a provider

  • Covered by Medicare/insurance when eligible

  • Time-limited, goal-directed care

Caregivers/Personal Support Workers:

  • Non-clinical assistance (bathing, meal prep, companionship)

  • Not covered by Medicare

  • Long-term support, often private pay or via long-term care insurance

  • Abnormality of gait and/or mobility

  • Low Back Pain

  • Unsteadiness on Feet

  • Repeated Falls

  • Difficulty walking not elsewhere classified

  • Unspecified Osteoarthritis

  • Encounter for other specified surgical aftercare

  • Wounds, unspecified

  • Generalized fatigue without medical cause

  • Need for companion care only

  • Stable, non-skilled chronic conditions without recent change

  • Solely medication refills without skilled need

  • Weakness, generalized or unspecified

  • Malaise

  • Falls

🚫 Not Typically Covered (Non-Examples):

A female doctor with black hair and glasses wearing a white coat and stethoscope, listening to an elderly male patient with white hair and glasses, in a medical office. The doctor is taking notes on a clipboard.

Questions?

We’re here to help. Contact Amanda McFetridge at office@mountdesertnursing.org 📧

CONTACT US

How to Refer a Patient

We accept referrals from any Maine-licensed provider.

1. Submit a Referral

  • Download and complete our Referral & Intake Form (PDF)

  • Fax completed form to 206-276-5185

  • Ensure patient has been seen by their provider within the last 60 days

2. We’ll Take It From There

  • Our intake team will confirm eligibility and initiate services as appropriate.

Our NPI: #1770955783