Written by Jennifer Kennedy

Home-based care brings healthcare to the place where many patients feel safest: their own homes. Depending on the care needs, medications may be required, some of which are controlled. With controlled medications in an uncontrolled home environment, drug diversion is a real risk. It happens when a medication prescribed for a patient is taken or used by someone else or used in a way it was not intended. In home health, hospice, palliative care, and other home-based services, controlled substances may be within reach not only of the patient but also of family members, caregivers, visitors, and others in the home.

For home health and hospice leaders, preventing diversion takes more than a well-written policy. It requires a deliberate, organization-wide approach that balances medication security, patient safety, effective symptom management, and respect for the patients and families we serve.

Understanding the Risk in the Home

While home health and hospice care serve different patient populations, both manage controlled substances in the home if an individual’s care plan requires medication intervention. Home is not like an inpatient setting where direct oversight of how medications are stored and used is under control of the provider. Home health and hospice providers educate individuals and caregivers about safe utilization and storage of all medications, but the home setting is the domain of that individual and can be unpredictable. In fact, much of the published research on diversion in home-based care comes from hospice, which offers an important lens on this challenge. The same medications that relieve pain and other distressing symptoms can also be vulnerable to misuse or diversion.

Those identified as diverting medications included informal caregivers or family members, family friends, and provider staff. Diversion in home-based care does not fit a single profile. Risk can come from within the patient’s informal support system as well as from individuals providing formal care. Hospice providers should watch for warning signs as part of medication management and patient safety, but a missing medication, an early refill request, or a change in how a medication is used does not automatically mean diversion has occurred. Each situation calls for careful assessment rather than quick conclusions.

The same lessons apply to home health. After surgery, an injury, or a hospital stay, home health patients may be prescribed opioids or other controlled substances, and they often manage these medications on their own between skilled visits. Because clinicians are in the home during care visits, medication reconciliation, patient and caregiver teaching, and prompt follow-up on any discrepancies at every visit are especially important.

Prevention Begins With Patients and Families

Education remains one of the most powerful tools providers have to decrease the risk of drug diversion. Ware, McPherson, et al. (2021) used a modified Delphi process with an interdisciplinary panel of 10 experts to develop 15 recommendations for reducing medication diversion and misuse in hospice. The recommendations address balancing prevention with quality care, screening clinical job candidates, patient and family education and screening, medication monitoring, responses to missing or diverted medications, and medication disposal. Notably, the expert panel rated patient and family education highest in importance.

That finding carries particular weight across home health and hospice. Patients and caregivers need to understand why medication security matters and why controlled substances require appropriate safeguards. Lowry and Childers (2024) recommend educating patients and caregivers about diversion risks and reinforcing that prescribed opioids are for the patient’s use only. Their guidance also addresses safe storage, including use of a lockbox; appropriate disposal; limiting the number of people who know controlled drugs are in the home; reviewing prescription drug monitoring program information; establishing clear refill protocols; and prescribing only the quantity needed until the anticipated refill.

These conversations should not be a one-time event. In both home health and hospice, they can be built into admission or start of care, medication reconciliation during visits, care-plan updates, and ongoing patient and caregiver education.

Recognizing Potential Warning Signs

Effective diversion prevention also depends on an alert, well-educated workforce across home health and hospice. Potential warning signs identified in the research include:

• Reluctance to allow medication monitoring
• Dysfunctional family dynamics
• Requests for higher medication doses (Ware, Cagle, et al., 2021)

These indicators should prompt further assessment, not an automatic conclusion that diversion has occurred.

Consider an unexpected request for an early refill. It may warrant a closer look at how the medication is being used and managed. Early refills can be a concern in some diversion scenarios, but patients may also run out of opioids early for reasons that have nothing to do with diversion (Lowry & Childers, 2024).

That distinction matters. A strong diversion-prevention program sharpens an organization’s ability to recognize and respond to risk without compromising appropriate symptom management.

Responding to Suspected or Confirmed Diversion

When concerns arise, organizations need a clear, consistent framework for evaluating and responding to them. Hospice organizations that described confirmed diversion reported responses that included limiting the medication supply, restricting access to medication, and increasing the frequency of staff visits (Ware, Cagle, et al., 2021). Expert recommendations for hospice diversion prevention likewise address medication monitoring, responses to missing or diverted medications, and medication disposal (Ware, McPherson, et al., 2021). When casual sharing of controlled medications is suspected, short prescriptions, regular visits, and random pill counts are identified as potential responses (Lowry & Childers, 2024).

For home health and hospice organizations, the message is straightforward: have an established process in place for evaluating concerns, escalating them when appropriate, and determining a response that fits the circumstances.

A comprehensive organizational approach should address:

• Medication security and monitoring
• Patient and caregiver education
• Identification and escalation of suspected diversion
• Documentation of medication discrepancies and concerns
• Controlled-substance disposal
• Staff education on potential warning signs and organizational expectations
• Interdisciplinary coordination when concerns emerge

Specific reporting and response requirements should be aligned with applicable federal and state requirements and with each organization’s own policies and procedures.

Protecting Access to Appropriate Symptom Management

If there is one guiding principle, it is balance.

Ware, Cagle, et al. (2021) concluded that good clinical practice and vigilance may help hospice agencies detect medication diversion. At the same time, the authors cautioned that diversion-prevention techniques should not adversely affect the quality of patient care.

The expert recommendations developed by Ware, McPherson, et al. (2021) reflect the same principle, recognizing the need to balance diversion-prevention efforts with quality care. Balance is especially critical in hospice and palliative care, where controlled medications are commonly used to manage burdensome symptoms such as pain and shortness of breath (Ware, McPherson, et al., 2021).

Home health clinicians face a similar balance when patients rely on controlled medications to manage pain during post-acute recovery and rehabilitation. The goal is not simply to restrict access to controlled substances. It is to ensure safe, accountable access for the patient who needs them while reducing opportunities for misuse and diversion.

Building a Culture of Vigilance, Not Suspicion

Drug diversion prevention belongs within a broader medication-safety strategy. It should not be treated as a reaction after medications go missing.

Home health and hospice organizations can reinforce this approach through consistent education, medication monitoring, clear escalation pathways, thoughtful assessment of concerns, and interdisciplinary collaboration.

Just as important, diversion concerns should be approached with sensitivity. Potential warning signs warrant evaluation, but they are not proof of wrongdoing. Holding to that distinction protects patients and caregivers while still allowing organizations to act decisively when legitimate concerns arise.

For leaders in home health, hospice, and other home-based services, the challenge comes down to balance: maintaining appropriate access to medications while putting safeguards in place to help detect and prevent misuse or diversion.

Strong policies matter. Staff education matters. Medication monitoring matters. But the most effective approach brings these elements together and keeps the patient’s comfort, safety, dignity, and clinical needs at the center of care.

References

Lowry, M. F., & Childers, J. (2024, May 14). Opioid diversion risk and management in palliative care (Fast Fact No. 484). Palliative Care Network of Wisconsin. https://www.mypcnow.org/fast-fact/opioid-diversion-risk-and-management-in-palliative-care/

Ware, O. D., Cagle, J. G., McPherson, M. L., Sacco, P., Frey, J., & Guralnik, J. (2021). Confirmed medication diversion in hospice care: Qualitative findings from a national sample of agencies. Journal of Pain and Symptom Management, 61(4), 789-796. https://doi.org/10.1016/j.jpainsymman.2020.09.013

Ware, O., McPherson, M. L., Barclay, J. S., Blackhall, L., Emmett, C. P., Hilliard, R., Schenker, Y., Shega, J. W., Guralnik, J., & Cagle, J. G. (2021). Recommendations for preventing medication diversion and misuse in hospice care: A modified Delphi study. Journal of Pain and Symptom Management, 62(6), 1175-1187. https://doi.org/10.1016/j.jpainsymman.2021.06.004