Semistructured interviews with nurses working for home health care agencies in five states raise serious questions about the deleterious effects of Medicare policies and procedures on depression care. The agencies have strong incentives to limit nursing time in a given payment episode and to increase volume, making it difficult to provide high-quality depression care for homebound patients. Some nurses felt forced to “abandon” many patients with depression. The authors call for incremental policy changes in several key areas. ObjectiveDepression affects one in four older adults receiving home health care. Medicare policies are influential in shaping home health practice. This study aimed to identify Medicare policy areas that are aligned or misaligned with improving the quality of depression care in home health care.MethodsThis qualitative study was based on semistructured interviews with nurses and administrators from five home health care agencies in five states (N=20). Digitally recorded interviews were transcribed and analyzed by using the grounded theory method. A multidisciplinary team iteratively developed a codebook from interview data to identify themes.ResultsSeveral important Medicare policies are largely misaligned with depression care quality improvement in home health care. Medicare eligibility requirements for patients to remain homebound and to demonstrate a need for skilled care restrict nurses’ ability to follow up with depressed patients for a sufficient time. Lack of explicit recognition of nursing time and quality of care in the home health prospective payment system provides misaligned incentives for depression care. Incorporation of a two-item depression screening tool in Medicare-mandated comprehensive patient assessment has raised clinician awareness of depression; however, inclusion of the tool at the start of care only but not at other follow-up points limits its potential in helping nurses manage depression care. Underdevelopment of clinical decision support for depression care in vendor-developed electronic health records constitutes an important barrier to improvement of depression care.ConclusionsSeveral influential Medicare policies and regulations for home health practice may be misaligned with evidence-based depression care for home health patients.