House Visit

Aka: House Visit, House Call, Homebound

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II. Epidemiology

  1. Incidence
    1. In U.S. 2015, House Calls under Medicare Part B: 2.6 Million
    2. Homebound U.S. population: 2 Million (and expected to double by 2030)

III. Indications

  1. Homebound patient per Medicare (see criteria below)
  2. Requested House Call (medically necessary or private pay)
  3. Patient and care-giver discussion regarding care or decision making
  4. Home environment assessment (safety, Caregiver interactions)
  5. Home health eligibility assessment
  6. Transitions of Care (e.g. hospital follow-up)
  7. End Of Life Care

IV. Diagnosis: Homebound (Medicare)

  1. Homebound definition requires 2 criteria to be present
    1. Criteria 1
      1. Leaving home is contraindicated due to medical condition OR
      2. Requires supportive device (e.g. Crutches, cane, walker, Wheelchair), special transport or assistance to leave home
    2. Criteria 2
      1. Normal inability to leave the home AND
      2. Leaving home requires considerable, taxing effort
  2. Homebound definition is NOT affected by (the following are NOT disqualifications)
    1. Licensed or state certified adult daycare program (therapeutic, psychosocial or medical treatment)
    2. Attending religious service
    3. Healthcare treatment (e.g. Dialysis, Chemotherapy, Radiation Therapy)
    4. Infrequent, short duration home absence
  3. Medical Documentation of health status in support of Homebound definition
    1. Related diagnoses (illness or injury and impacting comorbid conditions)
    2. Expected duration
    3. Clinical course (e.g. worsening, improving)
    4. Prognosis
    5. Specific functional limitations
      1. Broad, generic, non-specific phrases are insufficient alone (e.g. "taxing effort")

V. Efficacy: Provider Visits

  1. Cost effective
  2. Reduce hospital admissions and readmissions
  3. Reduce Longterm Care requirement
  4. Reduce Emergency Department visits (some studies)
  5. Reduce post-hospitalization complications at transition of care (e.g. medication errors, rehospitalization)
  6. References
    1. Edes (2014) J Am Geriatr Soc 62(10):1954-61 [PubMed]
    2. Gardner (2014) J Gen Intern Med 29(6): 878-84 [PubMed]
    3. Rotenberg (2018) J Am Geriatr Soc 66(4): 812-7 [PubMed]
    4. USHHS Independence at Home Demo Study
      1. https://innovation.cms.gov/files/fact-sheet/iah-yr3-fs.pdf

VI. Efficacy: Nurse, Social Worker Visits and other public health workers

  1. High risk mothers and children
    1. Kitzman (2019) Pediatrics 144(6): e20183976 [PubMed]
  2. Postpartum Care
    1. Yonemoto (2017) Cochrane Database Syst Rev (8): CD009326 [PubMed]

VII. Preparation: Equipment

  1. Sharps disposal
  2. Personal Protective Equipment (gloves, mask)
  3. Blood Pressure kit (sphygmomanometer, various cuff sizes)
  4. Thermometer (with disposable tips or covers)
  5. Exam Tools (Stethoscope, Otoscope and Ophthalmoscope, Reflex Hammer, Tuning fork, Tongue depressor)
  6. Glucometer
  7. Pulse Oximeter
  8. Bandage Scissors
  9. Toenail Clippers
  10. Wound evaluation (Topical Ointments, gauze, tape, Bacterial culture swabs, cotton swabs, tape measure)
  11. Suture Kit (forceps, scissors, needle driver, sterile Suture e.g. 4-0 Nylon, Lidocaine 1%, syringe, needles 18 and 27 gauge)
  12. Phlebotomy kit (blood draw, needles, syringes, vials)
  13. Sterile urine cups
  14. Urine catheterization kit

VIII. Evaluation: House Call Checklist (Mnemonic: INHOMESSS)

  1. Impairment and Immobility
    1. Mental Status Exam for Cognitive Impairment
    2. Geriatric Depression Scale
    3. Activities of Daily Living and Instrumental Activities of Daily Living
    4. Fall Risk (see Fall Prevention in the Elderly)
    5. Sensory Impairment (esp. Hearing, Vision)
  2. Nutritional Status
    1. See Geriatric Nutrition Checklist
  3. Home Environment
    1. Home safety (neighborhood, external building, indoor environment)
  4. Other People
    1. Caregivers
    2. Elder Abuse
    3. Advance Care Planning (e.g. POLST, DNR, Durable Power of Attorney, Living Will, Medical Directive)
  5. Medications
    1. See Medication Use in the Elderly
    2. Perform medical reconciliation (multiple prescribers?, OTC Medications)
    3. Polypharmacy (consider Deprescribing)
  6. Examination
    1. See Impairment above
    2. Vital Signs
    3. Weight (weight gain as in CHF or Unintentional Weight Loss)
    4. Height
    5. Bedside Glucose
    6. Focused exam based on history
    7. Urinary Incontinence
  7. Safety
    1. Observe patient navigate their home
    2. Emergency Service Numbers or contact devices
    3. Trip hazards (rugs, electrical cords, clutter, pets)
    4. Smoke detectors
    5. Lighting
    6. Stairs
    7. Kitchen safety
    8. Communication (land-line or mobile phone, internet)
    9. Reliable heating and air conditioning
  8. Spiritual Health
  9. Services
    1. Emergency Medical Services (Ambulance, fire department, police)
    2. Food delivery
    3. Social services
    4. Home health or Hospice

IX. Management: Billing

  1. Home Visit
    1. New Patient: 99341-5
    2. Established Patient: 99347-50
  2. Domiciliary or rest home visit (e.g. Nursing Home)
    1. New Patient: 99324-8
    2. Established Patient: 99334-7
  3. Oversight
    1. Care Plan: 99339 for 15-29 minutes (99340 for 30 minutes or more)
    2. Advanced Care Plan: 99497 for 15-29 minutes (99498 for each additional 30 minutes)

X. Precautions: Home Visit Safety

  1. Staff should call the patient ahead of time to remind them of appointment (avoiding surprises)
  2. Partner with other members of healthcare team on visits (e.g. medical provider, social services)
  3. Sit on bare furniture
  4. Wear gloves and mask as needed
  5. Arrive and leave area discreetly (e.g. without lab coat, expensive equipment)
  6. Cell phone with reliable service, connectivity
  7. Arrange for emergency plans (phone check-in before and after visit, emergency contacts with safety code words)
  8. Hosts should cage or restrain pets
  9. Use reliable transportation to and from visit

XI. Resources

  1. CMS - Home Health Services
    1. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Medicare-Home-Health-Benefit-Text-Only.pdf

XII. References

  1. Rerucha (2020) Am Fam Physician 102(4): 211-20 [PubMed]

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Related Studies

Ontology: Home visit (procedure) (C0020043)

Definition (MSH) Visits to the patient's home by professional personnel for the purpose of diagnosis and/or treatment.
Concepts Health Care Activity (T058)
MSH D006792
SnomedCT 439708006, 153417005, 185213002
CPT 99600, 1013774
English Call, House, Calls, House, Home Visit, Home Visits, House Calls, Visits, Home, House Call, Visit, Home, home care visit (treatment), home care visit, home visit, home visit (treatment), Home visit, Home visit (procedure), home services, house calls, home visiting, home visits, house call, Home visit procedure, (Seen in own home) or (home visit) (finding), (Seen in own home) or (home visit), Home Services
Swedish Hembesök
Czech návštěvy pacientů doma
Finnish Kotikäynnit
Russian VYZOVY MEDPERSONALA NA DOM, VYZOVY NA DOM, ВЫЗОВЫ МЕДПЕРСОНАЛА НА ДОМ, ВЫЗОВЫ НА ДОМ
Japanese 往診
Spanish visita domiciliaria (procedimiento), visita domiciliaria, Visitas Médicas a Domicilio, Consulta Médica a Domicilio
Croatian KUĆNE POSJETE
Polish Wizyty domowe, Wezwanie do domu
Norwegian Hjemmebesøk, Sykebesøk
French Visite domicile
German Hausbesuche, Krankenbesuche
Italian Visite a domicilio
Dutch Doktersvisites, Huisbezoek, Huisbezoeken
Portuguese Consulta a Domicílio
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Homebound Persons (C0242798)

Definition (MSH) Those unable to leave home without exceptional effort and support; patients (in this condition) who are provided with or are eligible for home health services, including medical treatment and personal care. Persons are considered homebound even if they may be infrequently and briefly absent from home if these absences do not indicate an ability to receive health care in a professional's office or health care facility. (From Facts on File Dictionary of Health Care Management, 1988, p309)
Definition (PSY) Individuals restricted to place of residence for health or disability reasons.
Concepts Patient or Disabled Group (T101)
MSH D018577
SnomedCT 138079003, 160689007
English Home Bound Persons, Home-Bound Person, Home-Bound Persons, Homebound Person, Homebound Persons, House Bound Persons, House-Bound Person, House-Bound Persons, Person, Home-Bound, Person, Homebound, Person, House-Bound, Persons, Home-Bound, Persons, Homebound, Persons, House-Bound, Shut Ins, Shut-In, Shut-Ins, homebound, homebound (history), Homebound, Housebound, Housebound (finding)
Swedish Personer bundna vid hemmet
Czech osoby bezmocné doma
Finnish Kotiin sidotut henkilöt
Russian NEVYKHODIASHCHIE IZ DOMA LITSA, НЕВЫХОДЯЩИЕ ИЗ ДОМА ЛИЦА
Spanish confinado en el domicilio, confinado en el domicilio (hallazgo), ligado al domicilio (hallazgo), ligado al domicilio, Personas que no Pueden Salir de Casa, Personas Imposibilitadas, Personas Confinadas a su Hogar
Japanese 閉じ込もり症候群, 閉じこもり, 閉じこもり症候群
Polish Osoby nie wychodzące z domu
Norwegian Personer bundet til hjemmet
Portuguese Pessoas Confinadas em Domicílio, Pessoas com Incapacidades Temporárias, Pessoas Confinadas no Lar, Pacientes de Resguardo em Casa, Pacientes Retidos em Casa, Pacientes Domiciliares, Pessoas em Tratamento Domiciliar
French Personnes dépendantes à domicile
German Ans-Haus-gebundene Personen, Hausgebundene Personen
Italian Persone confinate in casa
Dutch Aan huis gebonden personen, Aan huis gebonden persoon
Derived from the NIH UMLS (Unified Medical Language System)

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