//fpnotebook.com/
House Visit
Aka: House Visit, House Call, Homebound
- Epidemiology
- Incidence
- In U.S. 2015, House Calls under Medicare Part B: 2.6 Million
- Homebound U.S. population: 2 Million (and expected to double by 2030)
- Indications
- Homebound patient per Medicare (see criteria below)
- Requested House Call (medically necessary or private pay)
- Patient and care-giver discussion regarding care or decision making
- Home environment assessment (safety, Caregiver interactions)
- Home health eligibility assessment
- Transitions of Care (e.g. hospital follow-up)
- End Of Life Care
- Diagnosis: Homebound (Medicare)
- Homebound definition requires 2 criteria to be present
- Criteria 1
- Leaving home is contraindicated due to medical condition OR
- Requires supportive device (e.g. Crutches, cane, walker, Wheelchair), special transport or assistance to leave home
- Criteria 2
- Normal inability to leave the home AND
- Leaving home requires considerable, taxing effort
- Homebound definition is NOT affected by (the following are NOT disqualifications)
- Licensed or state certified adult daycare program (therapeutic, psychosocial or medical treatment)
- Attending religious service
- Healthcare treatment (e.g. Dialysis, Chemotherapy, Radiation Therapy)
- Infrequent, short duration home absence
- Medical Documentation of health status in support of Homebound definition
- Related diagnoses (illness or injury and impacting comorbid conditions)
- Expected duration
- Clinical course (e.g. worsening, improving)
- Prognosis
- Specific functional limitations
- Broad, generic, non-specific phrases are insufficient alone (e.g. "taxing effort")
- Efficacy: Provider Visits
- Cost effective
- Reduce hospital admissions and readmissions
- Reduce longterm care requirement
- Reduce Emergency Department visits (some studies)
- Reduce post-hospitalization complications at transition of care (e.g. medication errors, rehospitalization)
- References
- Edes (2014) J Am Geriatr Soc 62(10):1954-61 [PubMed]
- Gardner (2014) J Gen Intern Med 29(6): 878-84 [PubMed]
- Rotenberg (2018) J Am Geriatr Soc 66(4): 812-7 [PubMed]
- USHHS Independence at Home Demo Study
- https://innovation.cms.gov/files/fact-sheet/iah-yr3-fs.pdf
- Efficacy: Nurse, Social Worker Visits and other public health workers
- High risk mothers and children
- Kitzman (2019) Pediatrics 144(6): e20183976 [PubMed]
- Postpartum Care
- Yonemoto (2017) Cochrane Database Syst Rev (8): CD009326 [PubMed]
- Preparation: Equipment
- Sharps disposal
- Personal Protective Equipment (gloves, mask)
- Blood Pressure kit (sphygmomanometer, various cuff sizes)
- Thermometer (with disposable tips or covers)
- Exam Tools (Stethoscope, Otoscope and Ophthalmoscope, Reflex Hammer, Tuning fork, Tongue depressor)
- Glucometer
- Pulse Oximeter
- Bandage Scissors
- Toenail Clippers
- Wound evaluation (Topical Ointments, gauze, tape, Bacterial culture swabs, cotton swabs, tape measure)
- Suture Kit (forceps, scissors, needle driver, sterile Suture e.g. 4-0 Nylon, Lidocaine 1%, syringe, needles 18 and 27 gauge)
- Phlebotomy kit (blood draw, needles, syringes, vials)
- Sterile urine cups
- Urine catheterization kit
- Evaluation: House Call Checklist (Mnemonic: INHOMESSS)
- Impairment and Immobility
- Mental Status Exam for Cognitive Impairment
- Geriatric Depression Scale
- Activities of Daily Living and Instrumental Activities of Daily Living
- Fall Risk (see Fall Prevention in the Elderly)
- Sensory Impairment (esp. Hearing, Vision)
- Nutritional Status
- See Geriatric Nutrition Checklist
- Home Environment
- Home safety (neighborhood, external building, indoor environment)
- Other People
- Caregivers
- Elder Abuse
- Advance Care Planning (e.g. POLST, DNR, Durable Power of Attorney, Living Will, Medical Directive)
- Medications
- See Medication Use in the Elderly
- Perform medical reconciliation (multiple prescribers?, OTC medications)
- Polypharmacy (consider Deprescribing)
- Examination
- See Impairment above
- Vital Signs
- Weight (weight gain as in CHF or Unintentional Weight Loss)
- Height
- Bedside Glucose
- Focused exam based on history
- Urinary Incontinence
- Safety
- Observe patient navigate their home
- Emergency Service Numbers or contact devices
- Trip hazards (rugs, electrical cords, clutter, pets)
- Smoke detectors
- Lighting
- Stairs
- Kitchen safety
- Communication (land-line or mobile phone, internet)
- Reliable heating and air conditioning
- Spiritual Health
- Services
- Emergency Medical Services (Ambulance, fire department, police)
- Food delivery
- Social services
- Home health or Hospice
- Management: Billing
- Home Visit
- New Patient: 99341-5
- Established Patient: 99347-50
- Domiciliary or rest home visit (e.g. Nursing Home)
- New Patient: 99324-8
- Established Patient: 99334-7
- Oversight
- Care Plan: 99339 for 15-29 minutes (99340 for 30 minutes or more)
- Advanced Care Plan: 99497 for 15-29 minutes (99498 for each additional 30 minutes)
- Precautions: Home Visit Safety
- Staff should call the patient ahead of time to remind them of appointment (avoiding surprises)
- Partner with other members of healthcare team on visits (e.g. medical provider, social services)
- Sit on bare furniture
- Wear gloves and mask as needed
- Arrive and leave area discreetly (e.g. without lab coat, expensive equipment)
- Cell phone with reliable service, connectivity
- Arrange for emergency plans (phone check-in before and after visit, emergency contacts with safety code words)
- Hosts should cage or restrain pets
- Use reliable transportation to and from visit
- Resources
- CMS - Home Health Services
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Medicare-Home-Health-Benefit-Text-Only.pdf
- References
- Rerucha (2020) Am Fam Physician 102(4): 211-20 [PubMed]