House Visit

Aka: House Visit, House Call, Homebound

1. 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)
2. 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
3. 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")
4. 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
5. 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]
6. 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
7. 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
8. 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)
9. 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
10. 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
11. References
    1. Rerucha (2020) Am Fam Physician 102(4): 211-20 [PubMed]