Driving Me Nuts!
So, people call me. They email me. I get the occasional comment on my blog. These are the ‘little things’ that make me useful to the home health community. I am aware of what is going on at the front lines of our industry. Usually, I can answer questions. Sometimes, I take a while and look things up. But sometimes, I get stumped. that’s when I turn to y’all.
In the past several weeks, I have had calls about two patients. Both are men. Both have been referred to clients. The question is the same for both of them. Do they meet the homebound status requirement?
Patient 1:
This is a man who drives a car. Not every day but at least weekly. It is a smaller economy car that gets ideal gas mileage. I sincerely hope that if this were all that you knew about the patient that you would declare him ineligible for services in a heart beat.
However, this gentleman weighs 400 pounds. He cannot get in the car by himself; nor can he get out of the car by himself. He just likes to drive and sit by the lake while his wife works. If he had to, he could drive up to the ER but then someone would have to come and get him out of the car. Fast food is available as are banks and dry cleaners who offer in car service. He cannot buy gas unless someone else pumps it for him, go to the MD’s office or outpatient therapy. In fact, he was at outpatient therapy for a while. His wife would get him in the car somehow and the therapy employees would get him out. At some point, it was deemed to dangerous for them to do that in the black asphalt parking lot.
I have a lot of issues with this patient besides homebound status. Blood clots seem a very real possibility. It is rumored that he pees in a jar. I am having a hard time imagining that he can do this without some spillage. So, now I have immobility, acidic urine and obesity threatening this patient. I get all that.
But, is he homebound?
Patient 2:
This patient has dementia with episodes of moderate confusion. Like the patient above they drive. They are not supposed to drive. Everyone knows that this is dangerous to the patient and to the community but no one has taken his keys away from him, yet.
Again, I have real issues with this. If the family is okay with him risking his life, that is up to them. I am not okay with his risking someone else’s life because they don’t want to take away the car keys. But it isn’t my feelings that we are assessing here.
I suggested that they approach the MD to get a medical restriction on his license and let him be the bad guy. But what should happen is again, not the question.
Is this patient homebound?
What do you think? Email me or comment below. I will share my thoughts after I hear some of yours.
Pt number 1 definitely homebound it is a great and taxing effort to get him in and out of the car. People can be hurt trying to assist him!!! It is also very dangerous for him to be driving, because, if he is in an accident, poof, he is definitely a goner because no one will be able to free him, except maybe a transformer type individual with massive strength!!
Pt 2 is a different issue, he should not be driving, he is a danger to himself and others, it is not, apparently a great and taxing effort for him to leave the home, but, it could be on those he injures while his dementia is kicking in. The MD needs to take a stand, and the keys need to be taken away from him, but as of the moment, I don’t think he would be considered homebound.
Neither patient is homebound. Both should be homebound from a safety standpoint. How will homebound status be achieved for either? Patient #1:Explore the possibility of having persons to provide assistance and diversion (driving to enjoy nature) a quality of life issue which one does not want to deny him. Patient #2:Family and MD should collaborate to have driving privilleges removed and if possible, provide alternative quality diversions to meet his need for change of scenery, etc.
These are scenarios which place caregivers between a rock and a hard place…no right/wrong way that is easy.
Thanks for sharing. Enough food for thought and much contemplation.
I think part of the answer is
1 “can he SAFELY leave home”
2 Is it for brief and/occasional periods
3 is it a “severe and taxing effort”
I think patient 1 is not homebound due to reason #2 and #3
and patient 2 would be homebound due to reason #1
and someone needs to let the family/physician know that they might be open to changes of endangerment for letting patient 2 drive
IF patient #1 had a good skilled need you might be able to squeak by on considerable and taxing effort. You would definitely have to support well with documentation of his physical ability at home. Needs supportive documentation.
Patient #2 I would say no also. He has periods of confusion- is he clear in between? Is this when he drives?
The sad thing is that both these folks probably need home health but either could be denied on the basis of these things.
Patient 1 – Obviously great and taxing effort needing considerable assistance from another person. One could argue homebound from that point. Homebound status would also suggest that they are actually at home most of the time. The rest of the definition I believe is – absent from home for reasons of medical appointments or occasional attendance at events of infrequent occurance and limited duration – such as church, a wedding, etc. Seems to me sitting in a car at the lake doesn’t really fit, not too mention the obvious safety issues of driving when you can barely resposition – along with the health concerns you mentioned with the immobility, etc. We are sometimes too careful with “homebound” status, but I’d have to say “Not homebound.”
Patient 2 – Homebound definition doesn’t address confusion specifically. A case can be made for great and taxing effort when family has to be present at all times for supervision away from the home. Though there probably should be supervision in this situation, it is not happening so it would be hard to make that case. I would say Not Homebound and then consider a Vulnerable Adult intake call to the local authorities for the sake of the client and the public if family is not able to take the responsibility.
For both patients agency should appeal to the family to do homecare anyway under a different pay source than Medicare (may involve helping with eligibility for public funding). As you say, ultimately the patient and family makes a choice, good or bad, to get the appropriate level of care.
I just have to add that the questions to be posed to consider whether or not a patient is truly homebound, for the most part, can not be adequately answered without having assessed the situation in person.
Document, Document, Document. “Normal inability (pt’s usual state of being) to leave home and leaving home would require a considerable and taxing effort.” #1 but not #2. The patient may be considered as homebound “if the absences…are infrequent or for periods of relatively short duration.” Once a week for a few hours…#1 not #2. Homebound patients require the aide of “supportive devices such as crutches, canes, wheelchairs, and walkers…or the assistance of another person.” #1 not #2.
“THEY” (the ubiquitous, they) have been quoted as saying that “a drive around the block” means to be “DRIVEN” and not to drive oneself. What’s the old feller out yonder in the boonies supposed to do when he runs out of milk and bread and medicine and there is no one to drive him to get these things? He drives to town once a week to get these things, otherwise, he’s at home because he uses a walker to get to the car and would not be able to get to the car without it. He also is very dyspneic when he gets in the car and has to sit for a while to catch his breath. He has his portable oxygen tank with him. SO. Document, document, document. You can do it.
#2 on the otherhand, sounds like he just goes out and hops in the car whenever he wants to and goes where he wants to. Nevermind that he shouldn’t. Somebody in his family needs to take that bull by the horns. (Then we can document, document, document and sure enough, he WILL be homebound.)
Isn’t this fun? 🙂
Patient 2 needs supervision. Is it an APS issue? I don’t know. But it might be or it might be a police issue. I would not want to be the one who knew he shouldn’t be driving and didn’t do anything about it and he killed someone. A real possibility. Intervention is needed somewhere.
Patient 1 is sadly not homebound. He leaves home regularly and for longer periods of time. I cannot blame him. He’s not safe.
Patient #1: How does this patient get to and from his vehicle to enable himself to drive? To “sit” in a car may not be a taxing issue unless he requires i.e. oxygen as well..I would be curious to see his functional scoring as indication to which way this should go and comorbidities….
Patient #2: “not supposed to drive” does not necessarily make the patient homebound. There are many little ladies who never drove a vehicle but are not necessarily homebound. This person’s dementia may render him homebound due to the safety issue just as psychiatric issues makes other patients unable to leave home..again, more information is needed.
I believe pt#1 is homebound, in addition to a taxing and considerable effort for him to leave home, the condition of this patients should be such that there does not exists a normal inability to leave home, it is not normal for someone to have to assist a person out of the car due to obesity, also, his absence is infrequent or of relatively short duration. So safety would be a big consideration for homebound status.
#2 is questionable and I feel the physician should step in to make a clear determination of his status.
Both Homebound with the correct documentation…#2 go by the sherriff’s office and tell them the problem, they will wait by his house and pull him over when he drives down the street….believe me, if you tell the sherriff’s office lives are in danger, they will listen….I’d like to think it was because they cared…but I believe it is because they don’t want to be sued…..they should do it today…someone will die…I have seen it happen.