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Homebound Status

Last week, I posted about two patients who were driving but otherwise met the homebound criteria.  Your responses impressed me.  Above all, I was glad to see very few cut and dry answers and responses both sides of the fence were very convincing.   The best part was that it occurred to me that if you put that much thought into the answers, then maybe I wasn’t insane after all.

In order to be completely objective about it, I had to return to Chapter 7 of the Medicare Benefits Manual and review these patients compared to Medicare’s definition of Homebound.  Here’s the heart of the matter cut and pasted  from the manual but divided into two parts:

  1. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.
  2. If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment.

So, both patients meet the first criterion.  It is a considerable and taxing effort to leave the home.  In fact, I meet that criterion.  I live on the third floor and at least twice I week I forget something upstairs.

One patient definitely does not meet the second criterion.  Parking at the lake does is not how the patient receives healthcare or treatment and apparently this occurs ‘regularly’.

Based on the information I posted which is all I have, we cannot tell how often patient number two leaves the home.

The regs specifically address non-medical absences later in the section.  Again, this is cut and pasted directly from the manual:

However, occasional absences from the home for nonmedical purposes, e.g., an occasional trip to the barber, a walk around the block or a drive, attendance at a family reunion, funeral, graduation, or other infrequent or unique event would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home.

Now, go read it again.  How often is occasional?  What is meant by ‘relatively short duration’ and ‘infrequent’.  Steven Wright illustrates relativity even better than Einstein when he says that everywhere is within walking distance if you have the time.

Since Medicare offers no further clarification of these definitions, we have no choice but to use the most conservative definitions and therefore, neither of these patients are confined to the home.  I was so happy with my readers that none of you were happy with just stating that they weren’t homebound.  Neither am I.

My suggestion to my client with patient number 1 was that they go out and assess him and explain to him why he should not be cooped up in a car for hours at a time.  Homebound status is the least of my concerns at the point of referral.  That would come in later after I assessed his risk of blood clots, ulcers, etc. from immobility.  If he was willing, my client through diligent nursing care and therapy could restore his functionality to the point that it would be safe again in the future.  If he was willing to comply with a treatment plan that included diet and weight loss, he could improve his life to a level he had not experienced in years.  These things are not known prior to assessment.  In fact, it is often the non-verbal language that clues us into the sincerity of the patients’ desire to comply with a care plan.

The report I received on the second patient is that he had dementia.  Dementia as a diagnosis used on home health plans of care is very poorly defined in my opinion.  Patients with early memory loss who end up on Namenda with no diagnosis of Alzheimer’s are often put into the broad category of ‘dementia’.  Dementia can mean mild confusion at times or flat out psychosis.  Furthermore, patients will often come out of the hospital with a diagnosis of Dementia that is carried over to the home health chart.  Often times, quite sane people lose it considerably in the hospital due to drugs, illness, unfamiliar environment, etc.  and get right in the head again once home. (I am re-reading this before posting.  My first inclination was to find clinical terms to replace ‘lose it considerably’ and ‘get right in the head’ but those of you who live in other states will need to know these terms should you ever decide to work in the South.)

Pretty much everyone was on target with their responses.   If the patient only has mild memory loss, he may be able to drive but will get lost and end up on Crack Alley negotiating deals for those pretty little rocks.  If he is beyond mild dementia, the police or elderly protective need to be contacted immediately.  My experience with Elderly Protective Services or whatever they are called in your community is that their scope of usefulness varies widely between communities so choose carefully.

Sadly, sometimes we are best suited to be the bad guy.  The kindest thing to do may involve being the one who is willing to go toe to toe with a patient until they surrender their car keys.  I mean that figuratively, by the way.  There are laws against assaulting patients.  We cannot take keys from patients or steal them but we can be the ones who tell the patient that we are by law obligated to report dangerous situations.  We can notify the physician and even help him draft a letter to the Department of Motor Vehicles.  Remember, the life you save may be your child’s.  And even though it is no fun, it really is okay if the occasional patient doesn’t like you because truly caring for them means making them angry.

This is what upset me and why I asked the question of you.  These two patients were referred to two separate clients in two different communities 200 miles apart.  In both instances, other agencies had refused these patients due to the fact that they were driving.

I am not at all impressed with those agencies.  Either they are much better than us in their assessment skills because they were able to make that determination without seeing the patient or they were not able to think critically and assess patients as individuals.  In nursing, there are very few black and white decisions.  Our patients are people and they are all unique and deserve consideration in these grey areas.  Even if an admit isn’t forthcoming after the initial assessment, as nurses we should look at all the assessment data and determine what is best for the patient.   If they turn out not to qualify for Medicare home health, perhaps we could find an alternative.  And no.  Medicare doesn’t pay for that but that doesn’t mean we don’t benefit from taking care of our elderly.

And so on……

2 Comments Post a comment
  1. Mike Sipes, RN. Branch Mgr #

    I would have to disagree with the conclusion of Pt #2 presenting a “considerable and taxing effort”. The regulation quoted states that there should exist a normal inability to leave the home (and we may or may not assume this means safely) but then goes on to state “AND leaving the home requires a considerable and taxing effort” The “AND” indicates that the patient must meet both of these criteria. Pt #2 clearly comes and goes as he pleases without any effort documented.

    Pt #1 clearly presents a normal inablility and a considerable and taxing effort. And even though it is documented that his outtings are only weekly (infrequent) the documentation does not clearly indicate the duration of time. It states “while his wife works”. If she is paid to provide services to someone once a week for an hour or two, which may be considered a brief period of time, then the Pt may still meet that criteria. My Conclusion #1 possibly homebound with clearer documentation. Pt #2 clearly, presently does not meet the homebound criteria.

    Clearly both of these patients need intervention. Interestingly though what I did not find in your response was a definitive answer on where you would land on the question.

    Thanks always for the useful blog.

    M. Sipes RN

    February 28, 2012

    • Mike,

      Thanks for such a well thought out response. First of all, I believe that at the point the questions were asked, neither patient met homebound criteria. There’s my definitive answer. Whether or not they ultimately would meet the requirements depended on the assessment and ensuing plan of care AND the support and participation of the patient, family and physicians.

      As far as patient 2, I agree with you mostly. I did not and probably should have included the information about psychiatric homebound status. My bad. The ‘old manual’ used to have more verbiage (Palmetto GBA manual). In my current reference, chapter 7 of the Medicare Benefit Manual, the following is given as an example of homebound:

      A patient with a psychiatric illness that is manifested in part by a refusal to leave home or is of such a nature that it would not be considered safe for the patient to leave home unattended, even if they have no physical limitations.

      In this light, consider a male schizophrenic patient with aggressive tendencies who is maintained on multiple psychiatric medications managed by their family. A new diagnosis of diabetes or care for a new wound would be covered even though there is no physical reason why the patient cannot do the wound care independently or go elsewhere for care. Teaching diabetes would not be effective (and likely not covered) unless the caregivers were committed to learning and practicing what was taught but teaching would be a skill if they were motivated learners. Similarly, the patient with dementia, assuming the diagnosis met real criteria and the patient wasn’t just a tad off during a recent hospital stay, would not be safe to go out unattended.

      Patient number 1 meets homebound criteria in every single way except one. He leaves the house. I don’t have his exact schedule and I do appreciate the therapeutic value of sitting by a lake but alas, Medicare does not. The bigger question is whether or not the patient understands that he is putting himself in serious jeopardy by immobilizing himself for extended periods of time. If so, it is his right to drive daily or more frequently to the lake and he is not homebound. If he doesn’t understand that or if he has been told that in the past and doesn’t comply, it may because no one ever really assessed his goals. He may be more likely to comply with a plan of care when the end result is being able drive and get in and out of the car by himself. It is not unreasonable to hope that he may be able to actually take a walk by the lake.

      An interesting article I read last night was about advertising. What Madison Ave has found is that scare tactics do not work. They should have called us before spending money on that study. Telling a patient all the ways they can die does not open them up to new ideas and the only compliance you get is self limited until the fear wears off or they get a script for xanax. My point is that I would not make a determination about this patients willingness and ability to participate in a well crafted plan of care designed to meet his goals until I had a shot at him.

      Okay, so I ramble.

      Deal with it.

      Again. Thanks for a well thought-out response to my post. Did you take logic in college? Actually, the reason I became a nurse is because it was one of about two options that did not require math. I did have to take several logic classes and like you, we spent enormous energy defining the word, ‘And’ and also, ‘Or’. You are certainly able to think critically and I like that in a colleague.

      February 28, 2012

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