MU PT 7890 Case Management 1



Home Health (Medicare Part A): admission requirements & homebound status

Homebound Status Defined: Generally speaking, a patient is considered homebound if he has a condition due to an illness or injury which restricts his ability to leave his place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, the use of special transportation, or the assistance of another person or if he has a condition which is such that leaving his home is medically contraindicated. (HIM-11,204.1).

Key Components in the Evaluation of Homebound Status

• A normal inability to leave home.

• Leaving home would require a considerable and taxing effort.

• Absences from home are to receive medical care including attendance at adult day health centers, or ongoing receipt of outpatient dialysis, chemotherapy or radiation therapy.

• Occasional absences from home for non-medical purposes so long as the absences are infrequent, or 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.

• Leaving the home infrequently for short periods of time for special family occasions, such as family reunions, weddings, graduations, funerals, or to attend religious services is permissible.

Examples of Homebound Patients:

• An individual paralyzed from a stroke who is confined to a wheelchair or who requires the aid of crutches in order to walk.

• An individual who is blind or senile and requires the assistance of another person to leave his residence.

• An individual who has lost the use of his upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc. and thus, requires the assistance of another person to leave his residence.

• An individual recently discharged from a hospital following an illness, injury or surgery who may be suffering from resultant pain and weakness and whose physician has restricted his activities to getting out of bed for only limited periods of time or walking stairs only once per day.

• An individual with arteriosclerotic heart disease of such severity that he must avoid all stress and physical activity.

• An individual with a psychiatric problem manifested in part by a refusal to leave home or is of such a nature that it would not be considered safe for him to leave home unattended.

Home Health: Conditions that could justify Skilled PT intervention:

A. Mobility Dependence: The patient is dependent upon another person for skilled therapy assistance or supervision in such areas as transfer, gait training , stair climbing, and WC maneuvering due to (but not limited to):

1) decreased strength

2) marked muscle spasticity

3) moderate to severe pain

4) contractures

5) incoordination

6) impaired attention span

7) perceptual motor loss

8) lack of awareness of sensory cues

9) orthotic need

10) need for ambulatory or mobility device

B. Safety Dependence: examples requiring skilled PT intervention to protect the patient from further complications:

1) probability of falling

2) impaired balance and head control

3) swallowing difficulties

4) lack of awareness of safety hazards

5) severe pain

6) loss of skin sensation

7) progressive joint contracture

8) infection

9) environmental barriers or hazards

Homebound Quiz: answer YES or NO (answers below)

I . Mrs. Roberts is a 72-year old lady who had a left hip pinning. In addition, she has had a recent exacerbation of CHF and diabetes. She requires the assistance of one to ambulate and is dyspneic after ambulating 35 feet. Visits are needed to assess her condition, do medication and diet teaching, assess her accu-checks and report the findings to her physician. Mrs. Roberts is receiving physical therapy. Her physician and physical therapist have determined she needs to go to the hospital to receive therapy, as she needs use of equipment that wouldn't be able to be brought to the home. Her husband will drive her to the hospital three times a week. Is Mrs. Roberts homebound?

2. Mr. Newton is a 35-year old quadriplegic. The home health aide comes in twice a day to bathe, dress, get him up to his motorized wheelchair in the morning, and to put him to bed in the evening. A Skilled Nurse visits him three times a week for disimpaction. Mr. Newton travels daily in a handicapped van to attend classes at a local university. Would you consider him homebound?

3. Mr. Williams is a slightly confused 88-year old man who needs a Skilled Nurse to draw a monthly Digoxin level. He uses the assistance of a walker to ambulate. A neighbor comes by each evening to drive Mr. Williams to a local cafe. The SN feels this may be the only meal Mr. Williams has each day. Is Mr. Williams considered homebound?

4. Mrs. Cruse is; an 85:-year old lady who needs-.the Skilled Nurse to administer her B-12 injection for pernicious anemia. Mrs. Cruse is unable to self-administer the drug due to severe arthritis in her hands. She requires the assistance of one person to leave home. On Sundays, church members will transport her to church. Would Mrs. Cruse meet the homebound critenia as described by Medicare?

|Answers |

|1. YES An individual is considered homebound when they leave their home for medical reasons and the documentation shows it requires a considerable|

|and taxing effort to leave. Mrs. Roberts is receiving services that normally cannot be provided in the home. |

|2. NO Mr. Newton would not be considered homebound. Even though he requires assistance, he is leaving his home daily for non-medical reasons. |

|3. NO Again, when an individual leaves their home on a frequent basis for non- medical reasons, they will not be considered homebound. (The SN |

|could arrange for Meals on Wheels.) |

|4. YES Mrs. Cruse would still meet the homebound criteria, as she is leaving her home on an infrequent basis for non-medical reasons and the |

|documentation shows it requires a considerable and taxing effort for her to leave. |

|Excerpts from a discussion on the APTA Section on Geriatrics listserv, 2005: |

| |

|The requirement for Medicare A eligibility is not that the client CANNOT leave their home but that it requires significant assistance or such energy |

|demand that it is a "taxing" effort. So, the effort can place such an energy demand (think of clients with good musculoskeletal function but |

|respiratory compromise) that leaving the home on their own steam is a major effort. As we all know, walking 150 feet is a pretty artificial and |

|non-functional measure of mobility. |

| |

|Secondly, many home health agencies are able to see clients on a private pay or Medicare B basis and do so for client convenience and to improve |

|compliance. Homebound status only applies to a patient being seen under Medicare A, not part B. |

| |

|Many of our home health pts can leave their home, but we must consider how taxing it may be for them. A pt may physically be able to transfer in/out of|

|a vehicle, and be driven to an out-pt clinic, but...........the walk to the car, the transfer in and out, walking to the clinic, and then waiting to be |

|seen. When added together this may not leave the person enough energy to make their out-pt rx as effective as if they were able to be seen in the |

|comfort of their own home. |

|Federal amendments: |

| |

|In 2000, Congress expanded the homebound definition to allow patients to attend adult day care programs or religious services. |

| |

|The Centers for Medicare & Medicaid Services (CMS) issued a directive in July, 2002 regarding homebound status. The instructions make clear that |

|chronically disabled individuals who otherwise qualify as homebound should not lose home health services because they leave their homes infrequently for|

|short periods of time for special family occasions, such as family reunions, weddings, graduations or funerals. |

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