Understanding and Documenting Homebound Status

Gretchen Anderson, MSPT, GCS, COS-C

Member of the Home Health Section Speaker’s Bureau

This educational course was created and approved by the Education Committee of the Home Health Section of the American Physical Therapy Association.

Unauthorized duplication of this material is prohibited. CAUTION: The Home Health Section and APTA are not responsible for the content of the enclosed presentation and make no representation concerning its accuracy or completeness. The Home Health Section assumes no responsibility for any user’s reliance upon the presentation.

www.homehealthsection.org

The Home Health Section of the APTA is devoted to the development of standards of practice, education, providing information on regulatory and reimbursement issues, and development issues, and developing a unified approach to the delivery of home health services.

The Home Health Section: • Keeps members informed of vital issues • Shares current clinical and administrative knowledge and skills pertaining to home health • Encourages research and development • Monitors & actively participates in legislation related to HH documentation and reimbursement • Acts as a liaison between Section members and the APTA • Acts as a resource to other health care organizations www.homehealthsection.org

Objectives

 Understand Medicare regulations related to meaning of “homebound status”  Understand how and when to document homebound status  Understand how to incorporate teaching with patients/families homebound criteria  Review real-life examples of challenging situations

CMS Clarifies Homebound, Oct ‘13

Why the clarification?

(per CMS Manual, Transmittal 172) This instruction clarifies the definition of the patient as being "confined to the home" to more accurately reflect the definition as articulated at Section 1835(a) of the Social Security Act. In addition, vague terms, such as ‘generally speaking’ have been removed to ensure clear and specific requirements of the definition. “ This will prevent confusion, promote a clearer enforcement of the statute, and provide more definitive guidance to HHAs in order to foster compliance .”  But does it make it clearer??

Definition provided to beneficiary

(Official US government booklet about home health benefits for people with original Medicare —Medicare.gov/pubs/pdf/10969.pdf) You must be homebound, and a doctor must certify that you’re homebound. To be homebound means the following:  Leaving your home isn’t recommended because of your condition  Your condition keeps you from leaving home without help (such as using a w/c, walker, needing special transportation, or getting help from another person)  Leaving home takes a considerable and taxing effort. This definition seems pretty clear…

Homebound Definition

(transmittals for Chapter 7, Medicare Benefit Policy Manual)

For a patient to be eligible to receive covered home health services under both Part A and Part B, the law requires that a physician certify in all cases that the patient is confined to his/her home. For purposes of the statute, an individual shall be considered “confined to the home” (homebound) if the following two criteria are met:

Homebound Definition cont’d

1.

Criteria-One: The patient must either:

-

Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence OR - Have a condition such that leaving his or her home is medically contraindicated

Homebound Definition cont’d

If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional requirements defined in Criteria-Two below. 2. Criteria-Two:

-

There must exist a normal inability to leave home; AND - Leaving home must require a considerable and taxing effort.

Can a homebound person leave home?

 Yes they can.  For Medical purposes including outpatient radiation and dialysis   For Adult Day Health Care For a family event such as weddings, funerals, graduations, reunions  Key is short duration and meeting homebound criteria

“It is expected that in most instances, absences from the home that occur will be for the purpose of receiving health care treatment. 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 .” (Chapter 7)

This “clarification” can be confusing…

 What is “

Normal Inability

”?

 How do we measure “

considerable and taxing”?

 Aide of supportive device, special transportation OR assistance of another person?  What are conditions that are medically contraindicated to leaving home?

Let’s start with the easier one….Criteria one is one OR the other of the following:

 Assist of another person or assistive device  This is easy for us. Needing a device and/or physical assist is clearly understood and easy to document  Medically contraindicated?  Infection risk   Specific precautions —bed rest, limited activity Psychological risks associated with leaving home —anxiety, fear.



Criteria two is not so straight forward..

“Normal Inability”: is it a ‘normal inability’ that one with that condition would be confined to home?

AND  “Considerable and taxing effort”.

 Does this mean max assist?  Or can it mean pt is so fatigued upon returning home that they are wiped out and unsafe w/ADL?

 Or too fatigued once they arrive at outpatient to benefit from it? It can mean any of these.

What counts as “home”?

(Chapt. 7 Transmittal 30.1.2) A patient’s residence is wherever he or she makes his or her home. This may be his or her own dwelling, an apartment, a relative’s home, a home for the aged, or some other type of institution. However, an institution may not be considered a patient’s residence if the institution meets the requirements of a hospital or skilled nursing facility. **A patient may have more than one home and the Medicare rules do not prohibit a patent from having one or more places of residence. *The requirements of homebound must be met at each location.



So, how to document this??

Document upon initial assessment visit? Absolutely! However…    EVERY note should convey home bound status..

 Ideally, this is through your documentation of your interventions AND Specific explanation of homebound status Beware of copy/paste or pre-populated fields Homebound status changes as patient changes and documentation should change to.

 It should be clear to any person reviewing your documentation that your patient needs to receive care at home  Indicate the assist needed to leave home and this can be through treatment notes of interventions as well as separate documentation  Indicate the barriers to leaving home      Are there stairs?

Can patient transfer into a car without assistance?

Can they walk community distances w/o undo fatigue?

Do they have anxiety with out-of-home mobility?

Is patient confusion to extent where patient needs assist of another for community mobility?  Does the patient have too much pain to tolerate an outing or does the outing itself cause increased pain?

Tests and Measure

    Use standardized tests and measures to support homebound status  Can patient function at community levels?

  Fall risk by TUG/Tinetti/Berg/DGI?

Is Gait speed safe for community Can they traverse varied terrain?

Can patient ambulate sufficient distances for community? Can they do these things

SAFELY???

Other reasons than physical

 Cognition —Patients are homebound due to cognitive reasons. Are they safe to be out in community without assist?

 Infection risk —Open wounds or very compromised medical status where shouldn’t expose to community  Psychiatric Issues —severe anxiety or phobias can also be reasons for homebound support

OASIS Considerations

 Keep in mind how to correctly score OASIS items —the scores reflect

SAFETY

with tasks and what assist

should be

provided, not necessarily what the patient chooses to do.  If you are scoring a patient as a “0” with M1850 (transfers) or M1860 (ambulation) then you are saying that they are safe and independent in these skills. Homebound status might, and should, be questioned if we are stating that they are safe to ambulate on varied surfaces, with no device and no assist.  In this case, documentation must be present to support other reasons for the patient’s homebound status such as infection risk, MD orders, severe anxiety issues.

What happens when your patients go out of home for ‘non-acceptable’ reasons?

 Do you need to discharge patient if they go out shopping/to restaurant?  Investigate the effects of that outing  Do they say “it was great and tomorrow we are going to the movies” ? Or..

 “I was so exhausted from grocery shopping that I couldn’t even take a bath”  You can use the experience to SUPPORT homebound if they were very fatigued---okay to document this and use as education to patient of their limitations and safety



What about DRIVING???

If you discover your patient is driving…does that mean automatic discharge? Does that mean non-homebound?  The question is not if the patient

is driving

but whether or not the patient

should be driving

 Are they driving because that is only way to get their food or medicine?  Are they driving but are unsafe while doing so or unsafe to be walking to/from car on their own?  Remember the criteria —is it a considerable/taxing effort? Do they need assist of device or another person (to be safe)? Do they have contraindications to being out of home? THESE determine homebound status —not what they do but if they should do it.

Do our patients ‘choose’ to be homebound?

 NO. Patients meet criteria of being homebound or they don’t. It is not a patient choice issue.

 If pt should not be going out due to safety, contraindications, etc but are going out into community anyway, that does not change definition. It may change course of action and require discharge due to schedule challenges but do not confuse that with meeting criteria.  You can educate patient to risks, get MD/family involved and continue to see patient in home if they meet the homebound criteria

Do patients “become homebound” because they don’t go out?

 Again —patients do not ‘choose’ to be homebound.  If they COULD go out w/o assist or without taxing effort, they do not

become homebound

simply because they want to stay home and agree to stay home.  The criteria dictate homebound status, not the patient.  Inability to drive does not come into play. What matters is if patient can go with others or with public transportation.

Those who go out against medical advice

 Very similar to previous slides---if they meet homebound definition but they still choose to go out of home, they are taking a risk, and they are not changing the criteria.  If patient goes out against advice but meet criteria, you need to     Educate the patient to risks of going out Get family/caregivers involved Explore reasons for going out Okay to document these things, demonstrates teaching and why/how patient IS HOMEBOUND  Eventual result may be discharge due to non-compliance or scheduling challenges but not because patient isn’t meeting homebound criteria.



Homebound…

There is a definition —follow it.  Documentation should be with every visit that supports homebound status  Use objective terms/measures to communicate homebound to the reader of the notes  Remember that patient’s do not choose to be, or not to be, homebound  If you think the patient could go to outpatient therapy and not suffer medically or psychologically, it may be difficult to support homebound and time to transition out of home  Use of HHABN Non-Coverage form can help to educate patient to option if they want to continue with therapy in home when not meeting criteria

Other considerations

 Pay attention to paperwork obtained from referral sources.  If the hospital/SNF/Rehab facility paints a picture of an independent person who has met their goals, this may impact your ability to make a case that the patient is homebound and/or that the patient has need for skilled care.  Happens more often with therapy notes —the inpatient facility documentation can hurt the home health documentation.  Think about the documentation you put into your medical record.

Real Life Examples

 Patient has history of CVA with resultant hemiparesis — affecting UE and LE  Recently home from inpatient stay for a Total Knee Replacement  Lives alone in split level home —stairs are necessary for all in/out home and to do laundry.  Patient is unsafe on stairs —even with assist and should have supervision for ambulation  Patient is leaving home anyway —he is walking stairs, going out to truck and driving truck!!! What to do??

What to do??

 Explore why he was leaving o To get food and medicine  Explore options o Add services of Social Worker?

o Private help in home?  Inform MD/Family of risks/behaviors  Discharge if patient leaves home so much, cannot schedule visits.

How to Document?

 Make sure deficits come through in daily charting which should be easy as focus of treatment is likely on gait, ROM, stairs, etc.  Remember when scoring OASIS M1860 —you score based on what is best fit score for patient to be SAFE with activity  Also document on assistive devices used.  Should you mention the driving??  YES! Document teaching to safety, teaching to contact with MD/Family, reasons for going out, safety concerns, referral to MSW and why.  Document concerns but also reasons why therapy in home is needed —his stairs, his safety, his fatigue if he were to go out, etc.

Clinical dilemma #2

 Patient is young, severe respiratory dysfunction, ? mononucleosis  Patient is indep in home, not fall risk by TUG/Tinetti. Does not use assistive device but requires several breaks when doing any activity due to SOB/fatigue  Patient has home program for strengthening, activity tolerance  Goals are for patient to take walk with her little dog to near by park BID  Is she homebound?

Dilemma cont’d

 Yes she is homebound as she does not have tolerance for outside activities, does not have tolerance for safe community mobility and would be too fatigued for outpatient nursing or therapy if she were to get there.  Dilemma in this case is that she is indep in home program and her need for skilled PT is what should be the question  However..she is too fearful to ambulate to park on her own and needs guidance to monitor signs/symptoms fatigue, overwork, etc.

How to proceed?

 Patient is managed care and insurance gave authorization for visits for another certification period at a less intense rate.

 Patient DID develop bladder & kidney infection just after this recert and had decline in abilities  PT focus on teaching to pacing of activities and outdoor mobility skills, SN continued for medical management.

Scenario #3

 66 year old male w/history of gait instability, ETOH, recent GI bleed  Pt lives alone w/no family in the area  Pt has been walking outside daily to corner store to buy food, using walker  No falls but a few ‘close calls’.  Pt did take bus to MD appt, declined visit the following day due to fatigue.  Homebound??

YES! Homebound. How to address in chart?

 Patient clearly needs PT for safe mobility when out.  Document the ‘close calls’, use tests and measures to look at community mobility safety and activity tolerance.  Focus of treatment for PT should be to improve these skills and make it safe for these activities  In the meantime, explore options for help in home through community resources, social work, etc.

One more example..

 54 yr old woman with MS. Not ambulatory, assist with transfers, spends days alone in bed w/assist coming in mid-day to transfer.

 Pt has a power chair and manual chair.  On weekends, her husband transports her to a disabled yoga class and after class, they go out to dinner. This occurs routinely unless pt is feeling ill, which happens about 1x/month  Does she meet homebound definition?

Does she meet definition?

 I say yes spouse. —these outings are of short duration and are a ‘considerable and taxing’ effort for both patient and her  Some might be hung up on the nature of the outings — not medical appt but remember, one can go out for things like church, hairdresser, etc and this outing seems as important to this pt. Documentation does not need to focus on this weekend outing —also no need to hide it. Work with pt/spouse on ways to make these transfers easier and safer if that is indicated.

References

 CMS Manual, Pub 100-02 Medicare benefit Policy, Transmittal 172, October 18, 2013 Change Request 8444  Medicare and Home Health Care, the Official US government booklet about home health benefits for people with original Medicare —Medicare.gov/pubs/pdf/10969.pdf

 Medicare Benefit Policy Manual Chapter 7 —Home health Services, Rev. 179, 01-14-14  Medicare Interactive, Secion IV.f Home Health Care Benefit