Home Visits: Family Doctoring Outside the Clinic Carla Ainsworth, MD, MPH October 25, 2011
Goals of this talk • Clarify the RRC expectation of home visits in residency • Discuss the “nuts and bolts” – what do I need to do a good home visit? • Can I do home visits in practice? A bit about the finances of home visits in primary care
Why do home visits? • More convenient for the patient • Patient is too sick to get to the clinic • Patient mobility makes transport difficult • No one can accompany the patient to visit • Opportunity to see the patient in context • Change of scenery for the provider • Opportunity to change the pace of productivity expectations
Who is a good candidate? • Acute illness • Hospice patient dying at home • Home assessment • Unable to get to clinic • Failing at home for unclear reasons • Chaotic social situation • Follow up hospitalization
Home visits in residency • “Each resident must perform at least two home visits with at least one being for an older adult continuity patient” • ‘Faculty must supervise either on site or by prompt chart review as is appropriate”
This sounds great. How do I set it up? • Call patient and let them know you would like to see them at home • Ask if there is a friend or family member they would like to have present • Let them know about how long you think the visit will last • Confirm address and ask about directions or parking • Call to confirm that you are coming the day before
What to bring • Stethoscope • Documentation – computer with Epic? • Consider bringing: • Blood pressure cuff • Otoscope • Monofilament • Forms that pt/family can send back (POLST, advance directive) • Supplies for labs, vaccines, procedures?
Assessment - INHOMESSS • Impairments/immobility • Nutrition • Home environment • Other people • Medications • Examination • Safety • Spiritual Health • Services
Medication review • Ask to see the meds at home • Where/how are they stored? • Are there extra bottles/expired meds around? • Does someone help with organizing or administering?
Ask about mobility within the home • Your own home safety evaluation • Entryways • Stairs • Rugs, low chairs, overall visibility • How would your patient get out in an emergency?
Remember this feels significant to patients – a true “house call” • Be respectful • Be gracious – patients and family will often try and feed you • Take a moment to learn something about them that you would never know from seeing them in clinic • Family pictures • Where your patient spends his/her time • How things are set up for her to succeed (or not succeed) at home
A moment about personal safety • Think about where you are going • Don’t go in if it doesn’t feel good to you • Think about taking someone with you • Let someone know where you are going
Can I afford to do home visits in practice? • Home visits reimburse slightly better than clinic visits • Clinic visits • 99213 -- $179 • 99214 -- $266 • Home visits • 99348 (low complexity) -- $211 • 99349 (mod complexity) -- $312
Different settings, different reimbursement • Patients live in lots of different settings, reimbursement varies: • Home services – visit in a private residence • Domiciliary, Rest Home, or Custodial Care services – assisted living and adult family homes • Reimbursement is slightly higher • Nursing home care – in a certified long-term care facility
Medicare rules for “home-bound” Medicare patients have to be “home-bound” to be eligible for home health services. A patient qualifies if: • Leaving home isn’t recommended because of medical condition • Patient’s condition keeps her from leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person) • Leaving home takes a “considerable and taxing effort”
It’s okay to go to church • Patients may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as attending religious services. • Attending adult day care does not disqualify a patient from home health services
Care Plan Oversight Services • Don’t have to see the patient! • Review of home health agency plan of care, labs, phone calls to other members of the health care team, family members, and adjustment of treatment plan • Can bill for this once within a 30 day period • Not if they are in the nursing home • Not if there is no adjustment to their plan
Additional resources • American Academy of Home Care Physicians • www.aahcp.org • Centers for Medicare & Medicaid Services • www.cms.hhs.gov