12. Home Visit Guide

2018 Resident Editor:               John Landefeld, M.D.

Faculty Editor:                    Carla Perissinotto, M.D.


BOTTOM LINE

✔ There is a large and growing need for HBPC, especially among complex patients

✔ HBPC can lead to reduced hospitalizations and lower costs

✔ Preparation, especially in having all necessary equipment, is key to a productive home visit

✔ Use the INHOMESSS mnemonic as a guide

✔ Evaluate patient’s medication adherence, functional status, and social isolation

✔ Use the home visit to identify other resources (i.e. home health, transportation, food) that can help promote independence.  

Background/Evidence

  •  15% of individuals aged 75-85 report difficulty with ADLs; many of these individuals also have difficulty travelling to health care settings
  •  Estimates that 2-4 million people currently need home-based medical care
  •  Recent data from the CMS “Independence at Home” Demonstration Project suggests Home Based Primary Care for medically-complex elders may reduce risk of hospitalization by more than 20%
  •   Some (but not all) home-based programs have been cost-saving, including the “Independence at Home” Project
  •   In medically complex elders, it is likely that HBPC reduces specialist visits
     

Reasons to conduct a visit

  • Patient assessment: Missed appointments, safety concerns (medications, mobility, abuse/neglect), additional needs assessment (is there a skilled need for home health: PT/OT, nursing, etc)
  • Illness management: In particular multiple chronic diseases and medical complexity, which may be difficult in a traditional clinical setting (diabetes, heart failure) and geriatric syndromes (falls, incontinence, cognitive impairment)
  • Post-hospitalization: Also called transitional care, includes both clinical assessment, assessing medication changes, and a patient’s understanding of any changes
  • End-of-life care/serious illness/palliative care: Coordinated with or without hospice, depending on patient preference.  This also includes advanced care planning discussions

 

Before your visit

  • Confirm visit with patient, and if the patient has a caregiver, ask that he/she be present
  • Prioritize your safety – alert others of where you are going, if an unfamiliar part of town, try going with a partner or during daylight hours
  • Arrange equipment (see next section)

 

Equipment

  • To keep accessible (may not be brought to each visit):
    • Infection control: need to have gloves, hand sanitizer, PPE (personal protective equipment, barrier for equipment.
    • Clinical assessment: otoscope/ophthalmoscope, sphygmomanometer (with various cuff sizes), stethoscope, measuring tape, tongue depressors, tuning fork, portable pulse oximeter
    • Wound management: gauze, tape, bandages, packing, gloves (including sterile), alcohol swabs
    • Labs: phlebotomy supplies, lubricant, sharps container, sterile specimen cups
    • Paperwork: Advanced Directive packets, POLST forms, MoCA forms, PHQ-9 forms, patient instruction forms
    • Other: Hearing amplifier/Pocketalker
  • Your Home Visit equipment bag should have at least 3 compartments.
    • Two compartments should be ‘clean’; one for clean disposables and the other, lockable, for patient records
    • Keep hand-washing supplies near the top so they are accessible
    • In your car/office, the bag should be in a clean storage container or otherwise separate compartment
    • If you have a patient you know or suspect to have MRSA/VRE, do not bring the bag inside
    • Prior to setting the bag down, place a barrier on the ground (e.g a chuck)
    • Wash hands first, then remove items necessary for patient care
    • Close the bag prior to engaging in patient care; if you need to reopen the bag, rewash your hands
    • Disposable items must then be removed in a sealed trash bag or biohazard bag
    • Sharps must go directly into a sharps container
    • Any dirty reusable items must be bagged and returned to clinic for washing
    • The bag should then be cleaned weekly

 

The Home Visit

  • The INHOMESSS mnemonic provides a framework for a comprehensive visit:
    • Impairments/immobility
    • Nutrition
    • Home environment
    • Other people (e.g., caregivers, roommates)
    • Medications
    • Examination
    • Safety
    • Spiritual Health
    • Services
  • While these are comprehensive, a successful visit may focus on one or several of the domains above, and sometimes the assessments can be spread over multiple visits depending on urgency
  • See a sample INHOMESSS home visit checklist here: https://www.aafp.org/afp/2011/0415/hi-res/afp20110415p925-f1.gif

 

Patient

  • Medical: On medication review, ask to see all meds, including OTCs, supplements, traditional medicines. Discuss interactions and side effects,

reconcile any discrepancies from your records.

  • Consider whether any role for DME
  • Any skilled needs? See below.
  • Functional: Determine if independent or dependent in ADLs/IADLs, you can ask “do you need help with the following:
  • Social: Assess loneliness and social isolation, safety of neighborhood, accessibility of building.

 

Caregivers

  • Determine who is a caregiver for this patient, what his/her relationship is with the patient, and whether they are paid/unpaid.
  • What is his/her skill level? Is it adequate to the patient’s needs?
  • Assess burnout with the Caregiver Self-Assessment Questionnaire, available through the AMA and American Geriatric Society here: http://www.healthinaging.org/files/documents/caregiver.self_assessment.pdf

 

Connecting to other resources

  • If your patient has a skilled need (wound care, need for OT/PT, dysphagia, need for lab draws, medication management, etc) refer to your health systems’ Health at Home agency for home services
  • Refer early and often to these resources, and use them as further touchpoints for assessing your patient when you are unable to see them in the home

 

After the visit

  • Submit relevant referrals (home services, DME, specialist appointments) and schedule your next home visit or in-office visit
  • Consider other community resources: DMV placards, Meals on Wheels, Paratransit, medication blister packs or medication delivery, neighborhood social groups (churches, etc), adult day health centers
  • Document the visit as a standard clinic note, but with a clear description of the indication for the home visit. Bill Medicare with relevant CPT codes.

 

References

Edwards ST, Saha S, Prentice JC, Pizer SD. Preventing Hospitalization with Veterans Affairs Home-Based Primary Care: Which Individuals Benefit Most? Journal of the American Geriatrics Society. 2017;65:8, 1676-1683.

 

Yao N, Ritchie C, Camacho F, Leff B. Geographic Concentration of Home-Based Medical Care Providers. Health Affairs. 2016;35:8.

 

De Jonge KE, Jamshed N, Gilden D, Kubisiak J, Bruce SR, Taler G. Effects of home-based primary care on Medicare costs in high-risk elders. Journal of the American Geriatrics Society. 2014;62:10, 1825-1831.

 

Unwin BK, Tatum PE. House Calls. American Family Physician. 2011;83:8, 925-931.

 

 

The effects of home-based primary care on Medicare costs at Spectrum Health/ Priority Health (Grand Rapids, MI, USA) from 2012-present: a matched cohort study Stephen A. Stanhope1*, Mary C. Cooley2 , Linda F. Ellington1 , Gregory P. Gadbois2 , Andrew L. Richardson1 , Timothy C. Zeddes3 and Jay P. LaBine2*

 

Stanhope et al. BMC Health Services Research (2018) 18:161

 

J Am Geriatr Soc. 2018 Apr;66(4):812-817. doi: 10.1111/jgs.15314. Epub 2018 Feb 23.

Home-Based Primary Care: Beyond Extension of the Independence at Home Demonstration.

Rotenberg J1,2,3Kinosian B1,2,3,4,5Boling P5,6Taler G5,7,8Independence at Home Learning Collaborative Writing Group5.