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