In today's home care environment, a Medicare patient's homebound status is evaluated in terms of the effort required for the patient to leave his/her home. Does it take a "considerable and taxing" effort for the patient to leave home? For what reasons and how frequently does the patient leave home? From the conditions of participation, we know that determination of homebound status is not that simple. The regulation states in part:
In order for a patient to be eligible to receive covered home health services, the law requires that a physician certify in all cases that the patient is confined to his/her home. An individual does not have to be bedridden to be considered as confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort. If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in a State shall not disqualify an individual from being considered to be confined to his home. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of an infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration. 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 non-medical purposes, e.g., an occasional trip to the barber, a walk around the block, 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 (Department of Health and Human Services, Centers for Medicare and Medicaid Services [DHHS/CMS], 2005).
With these regulations as the backdrop of delineating homebound status, we sought to further understand and operationalize the determinants of a person's ability to leave home. A research study published in 2003 by Shumway-Cook et al., "Environmental Components of Mobility Disability in Community-Living Older Persons," describes the environmental components that affect an older person's ability to live in the community. This body of work influenced our organization's approach to the evaluation of homebound status in our patients. Our article outlines the dimensions of mobility that were described by Shumway-Cook and colleagues and how we translated them for use into our setting.
The research study discusses the evaluation of eight dimensions that affect an elder's ability to leave home. These include distance, temporal characteristics, ambient conditions, terrain characteristics, physical load, postural transition, attention and density, and the effect that each of them has on an individual's ability to move about effectively in his/her surroundings. This is referred to as "mobility disability." These dimensions are considered critical in the mobility disability because each requires the person to manage different demands.
Taking a multidisciplinary team of nurses and therapists, we began by listing the descriptors we use today to describe homebound status. We reviewed the dimensions discussed in the article to plan how we could include all patients who meet the homebound guidelines, rather than attempt to find reasons that they do not. For example, a screen-in approach, rather than a screen-out approach. This helped to frame our definition of homebound status. The dimensions described in the study are as follows, with our interpretation of the home care impact.
Dimension: Distance
Definition: The distance a person is able to walk in the community
Home care impact
This is the most common factor taken into consideration related to determining homebound status. Evaluate the distance a patient is able to safely ambulate, as well as whether the patient possibly avoids ambulation. The word "safely" is a key consideration to the evaluation of distance in this assessment.
As important as distance is, it is not, in itself, an adequate evaluation of homebound status. For the purpose of this study, a person was classified as disabled when he/she required assistance to walk one half of a mile or when climbing stairs. This represents a significant portion of the Medicare population. The entire disabled group in the study reported avoiding situations that would require ambulating 10 blocks or greater. As an example, although many patients live in senior communities or apartment complexes, some may live at the end of a long driveway. Even those who live in the controlled environment of a senior center determine the distance required to get to the dining room. In addition, distance, as it relates to the specific patient's needs, must be taken into account. The need to ambulate 10 blocks may not exist for one patient in a senior center (whose room is beside the dining room) but may be vital for the patient who must walk down a very long driveway or a half-mile to pick up prescriptions or get to a doctor's office visit.
Dimension: Temporal
Definition: Need to walk at a certain speed
Home care impact
Evaluation of the specific area a patient would need to ambulate to receive medical treatment outside the home is also a critical consideration. For example, can the patient cross a parking lot to get from a car to the physician's office in a reasonable amount of time? Can the patient get across a busy intersection before the light changes? This study determined that 59% of disabled persons avoided streets with traffic lights for this reason. Documenting this difficulty can demonstrate how a patient cannot effectively get all his/her medical care outside the home.
Dimension: Ambient
Definition: Varying light levels and weather conditions
Home care impact
Consider the effect that snow, ice, or extreme heat has on the person's ability to move about in the community. How does darkness impede that ability? Darkness was the greatest inhibitor in this study. As vision deteriorates, poor lighting conditions can further compromise the elderly person's ability to ambulate. Ice and snow also had a significant effect on the disabled person's ability to manage independently. Although this is typically limited to seasons, it must be taken into consideration in determining whether the patient is homebound. It is entirely possible for a patient to be homebound during the winter months and not during the spring and summer.
Dimension: Terrain
Definition: Various surface levels, including stairs, curbs, and escalators
Home care impact
Ambulating in an institutional setting typically is much easier than in the home or community setting. Gone are the elevators, open hallways, and side rails. A person usually must maneuver over a variety of uneven surfaces in seeking services outside the home. Even if a patient lives on the ground floor, the entire trip to potential sites of outpatient care settings must be evaluated. Does the patient have to walk down a gravel driveway or grassy area? Step onto a sidewalk? Across uneven pavement? All of these things may have a significant impact on an individual patient's ability to leave home to receive services. Thus, evaluation of homebound status cannot include only in-home ambulation.
Dimension: Physical load
Definition: Requirement to carry objects
Home care impact
As a person performs activities effectively in the community, he/she needs to be able to carry objects such as food and personal and household items. Consider the impact this will have on a patient's overall health status and the endurance level necessary to complete these tasks. All disabled persons in this study reported avoiding these types of activities, and even some of those without physical limitations avoided these situations. Can the patient carry a laundry basket? Can he/she carry a plate of food from the stove to the table? When patients need to seek medical care outside their home, frequently they need to take their medications, a purse or bag, or journal of medical information. Documenting a patient's inability to carry small items and ambulate independently in a safe manner helps to better evaluate their homebound status.
Dimension: Postural transition
Definition: Requirements to reach up or down for items
Home care impact
The patient's ability to perform a shopping activity is assessed. The shelves in grocery stores and kitchen cabinets are such that it is impossible to obtain goods located only at an arms reach. This dimension has a direct correlation to a person's ability to perform independent activities of daily living, as well as dressing and bathing. Does the patient lose his/her balance when reaching above the shoulder? Does he/she have the ability to bend to retrieve an object? Does he/she need to do these things on a regular basis?
Dimension: Attention
Definition: Demands on focus and ability when surroundings are loud, unfamiliar, or when the patient is alone
Home care impact
The world outside the home can be a noisy and unfamiliar place. For a person to effectively function in the community, he/she has to be able to handle the input of sensory factors. Not many places exist where background noise is not a factor. Being able to ambulate when someone behind you loudly drops something, or walking in a parking lot when a car backfires or a horn is honked may be real issues for some people. Such distractions can make it difficult for some to function in the community. Another activity that likely has significant impact on a Medicare patient is making and keeping appointments with new physicians or for diagnostic testing. Having to navigate in unfamiliar surroundings can be overwhelming for the elderly. Sometimes being alone, even in a familiar setting, may be too much for an elderly person. This research study showed that 65% of older adults with a disability avoided going into the community alone. This finding illustrates barriers to a patient receiving care outside the home.
Dimension: Density
Definition: Crowded places
Home care impact
This dimension is faced by everyone in the community. When in a crowded room or street, you have to frequently alter your gait pattern to maneuver around obstacles or people. This requires a level of balance and reaction time that may not typically be required in the home environment. In this dimension, all of the study group (those with physical limitations and those without) avoided situations where this dimension came into play. More than half of disabled persons (65%) avoided situations in which they would have to maneuver through crowds. This was one area we did not typically evaluate when looking at homebound status but which is a critical component for an elderly person to be independent in the community.
The research study provides the assessing professional with additional, objective measures to obtain an accurate assessment of each patient's normal ability to effectively leave home and move about in his/her surroundings. These additional characteristics help with the evaluation and documentation of the two primary considerations for determining homebound status: Does leaving home require a considerable and taxing effort? And, what are the barriers to the patient receiving services outside the home? To better document homebound status, we provided education for all field clinicians on evaluating the patient against these dimensions to help determine and document the patient's homebound status. This gave them additional elements to ensure homebound status was fully evaluated. In addition, we prompted accurate documentation by adding the following section to all assessment documents.
The evaluation of homebound status is not based on a rapid determination of whether or not the patient ever leaves his/her home. There are specific circumstances in which the patient can leave home (and for the purposes of treatment should leave home, to improve gait on that gravel driveway, for example). Homebound determinations must be made using professional judgment based on the patient's ability to move about in his/her surroundings to include all of the environmental dimensions discussed in this article.
It is the intention of home care agencies to provide needed services in patients' homes while ensuring that these same patients meet the Medicare coverage requirements when Medicare is the payer. Education for the assessing professional regarding these dimensions will improve this determination, enable more accurate, objective documentation, reduce denials for the agency, and ensure that Medicare beneficiaries have access to the care to which they are entitled.
Homebound status
The patient is homebound [white square] Yes [white square] No
[white square] Considerable and taxing effort to leave home ___
[white square] Illness/injury restricts ability to leave home ___
[white square] Other impairments ___
[white square] Supportive assistance to leave home ___
[white square] Considerable and taxing effort to leave home ___
[white square] Other reasons cannot receive care outside home ___
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