NoGo's for non-homebound

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Hey all (I lost my prior registration info so I had to reregister - I used to be anticoagulationurse BTW)-

But anyway, I've been in HH for a year now. LOVE IT! The learning curve for the OASIS and computer system has been very steep but my work load is now manageable without too many flame out's anymore about the computer etc. One thing I think I am particularly careful about is the HH criteria. 1) I don't want to be an active participant in fraud, 2) I want the company to get paid, 3) It is unethical to ignore the criteria.

I am an RN and do many of the admissions and discharges. Lately there seems to be a rash of referrals that make it through our intake department screening that are simply NOT homebound. This resulted in a week with 3 no-go's and an unplanned discharge for me. My supervisor questioned one of the no go's and the discharge and I was forced to go back the next day and admit one patient. The other 3 they had another nurse admit without questioning me directly.

I have tried to get some explanation for this and have explained my perspective but it seems to be unheard. Today I was told will be a meeting between my supervisor and the HH manager tomorrow. I can only assume the subject of said meeting, it is to educate me about my recent no go's. I am so nervous that I will be expected to turn a blind eye, by being "re-educated" about homebound status. Not sure what would change about my common analysis of homebound status over the last 2 weeks to explain the sudden frequency of my "inappropriate" no-go's. But, I'm sure it's my mistake right?

NO GO #1: Person was gone at church (which I know is OK) but he drove himself there and was there for over 4 hours, and verified by a family member that he drives regularly without apparent difficulty.

NO GO #2: Person has a 15+ year chronic stasis wound with recent infection being treated and family members caring for wound. Dressing change frequency has recently been increased and family requesting HH. Interviewed patient to discover he drives himself everyday to sit a local coffee shop to read and has not missed a day in over a year. He verbally states, "It's no problem for me to leave home."

NO GO #3: Person is a young guadrapalegic (not new) with a chronic pressure wound and a history of non compliance with medical regimen. When asked about homebound status, he explains how he leaves on the city bus which is not a difficulty for him. He says he can get to the wound clinic, hospital or MD office no problem.

Unplanned Discharge: LONG term foley patient with guadrapalegia and all the proper equipment including adapted van and caregivers (been on service for YEARS, but new to me). When asked if they are "getting out and about" (my favorite way to inquire about HB status) pt reports going to an event all day last week and occasionally going shopping as caregivers have time. Says this did not pose a hardship and when asked directly if it is a taxing effort to leave home in general, the response was, "No." in a why do you ask? kind of way. Haven't we been asking every visit for years now??? (Or are we?)

These are the visits being questions by the superiors and not only questioned, REVERSED by other nurses. Do I have reason to feel defensive?

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i just have a quick comment as i have also been faced with "questionable" homebound status , right from the patient home i call the office and give them the info and take direction from them, that way i feel i am off the hook as i have presented the case to them....when i have done this, i have always gotten--yup he isnt homebound...i think everyone of us has stretched the homebound status to be able to help the patients,,,when it is so obvious, let the management make the decision..just my opinion

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Thanks for your reply. I didn't realize how long my post was until I just re-read it now! Sorry guys. Anyway, I did call the office about each of these no go's and at the time had agreement from the Case Managers.

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Well, I guess you have to get used to how they want it. Either you agree to go along with them or you will probably end up leaving the agency. This is one of those occupational hazards, as I think many agencies run loose with the homebound rules. I agree with calling the office at the time and giving the decision to someone higher up the food chain.

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Specializes in Home Health, MS, Oncology, Case Manageme.
i.i think everyone of us has stretched the homebound status to be able to help the patients,,,

I wish this was the case, unfortunately, with some of the agencies that I have worked for its all about the money. They are glad to have the referral ($$$$) and are willing to look the other way re: homebound status. An ethical agency does not even question their nurses regarding these decisions. We have non-admits in my agency all the time and no one thinks anything of it.

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NO GO #1: Person was gone at church (which I know is OK) but he drove himself there and was there for over 4 hours, and verified by a family member that he drives regularly without apparent difficulty.

NO GO #2: Person has a 15+ year chronic stasis wound with recent infection being treated and family members caring for wound. Dressing change frequency has recently been increased and family requesting HH. Interviewed patient to discover he drives himself everyday to sit a local coffee shop to read and has not missed a day in over a year. He verbally states, "It's no problem for me to leave home."

NO GO #3: Person is a young guadrapalegic (not new) with a chronic pressure wound and a history of non compliance with medical regimen. When asked about homebound status, he explains how he leaves on the city bus which is not a difficulty for him. He says he can get to the wound clinic, hospital or MD office no problem.

Unplanned Discharge: LONG term foley patient with guadrapalegia and all the proper equipment including adapted van and caregivers (been on service for YEARS, but new to me). When asked if they are "getting out and about" (my favorite way to inquire about HB status) pt reports going to an event all day last week and occasionally going shopping as caregivers have time. Says this did not pose a hardship and when asked directly if it is a taxing effort to leave home in general, the response was, "No." in a why do you ask? kind of way. Haven't we been asking every visit for years now??? (Or are we?)

I think you are correct in the way you are doing your job . . . but maybe you might find a new company whose philosophy you can respect.

About the above cases:

1 - driving is not a limiter for homebound status. Effort required, however, is. An md visit can take 4 hours, so can church, both are "OK" within medicare homebound status. The question you did not answer in the case description was, was the pt "taxed" at this effort?

2 - discharge him, but not necessarily for homebound status. If the family is independent with wound care, and all necessary teaching has taken place, he's out. But this guy is not homebound either.

3 - See "1". He can do it, but is it a taxing effort?

4 - Ongoing education within the agency to maintain and improve quality is a hallmark of the agency where you might consider working next. This pt has seen the outcome of a lack of continuing education.

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Specializes in Home health, Cardiac Tele, Doc's office.

From the way I understand it, driving is fine, if the patient can't find someone to drive him, then he can drive himself. The operative words in # 1, I think is that he "drives regularly with no apparent difficulty" (which to me says it is not a taxing effort for him to drive or go out. If he drives and is gone for 4-5 hours then goes home and it totally wipes him out or he has to sleep the rest of the night, that is a taxing effort, but no apparent difficulties says it is not taxing). If it is something he does regularly, then Medicare will say he can go to the doctors office for what I am going to see him for. JMO

# 2 again he drives regularly to the coffee shop, he can drive himself to the doctor to do what I am doing. He is not homebound either.

# 3 again he says it is not difficulty for him to take the bus to the wound clinic or MD's office, not homebound.

A lot of times when asked if this is a "taxing effort" to a patient, some are thinking if I respond yes, then they will make me go to a nursing home or assisted living place. So they will naturally say of course it isn't hard to go out. Sometimes you have to read between the lines.If you can get a patient to do a few things around the house like show you their bedroom, bathroom, you can tell if it would be a taxing effort or not, in some instances. I will say the people that need retraining in homebound status is the office people. My office, had I admitted those patients I would have called me in to explain my reasoning why I admitted them (and most likely having to DC them.

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Specializes in COS-C, Risk Management.
1 - driving is not a limiter for homebound status. Effort required, however, is. An md visit can take 4 hours, so can church, both are "OK" within medicare homebound status. The question you did not answer in the case description was, was the pt "taxed" at this effort?

I have issues with this and had a brief tiff with my DON yesterday over it. We had a memo issued yesterday that said that if a patient can drive him/herself, even if in a modified vehicle, then s/he is not considered homebound. Then she sat right at the table and said that if it is a taxing effort for the patient to drive him/herself, s/he is considered homebound. It cannot be both ways.

Years ago, I worked for two separate agencies that were indicted for Medicare fraud. The owner of one went to prison and two nurses there lost their licenses for Medicare fraud. Most of the fraud case centered around homebound status and other inappropriate visits (like phlebotomy only, etc.). So I have huge issues anyway with the homebound guidelines.

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Specializes in COS-C, Risk Management.

Found the memo. Verbatim: Also remember that if a client is able to drive, even if it is a specially equipped automobile, he or she does not satisfy the homebound requirement.

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Kinda scary, then, isn't it. My agency is pretty firmly in the camp of "it doesn't matter how they got out of the home, it's whether they were spent after they get back home."

Many of my elderly patients never did drive . . . doesn't make them homebound.

Some of my medical patients that are younger drive without difficulty, but even going to the outpatient lab is a taxing effort.

Sorry you are dealing with an administrator who talks out of both sides of their mouth. As you said, you can't have it both ways.

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Specializes in Home health, Cardiac Tele, Doc's office.

I know about 10 years ago, I was told that same thing ***if a client is able to drive, even if it is a specially equipped automobile, he or she does not satisfy the homebound requirement.***

Several years ago, that became, a patient can drive infrequently and that does not mean they do not meet the homebound status. A patient can still be considered homebound as long as when he drives it is infrequently, and it is a taxing effort for him to leave home. If they can not find someone to drive them to the doctors office for an appointment, but it is a taxing effort for them to drive, they are still considered homebound. Just because a patient doesn't leave home does not make him homebound either. The operative word in homebound status whether they drive or not is, is it a "taxing" effort for the person to leave home. Do they, when they go to the doctor's office (again, whether they drive or not) do they become S.O.B. and have to take frequent rest periods when they are out, or become extremely fatigued (do they go home and have to sleep for half a day). Homebound status like I said does not just mean the patient stays home and doesn't go anywhere, it means that if they do go out it is a taxing effort for them to leave. This is the way I understand it. I could be wrong but that is how the agency I work for looks at it.

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Thanks for your replies! I do use the "taxing effort" as my guide and sometimes it's tricky eliciting a straight answer, taking a few tries to explain what "taxing effort" even means, in layman's terms. I do feel I have a good grip on homebound-ness and that some of our other nurses probably don't even ask about it! I say this because even for patients who may be new to me but on service with other nurses for months some seem bewildered about the question as though they have never heard it before. I've had other patients ask me if I am some kind of supervisor or charge nurse because I ask way more questions than the other nurses. So, maybe that is why I am singled out, because I am one of few people doing No-go's or discharging people for non-homebound status... because I bother to ask! Unfortunately, there are not many home health employemnt options in my area... so unless they axe the ineffectual middle management and start fresh... I'm out of luck.

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