I am a homecare physical therapist working with a patient who lives in an assisted living facility. She ambulates approximately 30’ with a roller walker but is otherwise essentially wheelchair-bound. There is a fully equipped gym on the floor of her facility available for use by residents. I would like to work with my patient on the Nu-Step located there. My supervisor at the home health agency has told me that according to Medicare guidelines, I am not allowed to bring the patient to the gym. He says that if the gym was in the patient’s private home, it could be used, but he states that if the patient could use the gym in the assisted living facility, she would not be considered homebound and could go to outpatient therapy. This makes no sense at all to me but I am unable to find any information on this issue. Can you help?
Thank you for the question; many agencies and their clinicians have, at best, a fuzzy understanding of the homebound definition as it applies to today’s Medicare home health patient. The basic homebound status is based on an ever-evolving functional profile that is reflective of the current programming mandates that CMS employs as the basis for the home health benefit. As Medicare has introduced numerous reforms and modifications to the home health program itself (IPS, PPS, 2008 New Rule), the ideas behind identifying the ideal patient profile have changed as well. Adding to the confusion is the lack of a definitive and published guideline from CMS as to the current homebound definition. We will address the many facets of this issue as well as examining the historical contributions to the many incorrect applications of the homebound concept.
Prior to the introduction of the PPS model to comply with the Balanced Budget Act in the late 90’s, Medicare offered home health services via a fee-for-service reimbursement model. When certified agencies provided homecare services to a Medicare client, they were paid in accordance with the volume of services provided. Despite specific regulatory qualification requirements, it is easy to see how spending costs might quickly out-pace traditional Medicare cost expectations. One control employed at that time to focus the scope of the qualifying patient profile was the homebound definition. Prior to the implementation of PPS, homebound patients were defined as those who were unable to leave the home independently (without the assistance of any other individual). Those patients able to independently mobilize themselves outside of their residences were considered not homebound and resultantly, not qualifying for Medicare home health services.
It is important to mention that during the pre-PPS era, corporate compliance efforts to prevent fraud and abuse of the Medicare system were not emphasized to either participating agencies or clinicians. It was not an uncommon practice that patients who actually possessed the ability to travel independently out of the home were still treated as if they were homebound. Agencies and clinicians often turned a blind eye to lack of homebound-ness as a qualifying concern out of clinical empathy for the patient. Post-BBA emphasis on corporate compliance and resultant penalties led to the sort of over-correction that prompts you to ask your question.
As the Medicare home health model has evolved, many of the previously held beliefs towards issues such as homebound status concerns have also progressed. The type of cost/results analysis that helped CMS formulate BBA reforms also prompted questions that led to the re-examination of a homecare patient’s ability to leave their residence. Medicare came to the conclusion that the home health benefit would emphasize and offer short-term transitional care based on recent onset functional deficits with the goal of return to the previous level of function. This emphasis on a relatively brief, intermittent homecare program model has resulted in the homebound definition in effect today.
Medicare has come to conclude that a patient possessing a higher level of mobility is, in effect, a healthier patient; ultimately, one who costs Medicare less over the course of their enrollment. In an attempt to prompt this desired functional status, today’s homebound patient is able to independently leave the home (yes, driving is acceptable) for medical appointments, pharmacy and religious activities. Any other independent trips outside the home qualifies the patient as not homebound.
Lastly, we will examine your situation. With the above principles in mind, clearly Medicare would want to promote the highest level of function and mobility in your patient. First, we must note that your patient lives in the assisted living facility. It is her residence. Unless she independently leaves the building (or campus), she remains homebound. Her independent use of the Nu-Step after your skilled assistance is an acceptable goal of treatment that does not compromise her homebound status. Most likely, your supervisor’s opinion, though incorrect, is based primarily on a desire to remain in appropriate compliance with regulations. Hopefully, this encounter will help you, your supervisor, and your agency employ this contemporary homebound definition for the benefit of current and future patients.
Teri N. Thompson and Arnie Cisneros are physical therapists with more than 35 years of combined home care experience. They are co-owners of Home Health Strategic Management of East Lansing, MI; providing clinical service management and home care consulting expertise. They also lecture and provide OASIS, HHRG, OBQI and P4P training at seminars nationally.