CMS Proposes a Broader Homebound Rule

A longtime requirement for Medicaid-covered home-health services may be changing. The Centers for Medicare & Medicaid Services (CMS) is seeking public comment on whether benefit recipients must be homebound or simply be at home after a hospital stay.

Homebound status is one of the three basic requirements for eligibility of home-health care (the other two are medical necessity and a physician’s plan of care), and it’s one of the first screens that a case manager uses when assessing a patient for possible levels of post-acute services. CMS considers a patient homebound if he leaves his home infrequently, for short periods of time or for medical treatment. If, however, this proposed rule (CMS 2348-P) becomes law, the concept of homebound – and the number of home-care beneficiaries – will expand.

Under the proposed regulation, patients could receive home-health services even if they’re able to function outside of their home, in the community. For example, a recipient with a disability may be able to work in a protected environment yet need wound care during the work day. This potential broadening of homebound requirements is significant and reflects a push to enable patients who have the potential to live at home with some support to stay out of a nursing home.

A Step in the Right Direction.
On its face, the proposal is admirable. The homebound requirement has been a barrier to services for many otherwise eligible at-home recipients and should be changed. However, the expansion of the meaning of “homebound” has confusing downstream ramifications.

For example, a hospital case manager would face the more involved task of assessing whether a patient needs services in his home or in the community – and, if the latter, where in the community? She is now responsible for creating and managing a more complex plan of care. Given that, coupled with confusing nomenclature (home care that’s not provided in-home?), there should instead be a new classification of care: community-based care or a community-care benefit.

A sharper distinction between home care and community care will help with the application of that care. That’s because while a community-based benefit can be provided within the existing infrastructure of home health, it requires more complex administration by case managers and the more active involvement of recipients. Services for a given beneficiary may need to be scheduled for more than one location. For example, a recipient who was scheduled to receive a nursing visit at his place of work and then is unable to go the work that day won’t be in the right place at the right time.

Home-health agencies stand to benefit the most since this community-based provision of care may be a whole new market for them. To maximize the opportunity, they should be working to develop relationships with various providers that can help support community care for a new population of patients.

Jackie Birmingham, RN, MS, is vice president, emeritus, of clinical leadership at Curaspan Health Group.

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