When are patients deemed "unsafe" for home care?

By Elizabeth E. Hogue, Esq., Burtonsville, MD

Discharge planners/case managers are likely to encounter instances in which home care, hospice, and home medical equipment (HME) providers state that they cannot accept patients because they are "unsafe" at home. The use of this term may be confusing to discharge planners/case managers. What is it about patients' homes that make it "unsafe" for them to receive services there? Aren't all patients appropriate for home care?

First, discharge planners/case managers may not have provided services in non-institutional settings. If so, it may be difficult to make a crucial distinction between institutional care and home health services.

Specifically, in institutional settings the provider controls the "turf" on which care is rendered. In post-acute care at home, providers have very little control over the environment in which services are provided. In fact, patients control the "turf" in home care because services are rendered in their private residences over which patients have almost absolute control.

Consequently, home care providers often confront barriers to the provision of services that many discharge planners have not experienced. Staff have, for example, encountered "attack geese" when they arrive at patients' homes and risk the consequences of a serious "pecking" in order to reach patients' bedsides! Or, they have come eye to eye with a pet alligator named "Bubba" in a mobile home in Louisiana!

Although patients may not be adversely affected by pecking geese and may have a cozy relationship with "Bubba," there may be other factors over which home care providers have no control that clearly jeopardize the well-being or safety of patients. These factors may make it impossible for providers to render services at home.

Patients' homes may, for example, be in such disrepair that both patients and caregivers are at risk. A home health nurse, for example, recently fell through the floor of a patient's home as she approached the patient's bedside.

Patients' homes may also be invested with roaches, rodents, and/or vermin of various types and descriptions.

Patients may suffer repeated falls at home despite appropriate interventions from providers that make it risky or "unsafe" for patients to remain at home.

Despite these examples, discharge planners/case managers may still be unclear about why patients cannot be cared for at home when post-acute providers decline referrals on the basis that patients are "unsafe." It may be helpful for providers to be much more specific in their communications. Specifically, it may be more helpful for providers to say, "The patient's home environment will not support services at home for the following reasons…"

When providers' communications with discharge planners/case managers are vague or unclear, it may be helpful for discharge planners to prompt more specific communication by asking: "What are the specific reasons why this patient's home environment will not support home care services?"

Institutional care and home health services are fundamentally different models of care. Because the differences are so great, it is reasonable to expect that providers who practice primarily in institutions and those who work in home care may not always understand or account for important factors involved in different types of care. Clear, specific communications are, therefore, absolutely essential for the well-being of patients.