Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity.
CPT4 code
Name of the Procedure:
Home Visit for the Evaluation and Management of an Established Patient
Common names: Home healthcare visit, At-home medical evaluation
Summary
This procedure involves a healthcare professional visiting an established patient in their home to assess their health condition and provide necessary medical management. The visit encompasses an expanded problem-focused interval history, an expanded problem-focused examination, and medical decision making of low complexity.
Purpose
The purpose of this home visit is to monitor and manage established health conditions, ensuring the patient receives the needed medical care in the comfort of their home. It aims to detect any changes in the patient's health status and adjust treatment plans accordingly.
Indications
- Chronic disease management (e.g., diabetes, hypertension)
- Post-hospitalization follow-up
- Mobility issues preventing clinic visits
- Homebound due to advanced age or disability
- Symptom management for chronic conditions
Preparation
- Ensure a comfortable, quiet space is available for the examination.
- Gather any medical records or recent test results for review.
- List all current medications and dosages.
Procedure Description
- Initial Assessment: The healthcare professional reviews the patient’s medical history and current symptoms.
- Physical Examination: Conducts an expanded problem-focused examination relevant to the patient’s condition (e.g., vital signs, inspection of affected body areas).
- Medical Decision Making: Based on the examination, the professional will decide on the next steps, which may include:
- Adjustments to current medications.
- Recommendations for additional tests or referrals.
- Health education and self-care advice.
- Documentation: All findings and plans are documented in the patient’s medical record.
Tools used may include a blood pressure monitor, stethoscope, thermometer, and portable diagnostic tools. No anesthesia or sedation is required.
Duration
The visit typically lasts between 30 to 60 minutes.
Setting
This procedure is performed in the patient's home.
Personnel
The healthcare team typically includes:
- A primary care physician or nurse practitioner
- A registered nurse or home health aide may also assist.
Risks and Complications
- Minimal risk, primarily related to insufficient examination facilities compared to a clinical setting.
- Possibility of missing subtle signs that might be more easily detected in a clinical environment.
Benefits
- Improved patient comfort and convenience.
- Timely medical interventions in the home setting.
- Enhanced patient compliance with care recommendations.
Recovery
- Follow the healthcare professional’s advice about medication changes or lifestyle adjustments.
- Schedule follow-up visits as recommended.
Alternatives
- Clinic or hospital visits for similar evaluations.
- Pros: Access to comprehensive diagnostic tools.
- Cons: Requires patient mobility and transportation.
Patient Experience
The patient might feel more relaxed being in their familiar home environment, enhancing comfort during the procedure. Pain management is not usually necessary, but comfort measures such as ensuring a quiet space can be beneficial.