Home Health Discussion Guide
Patient Name:
Birthdate:
Address:
Email:
*****, *****
June 14, 19**
*****
*****@gmail.com
I’m working with RubyWell to understand how home health services might help maintain my current health condition and lower my risk for hospitalization. RubyWell prepared this discussion guide to help us talk about whether you think home health is right for me.
My Risk Factors for Hospitalization *
In the last 3 months I’ve had:
frequently missing medication doses/refilling prescriptions
not following recommended diet, frequently eating unhealthy foods/missing meals
skipping scheduled healthcare appointments for [specific appts.]
In the last 6 months I’ve had:
[specific # of] hospitalizations for [specific reasons]
2 or more emergency room visits for [specific reason]
Surgery for [specific reason]
In the last 12 months I’ve had:
[#] falls in [month and month]
[#] fall(s) resulting in [specific injury] [in month(s)]
My Diagnoses **
The main health problem that I think home health could help me with is [compelling diagnosis, Code #, Diagnosed by Dr. __ on Date]
I also have these other health problems:
Diagnosis, Code #, diagnosed by [Dr. __] on [date]
Diagnosis, Code #, diagnosed by [Dr. __] on [date]
My Functional Limitations ***
I need assistance with the following activities:
When taking care of my personal hygiene, I need (their answer to oasis Section G, M1800.)
When dressing my upper body, I need (their answer to oasis Section G, M1810.)
When bathing or showering, I need (their answer to oasis Section G, M1830.)
My Homebound Status *
I need to use a [supportive device] or have help from another person to leave my house.
You have/ Dr. ___ has recommended I don’t leave home because it could make my condition worse.
I only leave home about x times/month for less than x hours at a time to go to [specific appts.]
Source: * Self-reported + Medicare claims data ** Medicare claims data ***Self-reported data