Any short answer questions were not scored. To enhance your learning, annotated answers for all questions are provided below.
A 93 year old woman presents to the Emergency Department after a fall. She is evaluated and no clear precipitating etiology is discovered through history taking, physical examination, and laboratory studies. She has a bruise on her left hip and flank, but no fractures. She is unsteady in her gait and has cataracts bilaterally which are impairing her vision to a moderate degree. The patient lives with her elderly husband in their home of 60 years and wants to return home.The patient’s daughter is able to stay with the patient over the next day to monitor her health and safety. What would be your next step to arrange a home safety evaluation to assess for hazards in the home environment?
A. Arrange home care services to provide case management in the home for safety
B. Instruct the case manager or social worker in the Emergency Department to call the hospital’s home health care agency to initiate a referral for home care
C. Order a PT/OT home safety evaluation through the local home care agency
D. Obtain prior authorization from the patient’s primary HMO for the home safety evaluation
Answer: C. Order a PT/OT home safety evaluation through the local home care agency. A home safety evaluation must be ordered by the physician or primary provider. Payment is made to the home health care agency that employs the PT/OT who conducts the assessment. Medicare Part B is the primary payer for the service in a patient who is eligible for Medicare.
A home safety evaluation may be helpful in identifying patients who are experiencing a “patient & environmental mismatch”. The patient described above has areas of weakness which may place her at greater risk of having an injury in the home. Her vision and poor gait and balance are significant. Which 4 domains must you assess?
A. Medical, Psychiatric, Functional and Social
B. Medical, Cognitive, Rehabilitative and Environmental
C. Physical, Cognitive, Functional and Social
D. Physical, Psychiatric, Functional and Environmental
Answer: C. Physical, Cognitive, Functional and Social. These are the four domains for geriatric assessment. Assessing all four domains is necessary to ascertain the complete picture of patient/environmental match vs. mismatch that may place your patient at risk for further environmental injuries.
In evaluating a home environment for safety, the PT/OT will assess various factors to maximize the patient’s independence and to decrease injury risk as much as possible. Which of the following home characteristics may put this particular patient at an increased risk for injury?
A. Dim lighting
B. Limited financial resources
C. Low bed height
D. Lower chair cushion height
E. Raised toilet seat
Answer: A. Dim lighting. This particular patient has experienced a fall. Reducing the risk of future falls is a multifactorial approach; however, given the patient’s decreased vision due to her moderate, bilateral, cataracts, dim lighting is the most significant risk of those mentioned. Consideration of cataract surgery may also be appropriate to help mitigate this risk. Low bed and chair height can make it difficult for people to stand from a prone/sitting position, and limited financial resources may decrease options for home improvement or other health needs. A raised toilet seat is generally helpful in decreasing risk of falls.