Once the clinician has assembled the basic equipment needed for a house call, the next step is to plan the visit to take full advantage of the array of information available to the clinician by virtue of seeing the patient at home. Comprehensive assessment identifies key challenges, barriers, and facilitators to patient care that may not be easily identifiable in an office visit. The comprehensive assessment framework can help the clinician understand factors that may contribute to one patient’s refractory hypertension or to troubleshoot another patient’s persistent medication nonadherence.

The approach to conducting a comprehensive assessment must be applied judiciously, taking into account individual patient preferences: for instance, if looking into medicine cabinets or cupboards seems important to the goals of the visit, the clinician must first ensure that the patient accepts this level of scrutiny and does not consider it an invasion of privacy.

Table 4.2 lists key considerations in a comprehensive home-based assessment. The INHOMESSS mnemonic [1] can promote recall of many of these specific considerations, but it is also useful to think about comprehensive assessment within three major domains: medical, functional, and psychosocial. Medication reconciliation, immobility, and home safety are issues in each of these domains that warrant special attention in the home-based comprehensive assessment, because these problems are prevalent, have potentially catastrophic consequences, and are especially well-suited to accurate evaluation in the home setting.

Medication reconciliation (medical domain): Medication reconciliation in the home can be very different from that in the office or hospital, because the clinician can review all of the actual medication bottles in the house, not just the ones the patient remembers or chooses to bring to these other settings. Importantly, the list that many patients bring to ambulatory settings can be reviewed and updated in the home by direct comparison with the pill bottles. Dates and prescriber information on the prescription labels can provide clues to adherence. Similarly, asking open-ended questions about medication administration (“how do you take this one?” instead of “do you take this one three times a day?”) can reveal problems with understanding or memory that may prompt changes in management, including negotiation with the patient or informal caregivers for more assistance.

Immobility (functional domain): “Immobility” in Table 4.2 captures general functional impairment. Activities of daily living (ADLs) include feeding, toileting, dressing, bathing, transferring, and managing continence. ADLs are the basic tasks required for minimally independent function. The home-based medical provider can usually quickly identify problems with ADLs just by noticing features of the patient’s environment that may not be apparent in an office visit: the presence or degree of involvement of a caregiver, visible stains or odor of urine in the home, or a refrigerator that is empty or filled with trays from “Meals on Wheels” can all be indicators of ADL impairment. Patients with ADL deficits require hands-on personal assistance to function in the home, and the absence of a caregiver who can help with these basic needs may mean that the patient cannot remain in the community but must transition to a care facility. Instrumental activities of daily living (IADLs) , in contrast, are tasks necessary to continue living in the community but do not necessarily require direct physical contact with the patient. They include meal preparation, housekeeping, medication management, money management, telephone use, and transportation. Patients with deficits in IADLs can often remain safely at home if they have a caregiver who can prepare meals and medications a few days in advance and visit or call a few times a week to check for any additional needs. A key advantage of assessing functional status in the home is the ability to ask patients to demonstrate their actual ability to complete a task, rather than having them simply report on their ability to perform activities.

Home safety (psychosocial domain): Basic home safety is easily assessed by asking the patient or caregiver to give a tour of the home, in which the clinician looks for potentially remediable fall risks (loose rugs, poor lighting, low contrast), hand rails, smoke alarms, carbon monoxide detectors, bathroom grab bars, and the layout of furniture and equipment. Evidence of cognitive impairment may also become apparent, in the form of reminders posted around the living space, safety measures such as child-proof door locks or missing stove knobs, or unusual placement of everyday objects that might signal simple misplacement by the patient (television remote control in the refrigerator) or serve as behavior prompts to maintain function (television remote control inside a box with daily medications).