HOME CARE

HOME CARE

The Heart of the Practice

Lecture Objectives

• To define “Home Care”

• To define the role of the family physician in home care.

• To outline the tasks of the physician in the home care setting.

• To grasp the actual practice of home care through an existing model.

What is Home Care?

• Provision of health care, whereby comprehensive services are provided in places of residence

• To promote, maintain or restore health

• To minimize the effect of disability

Aspects of Care

• PREVENTIVE • DIAGNOSTIC• THERAPEUTIC• REHABILITATIVE• LONG TERM MAINTENANCE

Home care • …defined as diagnosis, treatment, and

ongoing monitoring of the patient in the home.

House calls • …are seen as a subset of home care --as an

episodic care intervention or aid to practice.

According to the National Association for Home Care

• Approximately 7.6 million people in the US require some form of home health care

• More than 20,000 home health care providers exist today

• Almost two-thirds (62.3 percent) of home health care recipients are women

• More than two-thirds (68.6 percent) of home health care recipients are over age 65

Advantages & Disadvantages of Home Care

Advantages

• Less costly• Enhances physician-

patient relationship• Continuity of care

Disadvantages

• Time consuming• Minimal resources

Home Care Services’ Four Point Program

1.Comfortable transition to Home

2.Maintenance of optimal clinical condition

3.Ongoing Health Education and Reinforcement of Learning

4.Continuity of Care

Concept of Care

System I• Doctor orders home care service.• Then, work cooperatively with the Home Care Program

(FHCP) staff to plan and provide necessary home care.

System II• A physician of the Home Care Program (FHCP) provides

home care.• He is the overall manager but plans together with the

patient and other FHCP staff.

Role of the Physician

“The Physician is the overall manager, therefore the following goals should be achieved…”

• Appropriate home care assessment skills• Assessment of family caregivers and resources• Knowledge of community resources and home

care technology• Ability to integrate homeand hospital care• Lead the home care team

Levels of Care• Level I -the patient is his or her own case manager

• Level II -the patient needs the assistance of family members or significant others for planning/ coordinating care

• Level III -if problems are too complex for the family the patient-family-professional team must coordinate care

• Level IV -a multi-disciplinary professional team is needed to assist the patient and family with a designated case manager or team

-American Medical Association

The Role of the Family Physician

• Physician failure to follow patients through the continuum of care from hospital to home, by compelling terms is a "moral abandonment" or an "abdication of responsibility".

Bernstein, L.H., Grieco A.J., Dete, M.K.,"Primary Care in Home", Philadelphia; 1987, p.10

The Role of the Physician in terms of functional tasks

American Medical Association in their “Guidelines for the Medical Management of the Home Care Patients“

1.Management of medical problems2.Identification of home-care needs of the patient3.Establishment/approval of a plan of treatment with

identification of both short-and long-term goals4.Evaluation of new, acute or emergent medical

problems based on information supplied by other team members

The Role of the Physician in terms of functional tasks

5.Provision for continuity of care to and from all settings (institution, home and community)

6.Communication with the patient and other team members

7.Participation, as needed, in home-care/family conferences

8.Reassessments of care plan and outcomes of care9. Evaluation of quality of care10.Documentation in appropriate medical records; 11.Provision of 24-hour on-call coverage by a physician

The Five Star Physician in Home CareAs a Doctor…

As Clinicians we must also ensure…

• Medical stability compatible with treatment at home

• Adequate resources for treatment at home• A safe environment for the patient and the

professional caregiver

Medical News. Medical Information for Members of the Medical Society of Nova Scotia. Vol. III -No. III. Feb. 1998

The Five Star Physician in Home CareAs a Educator …

• Applications of this are…

• Ascertain what the patient has been told and how much the patient understands.

• Guidance about daily activities, diet, visitors.• Explain what they can expect to happen day-by-day• Explain plan of care. ( follow-up visits, specialty care coordination

etc.)• Explain simple caring techniques and instructing direct care-giver

regarding bedside care and monitoring etc.• Advise on the patient’s room and furnishings• Ascertain compliance of home meds.

The Five Star Physician in Home Care As a Counselor …

Deal with the emotional & social needs of the patient and family by …

• Helping patient to cope with the fear of chronic illness.• Understanding the psychosocial background of patients

so as to contextualize decision making in the home. • Helping maintain patient’s dignity.• Identifying and attending to Care-giver fatigue• Conducting Family meetings• Counseling in the face of advanced/life-threatening illness

The Five Star Physician in Home CareAs a Researcher …

1. Adopting guidelines for specific conditions from other settings.

2. Implementing selected "best practices" developed by within home care agencies (that are usually consensus-based).

3. Collecting outcomes data with the purpose of creating a home care specific evidence base.

The need for evidence-based guidelines in home care. Ahrens J. Home HealthcNurse.2005 Mar;23(3):147

The Five Star Physician in Home CareAs a Manager & Mobilizer…

• Provision for continuity of care to and from all settings (institution, home and community)

• Communication with the patient and other team members (refer & coordinate)

• Participation, as needed, in home-care/family conferences• Know how to address potential issues:

– Time Constraints and Competing Priorities– Remuneration– Physician Concern about Standards of Care

• Proper integration of services, documentation and adequate education and empowerment of patient and family during visits

– Physician Attitudes Towards House Calls – Lack Of Communication And Mechanisms

Patient Preparation Home Preparation•Educate patient on diagnosis•Treatment plans and options•Assess functional capacity of patient1. Physical condition2. Sensory3. Social Factors•Ensure adequate physical functioning before discharge

•Collaboration with trained caregivers•Safety measures•Mobility issues

Home Care through an existing models

Community based home care service

• “….provides hospital-at-homeservices through a series of partnerships and a collaborative team effort.

• Patients in this model are admitted, treated, and discharged by their own family doctor who becomes the attending physician.”

Hospital-based model

• “…outreach initiatives of acute care hospitals where the hospital runs its own home care agency as a department of the hospital.

• The obvious advantage of this type of model is the integration of hospital and home care services which enhances discharge planning, continuity of patient records, and the availability of hospital staff for care.”

Home Care through an existing models

Hospital-based modelAs a Doctor….

• Assessment• Home Care Chart• Socio demographic profile• Family Genogram• Systems PE• Pressure sore charting• Pain Chart• Holistic Problem List• Plan• Clinical Goal setting

Organizing a Home Care Program

1.Get Manpower2.Train Staff3.Prepare Home Care Program4.Establish networking and linkage5.Implement program6.Evaluate the program

Home Visit

• Medical, psychosocial and family problems• Dynamics of family interaction• Family’s role • Deepened understanding of the family• Thorough planning, preparation &

coordination

Guidelines for a Home Visit• Select the patient

– Admissions criteria of the home care program– Medical records Goals

• Inform staff• Prepare a home care plan

– All aspects of care– Include short & long-term goals

• Schedule• CARE

– MEDICAL– PSYCHO-SOCIAL– WELLNESS– ECONOMIC– ENVIRONMENTAL

Guidelines for a Home Visit

• Have all necessary instruments• Rapport• Medical history & psychosocial issues• Living conditions– Cleanliness, safety & comfort

• Write a post-visit report– Problem list– Specific interventions

• Follow-up visits• Coordinate with other disciplines if needed

Issues in Home Care Legal Issues• Home Care Policies must be properly drafted• Documentation of all examination, conversations and care

rendered• Constant surveillance and attention to quality care

Ethical Issues• Informed Consent

Financial Issues• Physician should discuss the financial agreement

Family Health Care Program

• Established in 1993, UST Hospital Family Medicine• Comprehensive & holistic home care service• 24 hrs/day• Patients of any age• Patients with a variety of needs – Recovering – Chronically ill– Palliative care

Admission

Assessment

Planning

Implementation

Evaluation

AssessmentDischarge Planning• Prepared by the discharge coordinator who will identify the

patient’s need for continued care• IMPORTANCE: Help prevent patient’s and their family’s

anxiety about post-hospital care• SCREENING who are warranted to be admitted to the

program based on the ff criteria:– a. medical merit– b. psychosocial merit– c. cooperative patient/family– d. residence location (5 km radius from the base hospital)– e. positive economic balance

Admission• Checking the referral form– Done at least 3 days prior to discharge– PURPOSE: for assessment, preparation, management planning,

and proper education of the patient and family members• Communication with the referring doctor– Assess extent of involvement

• Meeting the patient and the family– Establish rapport– Know patient and family’s expectation– Do goal setting

Planning

• Family Health Care Plan– Backbone of the patient medical record– Assess the following:

• a. Medical history• b. Family assessment• c. Environmental condition• d. Socioeconomic factor• e. ADL’s

• Data collection• Identify patient’s problems, goals and expected

outcomes of health care service

Implementation

• Home care visit• Each home visit shall become a means of

working towards the end goal

Evaluation

• A continuing process• 2 Methods of Continuing Care:– 1. Formal conferences• involve all the members of the team• patient’s progress are evaluated and modifications are

made– 2. Informal conferences• impromptu chat on the phone between health care

team members and personnel regarding a particular aspect of patient care• must be documented

Common Medical Problems

• Cerebrovascular Accident• Hemophilia• Chronic Obstructive Pulmonary Disease• Congestive Heart Failure• Diabetes Mellitus• Cancer

Cerebrovascular Accidents

• Important to Know– Pathophysiology – Clinical Manifestations– Acute Management– Medical Complications

Cerebrovascular Accidents

• Home Care Goals– Continuing Care• Feeding• Bed Sore Care• Physical Rehabilitation• Reintegration into Society• Counselling• Spiritual Care• Education• Prevention

Hemophilia• Important To Know

– Prevention– Prompt Self-Treatment– Home Treatment– Rehabilitation– Injury Avoidance

• Home Care Goals– Genetic Counselling– Factor Concentrates– Patient and Family Education– Maximizing Patient Capacity

Chronic Obstructive Disease

• Important To Know– Pathophysiology– Clinical Manifestations– Complications– Prevention– Management

• Home Care Goals– Prevent progression of disease– Prevent complications leading to acute deterioration– Treat reversible components of the disease– Teach patient how to participate in the management

Chronic Obstructive Disease

• Pulmonary Rehabilitation at Home• Evaluate Pulmonary Function and Disability• Set Goals and Modalities to be Used– Prevent exacerbations– Relieve bronchospasm– Reduce secretions– Breath retraining– Exercise conditioning– Oxygen therapy– Educating the patient and family– Psychosocial management

Congestive Heart Failure

• Important To Know– Pathophysiology– Clinical Manifestations– Complications– Prevention– Management

• Home Care Goals– Monitoring– Education– Physical Rehabilitation


• Monitoring– In heart failure patients, a multidisciplinary

management program and home-based intervention can reduce readmission rates and length of hospital stay because of the expectant management of problems as they arise

– e.g. early detection of gradual onset of tachycardia, tachypnea, rales accompanied by weight gain may be an indication of the need for lowering diuretic dosage


• Physical Rehabilitation– Most important component of care in low-risk

post-MI patients in the 2-12 weeks post-discharge to restore their ability to return to work and do the activities of daily living. This involves a daily exercise and ambulation schedule.


• Education– Counseling • e.g. sexual activity, energy conservation, self-

monitoring techniques– Improve understanding of coronary artery disease

and its management– Alleviate anxiety and have the patient assume

some responsibility for health care– Teach CPR to a family member

Diabetes Mellitus• Important To Know

– Pathophysiology– Clinical Manifestations– Complications– Prevention– Management

• Home Care Goals– minimalcost strategy– minimal weight gain strategy– minimal injectionstrategy– minimal circulating insulin strategy– minimalpatient effort strategy– hypoglycemia avoidance strategy– postprandial targeting strategy

Cancer• Important To Know

– Pathophysiology– Common Clinical Problems– Complications– Acute and Chronic Management

• Home Care Goals– Patient education– Assessment of patient’s emotional and behavioral status– Encouragement of lifestyle change– Prevention and early recognition of common clinical problems– Treatment of pain and common clinical problems– Assessment of reaction to therapy– Support for the patient and the family

Cancer

• Home Care Goals– Information about the disease

• Treatment options, prevention/early detection, environmental risks

• Prevent complications– Improve quality of life– Improve or maintain function and promote

independence or self-management skills– Psychosocial support

• Anxiety, fear, depression→ recognize, give advice, treatment

Cancer

• Home Care Procedures–Respiratory System• Mechanical ventilation• Tracheostomy Care– Tube changed when wound has matured (5 days)– Use of a rubber catheter as a guide to insert the

new tracheostomy tube– Inner cannula should be cleaned twice daily

Cancer

• Tracheostomy– Indications:

• Patient is unable to clear secretions by coughing

• Mucus bubbling in trach tube/audible gargling sounds

• Trouble breathing or restless

• Cyanosis• Increased ventilator

inspiratory pressure• Patient’s request

Cancer

• Home Care Procedures– Gastrointestinal System• NGT Insertion• Gastric Lavage

– Cardiovascular System• Venous Cutdown

Cancer

• NGT Insertion– Indications• Aspiration of stomach contents for either diagnostic or

therapeutic purposes• Feeding• Administration of therapeutic substances

– Contraindications• Facial facture with suspected cribriformplate injuries• Esophageal strictures• Comatose patients with unprotected airway• Penetrating cervical wounds

Cancer

• NGT Insertion– Lubricate NGT for 3-4 inches over the distal end– Patient should be sitting with head supported– Tube introduced along the floor of the nose towards the

nasopharynx, then to the esophagus– GE junction is typically reached at 40 cm length of NGT– Confirm tube placement by:

• Open end of tube placed in a glass of water• Patient is asked to talk• Syringe filled with air: “whooshing” sound of borborygmi

– Secure tube by anchoring it into nose

Cancer

• Gastric Lavage– Patients should be lavagedin the left lateral

decubitusposition– Large diameter gastric hoses; 32-40 French tip

recommended– NGT intubation done and placement confirmed– Initially, 200-300 ml of fluid is run into the stomach

then drained; repeat lavagewith small aliquots of lavagesolution

– Continue until the return fluid is clear (1-2 L)

Cancer

• Venous Cutdown– Prepare skin with antiseptic solution– Torniquet used proximal to the cutdown site to visualize vein– Skin incision made transverse across vessel– Isolate vein from adjacent tissue– Proximal and distal silk ties are passed under it– Puncture vessel and insert cannula– Proximal ligature is tied around the vessel and the cannula– Torniquet is removed, catheter affixed to the skin and

incision closed

Common Home Care Skills

• Basic Home Care Skills– Range-of-Motion Exercises– Hygiene– Tracheostomy Care– Elimination and Perineal Care– Transfers

Range-of-Motion Exercises

• Joint movements performed by a patient/caregiver to maintain muscle tone & joint mobility that has been lost through disease, injury, or lack of use

• Joint that has not been moved sufficiently– Can begin to stiffen within 24 hours– eventually become inflexible

Types of Range-of-Motion

• Active– patient performs the movements on a non-

functioning joint• Active-Assistive – carried out with the patient & caregiver participating

• Passive– exercise is performed by caregiver on a patient’s

immobilized joints

Hygiene

• Complete Bed Bath– Elevate patient in a semi-sitting position– Spread a towel across patient’s chest. Tuck under the

chin– Make a mitt out of a washcloth– FACE

• With a gentle stroke wash the face usually w/o water• Clean the eyes from the inner to the outer area• Use soap when washing the neck & behind the ears• Wipe dry

Hygiene

• Complete Bed Bath– ARM

• Place the towel lengthwise under the far arm• Wash the far arm first using long firm strokes towards the

center of the body (to increase venous blood return). Then the arm & axilla

• Rinse & dry thoroughly– CHEST

• Fold the blanket down to the waist, leave the towel over the chest & fold it back while washing

• Make sure to wash, rinse, and dry thoroughly under the breast of a female patient

• Leave the chest covered with towel while rinsing the mitt

Hygiene

• Complete Bed Bath– ABDOMEN• Fold the blanket down to the pelvic bone, leave the

towel over the chest• Wash, rinse and dry the abdomen

– LEG & FOOT• Wash the leg using long firm strokes towards the center

of the body• Dry• Wash and rinse the foot and each toes

Hygiene• Complete Bed Bath

– GENITAL AREA• Wash the genital area of the patient who cannot do it by himself• Wear gloves for infectious control• Wash area from front to back (clean to dirty)• Remove gloves & change water

– BACK• Drape the patient with blanket• Wash back and back of neck using long form strokes

– BUTTOCKS• Put on a new pair of gloves• Wash and dry buttocks• Help patient put on a clean gown or pajamas• Comb hair, cut

Hygiene

• Back Rub– Decreases anxiety & helps alleviate pain perception– Decreases muscle tone & fatigue– Stimulate circulation & enhance immune system function– Done after bath, during bedtime, those experiencing pain

or every 2 hours to prevent pressure sores– Use lotion to decrease friction– Long smooth flowing movements over the length of the

back is relaxing– Kneading motions relaxes specific tight muscles– Circular motions stimulates circulation

Hygiene• Oral Care for Unconscious Patient

– Place patient in semi-sitting position or turn the patient’s head towards caregiver if cannot tolerate

– Put towel beneath the chin– Put on gloves for infectious control– Keep patient’s mouth open using a tongue depressor wrapped with

gauze– Brush all tooth surfaces with a toothbrush moist lightly with

toothpaste– With a cotton tip applicator, clean all surfaces of the mouth (palate,

inner cheeks, tongue)– Rinse oral cavity with 1/3 antiseptic & 2/3 water– Allow water to drain into the emesis basis by gravity or using asepto

syringe to aspirate it

Tracheostomy Care

• Cleaning Inner Cannula & Changing Dressing– Purpose: • To clear the airway of

accumulated secretions• To rid the trach tube of

bacteria that can be harmful to the patient• Cleaning the inner cannula

is done at least 2x per day

Tracheostomy Care

• Cleaning Inner Cannula & Changing Dressing– Procedure:• Wash hands• Prepare materials

– Pour water in a large compartment– Pour normal saline in a smaller compartment– Open cotton bubs; maintain sterility

• Use clean gloves• Remove the inner cannula from the trach tube• Immerse in water

Tracheostomy Care

• Cleaning Inner Cannula & Changing Dressing– Procedure:• Remove used trach sponge & assess for secretions;

discard• Clean trach site w/ sterile cotton buds & normal saline.

Use only a single sweep w/ each cotton buds• Change the trach ties if they are soiled• Rinse the inner cannula well w/ normal saline• Reinsert inner cannula. Lock into place• Apply new trach sponge

Elimination and Perineal Care

• Equipment


• Procedure for assisting with a bedpan– Putting bedpan in place:

• Place one hand under lumbosacral area• Lift patients back while asking patient to raise buttocks (pelvic

bridging)• If immobilized: roll patient to one side then place and hold

bedpan firmly in place as patient is rolled back• Elevate the head of the bed• Leave the patient

– After elimination:• Clean the genital area with fresh tissue

– Urinary area to the rectal region• Remove pan, Cover, flush the content into the toilet


• Perineal / Perianal Care– Position bedpan under the patient– Pour tepid water over the area– Wipe with cotton/gauze from anterior to posterior

TRANSFERS

• Restores muscle tone• Stimulates respiratory system• Stimulates circulatory system• Improves elimination

Bed to Chair

• One-person assist • Two-person assist

Moving Patient in bed

• To one side of Bed • Up in bed

Moving Patient in bed

• Using a draw sheet • Turning the patient– LOGROLLING

POSITIONING the patient in BED

• Reposition every 2 HOURS• Supine Position


• Side Lying Position


• Prone Position

The Role of the Family Physician

• “Physician participation in home care goes to the very heart of the principles of family medicine..” -McWhinney

• “…an affirmation of a long-standing tradition in family medicine.”

HOME CARE

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