Home Care Medicine MELISSA VOURLITIS, DO

MICHAEL BOWERSOX, MD

House Calls

“House calls” can be conducted at home, B&C, AL, RCFE.

Insurance coverage: Medicare +/- secondary insurance

PPOs

HMOs (Arch health Partners, Scripps?, others?) *requires referral from primary care physician.

Private pay occasionally can be accommodated.

House Calls

Benefits to the patient: Patients are in their own environment, waiting for the doctor is much

easier.

“Home” environment can be evaluated for safety, other concerns.

Patients can have caregivers and family present at the appointment more easily in order to coordinate care effectively.

Reduces patient anxiety and confusion.

Reduces hospital readmissions.

Enhances doctor:patient relationship.

PREPARING FOR A MOBILE PROVIDER VISIT

NEW PATIENT

Demographics

Previous Medical Records/ Medications

Contact Information

Advance Directives

Forms to be completed

POLST 602-Physician’s Report for Admission

Any assessments already performed

Order pages

PREPARING FOR A MOBILE PROVIDER VISIT

ESTABLISHED PATIENT

List of concerns

Vital signs < Temperature Pulse BP O2 sat% >

Medication list

Refills needed

Patient forms to complete

Contact Sheet

Orders to sign

Common Problems

Fall

Fever

Cough/SOB

Constipation

Nausea/Vomiting

Agitation

Urinary tract infection

POLST form is important when determining intervention.

How to report a concern:

Discuss with the physician the best method for communication: Fax?

Email?

Phone?

Text?

Other?

Keep in mind that the nature of the problem will dictate the urgency of transmitting information. Also, the time of day (or night) should be considered.

How to report a concern:

OPQRST mnemonic:

O ~ Onset

P ~ Provocation/Palliation

Q ~ Quality/Quantity

R ~ Region/Radiation

S ~ Signs/Symptoms

T ~ Temporal

SBAR reporting system

S ~Situation

B ~Background

A ~Assessment

R ~ Recommendation

Common Problems

Fall

Serious consequences of a fall: Uncontrolled bleeding.

Major fracture or fracture that may require surgery.

Deformity of limb.

Acute change in neurologic status.

Epidural hematoma: rapid deterioration soon after injury.

Subdural hematoma: symptoms may occurs hours to days after fall.

Patients with serious consequence of fall need urgent evaluation, 911 appropriate in most situations.

Common Problems

Other consequences of a fall: Abrasions

Lacerations

Fractures, sprains, dislocations

Bleeding

What to do about this depends upon the severity of the situation. Stitches and splinting must be done at an office or urgent care. Other wound care can often be done at home.

Common Problems

Fever

Infectious Disease Society of America (2008) definition: Single oral temp >100 F or 37.8 C (100.4 for non elderly residents).

Repeated oral temp >99 F.

Rectal temp >99.5 F.

Any single temp greater that 2 F over baseline.

Elderly people have a lower febrile response.

Serious, life-threatening illness can occur rapidly in elderly residents.

Common Problems

Cough/Shortness of Breath Medical history important.

Asthma, emphysema, congestive heart failure, other?

Exertional symptoms or prandial symptoms versus symptoms at rest

Associated symptoms (edema, nausea, sweating, change in mentation)

Obtain basic vital signs, pulse and respiratory rate significant.

Pulse >100

Respiratory rate > 30

Fever?

Common Problems

Constipation AVOID, AVOID, AVOID.

Monitor bowel habits, keep a log.

Review med list and ensure there is a prn medication available to use if needed.

Intercede at first signs of change in bowel habits.

Call if standing orders are ineffective.

Common Problems

Vomiting/Diarrhea When did it start?

Others with similar symptoms?

How many episodes?

Associated symptoms?

Severe symptoms or symptoms that do not resolve in 24 hours, need medical attention.

In general: do not give food or drink for 2 hours after vomiting, trial of sips of water. BRAT diet for 24 hours once tolerating PO, advance slowly.

Common Problems

Agitation Review potential causes ~ Ask WHY? Agitation is usually the result

of an underlying, unrecognized problem:

Pain

Constipation

Urinary retention

Change in environment

Change in medication

Common Problems

Urinary Tract Infection.

Not all change in behavior is a UTI…Must have 1 and either A,B, or C, or 2.

1. Acute dysuria (painful urination). In males acute pain in testes.

And one of the following symptoms:

A. Suprapubic pain (lower abdominal pain)

B. Gross hematuria (bloody urine)

C. New or marked increase in one of the following: incontinence, urgency or frequency.

OR

2. Fever with Costovertebral angle pain (back pain).

**If indwelling catheter, criteria changes.

SERVICES AVAILABLE FOR PATIENTS IN THE HOME

Urine testing

by physician

collected at home, delivered to lab for evaluation

Blood testing

collected at home by physician or mobile lab tech

evaluate for causes of fatigue

evaluate diabetic control

evaluate levels of certain medications

Mobile Diagnostic Services

Radiology Studies

Chest Spine Extremity

Echocardiogram

Electrocardiogram

Ultrasound

Abdomen Breast Thyroid Pelvis

Evaluation for deep vein thrombosis

Evaluation for peripheral arterial disease

Other available services

Home Health Agencies Provide the following types of services: Skilled Nursing/Wound Care Nurse

Physical Therapy

Occupational Therapy

Speech Therapy

Dietitian

Social Worker

Behavior Health Specialist (in some cases)

Home health aid, once skilled service has been identified.