Multidisciplinary Approach to Home CarePresented November 29, 2011By Susan Katz Sliski, RN, DNP(c), CCM

Home Care: Fundamentals Provides safe,

appropriate care within the patient’s own surroundings

Supports patients – from those recently discharged to those requiring chronic care prevention strategies

Essential to all age groups – from assessment of newborns to successful aging for elders

Home Care in Massachusetts

Primary care physicians Nurse practitioners Nurse case managers Home care nurses Physical therapists Speech therapists Nutritionists, occupational

therapists Social workers and non-

licensed support staff

The Team

Home Care in Massachusetts

The right services,at the right time,

in the right place.

Skillful triage and care coordination are fundamental to support in the home that maintains optimal recovery, and promotes independence for patients.

The Approach

Massachusetts: Facts & Figures

Kuwait Massachusetts

US

Population (2010) 3,520,000 6,547,629 308,745,538Persons 65 years and over, percent (2010) 13.8% 13.0%Persons under 18 years, percent, 2010 21.7% 24.0%White persons, percent, 2010 (a) 80.4% 72.4%Living in same house 1 year & over, 2005-2009 86.2% 83.8%Median value of owner-occupied housing units, 2005-2009 $357,600 $185,400Average length of hospital stay 2.8 days

Source U.S. Census Bureau: State and County QuickFacts. Data derived from Population Estimates, American Community Survey, Census of Population and Housing, Small Area Income and Poverty Estimates, State and County Housing Unit Estimates, County Business Patterns, Nonemployer Statistics, Economic Census, Survey of Business Owners, Building Permits, Consolidated Federal Funds ReportLast Revised: Thursday, 13-Oct-2011 13:39:20 EDT

Home Care Patients in Massachusetts

Approximately 70% of patients who receive home care have: Underlying known chronic condition(s)

including Diabetes Mellitus Congestive Heart Failure (CHF) Coronary Artery Disease (CAD) Asthma Obesity Cancer HIV/AIDS Predictable co- morbidities

Home Care Patients in Massachusetts

Following an acute hospital event, a multidisciplinary home care team supports the patient in the home for approximately 3 months.

What Is Home Care?

Home care is any service where aides, therapists, and nurses provide assistance in a client’s residence, helping them remain independent and healthy.

Studies show that home care is often more cost-effective and beneficial than nursing homes or assisted living facilities.

© 2011 Home Care Alliance of Massachusetts, Inc.

What Is Home Care?

Depending on the situation, a person may need help around-the-clock, once a day, or for just a few hours a week.

For instance, a person may need home care: Briefly, to recover from an injury or a hospitalization; Occasionally, to supplement services from an assisted living residence or retirement community; or Regularly, to manage chronic illnesses or the difficulties in aging.

© 2011 Home Care Alliance of Massachusetts, Inc.

Multidisciplinary Home Care:Case Management"Case Management in Hospital/Health Care Systems is a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The Case Management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient's right to self determination.”

American Case Management Association’s (ACMA)

Multidisciplinary Home Care:The GoalsKeep patients independent in the community and promotes successful aging by: I. Reduce length of

hospital stayII. Minimize

hospitalizations by assessing and promote safety and independence

III. Promote self management through wellness education

Multidisciplinary Home Care:The Team Primary Care Physician and/or Nurse

Practitioner Home Care Nurse, Nurse Case Manager,

Behavioral Health Community Nurse, Nurses with advanced education and degrees

—Masters in Nursing Administration—Cardiovascular Clinical Specialist

Nurses with specialty education and certifications—Certified Case Manager —Certified Geritological Nurse—Certified Wound Care Nurse—Certified Ostomy Nurse etc.

Multidisciplinary Home Care:The Team (continued) Physical Therapist, Physical Therapist Aide (PT,

PTA) Occupational Therapist, and Occupational

Therapist Aide, (OT, OTA) Speech/Language Therapist (SLT) Licensed Clinical Social Worker (LCSW) Home Care, Personal Care Aide Vendors and suppliers for durable medical

equipment (canes, walkers, raised toilet seats, etc.), medications, oxygen, enteral feeding supplies, home suction and wound vac, etc.

Multidisciplinary Home Care:The GoalsI. Reduce length of

hospital stayUpon hospitalization simultaneous early discharge planning, including identifying: Barriers preventing

discharge Chronic conditions such

as CHF, Diabetes, COPD, asthma

Multidisciplinary home care team to provide appropriate supportive care

Multidisciplinary Home Care:The GoalsI. Reduce length of hospital stay

Early planning while at hospital— If a patient will require supportive oxygen, identify a

supplier who is able to provide and deliver O2 to the home prior to discharge

— If a patient will need a wound vac to promote successful wound healing, identify a vendor and arrange for supplies to be delivered to the home prior to discharge

— If the patient is assessed to have a failure to thrive, or an eating disorder, identify nutritional support in the community i.e. “meals on wheels”, tube feeding supplies etc.

— If the patient had a CHF event, arrange for cardiovascular multidisciplinary home care team follow up

Multidisciplinary Home Care:The GoalsII. Minimize

hospitalizations by assessing and promoting patient safety and independence

Early identification of patients at risk— New medical diagnosis, — New or change in medications— Failure to self manage their

illness

Triage and early intervention— Assess and promote follow up

with discharging specially health care provider

— Assess and promote follow up with primary care provider

— Assess and promote medication compliance, wound care strategies, etc.

Multidisciplinary Home Care: The Goals

II. Minimize hospitalizations by assessing and promoting patient safety and independence Advocate for patient

safety, fall prevention, independence, and any other specific needs for example

— Safe toileting/ safe access to washroom: patient may need portable commode

— Fall prevention associated with getting in and out of bed: patient may need temporary electric / or hospital bed on the first floor

Multidisciplinary Home Care: The Goals

II. Minimize hospitalizations by assessing and promoting patient safety and independence—Prevention strategies to promote successful aging —Regular screening and early detection—Immunizations and vaccinations, i.e.: flu, pneumonia— Screening by age, sex, demographic, i.e.

Individuals over age 50 should have a base line colonoscopy Woman over age 40 should have regularly scheduled

mammography Men over age 40 should have prostate assessment Vision screening every 2 years, or more frequently if high-risk :

Diabetes, family history of glaucoma or other diseases of the eye

Multidisciplinary Home Care: The Goals

III. Promote self management through wellness education

Transtheoretical Model of Behavior Change (TTM), sometimes called the Stages of Change

© 2010 - 2011 Pro-Change Behavior Systems, Inc.

— Assessment of motivation to change

— Is the patient willing to make changes to promote wellness, example: stop smoking, diet, reduce salt intake, exercise, etc.

— Research has shown that up to 80% of people are not ready to go to action right away

Multidisciplinary Home Care:The Goals

III. Promote self management through wellness education Assessment of the psycho-social resources

— Does the patient have supportive family, friends, or other resources in the immediate community?

— Is this patient home alone? — What are the other potential resources available to

patient? Assessment of the Family and/or community

resources— Family support in the community — Community and / or out of home resources

Multidisciplinary Home Care:Standardized Assessment ToolsAssessment of Mental & Cognitive Capability Behavior assessment: how well does the patient deal with stress? Does the patient have any underlying behavioral health issues

such as depression or anxiety

Mini-Mental State Examination (MMSE)

Montreal Assessment tool (MoCA)

Depression screening 36-Item Short Form Health Survey (SF-36) 12-Item Short Form Health Survey (SF-12) 3-Item Short Form Health Survey (SF-3)

Multidisciplinary Home Care Team

Primary care physician, and Nurse Practitioner are team leaders and the “Gatekeepers” of managed care Medically manage patient conditions and concerns Authorize and review all services Some PCP/NPs make home visits to patients who cannot

travel to clinic Home care nurse and/or physical therapist are team

leaders in the home Provide direct care, treatments, manage the rest of the

home care team, report assessment/findings to the primary care providers and make recommendations to primary care providers

Multidisciplinary Home Care Team: Home Care Nurse

Home Care Nurse’s “first intake” visit to homeExample:1. Nurse visits patient in his/her home who has been

discharged the day before from hospital2. Patient has been prescribed new antibiotic due to

identification of UYI ( #1 reason for admission for elderly is dehydration and UTI)

3. Nurse identifies new skin rash, takes a picture of a rash with cell phone and sends picture to PCP/ NP who can identify and determine if patient needs to be seen in clinic, and /or to stop antibiotic treatment

Multidisciplinary Home Care Team: Home Care NurseHome Care Nurse’s “first intake” visit to homeTools:

Portable tools used for home assessment include BP cuff, stethoscope, glucometer, oximeter, weight scale, tape measure, flash light for neuro assessment, mono filament for assessment for peripheral neuropathy, use of telemedicine, cell phone with a camera and the ability to email to treating physician and NP

Assessment tools for screening for depression and cognitive abilities; computer/laptop for access to patient history and ongoing real time documentation of clinical notes

Multidisciplinary Home Care Team: Physical TherapistPhysical Therapist’s “first intake” visit

to homeTools:

Portable tools portable tools for assessment include: tape measure, pulse oximeter, blood pressure cuff, stethoscope to osculate lungs, “goniometer to assess movement of joints, observation of the barrier s within the home, etc.

Assessment: Development of plan of care to improve or return the

patient to prior baseline Level of function prior to recent episode of injury/ illness

(Note : not the return to activity level of 20 year old, basketball player!)

Present ambulatory function Strength and balance “Get up and Go” test 1

1 American Academy of Neurology (www.aan.com)

Multidisciplinary Home Care Team: Physical Therapist

Physical Therapist’s “first intake” visit to home

Assessment continued: Barriers and safety issues within the home Space within the home to move around If they need can or walker to prevent falls, is there space for

devices? Assessment of clutter , small unstable rugs which might

contribute to patient falling or loosing balance Access to bathroom, height of the toilet seat, grab rails in the

tub/ shower chair? Width of door frames and hall way width, Can wheel chair or walker fit? Access in and out of home from street level

Multidisciplinary Home Care Team: Physical TherapistPhysical Therapist’s “first intake” visit to home

Assessment continued: Railing, surface levels- even ( paved) and uneven ( sand,) Carpets floors vs. bare floors, Bedroom : Height of the bed, Ability to get in and out of bed Proximity to bathroom and water Physical Therapist Assistant will implement plan of care

developed by the physical therapist

Multidisciplinary Home Care Team: Occupational TherapistOccupational Therapist’s “first intake”

visit to home

Observation & Assessment Dressing Bathing Meal preparation Cognitive ability to follow plan of care

Multidisciplinary Home Care Team: Occupational Therapist

Occupational Therapist’s “first intake” visit to home

Observation & assessment of barriers in the home

Bedroom Can they dress themselves Arrange and organized their bedroom for promotion of self carte

Bathroom Get in and out of tub Bathing : do they need tools to assist in washing Shower chair, hand held shower spray, back scrubber

Multidisciplinary Home Care Team: Occupational Therapist

Occupational Therapist’s “first intake” visit to home

Observation & assessment of barriers in the home Kitchen

Counter top level Sanitation, refrigeration, and running water Access to appliances Ability to make a simple meal Beverage, make sandwich, warm up food

Self medication management Ability to organize and plan daily activities

Taking medication on time Reminder strategies Pay bills on time

Multidisciplinary Home Care Team: Speech/Language Therapist Primary function is to assess the

patient’s ability to chew and swallow (bedside swallow testing)

Speech and word cueing

Multidisciplinary Home Care Team: Social Worker

Social Worker’s “first intake” visit to home

Assessment: Social and financial needs of the patient Family supports and family dynamics for example

Is the patient the ‘ bread winner” Do they live alone Do they have an extend family and friends , neighbors

Financial situation for example Can they pay for basics : food, electricity, clothing, medicating

and equipment Assess community resources available for this patient

Transportation needs Coordinate with medical team for feedback and collaboration

Multidisciplinary Home Care Team: Personal Care AideUnder the direction of the nurse and physical therapist, Personal Care Aides provide basic needs in home including: — Grooming— Dressing— Bathing— Meal predation — Home exercise program— Cleaning — Shopping— Assistance to medical appointments— Medication reminders

Multidisciplinary Team:Measuring Success Outcome and Assessment Information Set

(OASIS)/OASIS-C OASIS-C is a modification to the Outcome and Assessment

Information Set (OASIS) that Home Health Agencies (HHAs) must collect in order to participate in the Medicare program

Managed and implemented by Centers for Medicare & Medicaid Services (CMS) for measurement of outcome data

Prevention of Hospitalization Keeping patients out of the hospital and at the appropriate

level of service Patient independence

Keeping patients safe at home

Successful Aging:Keeping Patients Safe at Home( Picture of happy elders at home) 

References

National Gerontological Nurses Association http://www.ngna.org/

American Physical therapy Association: http://www.apta.org/