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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. T o grasp the actual practice of home care through an existing model.

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  1. HOME CARE The Heart of the Practice

  2. 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.

  3. 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


  5. 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.

  6. 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

  7. Advantages & Disadvantages of Home Care Advantages • Less costly • Enhances physician-patient relationship • Continuity of care Disadvantages • Time consuming • Minimal resources

  8. 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

  9. 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.

  10. 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

  11. 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

  12. 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

  13. 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 problems 2.Identification of home-care needs of the patient 3.Establishment/approval of a plan of treatment with identification of both short-and long-term goals 4.Evaluation of new, acute or emergent medical problems based on information supplied by other team members

  14. 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 care 9. Evaluation of quality of care 10.Documentation in appropriate medical records; 11.Provision of 24-hour on-call coverage by a physician

  15. 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

  16. 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.

  17. 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

  18. 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

  19. 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

  20. 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.”

  21. Home Care through an existing models 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.”

  22. Hospital-based model As 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

  23. Organizing a Home Care Program 1.Get Manpower 2.Train Staff 3.Prepare Home Care Program 4.Establish networking and linkage 5.Implement program 6.Evaluate the program

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

  25. 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

  26. 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

  27. 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

  28. 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

  29. Admission  Assessment  Planning  Implementation  Evaluation

  30. Assessment Discharge 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

  31. 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

  32. 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

  33. Implementation • Home care visit • Each home visit shall become a means of working towards the end goal

  34. 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

  35. Common Medical Problems • CerebrovascularAccident • Hemophilia • Chronic Obstructive Pulmonary Disease • Congestive Heart Failure • Diabetes Mellitus • Cancer

  36. Cerebrovascular Accidents • Important to Know • Pathophysiology • Clinical Manifestations • Acute Management • Medical Complications

  37. Cerebrovascular Accidents • Home Care Goals • Continuing Care • Feeding • Bed Sore Care • Physical Rehabilitation • Reintegration into Society • Counselling • Spiritual Care • Education • Prevention

  38. 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

  39. 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

  40. 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

  41. Congestive Heart Failure • Important To Know • Pathophysiology • Clinical Manifestations • Complications • Prevention • Management • Home Care Goals • Monitoring • Education • Physical Rehabilitation

  42. Congestive Heart Failure • 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

  43. Congestive Heart Failure • 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.

  44. Congestive Heart Failure • 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

  45. Diabetes Mellitus • Important To Know • Pathophysiology • Clinical Manifestations • Complications • Prevention • Management • Home Care Goals • minimalcoststrategy • minimal weight gain strategy • minimal injectionstrategy • minimal circulating insulin strategy • minimalpatienteffort strategy • hypoglycemia avoidance strategy • postprandial targeting strategy

  46. 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

  47. 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

  48. Cancer • Home Care Procedures • Respiratory System • Mechanical ventilation • TracheostomyCare • Tube changed when wound has matured (5 days) • Use of a rubber catheter as a guide to insert the new tracheostomytube • Inner cannula should be cleaned twice daily

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