Transcript HOME CARE Of Community

HOME CARE
&
Assessment of
Community-Dwelling
Elderly
James T. Birch, Jr., MD, MSPH
Assistant Clinical Professor
Department of Family Medicine
Landon Center on Aging
(in cooperation with Holly Cranston, MD)
HOME CARE & Assessment of
Community Dwelling Elderly
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Segments of this presentation were
modified, with permission, from one
originally developed by Deb Mostek, MD for
the University of Nebraska Program in
Aging under funding from the Donald W.
Reynolds and John A. Hartford
Foundations
Steps to Attaining Objectives
Types of Home Visits
 Indications for Home Visits
 Home visit statistics
 Advantages/Disadvantages
 Equipment
 Patient Assessment
 Safety issues
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Types of Home Visits
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Illness
When a patient is too
ill/functionally impaired
for office visit - for acute
or chronic illness
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Dying/Death
Hospice care, grief
support, pronouncement
of death, support visits
for family members
Types of Home Visits
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Assessment
Done for patients who
may or may not be
receiving home health
services.
Physical exam, home
safety evaluation,
patient safety evaluation
can be conducted at this
type of visit.
Types of Home Visits
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Hospital follow-up
May help to prevent
“bounce back” to
hospital prematurely.
Helps to assure that the
patient is receiving all of
the ordered supplies,
services, and adhering
to medication
schedules.
Indications for Home Visits
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Any condition creating physical impairment or
limitation of mobility; Lack of transportation
Caregiver burden concern
Suspected elder abuse or neglect
Polypharmacy or medication compliance
issues
Failure to thrive
Refusal to keep office visit appointments
Recent history of falls at home
Psychiatric illness or behaviorally difficult
Evaluation of need for placement outside
of home
Statistics
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Before WWII, 40% of patient-physician
encounters occurred in the home
1990: 0.88% (<1%) of Medicare
patients receive home visits from
physicians
1994: 66/123 medical schools offered
home visit specific instruction; only
3/123 required > 5 home visits
General practitioners 12% of PCP work
force but make 26% of house calls
Statistics
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Low frequency of home
visits is due to:
1.
2.
3.
4.
5.
6.
Deficits in physician
compensation for visits
Time constraints
Perceived limitations of
technologic support
Concerns about risk of litigation
Lack of physician training and
exposure
Corporate and individual
attitudinal biases
Statistics on Home Health Care
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$22.3 billion dollar industry
44% of patients discharged
from the hospital require posthospital care; either nursing
home or home health care
43 referrals/year per physician
among internists and family
physicians J Am Geriatr Soc 1992;40:1241-9
Statistics on Home Health Care
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5-10% of patients in a primary care
practice receive home health care.
National homecare and Hospice Survey 1992
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30%+ of patients age 85 or older require at
least one home health care visit per year.
Medical Management of the Home Care patient: Guidelines for Physicians 1998 by
AMA
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2% of home care patients received
physician home visits.
National Homecare and hospice Survey 1992
Advantages
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Improved medical care through the revealing of
unknown health care needs
Ability to assess the environment which can lead
to design and implementation of home-based
interventions that prevent falls and other selfinjury
Insight into psychosocial issues
Enhancement of physician-patient relationship
Advantages
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Home-based assessments increase the prospect of
elderly patients remaining at home. Cleveland Clinic
Journal of Medicine May 2001
Assessments are done in familiar surroundings
OT, PT can tailor rehab to
a patient’s home
Physicians report a higher
level of practice satisfaction
than those who do not
offer this service
Disadvantages
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Time intensive
Less technological
support
Financial issues
Provider safety
Equipment
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Essential
Stethoscope
Otoscope/Ophthalmoscope
Sphygmomanometer
Tongue depressors
Non-sterile (or sterile) gloves
Lubricant
Stool guaiac cards &developer
Sterile specimen cups
Disposable thermometers
Reflex hammer/tuning fork
Urine dipsticks
Prescription pad
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3.
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12.
Optional
Glucometer
Dictaphone
Laptop computer
Patient education materials
Tape measure
Bandage scissors
4x4 gauze and tape
Disposable suture removal kit
Sublingual nitroglycerin
Glucometer
Portable oximetry unit
Portable ECG
Equipment
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1.
2.
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5.
Anticipate the need for procedures
Debridement
Unna boot application
Dressing change
Phlebotomy
Suture removal
Assessing the Patient
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Use the “INHOMES” mnemonic to help recall the
areas of focus for the home visit
I Immobility
N Nutrition
H Home Environment
O Other People
M Medications
E Examination
S Safety, Spiritual health, Services
Assessing the Patient
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I-IMMOBILITY
1.
Assess ADLs and iADLs
Ask for a tour of the home
Observe gait and ambulation through hallways,
bedroom, and negotiating stairs
Ask the patient to act out their routines (getting in and
out of bed, opening medication bottles, performing
personal hygiene)
Direct corrective interventions where deficiencies are
noted
Talk with other members of the household about
functional concerns
2.
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6.
Assessing the Patient
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N-NUTRITION
1.
Ask about food preferences.
Ask for permission to look in the
refrigerator, cupboards, and/or pantry
Ask about food preparation: who prepares
it? How often does the patient eat during
the day? How is shopping for food
accomplished? How is it delivered?
2.
3.
Assessing the Patient
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H-HOME ENVIRONMENT
1.
Safe neighborhood
Proximity to services
Ambient temperature (are the heating
and air conditioning controls accessible
and easy to read?)
Utilities: running water and temperature
2.
3.
4.
Remember !
“…cleanliness is a cultural matter that should
be ignored, unless lack of it is a diagnostic
clue, an aesthetic barrier for the caregivers,
or a medical risk.”
Cleveland Clinic Journal of Medicine, May 2001
Assessing the Patient
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O-OTHER PEOPLE
1.
Social support system: family members,
neighbors, friends
Emergency help
Identification of person who will serve as
surrogate for the patient (DPOA, living
will)
Assessment of caregiver stress/burnout
2.
3.
4.
Assessing the Patient
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M-MEDICATION
1.
Gather ALL of the patient’s medications in the home
(medicine cabinet, refrigerator, drawers, counters, etc.)
Evaluate the type, amount, and frequency of medication
use, noting the organization and method of delivery (selfadministered or help from family/friends)
Review indications for medications
Consider potential for drug-drug or drug-food interactions
Assess patient compliance
Recognize the potential or presence of abuse of OTC
preparations and herbal remedies (i.e. diphenhydramine)
2.
3.
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6.
Assessing the Patient
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E-Examination
1.
Focused examination based on patient’s needs
Vital signs
Cardiopulmonary & neurologic exam
Skin/wound assessment
Mobility/Immobility assessment
Cognitive assessment (MMSE, GDS, SPMSQ)
Blood glucose monitoring (pt should demonstrate
proper technique)
2.
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Assessing the Patient
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S-SPIRITUAL HEALTH / SERVICES / SAFETY
1.
Peruse the home for religious objects/reading
materials. This could initiate a discussion of
spirituality as a healing and coping strategy
Coordinating the home visit with home health
agencies and having their nurses present can
facilitate communication and cooperation
between patient, physician, and other agencies.
Questions can be answered, orders clarified,
priorities and perspectives discussed, etc.
2.
Safety issues
1.
2.
3.
Utilities: running water and
temperature; hot water
temperature <49oC (120oF)
Cluttered hallways, desks,
and countertops (barriers
to the use of canes,
walkers, or wheelchairs?)
Lighting (stairs, hallways,
etc.)
Safety issues
1.
2.
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4.
Seat elevator in bathroom
Tables, chairs, and other furniture (sturdy
and well-balanced?)
Locks on doors and windows; ease of
escape in case of fire or other emergency
Ask : “What number do you dial in case of
emergency?”
Safety issues
1.
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6.
Electrical cords and appliances
Flooring, throw rugs, non-slip surfaces in
tub/shower, and bathroom floor
Smoke detectors, fire extinguishers
(batteries?)
Burners on stove easily left on?
Pets
Handrails in bathroom and on stairs
Personal Safety
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Take a map and your cell phone
Contact the patient or caregiver when you are en
route for a visit
If you’re going to a known high crime area,
schedule visits in the A.M., avoid wearing a white
coat, use alternative carrying vehicle instead of
the “black bag” (i.e fishing tackle box)
If you question your safety, KEEP DRIVING!
Improving Efficiency
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Limit geographical area to be covered
Plan a half-day of routine home visits (approx. 4
patients) in one general neighborhood
Start with the address furthest away and work
towards office or home
Document the reason for the home visit and
history and examination as medically appropriate
Summary
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Is assistance available to compensate for the
patient’s functional limitations?
Determine goals of treatment and their risks
Implement interventions where indicated
Address psychosocial issues
Be prepared for minor procedures
Utilize strategies to improve efficiency
Use the home visit checklist
http://www.aafp.org/afp/991001ap/1481.html
Summary
“…house calls are a vital part of
medical care, a link to the past, and a
unique opportunity for service,
commitment, and compassion.”
N Engl J Med, Dec 18,1997; 337(25): 1815-20
Visit the following websites to check
your skills
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www.riskdom.com
www.environmentalgeriatrics.org
Additional References
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Unwin, B.K., Jerant, A.F. The Home Visit.
American Family Physician; Vol. 60/No. 5
(October 1, 1999)
Meyer, G.S., Gibbons, R.V.; N Engl J Med,
Dec 18,1997; 337(25): 1815-20
Swagerty, D.L. House Calls in Primary
Care; Kansas Reynolds Program in Aging,
Univ. of KS School of Medicine