HOME CARE & Assessment o f Community-Dwelling Elderly James T. Birch, Jr., MD, MSPH Assistant...
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Transcript of HOME CARE & Assessment o f Community-Dwelling Elderly James T. Birch, Jr., MD, MSPH Assistant...
HOME CARE&
Assessment ofCommunity-Dwelling
Elderly
James T. Birch, Jr., MD, MSPHAssistant Clinical Professor
Department of Family MedicineLandon Center on Aging
(in cooperation with Holly Cranston, MD)
HOME CARE & Assessment of Community Dwelling Elderly
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
Types of Home Visits Illness
When a patient is too ill/functionally impaired for office visit - for acute or chronic illness
Dying/Death
Hospice care, grief support, pronouncement of death, support visits for family members
Types of Home Visits 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 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 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 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 Low frequency of home
visits is due to:1. Deficits in physician
compensation for visits2. Time constraints3. Perceived limitations of
technologic support4. Concerns about risk of litigation5. Lack of physician training and
exposure6. Corporate and individual
attitudinal biases
Statistics on Home Health Care $22.3 billion dollar industry 44% of patients discharged
from the hospital require post-hospital 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 5-10% of patients in a primary care practice
receive home health care. National homecare and Hospice Survey 1992
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
2% of home care patients received physician home visits.
National Homecare and hospice Survey 1992
Advantages 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 self-injury
Insight into psychosocial issues Enhancement of physician-patient relationship
Advantages 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 Time intensive Less technological
support Financial issues Provider safety
Equipment Essential1. Stethoscope2. Otoscope/Ophthalmoscope3. Sphygmomanometer4. Tongue depressors5. Non-sterile (or sterile) gloves6. Lubricant7. Stool guaiac cards &developer8. Sterile specimen cups9. Disposable thermometers10. Reflex hammer/tuning fork11. Urine dipsticks12. Prescription pad
Optional1. Glucometer2. Dictaphone3. Laptop computer4. Patient education materials5. Tape measure6. Bandage scissors7. 4x4 gauze and tape8. Disposable suture removal kit9. Sublingual nitroglycerin10. Glucometer11. Portable oximetry unit12. Portable ECG
Equipment Anticipate the need for procedures
1. Debridement
2. Unna boot application
3. Dressing change
4. Phlebotomy
5. Suture removal
Assessing the Patient Use the “INHOMES” mnemonic to help recall the
areas of focus for the home visitI ImmobilityN NutritionH Home EnvironmentO Other PeopleM MedicationsE ExaminationS Safety, Spiritual health, Services
Assessing the Patient I-IMMOBILITY1. Assess ADLs and iADLs2. Ask for a tour of the home3. Observe gait and ambulation through hallways,
bedroom, and negotiating stairs4. Ask the patient to act out their routines (getting in and
out of bed, opening medication bottles, performing personal hygiene)
5. Direct corrective interventions where deficiencies are noted
6. Talk with other members of the household about functional concerns
Assessing the Patient N-NUTRITION1. Ask about food preferences.2. Ask for permission to look in the
refrigerator, cupboards, and/or pantry3. 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?
Assessing the Patient H-HOME ENVIRONMENT
1. Safe neighborhood
2. Proximity to services
3. Ambient temperature (are the heating and air conditioning controls accessible and easy to read?)
4. Utilities: running water and temperature
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 O-OTHER PEOPLE1. Social support system: family members,
neighbors, friends2. Emergency help3. Identification of person who will serve as
surrogate for the patient (DPOA, living will)
4. Assessment of caregiver stress/burnout
Assessing the Patient M-MEDICATION1. Gather ALL of the patient’s medications in the home
(medicine cabinet, refrigerator, drawers, counters, etc.)2. Evaluate the type, amount, and frequency of medication
use, noting the organization and method of delivery (self-administered or help from family/friends)
3. Review indications for medications4. Consider potential for drug-drug or drug-food interactions5. Assess patient compliance6. Recognize the potential or presence of abuse of OTC
preparations and herbal remedies (i.e. diphenhydramine)
Assessing the Patient E-Examination1. Focused examination based on patient’s needs2. Vital signs3. Cardiopulmonary & neurologic exam4. Skin/wound assessment5. Mobility/Immobility assessment6. Cognitive assessment (MMSE, GDS, SPMSQ)7. Blood glucose monitoring (pt should demonstrate
proper technique)
Assessing the Patient S-SPIRITUAL HEALTH / SERVICES / SAFETY1. Peruse the home for religious objects/reading
materials. This could initiate a discussion of spirituality as a healing and coping strategy
2. 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.
Safety issues1. Utilities: running water and
temperature; hot water temperature <49oC (120oF)
2. Cluttered hallways, desks, and countertops (barriers to the use of canes, walkers, or wheelchairs?)
3. Lighting (stairs, hallways, etc.)
Safety issues
1. Seat elevator in bathroom
2. Tables, chairs, and other furniture (sturdy and well-balanced?)
3. Locks on doors and windows; ease of escape in case of fire or other emergency
4. Ask : “What number do you dial in case of emergency?”
Safety issues1. Electrical cords and appliances2. Flooring, throw rugs, non-slip surfaces in
tub/shower, and bathroom floor3. Smoke detectors, fire extinguishers
(batteries?)4. Burners on stove easily left on?5. Pets6. Handrails in bathroom and on stairs
Personal Safety 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 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 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
www.riskdom.com www.environmentalgeriatrics.org
Additional References 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