First Clinical Day 3.28.13

Autonomy is the hallmark of the practice of community based/public health nursing. You don’t have the usual nursing team to rely upon. You must be able to self-monitor and self-direct a great deal of your own work, and interact with the patient, their family and friends on their turf.

Home health nurses will tell you there are significant advantages to caring for individuals and families in their own homes. The home setting is intimate helping to foster familiarity and caring between clients, families, and their nurses. Behavior in the home setting is more relaxed, cultural practices may be more visible and there is often exposure to multiple generations of family.

Might the location of care rendered have an effect on the individual receiving the care as well as the caregiver? Your thoughts…

The location that home health care is given effects both the care giver as well as the client receiving care. For the care giver, “rewards stemmed from three main sources: practical autonomy on the job, especially relative to prior work in the service sector; skills building; and doing dirty work” ( Stacey, 2005). The nurse in the home care setting is able to work independently and does not have to deal with numerous other people as in the hospital setting. This allows the nurse to have a more flexible schedule when providing home care than when in a hospital. Because of this flexibility the nurse can spend more time getting to know his or her patient creating a relationship beneficial to both parties. The skills built while performing assessments and providing care in the community are beneficial to the nurse in every facet of his or her career.

Individuals receiving care in their own home not only have the comfort of their familiar environment, they are not inconvenienced by the hassle getting to doctor appointments. The relaxed environment of their own home can cause less anxiety than in the doctors office. These patients receive more one-on-one attention and are able to form more of a relationship with their caregivers when out of the hospital setting. Having the nurse care for them in their own home allows patients to have more of their needs met, both physically and emotionally. The patients cared for in their own homes take more of an active role in their care than when in the hospital. “The home health care patient often has a greater role in determining how and even if certain interventions will be implemented. For example, in a hospital, nurses, physicians, and pharmacists may all play a role in ensuring that the patient receives antibiotics at therapeutically appropriate intervals. At home, however, the patient may choose to take the medication at irregular times, despite advice about the importance of a regular medication schedule. Thus, interventions to promote patient safety and quality care must account for the fact that patients will sometimes choose to act in ways that are inconsistent with the relevant evidence, and the clinician’s best efforts may not result in desired outcomes” (Ellenbecker, 2008). This sense of control along with the other previously mentioned benefits of home health results in high patient satisfaction.

Ellenbecker CH, Samia L, Cushman MJ, et al. (2008). Patient Safety and Quality in Home Health Care. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality.

Stacey, C. (2005). Finding dignity in dirty work: the constraints and rewards of low-wage home care labour. Sociology Of Health & Illness, 27(6), 831-854.

The location of care greatly impacts the individual receiving the care as well as the caregiver. On Thursday, I saw patients benefit from the home care being offered. According to Sutter Care at Home, “Home health care enables patients to recuperate from short-term illness or deal with chronic disease in the comfort of their own homes” (Sutter VNA & Hospice, 2008). I saw three patients last Thursday with my assigned nurse, all of which enjoyed were dealing with a chronic disease in the comforts of their own home. I witness these patients being happier than I have seen them in hospitals. They showed a decreased anxiety level, which creates a better learning environment for patient teaching. There are advantages to home care that cannot be achieved in a hospital setting that I was able to take part in at the VNA. Sutter Care at Home states that its benefits include “one-on-one care at home rather than in the hospital”. In the hospital, the patient cannot get this one-on-one care, since one nurse is usually assigned to about five patients and must divide her time. Sutter Care at home also says that the patient can have “communication at any time of the day by phone” is there is a problem or question. I saw these occur in the three homes I visited. The first patient was an elderly man who was very content in his home. I was able to see how comfortable he was. It was a familiar setting for him being cared for in his own environment. Another patient I visited was transitioning, or passing away, and was hardly waking up. However, the family felt a great deal of comfort having their family member at home. This type of care benefitted the family in his situation and allowed a familiar environment for this difficult time. This home was a Spanish speaking family, and they were able to perform their cultural practices more easily.
The caregiver also benefits from home care nursing. The nurse can get to know the patient and the family much better than in a hospital setting. The nurse is able to observe the family’s lifestyle and support systems first hand by being in their environment. The nurse also is able to work one-on-one with this patient in a more quiet setting, allowing a more thorough assessment to be completely with no interruption, which is not always achieved in hospitals due to a heavy patient assignment. The patients I saw on Thursday greatly benefitted from home care. How would experiences differ for these patients if they were in hospitals or nursing homes? Would their families not be able to see them as much? This would greatly impact their coping ability and the patient’s ability to be as happy as possible.

Sutter VNA & Hospice (2008). Home Care Facts for Physicians and Health Care Professionals. Retrieved from http://www.suttervnaandhospice.org/doctors/doctors_homecarefacts.html

The location of the care given to a patient, greatly affects both the patient and the caregiver. Statistics retrieved from the journal article,” Challenges for Home Health Care Providers: A Needs Assessment”, describes the demographics of people receiving home health care, “These data showed that this population is predominantly women (65%), 65 years and older (71%), unmarried (58%), living in private or semiprivate residences (94%), and living with their family members (63%”)”(Beer, McBride, Mitzner, Rogers, 2011). Through this data one can see that the majority of people receiving home health care are elderly patients, who are probably most comfortable in his or her own home. The first day of clinical I had the pleasure of going with the nurse to assess two elderly women. Both women were dressed to their liking, familiar with their environment and seemed to have a sense of control. In my personal opinion I felt these women benefited from relieving care at home, with the help of their loved ones and family members. “Most home health care takes place in private residences, where other family members are living, and involves multiple caregivers, including informal caregivers”(Beer, McBride, Mitzner, Rogers, 2011). This statement is very important when it comes to home health care, because some patients have multiple caregivers helping them with their disease process. Although having a strong family support with multiple caregivers probably benefits the patients, I feel this may be a challenge for the nurse. VNA Nurses must make sure that all of these caregivers are on the same page, and educated correctly in regards to the patients plan of care, medications and much more. All of the caregivers need to have great communication skills in order for a patient to fully benefit from home health care.
I feel that VNA nurses need to have confidence in their assessment skills to be comfortable in their professional role. Seeing no one is around the corner to confirm ones assessment, the nurse carries a lot of personal responsibility for each patient’s health. On my first day of clinical I saw a challenge the nurse encountered with miscommunication between the hospitalist, who discharged the patient, and the pharmacy. Unfortunately the doctor wanted the patient to be on a medication, which was not sent to the pharmacy for the patient to pick up. “Errors in transition and handoff communication can greatly impact the quality of care received in the home. For example, an error in diagnosis, prescribed therapy, treatment, and/or medication could result in mistreatment or an adverse drug event”(Beer, McBride, Mitzner, Rogers, 2011). Clearly there are challenges to every profession, and miscommunication is a challenge that faces home care providers. The nurse needs to work hand and hand with other health care professionals and the patient’s informal caregivers in order for the patient to receive adequate care.
In general, allowing the patients to remain in a familiar environment while receiving care will benefit the patient. The nurse and other health care professionals can see firsthand how the patient handles life at home and the patient can show his or her true abilities. Caregivers, who feel comfortable with working autonomously and who have strong assessment skills can also benefit from giving care to patients at home.
McBride, S. E., Beer, J. M., Mitzner, T. L., & Rogers, W. A. (2011). Challenges for Home Health Care Providers: A Needs Assessment. Physical & Occupational Therapy In Geriatrics, 29(1), 5-22. doi:http://dx.doi.org/10.3109/02703181.2011.552170

The point made by CMOS that the nurse has a stronger relationship with the patient in the home environment, is a positive outcome of home care. In the hospital, patients do not get one on one personal time with the nurse for extended periods of time, due to competing factors. I also agree that unfortunately when people live and are being treated at home, he or she needs to take responsibility for some interventions, like medications as noted by CMOS. This barrier is one that home health care nurses and providers need to assess and create interventions for, in order for the patient to stay healthy at home.

Cassie,

These are great reasons to the benefits of home care for patients. They enjoy the comfort of their own home and it less hectic for them than being in the hospital. You make an excellent point addressing the one-on-one care that the nurses are able to provide for their patients. They are able to know their patients better, making the quality of care higher. You make a good point about the medication schedules for patients living at home. They may not take their medications at correct times, since a nurse is not administering them routinely as they do in the hospital. That is a great example for increasing patient safety, quality of care, and patient knowledge in the home setting.

Depending on a given community, the location of care can significantly impact most, especially the older adults, due to the fact that older adults are at risk of developing chronic diseases and related disabilities as per 'healthy people 2020'. They are remarkably increasing in numbers due to the 'baby boomers' effect making it harder to access healthcare in given institution and rather they tend get cared for at home. Supposedly, this puts the caregiver in a position to best practice and properly maintain the required assessment skills, intervening, evaluating and advocating for this kind of individuals. Health education and literacy seems to be the best tool to target almost every client who is being cared for in any given setting.

Proper teaching towards health maintenance and promotion should be catered for fully by the caregiver through empowering all clients to be cared for. "Older adults use many health care services, have complex conditions, and require professional expertise that meets their needs. Most providers receive some type of training on aging, but the percentage of those who actually specialize in this area is small. More certified specialists are needed to meet the needs of this age group" obtained from Healthy people 2020-Older adults objectives. The implication in this long statement seems to leave the caregiver with a maximum need to posses more knowledge and skills to care for individuals in their homes or any other institution.
Last thursday, l experienced a major need for older adults living alone that they should have a clear and continued teaching in case they are newly diagnosed with a condition that is not familiar to them. Diabetes affects most of the older population and therefore anyone caregiver admitting any newly diagnosed diabetic should closely follow them up with proper teaching in terms of diet, exercises and how to promote and regulate blood sugars normally. Teaching remains the key role of a caregiver, no matter how much drugs you are giving this patients, they need knowledge on how to prolong their lives.

POSTED FOR "JJ"

The majority of Americans are most comfortable in their own home where they feel safe and close to the things they love, and home care is the long-term care option that promotes the individual's independence and ability to continue with their daily routine as long as possible. The goal of home care is to provide care for those who need it, and to allow an individual to remain living in their home as long as possible, regardless of age or disability.


The location of a clients care certainly has a a profound effect on the individual receiving the care, as well as the caregiver. “According to the LTCi Sourcebook, published by the American Association for Long-Term Care Insurance, some 7.6 million individuals currently receive care at home because of acute illnesses, long-term health conditions, permanent disability or terminal illness. By comparison, there are just over 1.8 million individuals in nursing homes” (Home Health Care, 2013). Clearly there is a patient preference to wish to remain in their home environment, where they feel safe. There is evidence that supports patients living in their own home not only have better outcomes from chronic illness, but also experience less complications (such as falls) due to the familiarity of their environment.

Along with the health benefits that come along with remaining in ones own home for care, patients develop close, personal relationships with their caregivers. Often times, those who receive home care don't venture into society very often, so public health care nurses are their window to the world and they therefore rely heavily on them. Also, patients who live at home can be socially isolated if their family doesn't live close or they don't have any family left. So, public health nurses serve as a necessary social contact for patients and nurses appreciate the relationship as well.

The ability to remain in your own home is one of the greatest benefits of owning long-term care insurance (2013).
Retrieved from http://www.aaltci.org/long-term-care-insurance/learning-center/home-health-care.php

POSTED FOR "JA"
The location in which care is provided means a world of difference for everyone involved. For starters the milieu is more accessible in a medical model type of facility. When and if a particular crisis arises, the various disciplines are available to tend to this. That said, by having these services readily available a prevention of crisis aspect is obtained and ultimately the patients overall wellbeing is greater. Some negative aspects of living in nursing home type facility are that the patient is held to staff’s schedule and plans. The stuff provides the structure and routine for the day, removing a sense of autonomy. The patient is also held more so to the plan of care vs the home model. What I mean to say is that if a patient in the home setting wants to eat a doughnut they very well may but in the nursing home they may have to sneak the doughnut and/or receive “re-education.” In the nursing home the patient is beholden to visiting hours, late night assessments, and sometimes forced to live with a roommate.
When a patient lives at home, they are responsible for medication administration, performance of ADL’s, house work, and meal prep, unless services are in place to assist in some of these areas. The burden of care is often shifted to family and/or the various support agencies. The logistics for care at home can be extensive.
A comparison study was done by Arnetz and Hasson (2011), on care recipients' and family members' perceptions of quality of older people care, a comparison of home-based care and nursing homes. The study found that patients rated there opportunities for activities as lower in the home based model and as important, while relatives rated staff competency as being lower in the same setting vs the nursing home model.
With all this said, why is it that many patients prefer to be in their own home vs the nursing home model? I touched upon it briefly and in my opinion it comes down to autonomy and what home means. Home is where you look forward to being at the end of long trip, not unlike the long trip that is life. The nik-nak is turned just the way you like it, the thermostat is set to a blistering 95 degrees just the way you like it and everywhere you look you see your stuff. This stuff is the fruit of your life’s labor. It’s where your memories are, where you’re comfortable and maybe most comfortable dying. This is why in my opinion all that junk I was rattling off is trumped by what it means to be at home.
Arnetz, J.E., & Hasson, H. (2011). Care recipients' and family members' perceptions of quality of older people care a comparison of home-based care and nursing homes: Journal of Clinical Nursing, 20 (9/10), 1423-1435.

POSTED FOR JA:

Discussion response to LD: First Clinical Day
You touched upon what I was trying to get across, and that’s like what Dorthy from the Wizard of Oz said; “there’s no place at home.” I began my search for evidence based material on the better care that was provided in the home setting but found most found the hospital setting to deliver better outcomes. I also found that the literature was roughly split on the perceived happiness in the home vs. facility. I venture to guess that it depends on what you’re seeking from the healthcare system. If you are wanting to be fixed then you want to be in a hospital setting and inversely if you want to be comfortable, then home is more your option. We can argue care is the same here or better there but in the end it comes down to perception. It’s less taxing mentally if you will, to have blood drawn at home in a familiar setting than in a strange place, where you know no one. I believe that if the home model can deliver the same services or we can say achieve the same patient goals, then this is the better setting. It serves to better treat the whole patient and would make Martha Rogers happy with all her metaphysics and stuff.

JA,
I find it interesting that more people prefer to be in their own home and receive home based care yet they report less activities available for them to do and their relatives rated staff competency lower in the home based model. I agree with you that it is due to the patient feeling autonomous and having sense of comfort in their own environment. I think that is a struggle for many families deciding on which route is best for their loved ones care. I know I would want to feel my family will receive the best, most competent care but at the same time I would want them to feel comfortable and retain their dignity. It must be a difficult decision for many to make whether to put their loved one in a nursing home or to have visiting nurses take care of them.

Caring for patients in their home setting has many advantages for the patient and their families rather than having the patient in a hospital setting. Many patients that are elderly decline when they are in the hospital because they aren't familiar with the surroundings and this can lead to further health issues. I find that caring for the patient in their homes allows them to feel comfortable, they know their surroundings and who everyone is. Also, having the patient at home decreases the risk of falls in patients because of the familiarity they have in their homes. Many of the patients I saw with the VNA hospice nurse were cancer patients who decided to be at home rather than in a hospital because its more comfortable for them. There are pro's and con's for the families about these types of situations. Studies have found that having patients receive care at home is cheaper than having them stay at hospitals, but it can also be more stressful for the caregivers because they are doing all the work most of the time. On my first clinical day I met the families of the patients we were taking care of and they all said the same thing how tired they were, and how stressful it is for them to be there for the patient 24/7. As the nurse you have to look for the best interest in the patient and the caregiver, because caregiver role strain can lead to neglect or elder abuse as we learned in class so it's important to assess the everything. It can be very pleasant for a nurse to care for a patient in their home knowing that this is where they feel more comfortable and it allows the nurse to get a feel of the patients environment looking for potentially harmful things in the house, or assessing ways that can contribute to falls and fix them. In the case that the house the patient lives in isn't very peaceful and helpful for their rest, then it can be hard for the nurse to feel comfortable having the patient receiving care in the house setting. One of my patients on the first clinical day was living in a very hectic house where there was a young boy with severe ADHD who wouldn't let the patient rest. This patient had brain cancer and was very ill, requiring rest to have any recovery of energy. This situation made the hospice nurse and myself not feel comfortable having this patient living at home to receive care. I think it all depends on the patient, their diagnosis, the family and how they are going to care for the patient, and the environment the patient will be in to factor out if home care will be a positive or negative effect.

"Through this data one can see that the majority of people receiving home health care are elderly patients, who are probably most comfortable in his or her own home", this quote from your response is very true, almost all the patients I saw that were elderly had no desire to be anywhere else but their homes due to many reasons. I think that elderly people become easily disoriented when they are away from familiar surroundings and this can happen in a matter of 48 hours where you will see a huge change in their orientation. I agree with you that caring for certain patients in the home setting will result in better outcomes for them, even if it is hospice patients who are terminally ill. The outcome may just be that they were allowed more quality time with their families in the comfort of their own homes, and that to them may be a better outcome then being in a hospital receiving medical care 24/7 possibly extenuating their lives.

CMUR,

I couldn't agree more that diabetes seems to effect the elderly at a disproportionate rate. It is vitally important that public health nurses make it a priority to reinforce diabetic teaching in the elderly due to the complexity of their disorder. It is important that the elderly test their blood sugar regularly and inspect their skin for any breakdown or cuts so that complications are kept to a minimum. With proper diabetic management, elderly patients can live a long and healthy life and public health nurses can ensure this by being diligent.

Having worked for a home health care agency before, I absolutely think that location of care has an effect on the patient. When the patient is in the comfort of his or her own home, they feel safe, secure and the level of stress and anxiety is significantly decreased. When ones body isn’t stressed or anxious, it makes the recovery process a lot easier and quicker at that. If the patient lives alone, ive noticed especially with the elderly how much happiness it brings them to have someone come and help them or even just sit there to talk and ask them how their day is going. The article I found called Benefits of Community Home Health Care made a good point in saying “Many patients report feeling more comfortable in their own homes and say that they sleep better in their own beds and eat better when served the home cooked food they are used to eating. They have more privacy at home, it’s quieter and more peaceful at home and they retain more control over their own lives and health care in the home setting.” (CACC, 2011) I thought those were all great points and it drew attention to sleep- we all know that sleeping in a hospital bed on a busy medsurg floor is close to impossible. When a patient is able to get a full nights sleep in their own bed, the difference it makes is huge.

In regards to the effects of location on the nurse, I think that also makes a difference in both good and bad ways. As stated before, a home health care nurse is extremely independent. They have to make decisions based their own knowledge, background and skills. Home care has come such a long way that more acute care is being done in the home setting so the set of skills needed is expanding even more. On one of my home visits with the VNA, we were in a bad part of East Boston and the patient we were going to admit was an older man who had a history of drug abuse. The nurse I was with stated that drug users always made her a bit nervous and I agreed- in this case, the home setting was less than ideal for a young female nurse. I don’t think that I personally would feel comfortable if I was the RN doing this home visit by myself. On the other hand, we also visited an elderly man in his home who lived with his sisters who were helping to care for him and it was a very pleasant home visit- the family was very welcoming making this location a lot more comfortable and the care that we provided was that much easier.
Common Association for Community Care (2011). Benefits of Community Home Health Care. Retrieved from http://www.cacc-acssc.com/benefits-of-community-home-health-care/

CMOS,
I appreciated what you said about the patient having their needs met not only physically but emotionally. You see this especially with the elderly living at home alone- most often a visiting nurse is the only person they see or talk to during the day. Depression is a huge issue in the elderly and mental health directly effects physical health and depression certainly takes a toll on someones body. It is really nice to know that nurses truely can make a difference not only providing care for someone by doing a dressing change or giving meds, but by sitting down and simply asking someone how they are and investing a little extra time in patients lives.

Am glad you mentioned about safety in regard to home care visits. It is really unsafe to visit some homes which may seem a threat to ones safety. How the nurses are supposed to cope with the issue remains a dilemma. The only option left is to contact the local police, and somehow supposedly this brings a controversy towards confidentiality, since the nurse has to explain about her home visit and the patients address including the location. HIPPA remains a huge issue to follow lawfully as nurses. To maintain safety, we always have to remember where the exit is after we get in all our clients houses; we should try as much as possible to avoid blocking the exit or even double locking the doors, as a safety measure for easy access in case of emergency.

Some day i will also share my thoughts.