Home Health Care
Team Members
Author:
Nabil Yassin Al Kurashi, M.B.B.S., FFCM (KFU)
President, Saudi Society of Family
& Community Medicine
Associate Professor of Family Medicine,
College of Medicine, King Faisal University
Dammam, Kingdom of Saudi Arabia
Member, Scientific Council, Arab Board of Medical Specialties
Correspondence:
Nabil Yassin Al Kurashi,
M.B.B.S., FFCM (KFU)
President, Saudi Society of Family & Community Medicine
Associate Professor of Family Medicine,
College of Medicine, King Faisal University
Dammam, Kingdom of Saudi Arabia
Member, Scientific Council, Arab Board of Medical Specialties
Email: dr_nabil_kurashi@yahoo.com
Phone + (966) 8966666 ex 3079
|
Abstract
Home health care (HHC) is that
component of a continuum of comprehensive health care
whereby health services are provided to individuals and
families in their places of residence for the purpose
of promoting, maintaining or restoring health, or maximizing
the level of independence, while minimizing the effects
of disability and illness, including terminal illness.
9 Even if HHC programs have been established as hospital-based
programs for over the past ten years to solve the long-term
occupancy of their hospital beds, it has just started
in Saudi Arabia. There are no-community-based HHC services
in the country.
The members of the home health
care team may include: physician, nurse, medical social
worker, home health aide, physician's assistant, psychologist,
paid homemaker, dentist, rehabilitation personnel, dietician,
optometrist, volunteer, friend, and family caregiver.
Each professional from each discipline brings a special
set of knowledge, attitudes, and skills to home care.
The patient's needs and the requirements outlined in the
home care plan are the bases of the level of involvement
of each professional in the home care. There may be overlapping
of functions because of patient's needs and the intermittent,
part-time nature of professional home care services. 2
The home care professional is alone in the patient home
with the patient, and must often provide, in addition
to the planned professional interventions, a general view
of the entire team's home care program. The shared tasks
are brief assessment of the overall effectiveness of the
comprehensive home care plan; assessment of patient and
caregiver interactions and satisfaction with the home
care program; identification of any new problem; notification
of appropriate team member(s) for follow-up of new problems;
and encouragement and reinforcement of instructions from
other team members.2 Each team's composition depends on
each patient's needs and on its responsibilities to take
care of these needs.
Key words. Home Health
Care (HHC)
|
Home health Care (HHC) is a formal,
regulated program of care provided by a variety of health care
professionals in the patient's home. 1 The unique aspect of
home care is the nature of the collaborative team effort.2 Each
professional from each discipline brings a special set of knowledge,
attitudes, and skills to home care. The patient's needs and
the requirements outlined in the home care plan are the bases
of the level of involvement of each professional in the home
care. There may be overlapping of functions because of patient's
needs and the intermittent, part-time nature of professional
home care services. 2 Unlike in the hospital setting where other
team members are readily around, the home care professional
is alone in the patient home with the patient, and must often
provide, in addition to the planned professional interventions,
a general view of the entire team's home care program. The shared
tasks are brief assessment of the overall effectiveness of the
comprehensive home care plan; assessment of patient and caregiver
interactions and satisfaction with the home care program; identification
of any new problem; notification of appropriate team member(s)
for follow-up of new problems; and encouragement and reinforcement
of instructions from other team members.2 Each team's composition
depends on its responsibilities which each patient needs. A
HHC team may include any of the following: physician, nurse,
medical social worker, home health aide, physician's assistant,
psychologist, paid homemaker, dentist, rehabilitation personnel,
dietician, optometrist, volunteer, friend, and family caregiver.2
This article is a review of literature
on the role of HHC team members.
According to Home Health Care websites,
the home health care team consists of physicians, nurses, home
health aides, medical social workers and therapists who coordinate
care based on an individual's needs. 3,4,5,6,7
The physician's role in the HHC team
cannot be undermined.8 Home visits very important to HHC for
many reasons. They can help the physician gather information
that may not have been uncovered in the office visit as evidence
of neglect, incontinence, or use of multiple medications, understand
better the environmental and family factors that might influence
a person's health, and assess better pertinent activities of
daily living and clarification of a situation that may have
been perplexing in the office setting. Home visits serve as
opportunities to monitor home care service. Physicians can act
as administrators and active participants. By knowing the patient's
baseline data, the physician can direct other health care professionals
who are members of the HHC team. By understanding the role of
each team member, the primary care physician will be able to
provide more cost effective care. Another purpose of home visits
is providing emotional support to the patient and the family.
When a patient is seen by a physician in the home, fears of
being abandoned will be relieved.9
There are two models for physician participation
in the HHC team. The common model shows the physician relying
on the home health care nurse to be liaison, team leader, and
coordinator in addition to performing the regular nursing activities.
2 The second model is active physician participation in HHC.
A mnemonic INHOME 9 (which stands for Immobility, Nutrition,
Home Environment, Other home health care team members) was devised
to help family physicians to remember their role. It expanded
to INHOMESSS 4 (which stands for Immobility, Nutrition, Home
Environment, Other home health care team members, Medications
Examination, Safety, Spiritual Health, and Services by home
health agencies).
Corrective interventions can be made
by physicians when proper assessment can be done of patient's
mobility (daily activities of bathing, dressing, feeding, toileting,
continence, shopping for food, paying bills, preparing meals,
doing homework, etc.) and these can be properly evaluated more
properly in the home. Corrected interventions can be made at
any deficiencies noted. 9,10 Physicians can better evaluate
the patient's current nutritional status and state of hydration
as well as his capabilities for maintenance of proper nutrition.
9,10
The patient's home environment should
allow for privacy, social interaction and both spiritual and
emotional comfort and safety. It can also reflect the patient's
interests and hobbies. The physician can assess the patient's
safety and sense of security in his home, and thus can recommend
activities, which the patient can do at home.10
Family physicians should evaluate and
assess the other home health care team members' tasks. As the
patient's social support system cannot be fully appreciated
during office visit, the accessibility and helpfulness of family
members and neighbors, especially in an emergency situation,
need to be evaluated. Evaluation of the caregiver's needs and
risk of burnout is critically important. 10 In the home, cues
for caregiver stress or burnout are more evident and can be
assessed easier, thus recommendations for respite care can be
made more easily 9, 11
The physician can assess the patient's
medicine cabinet to be certain of the full extent of the prescription
and nonprescription drug use by an individual patient, 9 and
also allow a direct estimate of patient compliance, uncover
evidence of "doctor shopping," and identify the use
or abuse of over-the-counter medications and herbal remedies.10
The physician should be able to assess the patient's and caregivers'
ability to manage the equipment at home such as ventilators,
peak flow meter, self monitoring glucose levels, and others
so as to teach them the proper use of each.9,10
Home safety assessment is done to assess
the patient's environment as to his comfort and safety so that
unreasonable injury is avoided. The physician should simply
state the intention to identify and help modify condition to
ensure safety. 10 Home safety elements are: furniture such as
tables and chairs, stairs, bathroom, loose carpets and throw
rugs, lighting and night lights, emergency actions and safety
route, fire and smoke detectors, and fire extinguishers, water
source, hot water heater, heating and air conditioning, gas
and electric utilities.
The physician should well know that
religion and tradition plays a strong role in Saudi Arabian
society. The patient's ability to fast and to pray may be affected
by his illness, and the physician should be able to assess this.
He should be able to convince the patient on the medical aspect
of health.
The nurse's role in the team is very
important in the HHC since most HHC service is provided
by nurses. 10 The nurse collaborates with the physician to provide
the patient with home care that he needs. Home care nurses also
work with various personnel from ancillary disciplines to coordinate
services designed to optimize a client's quality of life. A
nurse determines the type and frequency of nursing interventions
to be implemented and evaluates the patient for any needed ancillary
services when performing a client's initial assessment. 10The
home care nurses primarily implement the medical and nursing
care plans and identify needs for ancillary services and make
recommendations to physicians. 12 Physicians revise treatment
plans based on the nurse's report of changes in the patient
since they see the patient more frequently than the doctor.
Developing comprehensive problem lists and assessment of care
and goal plans are HHC nurses' responsibilities, too.10, 11
All the HHC team personnel perform initial assessments, and
subsequent assessment hereto after which all their services
are based from; these they coordinate with the nurse. Case conferences
are held wherein multidisciplinary team meets collectively to
brainstorm strategies that will most effectively help patients
to achieve their goals which the team members' goals are compatible
with. The nurse coordinator establishes a schedule of visits
with several people performing different interventions in rapid
succession to not overwhelm patients. Lack of communication
can cause unnecessary conflicts in treatment plans that send
mixed messages to patients and lay caregivers, thus resulting
in lay caregivers to lose trust in the home care team. The nurse
coordinator sees to it that regular communication is important
to ensure that interventions are complementary. 10, 11
In addition, the nurse should provide
the documentation, keeping all patient data (patient clinical
assessment, diagnosis, HHC treatment plan, objectives, and goals)
recorded. 10,12 Nurses must also stay in contact with different
community services and organizations which will meet the comprehensive
long-term needs of patients as: equipment, medical supplies,
food, socialization, laboratory testing, and personal care.
These organizations can facilitate and enhance the ability of
patients to maintain independence in their own homes.10,13
The Pharmacist's role in the HHC
team is guided by the American Society for Hospital Pharmacists'
guidelines. He is responsible for willingness and ability of
the patient or caregiver to be trained to properly administer
medication; and appropriate indication, dose, route and method
of administration of medication; and appropriate laboratory
test for monitoring patient to medication orders. The appropriateness
of whether the first dose of medication is to be given in the
home should be guided by clinical judgment. The pharmacist should
ensure that the patient or caregiver receives the appropriate
education, training, and counseling regarding the patient's
drug therapy. Pharmacist should be readily accessible in the
event that problems or questions arise. The pharmacist should
use clinical judgment for many procedures and equipment use
and maintenance, home inventory maintenance, and procedures
for securing additional supplies and medication when needed,
potential adverse effects, drug interactions, drug nutrient
interaction, and their management; special precautions for the
preparation, storage handling, disposal of the drug, supplies
and biomedical waste, and emergency procedures. 13 The pharmacist
with the patients or caregiver and other health care professionals
is responsible for developing an appropriate pharmaceutical
plan for each patient.
The physical therapist's role in
the team is helping evaluate a patient's need for assistive
devices (such as canes, walkers, crutches) and educate patients
about their safe and appropriate use. He also assists patients
to improve mobility and to reduce the risk of injuries resulting
from accidents. He is most useful in putting up a plan for patients
with mobility problems, difficulties with ambulation, transfers,
or bed mobility and chronic pain, balance or coordination problems,
or decreased range of motion and strength. He establishes the
home exercise program to enhance or maintain a client's range
of motion, muscle strength, and endurance. 9,10
The occupational therapist's role
in the HHC team is managing patients with diseases or disabilities
affecting their functional status. Occupational therapists provide
services to increase a patient's ability to perform activities
of daily living such as: bathing, dressing, toileting, cooking,
eating, and homemaking. They instruct clients on techniques,
equipment, and aids that can help them to overcome their disabilities.11
They also assist patients incapacitated by illness or injury
with adapting their homes to improve functionality, as well
as educate patients with reduced respiratory capacity (such
as COPD, CHF) or with chronically compromised strength and endurance
(such as muscular dystrophies) in energy conservation techniques.
10 They may recommend ways to adapt clothing that enable patients
to dress themselves , use specially designed utensils or devices
that will help patients maximize their autonomy, which can profoundly
affect self-esteem and the ability to leave alone. 10, 11
Occupational therapists develop exercise programs for home care
patients who have decreased functions in upper extremity or
hand because of impairment such as nerve or brain injury, or
CVA. They can apply splints, which are used to rest inflamed
joints in optimal positions to prevent or to correct deformities.
Occupational therapist also deals with applications for home
adaptations, including stair lights or rails, grab rails, bathroom
adaptation, widening door for wheel chairs, and positions of
switches and extra heating appliances. 10
The primary objective of a caregiver
for an aging or disabled individual is to provide a safe environment
combined with the highest level of achievable independence.
Fortunately, the home health care industry and medical products
manufacturers have produced innovative products and equipment
designed to help patients maintain independence, dignity and
safety. Medical Supplies & Equipment is a reliable, established
home health care supplier offering a wide range of physician-prescribed
home health care.14
The speech therapist's role in
HHC team is to help patients develop their remaining communication
skills and to learn compensatory communication mechanisms through
visual cues and cognitive retraining. He sets up a variety of
communication aids and technology, assists patients with learning
sign language, obtaining hearing aids or mastering the use of
an electrolarynx, and teaches them to use a simple communication
board that includes common messages they wish to communicate,
which enable patients to point messages on the board indicating
whether they are hungry, thirsty, hot, or cold. Recent advances
in computer technology provide telecommunication systems for
hearing loss patients, which transcribe spoken words into written
messages on a screen. 10
The role of social workers in the
HHC team is to provide invaluable assistance to the home
care team by providing emotional and psychological supports.
Sometimes HHC becomes stressful due to conflicts between the
caregivers and patients, limited community resources, restrictions
on the type and amount of care provided, and the challenges
to patient autonomy that arise as a result of chronic and acute
illnesses.
When patients inexplicably fail to comply
with instructions outlined in their treatment plans and the
refusal of care to participate in the care of a patient for
reasons that are not apparent to the clinicians involved, social
aspect of HHC management may appear. The social worker is the
key figure in access to community care services for care of
elderly patients or old age psychiatry. 15 When an extra support
at home is needed, social worker will start a formal assessment
procedure, which varies from an initial assessment of mobility,
personal care abilities, and current environment process involving
input from other members of HHC team and including assessment
of finances. 16 He links the patients also to formal and informal
sources of support, and providing emotional support to help
them resolve feeling related to loss, the burden of caregiver,
and the need to readjust relationships in the face of illness
and disability. 16 The social worker's community-based activities
of care are coordination, health education, counseling, assessment,
and skill in facilitating decision making related to ethical
issues. To insure that standard are maintained the social worker
will do regular inspection and monitoring unit visit 16. The
social services departments provide 24 hour emergency call system
for people who are: elderly or disabled; living alone or unable
to use an ordinary or adopted telephone, which consists of press
button and loud speaker installed in the phone or a portable
pendant that is worn around the neck or as a bracelet or brooch.
16
The role of home health aid in the
HHC team performs services involving the personal care of
the patient. The home health care assistant works under the
direct supervision of the home care nurse to follow a course
care outlined in the written care plan. 10 He may help the patient
in bathing, transferring in and out of bed, grooming, dental
care, exercise, and taking of medications. He may also help
with light housekeeping chores, such as changing bed linens.
10 A trained paid housekeeper can take this role of the home
health aid.
Family members can provide personal
care, wound care and administration of intravenous medications.17
Although HHC has the ability to lower the more obvious health
care costs associated with hospitalization or long-term institutional
care, home health care may also increase the personal cost to
family member's emotional, social, physical, and financial well-being.
17, 18 If the patient's informal support network becomes unable
to handle the increased burden resulting from disease progression,
treatment intensity or depletion in available resources, home
health care may collapse. A home health care team should consider
the increased family caregiver burden and try to decrease it
by looking for other alternative such as respite care. The aim
of respite care is to ease the pressure of the caregiver by
substituting an alternative method of care for a period of time,
which may be a few hours, days or weeks.16
In cancer care, home health care team
members are composed of the following:19,20 oncologist, rehabilitation
specialist, nurse, psychologist, psychiatrist, social worker,
dietary or nutritional service , and home health aides. The
services of a rehabilitation specialist help people recover
from physical changes caused by cancer or cancer treatment.
It includes the services of physical therapists, occupational
therapists, counselors, speech therapists, and other professionals
who help you physically recover from cancer.
In Saudi Arabia, the results of the
Al Hazmi study 21 showed that health care professionals had
positive attitudes toward HHC services. Virtually all health
care professionals agreed that there is a need for home health
care services in Saudi Arabia because of their importance to
patients. This was supported by almost all their answers to
the important questions related to providing HHC to their patient.
This reflects from their experiences from their professional
day-to-day practice, the actual patients' needs of home health
care. It was also found out that no structured HHC services
were available in government hospitals and PHHCs in Al-Khobar
and Al-Dammam.
The quality of life of the terminally
ill patients relies heavily on the psychosocial skills of health
care professionals. The health care team consists of a physician,
nurse, respiratory pharmacists, therapists, social worker, home
health aide and volunteers. The team develops an individual
care plan, which will provide an appropriate support system
for the patient and their family up to and beyond patient's
death. Weekly meetings allow the team to focus on the changing
needs of the patient and make adjustments to their plan.13
| 1. |
Montauk L. Home health care. .Am
Fam Physician 1998; 58: 1608-1614. |
| 2. |
American Medical Association.
Medical management of the home care patient: guidelines
for physicians. 2nd ed. Chicago: The Association, 1998. |
| 3. |
Frequently Asked Questions on
Home Health Care. July 16, 2005. <http//www.co. sauk.w.us/dept/ph/homecare/faq.htm. |
| 4. |
Our Multidisciplinary Team. November
2005. http://www.uchs.org/hch/ homehealth.cfm. |
| 5. |
Home Health Care. Jan 2006 http://phcris.org.au/publ.
|
| 6. |
Anonymous. Geriatrics in GCC Countries.
2000. |
| 7. |
Neighbors M, Monahan, F. A re
ADNS Prepared to be Home Health Nurses? N & HC: Perspectives
on Community 1997: 18:15-18. |
| 8. |
Unwin B, Jerant A. The Home Visit.
Am Fam Physician 1999; 60:1481-1488. |
| 9. |
Knight A. Adelman
A. The family physician and home care. Am Fam Physician
1991; 44: 1733-1737. |
| 10. |
Green K. Home care survival guide.
Philadelphia: Lippincott; 1998. |
| 11. |
American Medical Association.
Physician guide to home care patient: guidelines for physicians.
Chicago: The Association, 1989. |
| 12. |
Bean C. High-Tech Homecare Infusion
Therapies. Critical Care Nursing Clinics of North America
1998; 10 (3): 278-304. |
| 13. |
Swanson J, Nies M. Community Health
Nursing. Second edition, Philadelphia: Saunders company;
1997. |
| 14. |
Egan M, Kadushlik G. The Social
Worker in the Emerging Field of Home Care: Professional
Activities and Ethical Concerns Health and Social Worker
199; 24 (1): 43-55. |
| 15. |
Health Care Alternatives. July19,2005.
<http://www.homehealthworks.com
/faq.asp > |
| 16. |
Simmons J Community-based care:
The new health social work paradigm. Social Work in Health
Care 1994; 20: 35-46. |
| 17. |
Reswick D. Caring for older people:
Community care and social services. BMJ 1996; 313: 869 -872. |
| 18. |
Sevick MA, Kamlet MS, Hoffman
LA, Rawson I. Economic cost of home-based care for ventilator-assisted
individuals: a preliminary report. Chest 1996; 109:1597-1606. |
| 19. |
Thimoleon, Jacqueline. Home Health
Care. July 19, 2005.
<http:
//www.nu.educlasses/keefer/com/thimo.html>. |
| 20. |
Cancer Care, Inc. December 2005
http://www.ufaqs.com/cancerfacts/
Your%20Health%20Care%20 team%20%20Your%20Doctor%20 Is%20Only%20
the%20Beginning.htm |
| 21. |
Al Hazmi, A. Home Health Care
in Al-Khobar and Al-Dammam. 2001. |
