When people are asked where they would wish to be cared for, they usually say “at home.” How does the health-care system move from a building-intensive and uber-specialized model to a person- centered one at home? There is almost no more sacred place or space than our homes. Homes represent who we are: the food, beverages, furnishings, traditions, neighborhoods, gardens, pets and plantings are all reflections of ourselves. Healthcare should be no different. Life-long health habits and behaviors are learned and honed across years in homes. Where better to initiate and continue health education and care than at home?
The model visualized makes the home the central place around which all other healthcare revolves; this is a very different construct from most healthcare today. Home is where people usually want to be, and where health decisions are made every day including diet, lifestyle, and other choices. The following eight areas address some of the factors making care at home more desirable and practical.
1. The aging of the world’s population. Much has been written about the gray tsunami. We know that the oldest old (those over age 85) are one of the fastest growing segments of the population. It is recognized that many aged people need assistance with activities of daily living and personal care. The question then becomes: How do we best care for this growing population? For example, what are the metrics that measure how well we are doing and what feedback should be sought from the care provided? Many older adults do not have one healthcare condition, but may have several comorbidities impacting their health.
Practical Application: Consider models and processes that bring healthcare to the person at home when possible. Consider the very frail oldest old, the homebound, the chronically ill and others where the logistics and experiences of getting out to go to the doctor’s office is an ordeal from a mobility and safety perspective. Now consider how we can get needed healthcare to these homes and who is best skill-matched to provide such care and support?
2. Much care can be safely provided at home with knowledgeable nurses and other clinicians. Care has been provided in homes for hundreds of years. Such care includes home visitors for mothers and infants, case management, infusion and medication therapies, specialized treatments, skilled nursing services, personal care, hospice and palliative care, and other models and care. In the United States, Medicare, Medicaid, and private insurance covers care in the home. This coverage is complex with a number of requirements. Generally, there must be physician orders for care and for any changes to that plan of care. There are a number of requirements and structures in place that can make obtaining care or obtaining enough hours of needed care a difficult process. The nurse who admits and cares for patients in homes must have a specialized knowledge base to provide care and have their organization receive appropriate reimbursement for medically necessary services. In addition, there are numerous standards related to documentation of the care provided and other requirements. There is a “For Further Reading” section at the end of this article for more information and resources. Home care is complex and this is the reason it is a nursing specialty. The complexity of the rules alone is sometimes akin to fitting a round peg into a square hole.
Practical Application: The payers determine the rules and sometimes the person needing the care does not “fit” neatly into the model. Try to envision a healthcare space where the person is assessed and then services are based primarily on the assessed needs without the complex and sometimes byzantine frameworks that create episodic and uncoordinated care, particularly when the person must traverse across healthcare settings.
3. Emerging models of care that make the nurse central to the care of the patient and family constellation. In the home as a healthcare setting, the nurses function somewhat autonomously and provide of broad range of care and care management. Nursing is an important specialty of care in the home, with a focus on promoting health and healthy habits, education, and practical applications of care that support health and function. Home care nurses employ many skills and clinical reasoning or critical thinking strategies in care planning to help patients reach their unique, identified goals. In home care, nurses use skills such as observation and assessment, specialized teaching and training, management and evaluation of the patient’s plan of care, providing injections, caring for urinary catheters, and providing skin and wound care. For example, wound care could include assessment and management of the wound, teaching and training related to the wound, hands-on care of the wound, and infection control and prevention.
Practical Application: Nurses can play a pivotal and leading role in reframing healthcare and bringing healthcare back to homes and communities. Think of Lillian Wald and other nurse leaders who are the benchmark for what health and healthcare in communities could “look like”.
4. The team focus. There is an adage that, “no one is as smart as all of us.” In home care and hospice at home, the care is not “siloed,” the team communicates and coordinates and the patient is an active participant in care, care planning and in the identification of goals. There may be nurses, therapists, such as an occupational therapist, a physical therapist, speech-language pathologists or speech therapists, a social worker, a home health aide, chaplains and others. Each of these team members contribute their expertise to the plan of care so patients meet their identified goals and reach positive outcomes in a timely manner.
Practical Application: How does this model get replicated and enhanced in other care settings? What is the overlap and contribution of each team member to ensuring safety and quality? This interprofessional care and care planning is very important for patients and families as healthcare team members are role models for health, effective communications and advocacy.
5. The home environment as the setting for healthcare. Homes and housing are as unique as the people that live in them. Unlike the hospital, where patients are generally wearing the same clothes (a hospital gown), eating the same foods (the offerings from the kitchen), visitors must come at certain hours and may need to be a certain age and more. Now consider a home in any city or place in the world. It is the home care nurse or other team member who is invited in. Remember that usually we do not enter someone’s home unless we “know” them and have been invited in. Imagine a day full of “home visits” where in the morning neither the patient/family nor the nurse has ever met each other. And now the visiting nurse must establish a rapport and connect with the patient and family to “admit” them to the home care program and then provide care. (And there are usually productivity standards to do this effectively and efficiently). This is an entirely different headset from that seen in the hospital. The nurse or therapist is on the patient’s home turf. And think of what else we have in our homes; our own ways of cooking and eating, different ways of keeping a home or house “clean” (always open to personal interpretation) and maintained. There may be pets that might not qualify as house pets by some people. (As a visiting nurse for many years I have met patients with squirrels, crows, and snakes as pets and more!). And remember a dog or cat that is “close” to their owner may have very strong (read: negative feelings) toward a stranger (in this case the healthcare team member) who comes in and wants to “touch” their owner, such as when taking a blood pressure or helping them move in bed, or providing catheter or wound care. All these moving parts of complexity come together in a home visit and, when it works, great nurses make it look easy. It is not. Somedays the nurse makes 6-7 or more visits, depending on the care needed, the schedule and a myriad of other factors.
Practical Application: Nurses providing care in homes must have the well-honed interpersonal gift of “meeting people where they are” and acceptance of varying lifestyles, and "be able to converse and interface with new patients and their families on any number of topics. This comfort level with a diverse and changing “caseload” of patients does not happen overnight, and is forged though an effective orientation and with ongoing education, mentorship and role modeling.
6. Technology and its use to improve safety, quality and costs. There has been much in the literature and news about the safety and quality equation in healthcare. Sadly, some have estimated medical errors may be the third leading cause of death in the U.S. behind heart disease and cancer. If true, this is an untenable position from a cost perspective—and not solely in dollars of course. The emergence of technology to identify potential problems, such as drug interactions, to avoid additional tests, such as in duplicative x-rays when the prior one is “lost” and e-based educational programs and innovations is a great thing for patients and clinicians alike. Telehealth, electronic health records and documentation software and systems can help with improving care and coordination which are needed from safety, quality and costs perspectives.
Practical Application: Embrace and learn new products as they become available and have the potential to help patients and families. Seek to become a “super user” should the opportunity emerge. Provide input to better enhance the products and their functionality.
7. Caring for people across the life span and where they are. Home care services can assist people regardless of age and healthcare problem. When caring for people of all ages and health challenges, it is important to be cognizant of their socioeconomic and psychosocial support circumstances. This is why care in the home is so different—it is holistic. For example, does the premature infant have the formula needed to grow and meet developmental and other goals? Does the frail elder, who lives alone and cannot leave their home unattended, have access to good foods and nutrition that support health needs? Is there a social worker who can help identify community resources and linkages to assist this patient and family? The types of people cared for in home care have a broad range of diagnoses. They can range from an older, obese adult with hypertension and chronic lower leg wounds to a young adult after a traumatic injury who is on a ventilator, with a tracheostomy and more. In some instances, these bedrooms look more like hospital rooms. The rooms and homes are often very uniquely individualized for that person, be it with their stuffed animals, video games, choice of movies and more.
Practical Application: Try to see people, families and their homes as a reflection of themselves. Skillfully and kindly frame questions to elicit information to be sure there is (enough) food, there is working heat or electricity and air conditioning, that they can afford their medications, and other resources to support health at home. These factors are important parts of health and care and can be determined during effective home visits.
8. Family, friend and other “lay” caregivers are starting to be recognized as an untapped resource. Who knows their family member or loved one the best? This is so fundamental. We must return to a common-sense structure for healthcare, and support these most important caregivers as part of the team! Some years ago I was in Thailand and Korea making presentations about home care. I remember touring a hospital and thinking “how neat is that; seeing family members in the hospital room with their family member? And bringing in food?” These family members, friends, partners and others should be more formally recognized and educated to improve care and outcomes. This is particularly true in some hospitals and health systems as this could assist in discharge planning and care once back at home.
Practical Application: Embrace these caregivers for what they are: an engaged and interested care team member. Visit www.e-caregiving.com for resources related to educating and supporting caregivers.
This is the time to think about how to “reframe” healthcare. If home was the central place for health and healthcare, think of the costs that might be saved from a quality, safety, and costs perspective. For example, medication errors and related costs could decrease as there is only “one” patient usually in the home receiving care. The effectively educated and valued family caregiver could be an active part of the team and assist in care and advocacy. Talk about a person-centered model—it does not get any more individualized than that. It might also be time to have one glossary and language for healthcare. There should not be “medicalese” spoken by healthcare professionals and another easier language for patients and families. For safety and respect reasons, patients need to know the correct terms, such as atrial fibrillations and others terms whenever possible. This “same language” may assist in clarity of communications from a safety perspective.
Healthcare has been highly specialized and we have an aging population where this complexity might not be the best model. Perhaps it is time for a more thoughtful way to provide compassionate care? Ask questions. Consider who might be the best direct care worker or nurse for a specific patient or patient population. In thinking about reframing or restructuring models to make the home the center of care, think of costs and the “true value” of person-centered, holistic care. This is especially true in hospice care, which I believe leads the models in truly person-centered care. Think of the healthcare world as you want it for yourself and your loved one. It may be a vision of the model where healthcare began – in the home.
For Further Reading
A Guide for Caregiving: What’s Next? Planning for Safety, Quality, and Compassionate care for Your Loved One and Yourself! by Tina Marrelli
Handbook of Home Health Standards: Quality, Documentation and Reimbursement, by Tina Marrelli.
Home Care Nursing: Survival in an Ever-Changing Care Environment. By Tina Marrelli
Hospice and Palliative Care Handbook, by Tina Marrelli
No Place Like Home: A History of Nursing and Home Care in the United States, by Buhler-Wilkerson.
Nurse Manager’s Survival Guide, by Tina Marrelli.