Cueto, Cunanan, Dadgardoust, Daguman, Damo, David H.L., David H.A., De

Guzman J. , De Guzman R., De Leon, De Mesa, De Vera, Dela Cruz C., Dela Cruz F., Dela Cruz I.,

Dela Rosa, H., Delos Santos K.

HOME CARE

Home Care• Provision of comprehensive health services

to individuals and families in their own residence -promote, maintaine or restore health

- Minimize the effect of illness and disability

• Being prepared to become a member of the team caring for a chronically-ill or terminally-ill patient at home

• More people-oriented

Services Offered in a Home Care Program

Medical CareRehabilitationCounseling and health educationWellness programDiagnostic and therapeutic proceduresNursing careSpiritual careSupport groupCommunity resourcesTransportationBereavement and respite careFirst aid

Therapeutic Procedures Transferred at HomeParenteral nutritionHome enteral nutrition (nasogastric tube)Intravenous antibioticsBlood transfusionsRespiratory therapyRenal and peritoneal dialysis

Home care services must be able to provide comfortable transition to home, maintenance of optimal clinical condition, ongoing health education and reinforcement of learning and continuity of care

Role of the PhysicianManager

Acquisition of appropriate home care assessment skills

Assessment of the adequacy of family caregivers and resources

Knowledge of community resourcesKnowledge of home care technologyIntegration of home and hospital care for

patientsAbility to lead the home care team.

Preparations for Home Care

MultifacetedAssessment and

preparation of both patient and home environment – facilitate safest and smoothest transition

Sharing information about diagnosis being considered

Discussion of treatment plans and therapeutic options

Assessment includes:Evaluation of physical

conditionsFunctioning of

extremitiesSensory components Excretory functionsSocial factors

Prior to discharge, physical functioning must be enhanced by:Elimination

unnecessary bed rest Physical activity must

be encouragedCaregivers (trained)Safety measuresCareful planning of

mobility for bathroom, doors, and stairs

Organizing a Home Care Program

a. Get manpowerHome care team consists of:

Primary care physicianNurseTherapistSocial workerVolunteers

Effective Cost-saving manner to the patient

b. Train staff

Assess hazards in the homeConduct functional assessmentMonitor medicationsAssess caregivers

c. Prepare a home care program

Includes the various services offered mechanics of implementationSet policiesIssues on reimbursement or fees

d. Establish networking and linkagesHelp people deal with health and social

problemsEstablish good lines of communication

(agencies, communities, etc)Awareness of what they offer

e. Implement the program• Diagnosis and prognosis should be clear• Verify if the patient & family is informed

about the referral• Clarifications: Call the attending physician• Meet and establish rapport, know their

expectations, Do goal setting.• Schedule-frequency of visits• Checklist of gadgets and equipments• Financial agreement

f. Evaluate the programMonthly health management meetingDetermine if the planned care is effectively

achieving its expected outcomeAdjustments to be done

Guidelines for Home VisitPreparationPlanningCoordination

Guidelines for Home VisitPrior to home care:Patient selection

Admission criteriaReview medical records – goal for a patientTake notes, form questions, make hypothesis

Schedule visit

Guidelines for Home VisitPrepare a home care plan

MedicalPsychosocialWellnessEconomicEnvironmentalIncluding short and long term goals for the

patient and his family

Guidelines for Home VisitDuring the visit:Establish rapportBrief review of medical historyExploration of psychosocial issuesLiving conditionsSelect a primary caregiver appraise his capabilities

Guidelines for Home VisitDuring post-visit: • Write the report of visit– Problem list– Specific interventions performed

• Schedule follow-up visits– Check compliance– Render continuing care

• Refer to other disciplines and coordinate with them, if needed.

COMMON HOME CARE PROCEDURES AND

INTERVENTIONS

NGT (Nasogastric Tube) Insertion

Source: http://emprocedures.com/ngt

NGT (Nasogastric Tube) Insertion

1. Gloves, protective gown, and face shield2. Nasogastric tube3. 2% lidocaine jelly4. Phenylephrine nasal spray 5. Atomized lidocaine or benzocaine spray6. Cup of water with straw 7. Emesis basin8. Towels, chux9. 60cc catheter tip syringe10. Stethoscope11. Tape12. Suction

Source: http://emprocedures.com/ngt

NGT (Nasogastric Tube) Insertion INDICATIONS:

a)Aspiration of stomach contents for either diagnostic or therapeutic reasons

b)Feedingc)Administration of therapeutic substances

Source: The Filipino Physician Today, 2nd Edition, Maglonzo

CONTRAINDICATIONS:

a)Esophageal stricturesb)Facial fracturec)Comatose patients with unprotected

airwaysd)Penetrating cervical wounds

Source: The Filipino Physician Today, 2nd Edition, Maglonzo

Mechanical Ventilation• Indication: respiratory failure

• Recommendations– VT = 10-15 mL/kg– Rate = 60-80 breaths/min– FiO2 = 0.40– Ventilator mode: assisted control– Inspiratory flow = 50%– Peak pressure = 50 cm H2O– I:E ratio = 1:2– Humidifier temperature = 35˚C

3. Tracheostomy Tube Suctioning and Cleaning

Tracheostomy tube consists of: inner canula, obturator, ties and fenestrations

Remove accumulated secretions to:facilitate patient comfortincrease respiratory efficiencydecrease risk of complete airway obstructiondecrease the risk of infection

Clean the inner cannula- done twice a day- done by immersing it in hydrogen peroxide and then rinse with normal saline

Clean tracheostomy site with sterile cotton buds and normal saline

Replace soiled ties

Catheter InsertionFemale

Catheterization• Half the catheter must

be inserted before inflating the balloon.

• Place it in the urethral meatus.

• From the urethral meatus, catheter advances towards the bladder as it proceeds in a slightly upward direction.

Catheter InsertionMale Catheterization• Insert at least 24cm

before inflating the balloon.

• Place the distal urethra in a slight stretch straight up to straighten the urethra.

• Catheter then needs only a single curve on its way to the bladder.

Intravenous (IV) Intravenous (IV) MedicationsMedications enter the patient’s bloodstream directly by

way of a veinAppropriate when:

rapid effect is requiredMedications are too irritating to tissues to be

given by other routes

Take note!Assess caregiver’s eyesight & manual

dexterityCheck appearance of medication and

expiration dateKnow which medications are unsuitable for

IV administrationObserve patients for any adverse reactions

Home Care

IV InfusionIV InfusionFor shortened hospital stays and the need

to cut costsPeripheral IV lines are used for the

maintenance of fluid balance, administration of medications and nutrition.

The butterfly or catheter set may be used. Then it is connected to the tubing of the intravenous system.

Home Care

IV InfusionIV InfusionPermanent access

Long-term or home parenteral nutritionAchieved by placement of a catheter with a

subcutaneous part for access, by tunneling a catheter w/ a substantial subcutaneous length, or threading a long catheter through the basilic or cephalic vein into the SVC.

Temporary/ Short-term accessAchieved w/ 16- gauge, percutaneous catheter

inserted into a subclavian/ IJV and threaded into the SVC

Nursing Care

Includes:• Positioning and moving the patient in bed• Perineal care• Oral care• Bed bath• Transfers

Nursing care

Positioning and moving the patient in bed

Nursing Care

Perineal care

Oral Care

Nursing Care

Bed Bath

Nursing Care

Patient transfers

Immunizations Most cost-effective form of disease control and the only

form effective against many viruses 2 types: Active immunization occurs by administration of antigen,

and requires an immune response. Passive immunization occurs by transfer of preformed

immunoglobulin. “Booster” immunizations generate secondary responses

and increase the strength of immunological memory. Home vaccination are provided by physicians

themselves, including a pre-assessment Several factors needed to be considered before any

patient is vaccinated: susceptibility of the patient, the risk of exposure to the disease, the risk from the disease, and the benefits and risks of the immunization.

Wound Dressing• One of the most common services provided• Wounds that are difficult to heal, usually because of

underlying disease processes, anemia, poor nutrition, wound contamination, chemical irritants and other factors

• Chronic wounds: basic wound care including frequency of dressing change, type of dressing used, cleaning solutions, and topical medications, is generally determined by the physician

• Wound treatment and management include the following:– Prevention of further tissue destruction– Prevention of infection– Planning treatments as appropriate for the type of

wound, condition and size of the wound

Lab Screening• Yearly physical examination and home

laboratory screening for undetected diseases at the confines of your home

• Complete with interpretation by a fully licensed physician

• Cholesterol screening, Blood pressure screening, Obesity screening, Diabetes mellitus screening

• Cancer screening tests

Ancillary ProceduresMobile x-raysUltrasound

Caregiver TrainingModules are designed to train family

members, informal household carers, and caregivers on the proper management of patients

Treatment plan that addresses needs of caregiver and the patient. Identification of caregiver burn-out or stress.

Issues in Home Care

LEGAL ISSUESHome care policies must be properly drafted

to avoid medicolegal riskIncludes documentation of all examinations,

conversations and care rendered Constant surveillance and attention to quality

of care are the best preventive measures

Ethical IssuesThere must be an informed consent

All risks regarding the procedure must be explained to the patient

There must be an agreement before a procedure can be started

If the patient is not competent to make a decision, the guardian or any family member can give the consent

Financial Issues

The Philippine Health Care Insurance System does not have any provisions for reimbursement in the home care setting.Before entering the home care, the patient’s

family should be informed regarding the financial agreement.

Legal Issues and Considerations on Home Care

Legalities of Home Carelegal documents and formalities for

completionDone ASAPInclude the person/patient involve and his/her

family in the decision makingOnly a very close friend or family member with

no conflicting motives should be given these powers.

Letters of Instruction• A letter of instruction provides important

information and instructions a caretaker may need.

• It includes – the contact information for close family

and friends, – a list of assets and liabilities, a list of

insurance policies – and information on all financial

accounts.

WillA will designates who will receive major

assets after a person dies.. It also includes guardianship of any children

under the age of 18. Smaller items such as heirlooms, furniture

and other household goods, should be addressed in a separate testamentary letter.

This letter should be referenced in the will.

Living WillsA living will is a clear statement about

wishes regarding artificial life support. If a person's brain is dead yet the body

remains functioning only with the help of life support, a living will directs attendants in what choice to make - to keep the machines functioning or turn them off.

Power of AttorneyIf the people under your care are unable to

make decisions for themselves because they are somehow incapacitated, you will need to have power of attorney to make these decisions for them. Of course, they will need to create powers of attorney before they are actually needed

Two Types of Powers of AttorneyDurable Power of AttorneyHealthcare Power of Attorney

Durable Power of Attorneygives a person, or people, authority to

manage finances and other legal affairs if the person needing care is not capable of managing these.

It can be long-term or short-term. Allows the party that has power of attorney

to use money to provide care, sign tax returns, handle investments and other important matters.

Healthcare Power of AttorneyAllows the person designated to make

healthcare decisions if the person being cared for is unable to make these himself or herself.

For example, someone holding power of attorney may be able to decide against dangerous surgery if he or she feels that is in the patient's best interest.

Trust• Establish financial resources for family

members, especially for those who cannot easily do so themselves, or for those with a disability

• To protect assets in the event of an older person requiring residential care

• Organise your personal financial affairs• Provide a form of protection for various

beneficiaries• Protection of assets against creditors• Establish a Trust for charitable purposes

THANK YOU!