The transition from hospital, rehabilitation center or other care setting to home has brought new challenges and opportunities for providers in a patient’s care circle. Clearly accelerated by the pandemic, health care trends have increasingly reflected earlier and more rapid hospital discharges and more acute care delivery being facilitated in the home. With this shift, the homecare industry has an opportunity to be a critical partner among allied health care providers to improve patient outcomes.
In addition to being the least restrictive care environment, what patient would not prefer to recover in the comfort and familiarity of their home if the appropriate care resources were available?
Homecare providers and their nonclinical, highly skilled caregivers can play a significant role in promoting a patient’s health, safety and recovery. While many health care providers come into the home for various medical interventions, they tend to be there for much shorter durations than a homecare provider. Not only does having a nonclinical caregiver in a home for extended periods of time provide critical assistance with activities of daily living (ADLs), but the caregiver can also observe changes in a patient that warrant alerting members of the care team.
Care Coordination to Improve Patient Outcomes
As soon as homecare appears to be a needed resource to support a patient’s recovery, a homecare representative and/or the caregiver should be part of the care team’s discharge planning discussions.
Homecare providers can play a significant role in care coordination. With proper training, caregivers can become critical eyes and ears in the home to report behavioral changes that may indicate a need for medical interventions. Such observations may include:
- Physical evidence of the need for
- wound care
- Changes in appetite and food consumption
- Increased isolation or withdrawal
- Changes in or increased difficulty with speech or mobility
- Erratic behavior or physical complaints that may be associated with medication side effects
- Changes in the frequency or patterns of toileting or sudden incontinence
- Increases in pain, weakness or disorientation
- Changes in the patient’s mental health
Any of these changes during a patient’s recovery could warrant outreach to a primary care physician or home health clinician. In-home care providers and their caregivers should participate in care team meetings and have contact information readily available should they need to initiate and escalate outreach for medical intervention.
At the same time, health care professionals should understand the myriad ways in which nonmedical care in the
home can support a patient’s successful recovery and the patient’s aftercare plan. Just a few of the critical homecare interventions that directly help promote patient recovery include:
- A post-discharge safety checklist and review of the home to reduce the risk
- of falls
- Coordination of any home modifications necessary to support a patient’s recovery at home
- Assistance with meal preparation and any special dietary needs
- Mobility assistance
- Transportation and escort assistance to follow-up medical appointments
- Personal care such as dressing, bathing and toileting
- Medication reminders
- Companionship and friendly conversation to encourage healthy recovery
- Assistance in facilitating video conferencing platforms with medical professionals or connection with family members
- Light housekeeping such as linen changes and running errands like picking up prescriptions
Discharge Planning
All too often for the family member or patient, the discharge process feels rushed and unexpected. Yet discharge planning should really begin at the time of admission and leave the patient and family feeling relieved that an aftercare plan is in place—along with all of the appropriate support and follow-up necessary for a successful and seamless recovery.
Homecare providers can take proactive steps to prepare the family and patient as well by providing checklists, tips and tools that include such things as medication
lists, questions one should ask their health care provider and action items to prepare one’s home.
Everyone in a patient’s care circle will feel relieved knowing there is a homecare plan that includes which ADLs the patient needs assistance with, plus a safety checklist to ensure the environment is conducive to recovery. In addition, a list of follow-up medical appointments, regular therapies like dialysis or other appointments the patient will need assistance in attending is also critically important.
Understanding the Homecare Referral Partner’s Needs
Hospitals and other health care providers are seeking to avoid emergency room visits and reduce hospital readmissions and falls. Such measures should be part of any homecare provider’s care management processes and providers should be able to track and report their outcomes to potential referral partners.
We have all heard clients and patients sometimes confuse the differences between home health and in-home care provided by those who aren’t clinicians, causing the broader homecare industry to often use the term “nonmedical” to emphasize the limits of the service provided. While it is true that homecare isn’t clinical in nature, it can’t be overly stated the profound and positive impact that homecare has on an individual’s health, well-being and safety.
While the value of homecare has certainly become clearer as a result of the COVID-19 pandemic, it is still critical that potential referral partners such as hospitals, rehabilitation centers and assisted living communities have a better understanding of the impact of homecare on patient recovery.
