Facing Challenges in the Field

Clinicians entering home health face numerous challenges during patient visits. They must navigate the complexities of traveling between homes, managing visit schedules, assessing and treating patients, completing essential documentation, and maintaining effective communication with the interdisciplinary team—all while on the move in their vehicles.

The experienced team at ILS used their real-world experience to curate some of their best advice for home visits and built this guide on effectively managing these challenges through a set of simple, but valuable, tips.

Using COPE to Improve Patient Care

By utilizing the acronym C.O.P.E., we will focus on actions to take before, during, and after each patient visit and work to provide a more successful and fulfilling home health experience.

COPE = Communicate ⇒ Organize ⇒ Plan ⇒ Empathize

Before The Visit

Communicate

1. Call Your Organization: Contact your organization’s scheduling department to determine if there are new patients that need to be seen.
2. Call Your Patient: Provide a reminder to your patient, their family, or caregiver of the scheduled visit time for the next day. In the case of the first visit, engage in a conversation to gather important information. Inquire about parking arrangements, gate codes, the precise location of the residence, the presence of animals in the home, and their preference regarding wearing a mask during the visit.

Organize

1. Review Patient Information: Review documentation about the patient’s history, current plan of treatment, safety concerns, and the previous clinician’s documentation to determine if there are any new issues to address.
2. Check Supplies: Check that the supplies in your medical bag and car are what you will need for the day. Make sure no supplies have expired.
   Food for Travel Pack a lunch or snacks that will be ok in the car all day.

Plan

1. Mapped It Out: Schedule patients using a geographical map, always noting patient’s priorities, such as a timed event like an IV. Zip codes next to the patient’s names on your schedule may help in the planning.
2. Schedule Routine Times: Try setting up specific times during the day to schedule patients. For example, choose 4-5 key time slots such as 9:30 am, 11:00 am, 1:00 pm, and 3:00 pm and see if the patients can accommodate that schedule.

Empathize

1. Stuff Happens: Be flexible if the patient is not home when you arrive, even though you called them the day before. Always know that stuff will happen no matter how well you plan. Have alternative tasks such as documenting during that time.
2. Take Care of You: Be mindful of your current mental state and prioritize your well-being when creating your schedule. It’s crucial to consider your own mental health and avoid overloading yourself with an excessive number of patients, as this may have negative impacts. Find a balance that allows you to provide quality care while also taking care of yourself.

During the Visit

Communicate 

1. First Impressions are Important: Establishing trust and rapport, begins the minute you walk through that patient’s door. Be on time! Call if you run into anything that will change that time.  Strive to find a balance so you don’t get there too early or too late!
2. Introductions: When you enter the patient’s home, it is important to introduce yourself and visibly wear your name badge. Acknowledge each person present in a friendly and respectful manner. Clearly communicate:
   
   • The purpose of your visit for the day and provide an estimated duration. 
   • Inform them that you will be asking questions to better understand their health status and to clarify any goals they may have for improvement. 
   • Asking open-ended questions invites the patient, their family, or caregiver to provide detailed responses and express their thoughts and concerns. Additionally, utilize active listening techniques to demonstrate your attentiveness and genuine interest in what they have to say. Active listening involves giving your full attention, maintaining eye contact, nodding or providing verbal cues to show understanding, and refraining from interrupting.
   • Review  their medications and conduct a medication reconciliation process, 
   • Discuss their homebound status (explaining what it entails), and inquire about their medical history, illnesses, and any concerns they may have.
3. Team Collaboration and Patient-Centered Plan of Care: Discuss the team approach to their care emphasizing how you collaboratively develop a comprehensive plan of care that is focused on their specific needs. Explain that they may be meeting other members of the home health team including LVN,s CHHA. MSW, the therapy team and their assistants. Encourage the patient and family to actively participate in their care and express any concerns or questions they may have.
4. Electronic Devices for Documentation: Discuss with the patient, family, and caregivers that you will be utilizing an electronic device during your visit.  Let them know you will be documenting during the visit so you can capture their information immediately and accurately.
5. Setting Expectations: During your visit, it is important to have open discussions with the patient, their family, and caregivers about certain expectations and boundaries to ensure a smooth and effective care experience. Two important areas include having a clean space to set up the patient’s treatment area including wound care supplies and setting clear expectations regarding the duration of your visit based on the care you will be providing that day. By setting clear expectations and engaging in open communication, you can establish a foundation of trust and ensure effective collaboration throughout the visit.

Organize

1. Initiate the Bag Technique: After completing introductions and addressing any information, request permission to place your bag and supplies on a hard surface to begin the bag technique. This action signifies the beginning of the treatment process and can help minimize unnecessary or aimless chatter.  If there are obstacles that prevent you from performing infection control measures, decide the next and best course of action. You may need to take your bag back to the vehicle, and bring back only immediate and necessary equipment in a small separate bag that can be easily cleaned or be prepped with hand hygiene and gloves.
2. Documentation:  It is important to be mindful that completing documentation in the home or shortly after the visit is considered best practice in order to capture an accurate and comprehensive patient assessment. Research studies have demonstrated that immediate charting yields a retention rate of approximately 99% for newly acquired information. However, this retention rate decreases significantly over time, with a reduction to 50% after one hour, 30% after one day, and 10% after one week. Therefore, timely and immediate documentation is crucial to ensure the information is accurately recorded and readily available for future reference, effective care coordination, and continuity of care.

Plan

1. Be Alert: Pay close attention to potential distractions in the home, such as pets, loud noises from music or television, or the presence of young children. Collaborate with the patient to minimize these distractions, ensuring that they receive your full attention during the visit. Additionally, be vigilant about the safety of the home environment. Prior to initiating the physical assessment of the patient, assess and address any immediate safety concerns. Observe any potential risks, such as smoking while using oxygen, pills scattered on the bed, improper heating during hot weather, or the patient being inadequately dressed for the visit. Taking note of these issues allows for prompt intervention and ensures the overall safety and well-being of the patient during your visit.
2. Scheduling the Next Visit: Utilizing the calendar in the patient’s home can be a helpful tool to keep everyone informed and prepared for the next visit. Be alert to difficulties that may arise as you try to schedule the next visit, maybe they need an afternoon appointment as they do not sleep well at night.

Empathize

1. Practice Patience: While we are familiar with the responsibilities and purpose of a home health visit, it’s important to recognize that the patient, their family, or caregiver may not fully understand the process. Therefore, it may be necessary to exercise patience in addressing their questions and providing clear explanations regarding your role as their healthcare provider in the home. Taking the time to clarify and reassure them can help establish trust and ensure that everyone involved has a clear understanding of the objectives and expectations of the visit.
2. Patient Privacy: Note who else is with the patient, and verify they want to proceed with someone else there. Such as a roommate at a facility, or a family member.
3. Identify Psychosocial Factors: Understand the psychosocial aspects of the patient and their surrounding support system. They may be fearful of the cost of the visit, that a visitor to the home may force them to clean the home, and they are avoiding recognizing their illness or the illness of their loved one. Be ready to provide  reassurance prior to the visit that you are there to simply provide support for their current health care needs that the MD has ordered.
4. Stay Flexible: As we are visitors, be alert that the visit may go in a different  direction than you anticipate! The patient may refuse home health care AFTER you have obtained consent and provided an assessment and even care the ordering practitioner may have requested. When you arrive the patient may request you wait until they finish lunch, a call, using the restroom. They may also ask you to park somewhere else!
5. Pay Attention: Remember as a visitor to the patient’s home you must give the patient, family, and caregiver one hundred percent of your focus. Do not take personal calls, if you must take a work call alert the patient that you may receive a call regarding another patient from the MD and you may have to excuse yourself briefly.
6. Embrace Differences: Maintain an open and understanding mindset, appreciating the diversity of the patient, their family, and caregiver. Meet them at their level of understanding when providing education. Assess their specific needs, such as whether they require handouts or if they have access to email for online learning materials. Remember that patients’ rights require that information must be provided in their preferred language.  By adapting to their unique circumstances and preferences, you can ensure that the educational information is effectively communicated and accessible to them.

After the Visit

Communication

1. Call The Team:  It is important to share a report with the team promptly, ideally right after the visit. You can accomplish this through secure messaging, verbal reports, or a teleconference. Include key information such as your assessment findings, interventions administered, any orders received, medications given, and details about consultations with other practitioners. Describe the patient’s response to the interventions provided. Identify any obstacles or challenges that the team may need to address in order to ensure continued care.
2. Document: It is crucial to thoroughly document all aspects of the patient’s care, providing specific details about the times and individuals you interacted with. Remember that incomplete documentation can result in other team members being unaware of your findings, potentially impacting patient care. Ensure that your documentation is comprehensive and timely to facilitate effective communication and continuity of care within the healthcare team.
3. Changes in Plan of Care: When a patient experiences a change in condition, it is essential to promptly report and respond to the physician or approved provider responsible for managing the patient’s home health care. Immediate communication is necessary to ensure appropriate and timely interventions can be implemented to address the change in condition.

Organize

1. Check Your Inventory: After completing a patient visit, it is important to reflect and ask yourself if you have utilized any supplies during the visit. Assess whether you need to reorder any necessary items to ensure you are adequately prepared for future visits.
2. Think Ahead: To ensure preparedness for your next visit, it is crucial to be organized and have a clear understanding of what you need and what needs to be done. Take the time to gather and arrange the necessary supplies, equipment, and documentation required for the visit.
3. Request Help When Needed: If you find yourself stuck or facing difficulties with electronic medical record (EMR) documentation, remember that you are not alone. It is common for clinicians to encounter challenges with EMR systems. In such situations, don’t hesitate to reach out for assistance.

Plan

1. Think Ahead: Stay mindful of when the patient will require their next visit or follow-up appointment. This allows you to effectively plan and allocate your time, ensuring that you can accommodate the patient’s needs and provide continuity of care.
2. How Did The Visit Go: Reflect on the recent visit and ask yourself if there were any safety concerns that should be addressed before the next visit. It is important to identify and address any potential hazards or safety issues to ensure the well-being of both the patient and the healthcare provider. Additionally, if you encountered any concerns during the visit, consider discussing them with your supervisor.

Empathize

1. Ask For Help: Don’t hesitate to ask for help when faced with tasks or situations that you don’t fully understand. It’s important to recognize your limits and seek assistance when needed. If there was something that arose during the visit that you were unable to complete or understand, reach out for support.
2. Remain Flexible: It is essential to embrace flexibility and multitasking as part of your routine. Understand that changes can occur frequently, and it’s crucial to maintain a mindset of acceptance and adaptability.
3. Is More Training Needed?: Acknowledge that you may require additional training and support to enhance your skills and knowledge. If you are still in the learning process, be patient with yourself and don’t hesitate to reach out to your supervisor for guidance and assistance. They can provide the necessary support and resources to help you excel in your role. Remember, seeking help and having a growth mindset are valuable qualities that contribute to your professional development in the field of home health.
4. Practice Self-Care: Home health visits can indeed be rewarding, but they also present unique challenges on a psychosocial level. As a healthcare professional, you will often work closely with patients, their families, and caregivers who may be navigating a disabling health crisis or facing end-of-life situations. It is crucial to recognize the emotional impact of such situations and prioritize self-care and avoid burnout. By prioritizing self-care and maintaining a healthy work-life balance, you can preserve your own well-being while continuing to provide compassionate and high-quality care to your patients and their families. Remember that taking care of yourself is a fundamental part of being able to care for others effectively.

Final Thoughts on Home Visits

Home visits can be intimidating but applying the COPE method and the tips above can help you to provide excellent patient care.

References

https://ahhqi.org/media-center/attach/109-1.pdf

https://pubmed.ncbi.nlm.nih.gov/31865617/

https://blog.brookespublishing.com/6-things-to-do-at-the-beginning-of-every-home-visit/

https://safetyculture.com/checklists/home-visit/#:~:text=Home%20visit%20checklists%20are%20used,patients%20and%20provide%20patient%20care.

https://www.indeed.com/career-advice/career-development/home-health-nurse-tips

https://dailynurse.com/home-health-basic-tips-for-a-safe-successful-practice/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4503505/

https://shccares.com/top-10-tips-for-home-health-care-professionals/

https://allnurses.com/tips-home-health-nursing-t207956/

https://www.indeed.com/career-advice/career-development/home-health-nurse-tips

https://www.medprostaffing.com/successful-home-health-nurse/

 

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