Vol. 16 •Issue 15 • Page 15
Home Care Challenges
Beyond the Door
Your emphysema is just going to get worse over the next few years, and you need to think about how you are going to deal with even simple tasks as you get more short of breath.”
That was the advice his doctor gave him two years ago, and now JB knows full well how bad it is going to be. Buying groceries, once a formidable task, is now virtually impossible due to labored breathing that cannot seem to support even the slightest exertion. A widower for the past five years, JB is on his own, and his future looks very dark indeed.
Elderly patients like JB present a special challenge for home care providers. Physical and psychological problems can impair treatment compliance in the home, and as a patient’s clinical condition worsens, so does his quality of life. Without timely intervention, a vicious cycle develops that can bring any patient to the brink of despair. Fortunately, help is available in several forms. One ap.proach involves high tech; the other, high touch.
Patients who are home alone lose the benefit not only of warm companionship but also the watchful eyes that can detect subtle changes in symptoms before they become clinical problems.
So just imagine the benefits of a technology that can send vital signs and responses to basic questions about symptoms to a distant nurse who notes trends in that information and communicates directly with the patient’s physician. Enter the world of telemedicine in the home care arena.
Such a system is already in place in a six-county region of central Pennsylvania, where telemedicine “has become a standard of care,” according to Therese Rossman, MA, RN, CPHQ, director of Home Health and Community Nursing Services at the University of Pittsburgh Medical Center, Lee Regional Hospital in Johnstown. The hospital began a partnership with HomMed, Wisconsin, in October 2002 and now has the capacity to monitor 28 home bound patients.
Equipment delivered to the patient’s house enables vital signs (weight, blood pressure, temperature, heart rate and pulse oximetry) to be transmitted via a modem to a central monitor in the hospital. The process is fairly simple. The patient sits in a chair for about three minutes while the equipment gathers the measurements. In addition to collecting the vital signs, the monitors prompt the patient to give “yes” or “no” responses to several questions designed to identify important trends in the patient’s condition.
For example, COPDers might be asked: “Are you using your inhaler more than usual?” “Did you limit your activities over the last day?” or “Are you experiencing more difficulty breathing today compared to a normal day?”
Other questions might address any difficulty a patient might have in taking medications or whether the patient used extra pillows to sleep comfortably.
Seven days a week, an RN reviews all information that is sent to the central monitoring station and then communicates with the patient’s primary case manager for possible follow up.
Data are color coded for easy recognition of values that might fall outside of normal ranges and can be trended over time to identify a declining clinical condition. The past several days’ vital signs can then be automatically faxed to the primary care physician for further review.
“Clinical judgment by the RN reviewing the data is critical,” said Rossman. The nurses look for troubling findings, such as one patient who had a consistently lowered heart rate and nausea which, following a visit to the PCP, turned out to be toxicity to digitalis.
Then there was the patient who had steady weight gain which prompted a call from a visiting nurse, who changed the dosage of the patient’s diuretic. Rossman also recalled a patient who could not receive reimbursement for home oxygen because each pulse oximetry spot check in the hospital did not reveal significant arterial desaturation. Closer monitoring with pulse oximetry in the home revealed a far different picture, one that ultimately resulted in Medicare approval for the home O2 therapy.
Telemedcine technology is not yet widely available, so where does that leave patients like JB, who may not have that option?
Fortunately, there are professional and compassionate home care providers who apply high-touch strategies.
“Monitoring the patient for compliance with the physician’s orders is an important aspect of providing home care to our patients” said Bob Shellenberger, RCP, area manager of Health Care Solutions. For example, Respiratory Care Medication Controllers provides a “customer service focus” and calls the patient to determine whether they are using and ordering their medications correctly. They also look for telltale symptoms such as tremor, lightheadedness or palpitations and schedule a visit by an RCP if indicated.
“Education is the key to getting good patient compliance with the physician’s orders,” Shellenberger added. To that end, RCPs must assure the patient fully understands medications and equipment before they leave the patient. Oxygen equipment can be especially daunting, and Shellenberger noted a therapist can easily record the hours of use on the concentrator or the frequency of O2 deliveries to determine whether the patient is using oxygen as prescribed.
Sometimes compassion can not overcome depression and a feeling of helplessness that might confront the elderly patient. In those times, home care providers can enlist the services of social agencies like Meals on Wheels or Visiting Nurses to assist the patient. Working more intensely with the patient and the PCP is key, and Shellenberger described how this approach worked for one patient.
After much planning and physician involvement, a therapist took a female patient to a local department store to demonstrate how easy it might be for her to go about the process of living with her disease.
This had a dramatic impact on the patient, whose goal is now to be a volunteer at her local hospital.
There will always patients like JB, who will need an extra helping of understanding and assistance.
But whether it is with high-tech or high touch-care, the professional home care provider must go beyond the door to meet that challenge and assure the best possible care for patients.
Eric Bakow is a Pennsylvania practitioner.