A systems approach to asthma care

This two-year asthma intervention focuses on provider education emphasizing early diagnosis of asthma, early use of oral steroids, proper use of inhalation devices, objective monitoring of patient status, and use of daily preventive treatment. Patient education is an integral part of treatment. This approach supports the primary care physician as the provider and coordinator of care by supplying monitoring and treatment devices, books, diaries, home care services, and allergy consultation. It also manifests a systems approach to asthma care in its reliance on a nurse case manager who oversees patient and family support network.     

Facilitating cancer pain control in the home: Opioid-related issues

The basic principles of pain management are the same whether the patient is in an acute care setting, their home, or a long-term care facility. Wherever the setting, pain management is part of the comprehensive care for the cancer patient. Successful therapy depends on a clear definition of treatment goals, an informed patient and family, collaboration and effective communication between the physician, home care nurse, patient and family, and ongoing monitoring to ensure effectiveness of pain relief measures. Careful discharge planning to ensure appropriate home care for the patient with pain and their family is critical.     

A clinical pathway for deep vein thrombosis

The use of low molecular weight heparin to treat deep vein thrombosis at home represents a relatively new patient population for home care agencies. Use of a clinical pathway provides a framework for defining expected outcomes of care and direction for patient assessment, care, monitoring, and documentation. Implementation and evaluation of a clinical pathway are described.     

Continuous home heparin infusion therapy in the ambulatory patient.

Until recently, continuous heparin infusions have been rendered only in the hospital setting. With the expansion of high technology, proper monitoring, and patient and family participation, it is practical and safe to administer heparin anticoagulation therapy in the home setting. The home care coordinator plays a key role in coordinating a smooth transition from hospital of home. This article provides an overview of the history of heparin, the indications for home heparin anticoagulant therapy, patient teaching goals, and the role of the home care coordinator.     

Home care of the patient with advanced lung cancer

Improvements in early detection and treatment of lung cancer, as well as health care cost containment, have combined to make home care of the patient with advanced disease common today. Treatments once performed only in medical centers are now routine parts of home care. Families are providing sophisticated bedside care under the guidance of the home care clinician. This article has highlighted home management for the respiratory-related problems of patients with advanced bronchogenic cancer: dyspnea, cough, and hemoptysis. Such patients experience many difficult physical and emotional problems. The home care nurse, as teacher and coordinator, assists the patient and family to live each day to the fullest.     

Safety in transfusion practices. Red cell compatibility testing issues.

Pretransfusion compatibility testing, if performed properly, helps to maximize the effectiveness of transfusion therapy and to minimize the risk of hemolytic transfusion reactions. Each laboratory should select the procedures and protocols that are best suited to meet their patient care and institutional needs. Quality assessment monitoring of the elements of compatibility testing helps to ensure a high level of safety for patients receiving transfusion therapy.     

Partnering for optimal respiratory home care: physicians working with respiratory therapists to optimally meet respiratory home care needs

The need for respiratory care services continues to increase, reimbursement for those services has decreased, and cost-containment measures have increased the frequency of home health care. Respiratory therapists are well qualified to provide home respiratory care, reduce misallocation of respiratory services, assess patient respiratory status, identify problems and needs, evaluate the effect of the home setting, educate the patient on proper equipment use, monitor patient response to and complications of therapy, monitor equipment functioning, monitor for appropriate infection control procedures, make recommendations for changes to therapy regimen, and adjust therapy under the direction of the physician. Teamwork benefits all parties and offers cost and time savings, improved data collection and communication, higher job satisfaction, and better patient monitoring, education, and quality of life. Respiratory therapists are positioned to optimize treatment efficacy, maximize patient compliance, and minimize hospitalizations among patients receiving respiratory home care.     

Early rehabilitation at home of elderly patients with hip fractures and consumption of resources in primary care

From 1976 onwards an active rehabilitation programme has been applied to elderly patients with fresh hip fractures at the Department of Orthopaedics in Lund in Southern Sweden. This involves early mobilisation in the hospital (internal fixation and immediate weight-bearing) and at home, rehabilitation in cooperation with primary health care personnel from the time of the patient's admission. The purposes of this investigation were to evaluate the effect of this programme in primary care and to assess the consumption of resources for rehabilitation at home of patients with cervical or trochanteric hip fractures. One hundred of 161 consecutive patients returned home directly on discharge from the hospital and were followed up until four months after the fracture by the home care unit (a primary health care centre). Most patients regained their previous functions within four months of their fractures. Patients with cervical fractures consumed less resources for rehabilitation than patients with trochanteric fractures. The total cost per patient was ten times higher for care at a convalescent-home than for rehabilitation at home through primary care. Early at home rehabilitation of elderly patients with hip fractures gives good results at a minimal cost and is thus of advantage both to the patient and to the community.     

Which type of observation for patients with high-risk mild head injury and negative computed tomography?

OBJECTIVE: Current guidelines suggest hospital admission followed by home monitoring for high-risk patients with mild head injury and negative computed tomography scan. We tested early home monitoring under the care of a competent observer. METHODS: A total of 1480 patients with mild head injury and negative computed tomography scan were prospectively studied. Based on clinical status and available home caretakers, patients were managed by in-hospital observation (n = 646) or early home monitoring (n = 834). Outcome measures were: (1) the detection of previously undiagnosed post-traumatic intracranial injury; (2) neurosurgical intervention; and (3) unfavourable outcome (death, permanent vegetative state or severe disability). RESULTS: In the in-hospital arm, nine cases (1.4%) developed intracranial injuries (in three after discharge). In the early home-monitoring arm, six patients (0.7%) had a previously undiagnosed lesion after re-admission (P = 0.773 versus in-hospital arm). No patients with previously undiagnosed intracranial injuries had a neurosurgical intervention. After 6 months, five patients had died in the home monitoring arm (0.8%) versus eight (1.0%) in the in-hospital arm (P=0.785). No permanent disability or vegetative state was observed. CONCLUSION: Early home monitoring may be safely proposed to selected "high-risk" patients, with an early negative computed tomography scan, normal clinical examination and feasible home monitoring.     

Patient satisfaction in home health care

Aims and objectives. To assess the current use of patient satisfaction measures in home health care and to examine the reliability and validity of current measures of patient satisfaction in home health care. Background. Patient satisfaction has been one of the widely used measures in home health care as an indicator of quality of care. A few efforts have been made to develop psychometrically sound patient satisfaction scales for use in home health care. Design. A critical review of the literature. Methods. Electronic databases were systematically searched to identify the studies or publications that measured and addressed patient satisfaction and its measurement in home health care. Results. The review of the literature showed that patient satisfaction measures have been used in the evaluation of care programmes including rehabilitation programmes, discharge and home follow‐up programmes, care process and management practices. Also, patient satisfaction measures were used to evaluate new care protocols and treatments. Conclusions. Home healthcare agencies need valid and reliable patient satisfaction scales. Frameworks of patient satisfaction are still in their early developmental stage. Only some of the variables related to patient satisfaction are explained by many frameworks. Relevance to clinical practice. Home healthcare mangers and researchers need to take in consideration the reliability and validity of measures and tools of patient satisfaction.     

Remote telemonitoring for patients with heart failure: might monitoring pulmonary artery pressure become routine?

Heart failure is one of the most important medical problems facing societies in developed economies and its prevalence is predicted to rise inexorably in the next few decades as longevity increases. Worsening heart failure leading to hospitalization is associated with a poor prognosis and imposes a substantial burden on health care resources and budgets. Interventions that can stabilize patients should reduce the need for hospitalization and improve prognosis. This might be facilitated by frequent self-monitoring of clinical and physiological variables by patients themselves at home. Rising pulmonary artery pressure is an early sign of cardiac decompensation that may be more sensitive than conventional methods of patient assessment and thus allow early adjustment of medical therapy to avoid hospitalizations and improve patient outcomes. Remote monitoring of pulmonary artery pressure is now possible using devices that can be implanted percutaneously. This innovative technology could become a routine part of the management of heart failure in the next few decades.     

Improving care of HIV-infected patients in the outpatient setting with patient data flow sheets.

Medical management of pediatric/adolescent HIV has become increasingly complex, requiring a multidisciplinary approach to care. Close clinical monitoring is needed to minimize opportunistic infections, initiate appropriate antiretroviral therapy, and ensure optimal health care to the patient. Monitoring should include evaluation of efficacy and side effects of therapy, early detection and treatment of HIV-associated complications, and maintenance of current immunizations. Tracking clinical data in chronically ill patients is a difficult task without an effective monitoring system. A patient data flow sheet was created to assist in planning care and monitoring disease progression by consolidating clinical information into an organized, one-page summary for each patient. One year after the patient data flow sheets were instituted, there was a significant improvement in the consistency of obtaining and monitoring routine HIV labs as well as serologies, and other recommended tests. The flow sheets have increased effectiveness of patient care and have been used to assist with quality assurance monitoring and quality improvement in the clinic setting.     

A disease management program for heart failure: collaboration between a home care agency and a care management organization

This article describes a collaborative approach to manage patients with heart failure between a home care agency and a care management agency. The resulting disease management program used a combination of home visits and phone contact. Care management plans emphasized patient education on increasing adherence to medical and diet regimens, and recognizing early symptoms of exacerbation that could lead to rehospitalization. Clinician activities and patient outcomes are described.     

Early Rehabilitation at Home of Elderly Patients with Hip Fractures and Consumption of Resources in Primary Care

From 1976 onwards an active rehabilitation programme has been applied to elderly patients with fresh hip fractures at the Department of Orthopaedics in Lund in Southern Sweden. This involves early mobilisation in the hospital (internal fixation and immediate weight-bearing) and at home, rehabilitation in cooperation with primary health care personnel from the time of the patient's admission.

The purposes of this investigation were to evaluate the effect of this programme in primary care and to assess the consumption of resources for rehabilitation at home of patients with cervical or trochanteric hip fractures.

One hundred of 161 consecutive patients returned home directly on discharge from the hospital and were followed up until four months after the fracture by the home care unit (a primary health care centre). Most patients regained their previous functions within four months of their fractures. Patients with cervical fractures consumed less resources for rehabilitation than patients with trochanteric fractures. The total cost per patient was ten times higher for care at a convalescent-home than for rehabilitation at home through primary care.

Early at home rehalibitation of elderly patients with hip fractures gives good results at a minimal cost and is thus of advantage both to the patient and to the community.     

Feasibility of using ambulatory electrocardiographic monitors following discharge after cardiac surgery

Although ambulatory electrocardiographic (ECG) monitors are increasingly being used to detect arrhythmias in outpatient and home care settings, little is known about patients' reactions to these devices and their ability to use them correctly. This study determined the feasibility of this type of monitoring. It provides clinicians a research-based approach to patient care and teaching in the home.     

Down to the fundamentals of telehealth and home healthcare nursing

Many changes have taken place in the field of home healthcare. Because of these changes, home health agencies must be creative and implement various tools that help improve quality of care for their patients. Starting with the most basic intervention definitely can lend a hand in improving patient outcomes. Phone monitoring, the most basic form of telehealth, can be an important aspect in a patient's plan of care.     

Early Discharge and Specialist Transitional Care

A model has been designed to discharge patients early from the hospital by substituting a portion of hospital care with a comprehensive program of transitional home follow-up by nurse specialists. The model, initially tested with very low birth weight infants, provides a framework for examining both the quality of care as reflected in patient outcomes and cost of care to specific patient groups. Its design documents nursing interventions and allows for comparisons of care by nurse specialists and other health care providers.     

Using nursing research to assess families managing complex home care

Families have become "health care systems" by providing physical, emotional and social home care for their loved ones dependent on technology. Examples of home technology equipment include renal dialysis, mechanical ventilation for sleep apnea, electronic apnea monitoring for premature infants, intravenous infusions of antibiotics, hyperalimentation, or narcotics and spinal infusions for pain relief. There is much more to the 24 hours of family involvement than the actual bedside physical care. For example, some of the activities a family would need to do for a patient with an intravenous infusion of antibiotics is: go grocery shopping, setup the infusion, cleanse the infusion site, walk the dog, prepare meals, order supplies, clean the house, and check equipment for expiration dates. All the "health care systems" responsibilities become "home care systems" the family must initiate and successfully complete.     

Home Delivery: Transfusion Services When and Where They Are Needed

Home blood product transfusion has been utilized around the world in various forms over the past few decades. There is current interest in decentralizing hospital care to improve patient independence and convenience, minimize cost to the health service, and to prevent nosocomial infection, especially with the recent COVID-19 pandemic. The transition to “hospital in the home” is occurring across the healthcare sector driven by aims to improve patient outcomes and patient satisfaction, capacity pressures in the acute care sector, and most recently due to concerns regarding infectious disease transmission in hospital settings. This review explores the published literature on home red cell and platelet transfusions, and where the literature is limited, also considered data from subcutaneous immunoglobulin studies. Current published experience on red cell and platelet transfusion at home has identified benefits to the patient and health service, with further studies needed to quantify improvement in quality of life and health-related outcomes. Safety concerns may be a perceived barrier to implementation of home transfusion, however current published data suggests serious adverse reactions are rare. Cost-effectiveness data for home transfusion are very limited and a key area for future research. Home transfusion has the potential to benefit from newer technologies, such as portable/remote monitoring and electronic patient identifiers.     

Management of Alzheimer's disease. A family affair

The various approaches to the patient with Alzheimer's disease are receiving much attention, but relatively little has been written about the important role physicians can serve in helping the patient's family deal with the disease. In managing Alzheimer's disease, the physician's relationship with family members may be as important as or even more important than his or her relationship with the patient. Establishing and maintaining a successful relationship involve early assessment of family function, periodic home visits, coordination of available community resources, regular assessment of caregivers' coping skills, and regular discussions about the limits of home care and the possibility of placement in a nursing home. When nursing home care is chosen, the physician can, by continuing his or her involvement, help assure provision of the highest quality care possible.