Domiciliary Care

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Definition

Home care is defined as the provision of health services by formal and informal caregivers in the home in order to promote, restore, and maintain a person’s maximum level of comfort, function, and health including care towards a dignified death.

It is an integral part of community-based care.
Community-based care is the care that the consumer can access nearest to home, which encourages participation by people, responds to the needs of people, encourages traditional community life, and creates responsibilities.

Background

Members of Roman Catholic religious orders in Europe first delivered HC in the late seventeenth century.
From 1885 to 1889, most nurses' workplace was in the home of their clients.
Today, there are many home care agencies and visiting nurse associations.

Rationale for Home-Based Care

Due to the epidemic of AIDS, the increase in noncommunicable diseases, the complications thereof, and an ageing population’s impending impact on communities.
Shortage of hospital beds.
Inadequate number of medical, nursing, and allied health professionals in the public sector.
Hospitals, which are crowded and over-stretched, are often unsuitable for managing patients with terminal or long-term diseases.
Cost of institutional care.

To shift the emphasis of care to the beneficiaries – the community.
To ensure access to care and follow-up through a functional referral system.
To integrate a comprehensive care plan into the health system.
To empower the family/community to take care of their own health.
To empower the client, the caregiver(s), and the community through appropriate targeted education and training.
To reduce unnecessary visits and admissions to health facilities.
To eliminate duplication of activities and enhance cost-effective planning and delivering of services.
Be pro-active in approach.

People who need basic support services to continue to live and/or die in their community and without which they would have been either prematurely or inappropriately moved to institutional care.

This shall be directed to:

Healthy people.
At-risk or frail older persons.
At-risk people with moderate to severe functional disabilities.
People recovering from illness, in need of assistance e.g. post deliveries or after specific treatment.

Key Stakeholders

Formal system (doctors, nurses, psychologists, rehabilitation/physiotherapists, social workers)
Non-formal system (NGOs, traditional healers, and leaders)
Informal sector (families, CHWs, volunteers, caregivers)
Client/Consumer

Holistic: addressing physical, social, emotional, economic, and spiritual needs of the community, integrated into existing systems.
Person-centered: sensitive to culture, religion, and value systems to respect privacy and dignity (community-driven, customer-centered).
Comprehensive, interdepartmental, and all-encompassing; preventative, promotive, therapeutic, rehabilitative, and palliative (multisectoral involvement).
Empowering and allows capacity building to promote the autonomy and functional independence of the individual and the family or caregivers. Leadership is from within the community.

Prevention, early identification, as well as care and rehabilitation at the community level will prevent the need for expensive institutional care.
To reduce the pressure on hospital beds and other resources at different levels of service.
To reduce and share the cost of care within the system.
To allow people to spend their days in familiar surroundings and reduce isolation.
To promote a holistic approach to care.
To create awareness of health in the community.
To put care providers in touch with potential beneficiaries/partners.
It links and complements existing health services.
To be pro-active rather than reactive.
To allow the right to decide about care within own environment.

Based on:

Assessing the patients
Assessing the home and living environment
Identifying the caregiver, their knowledge, and challenges
Listing the diagnosis/problems
Planning the care delivery includes assessing the care resources within the circle of the patients’ caregivers
Educating the caregiver, family, and patient/client
Implementing specific interventions
Evaluating outcomes of the efficiency of the implementation phase

Who Pays?

By the government through Medicare and/or Medicaid
Private insurance
Patients themselves
Non-profit communities
Charitable disease advocacy organizations
Faith-based organizations

The four major types of home visits are:

Illness visits
Visits to dying patients and their families
Assessment visits
Hospitalization follow-up visits

Major Types of Home Visit

Illness Home Visits

Emergency
Acute illness
Chronic illness

Dying Patient Home Visits

Terminal care
Pronouncement of death
Grief support

Assessment Home Visits

Polypharmacy and/or multiple medical problems
Immobility, social isolation, or suspected abuse or neglect
Possible need for nursing home placement

Hospitalization Follow-Up Home Visits

Acute illness, injury, or surgery
Parents with newborn infants

Equipment and Planning
Home Visit Checklist: "INHOMESSS"

I Immobility
N Nutrition
H Housing
O Other people
M Medications
E Examinations
S Safety
S Spiritual Health

Equipment and Planning

Physician-Supplied Equipment

Essential Lubricant
Otoscope and ophthalmoscope
Patient records
Prescription pad
Sphygmomanometer (various cuff sizes)
Stethoscope
Sterile specimen bottles
Thermometer
Tongue depressors
Urine dipsticks
Optional Glucometer
Laptop computer
Patient education materials
Other supplies as dictated by patient’s need

Patient-supplied equipment (as needed)

Glucometer
Peak flow meter
Weighing Scale

Home Visit Checklist: "INHOMESSS"

Immobility

Evaluation of the patient's functional activities includes assessment of the activities of daily living (bathing, transfer, dressing, toileting, feeding, continence) and the instrumental activities of daily living (using the telephone, administering medications, paying bills, shopping for food, preparing meals, doing housework).
The physician can ask the patient to demonstrate elements of the daily routine, such as getting out of bed, performing personal hygiene and leisure activities, and getting in and out of a car.
Corrective interventions can be directed at any deficiencies noted. For example, modified pill-bottle caps can be obtained for the patient who has trouble opening medication containers because of a condition such as arthritis.

Nutrition

The physician should assess the patient's current state of nutrition, eating behaviors, and food preferences. Permission to look in the refrigerator or cupboard can be obtained by asking open-ended but directed questions.
"Would you mind if I look in your refrigerator to see the types of foods you eat?"
Improvements in product labeling allow the physician to assess serving sizes and the nutritional value of foods with relative ease.
Healthy food preparation techniques can also be reviewed with the patient.

Home Environment

The patient's home environment should allow for privacy, social interaction, and both spiritual and emotional comfort and safety.
A safe neighborhood with close proximity to services is important for many older patients.
The home may reflect pride in the patient's family and past accomplishments and reveal the patient's interests and hobbies.
The physician should not make assumptions about social class or material wealth based on the patient's physical environment.

Other People

Having the patient's social support system present at the home visit clarifies the roles and concerns of family members.
During routine visits, the physician can assess the availability of emergency help for the patient from family members and friends and can clarify specific issues, such as who is to serve as surrogate for the patient in the event of incapacitation.
Evaluation of the caregiver's needs and risk of burnout is critically important.

Medications

To avoid polypharmacy, the physician must evaluate the type, amount, and frequency of medications, and the organization and methods of medication delivery.
An inventory of the patient's medicine cabinet can provide clues to previously unidentified drug-drug or drug-food interactions.
A home medication review can also allow a direct estimate of patient compliance, uncover evidence of "doctor shopping," and identify the use or abuse of over-the-counter medications and herbal remedies.

Examination

The home visit should include a directed physical examination based on the needs of the patient and the physician's agenda.
Practical, function-related examination techniques may include having the patient demonstrate getting on and off the toilet or in and out of the bathtub.
The physician can have the patient demonstrate proper technique for the self-monitoring of blood glucose levels. In addition, the physician can weigh the patient and obtain a blood pressure measurement.
In-person correlation of home and office measures provides useful information for future telephone and clinic contacts.

Safety

The goal of the home safety assessment is to determine whether the patient's environment is comfortable and safe (no unreasonable risk of injury).
To raise the subject, the physician should simply state the intention to identify and help modify potential safety hazards.
For example, furniture placement or rugs may create problems for an elderly patient with gait instability, or the tap water may be so hot that the patient is at risk for scald injury.

Spiritual Health

If the home contains religious objects or reading materials, the physician can ask about the influence of spiritual beliefs on the patient's sense of physical and emotional health.
This information may provide the impetus, as desired by the patient, for a discussion of spirituality as a coping and healing strategy.

Services

Having members of cooperating home health agencies present for the house call can enhance communication and cooperation among the physician, patient, and agencies.
Existing orders can be clarified, priorities for future care can be established, and other perspectives on the care plan can be solicited.
The patient's relationship with home health agency providers can also be assessed.

Elements of the INHOMESSS mnemonic may be used independently, based on the needs of the patient and the physician's agenda.

For example, the physician may wish to focus on polypharmacy and safety in a patient with a recent fall, or to assess mobility and the extent of social support in a patient with newly diagnosed Alzheimer's disease.

Medical or psychological assessment
Wound care
Medication teaching
Pain management
Disease education and management
Physical therapy
Speech therapy
Occupational therapy

Proactive telephone calls are an underutilized method of conducting highly focused and time-efficient "virtual" home visits.
Provider-initiated telephone calls can be used to reassure family members after a patient has had an acute illness or has been hospitalized.
Telemedicine is the use of communication technologies to provide patient care across distances.
A variety of institutions are exploring these technologies as methods of delivering health care in the home.

Telecare

With advances in technology and the increased effort to control cost, HC delivery services are using telecare.
Technological advances have enabled patients to access telecare through the internet using personal computers.
The following services may now be offered:

Instant access to patients' records
Prescriptions for treatments
Assessments of possible dangers to the patient
Evaluation of the patient’s treatment and medication
Follow-up care

Social environment is restricted - set beliefs and customs, ideologies and local conflicts, and inappropriate housing.
Emotional and physical strain and stress experienced by caregivers.
Insufficient empowerment of clients and caregivers regarding care/resources and diagnosis.
Uncertainty about the duration of the situation.
Inadequate support structures for the caregiver.
Dependency - allows for dependency of the client.
Social isolation, related to confinement of the person to bed and the home.
Emotions such as rejection, anger, and grieving.
Economic constraints and exhaustive care needs.
Focus too often on health service activities only – no common vision.
Fear or mistrust of the primary caregivers.

Lack of reimbursement and the busy pace of office practice are the reasons commonly cited for not conducting house calls.
Poorly organized, sporadic home visits may indeed interfere with clinical practice.
Therefore, it is important to develop a systematic approach for planning home visits.
Most practices will benefit from using home visits with patients who have difficulty accessing outpatient facilities because of sensory impairment, immobility, or transportation problems.
Removing such logistically difficult appointments from the clinic schedule and performing them in the home setting may actually enhance clinic functioning.
Clustering home visits by geographic location and within defined blocks of time may also improve efficiency.
Finally, nurses and physician assistants can conduct visits as part of a home health care delivery team.

Domiciliary Care is advantageous for the frail elderly
Model based on Team, Timely Communication, Supportive Technology, and Mixed funding
Effective
Efficient
Sustainable

Practice Questions

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