Home Care Physicians Research Articles

Home Care Physicians Promise 5% in Savings

Home Care Physicians Promise 5% in Savings

A Day in the Life of a Home Care Physician

On a typical workday, instead of driving to a medical office, I take to the highways around Miami, Florida, and travel to see my patients in their homes. I am a doctor who makes house calls for a living.

AMDA Effort Signals Increase In Physician Work Values

AMDA Effort Signals Increase In Physician Work Values

Management of Community-Acquired Pneumonia in the Home: An American College of Chest Physicians Clinical Position Statement

The number of patients with community-acquired pneumonia (CAP) who are being treated at home is increasing for a variety of reasons. These reasons include the increased availability and cost considerations of oral antibiotics that have been shown to be effective, as well as the consideration of patient and family preferences. However, there is still considerable variability in strategies for the management of patients with CAP. This American College of Chest Physicians position statement, which was cosponsored by the American Academy of Home Care Physicians, provides recommendations on the various aspects of home care for patients with this condition. Included are recommendations for evaluation and diagnosis in the home environment and the determination of the site of care, and an outline of an in-home management plan. The position statement also provides recommendations for issues related to patient and caregiver commitment to the plan, and for monitoring and follow-up. Recommendations are directed toward immunocompetent adult patients with CAP who are at home or in other unskilled residential facilities. These patients can include previously healthy individuals or chronically ill individuals who choose not to go to the hospital, or hospitalized patients who are completing a hospital discharge plan. The recommendations in this statement take into consideration the best course of action for the patient, as determined by incorporating the most recent evidence with clinician judgment and patient preferences. These recommendations also consider the available resources. Therefore, these recommendations may not apply to every patient, and interventions may need to be structured based on the individual. In addition to providing recommendations for the home care management of patients with CAP, we hope that this clinical policy statement will alert readers to the need for more scientific evidence related to the clinical and psychosocial issues associated with managing this condition.

Sexuality in palliative care: patient perspectives

This qualitative study investigated the meaning of sexuality to palliative patients. Face-to-face interviews were conducted with ten patients receiving care in a tertiary palliative care unit, a hospice or by palliative home care services in their homes. Several themes emerged. Emotional connection to others was an integral component of sexuality, taking precedence over physical expressions. Sexuality continues to be important at the end of life. Lack of privacy, shared rooms, staff intrusion and single beds were considered barriers to expressing sexuality in the hospital and hospice settings. Only one subject had previously been asked about sexuality as part of their clinical care, yet all felt that it should have been brought up, especially after the initial cancer treatments were completed. Home care nurses and physicians were seen as the appropriate caregivers to address this issue. Subjects unanimously mentioned that a holistic approach to palliative care would include opportunities to discuss the impact of their illness on their sexuality.

Osteoporosis for the Home Care Physician Part 2: Management

Osteoporosis and its related fractures constitute a great threat to the functional independence and quality of life of home care patients. Fortunately, there are currently multiple therapeutic options available that can prevent bone loss and promote its formation. It is important to emphasize, however, that the management of individuals with osteoporosis should not only focus on measures to preserve or augment bone density, but also on preventing falls and protecting the hip. This article discusses the therapeutic modalities that are available for the home care physician to manage patients with osteoporosis.

Osteoporosis for the Home Care Physician Part 2: Management

Osteoporosis and its related fractures constitute a great threat to the functional independence and quality of life of home care patients. Fortunately, there are currently multiple therapeutic options available that can prevent bone loss and promote its formation. It is important to emphasize, however, that the management of individuals with osteoporosis should not only focus on measures to preserve or augment bone density, but also on preventing falls and protecting the hip. This article discusses the therapeutic modalities that are available for the home care physician to manage patients with osteoporosis.

Osteoporosis for the home care physician. Part 1: etiology and current diagnostic strategies.

Osteoporosis affects over 20 million individuals in North America and is responsible for over 1.5 million fractures in the US. Although most cases of osteoporosis are primary, in 20% of older women and 40% of older men presenting with vertebral fractures, a secondary cause can be identified. The WHO based the diagnosis of postmenopausal osteoporosis on the presence of BMD T-score that is 2.5 standard deviations or greater below the mean for young women. The International Society of Clinical Densitometry defined male osteoporosis as BMD T-score of 2.5 or greater below the mean for young men. BMD assessment at the hip and spine by DXA is the standard procedure to assess bone density. Laboratory testing in patients with low BMD is performed to exclude other conditions that could cause low BMD such as multiple myeloma, endocrinopathies and osteomalacia. Bone turnover marker levels currently do not predict bone mass or fracture risk and are only weakly associated with changes in bone mass. Subsequently, they are of limited use in the clinical evaluation of bone density changes.

Osteoporosis for the Home Care Physician, Part 1: Etiology and Current Diagnostic Strategies

Osteoporosis affects over 20 million individuals in North America and is responsible for over 1.5 million fractures in the US. Although most cases of osteoporosis are primary, in 20% of older women and 40% of older men presenting with vertebral fractures, a secondary cause can be identified. The WHO based the diagnosis of postmenopausal osteoporosis on the presence of BMD T-score that is 2.5 standard deviations or greater below the mean for young women. The International Society of Clinical Densitometry defined male osteoporosis as BMD T-score of 2.5 or greater below the mean for young men. BMD assessment at the hip and spine by DXA is the standard procedure to assess bone density. Laboratory testing in patients with low BMD is performed to exclude other conditions that could cause low BMD such as multiple myeloma, endocrinopathies and osteomalacia. Bone turnover marker levels currently do not predict bone mass or fracture risk and are only weakly associated with changes in bone mass. Subsequently, they are of limited use in the clinical evaluation of bone density changes.

Osteoporosis for the home care physician. Part 2: Management.

Osteoporosis for the home care physician. Part 2: Management.

Canada’s Single-Payer Plan Solves Some Access Issues

Canada’s Single-Payer Plan Solves Some Access Issues

What is important to continuity in home care?: Perspectives of key stakeholders

In Canada, home care is growing rapidly. Each province takes a somewhat different approach to its delivery. Ontario uses a competitive bidding model to award contracts to community agencies that bid for service delivery rights. Contracts are to be awarded based on quality and price. However, the attributes thought to contribute to high quality, such as continuity of care, are not clearly defined and are not measured. We sought to identify factors that were important to experiencing continuity of care in home care. We interviewed home care clients and their caregivers, workers in the home care system (nursing and homemaking service providers, case managers) and physicians whose patients use home care. During in-depth interviews with these key stakeholders, they described the conditions that led to continuity of care in home care. Service providers and case managers were also asked about the types of clients who need a high level of care continuity. Care that is experienced as running smoothly, that responds to clients’ needs and requires no special effort for clients to maintain, was seen as having continuity. The attributes of care experienced as facilitating continuity could be grouped under two dimensions of care—managing care (care planning, monitoring and review; and care coordination) and direct service provision (uninterrupted service delivery; consistent, appropriate knowledge and skills; ongoing accurate observation; trusting relationship between service provider and client/caregiver; rapport among team members; and consistent timing). Different stakeholders emphasized different attributes of care as most important to continuity. Clients included consistency of timing of service delivery while rarely mentioning care management issues. They emphasized the importance of consistent knowledge and skills in the workers and trusting relationships as important to experiencing care continuity. The description of attributes of continuity of home care that emerged from this study is compared to definitions found in the nursing, mental health and primary care literature.

House calls well worth a visit.

Until the 1940s or 1950s, most health care was provided at home, and now there are sound reasons for reviving that approach, according to Edward Ratner, MD, Assistant Professor of Medicine at the University of Minnesota Medical School and President of American Academy of Home Care Physicians (AAHCP).

House Calls Well Worth a Visit

Until the 1940s or 1950s, most health care was provided at home, and now there are sound reasons for reviving that approach, according to Edward Ratner, MD, Assistant Professor of Medicine at the University of Minnesota Medical School and President of American Academy of Home Care Physicians (AAHCP).

The use of corticosteroids in home palliative care.

Evidence for the effectiveness of corticosteroids in palliative care is anecdotal, and more information is required. From January to December 1999 a total of 376 consecutive patients admitted to a home palliative care program were longitudinally surveyed. Patients who started a corticosteroid treatment after admission on the basis of common indications prescribed by their home care physicians were selected. Fifty patients were enrolled in the study. Dexamethasone, in doses ranging from 4 to 16 mg, was the drug of choice. Corticosteroids were found to be effective in anorexia, weakness, headache, and nausea and vomiting. The reduction of symptom intensity was achieved in less than 3 days on average. However, no great advantages were found in terms of controlling drowsiness or confusional states associated with advanced illness because of cerebral involvement. It can be concluded from this study that: (a) corticosteroids may be effective in controlling anorexia, weakness, headache, and nausea and vomiting associated with cerebral involvement or bowel obstruction; (b) they should be stopped if no therapeutic effect has become evident within 3-5 days; (c) the treatment is not useful when given in the presence of severe neurological impairment resulting from the advanced stage of disease; (d) the range of adverse effects was acceptable for limited periods and in the circumstances in which the preparations were used in this study; and (e) corticosteroids may have an adjuvant role in potentiation of analgesic drugs. These findings will be very useful in the planning of future controlled studies designed to yield evidence-based data on the role of corticosteroids in the relief of specific symptoms.

Characteristics of Terminal Cancer Patients Who Committed Suicide During a Home Palliative Care Program

Cancer patients may commit suicide at any stage of the disease and many risk factors of suicide have been described in the literature. To identify the possible vulnerability factors of suicide in five terminal cancer patients who committed suicide while they were cared for at home by well-trained palliative care teams, a psychological autopsy study was carried out by reviewing their medical records; their report of symptoms at the time of care; and with the caregivers', doctors', and nurses' recollection of events by means of a structured interview prepared ad hoc. We collected data regarding the physical, emotional, and social suffering of the patients, their personality profile, and their feelings with respect to the illness and disability. The interviews lasted for a mean of two hours and were performed from 2–8 years after the suicide events by the social worker at the Rehabilitation and Palliative Care Division. The interviews took place between June 1996 and January 1998. All the patients showed great concern about the lack of autonomy and independence, refused dependence on others and had fear/worry of losing their autonomy. Four patients presented functional and physical impairments, uncontrolled pain, awareness of being in the terminal stage, and mild to moderate depression. They had a feeling of hopelessness consequent to their clinical conditions, fear of suffering, and feeling of being a burden on others. They had a strong character and managerial professions. They had isolated themselves from others and they had previously talked about suicide. Before committing suicide, three patients had adverse physical/emotional consequences to the oncological treatments—they showed aggressiveness towards their family and one towards the home care physician. Multiple vulnerability factors were present simultaneously in all patients. However, the loss of, and the fear of losing, autonomy and their independence and of being a burden on others were the most relevant. The identification of a cancer patient at risk of committing suicide forms the first step for the prevention of and the setting up of adequate psychosocial rehabilitation of these patients whenever possible.

House Calls for the 21st Century

House Calls for the 21st Century

Are you ready for this?

Are you ready for this?

Strategies to support families of children with end-stage renal failure

The burden of care for families looking after children with end-stage renal failure can be considerable, especially when it involves home peritoneal dialysis and supplementary feeding. Good communication with the family and between team members delivering the multidisciplinary care is essential. Stress may be partly reduced by meeting the information needs and supplementing the spoken word with booklets, videos, tape-recorded interviews and play preparation for children. Families greatly appreciate a continuum of care between the hospital and community which is enhanced by team members visiting the home, nursery/school and primary care physician to impart and update knowledge. Respite care is essential for home dialysis patients. It can be enhanced by an evening baby-sitting service and the involvement of a home care renal nurse, as well as a holiday support strategy. Participation of the families in a regular parents support group provides not only an opportunity to integrate families into the unit, but also allows direct feedback on issues affecting the quality of care.

Physician collaboration in home health care

To better understand physician participation in home care, leaders of the American Academy of Home Care Physicians determined current physician home care attitudes and activities (house calls and agency referrals). Physicians who directly get involved with home care and make house calls have a greater likelihood to work with home health agencies. The key to success in physician collaboration is understanding what physicians need and providing services they have had a role in planning, implementing, and evaluating. Major educational initiatives will be required to prepare physicians for their collaborative role. Key words: home health care; physi cian home health attitudes, practices, and activities; physician home health agency referrals; physician house calls