Hospital-based Home Care Research Articles

Pain and pain alleviation in hospital-based home care: demographic, biological and treatment factors

The aim of this study was to contrast two opposed groups, namely palliative cancer patients who were suffering significant pain (VAS> or =4) and palliative cancer patients with no pain (VAS = 0) in hospital-based home care and, retrospectively, to study possible differences in relation to demographic, biological and treatment factors. The ESAS (Edmonton Symptom Assessment Scale) was used to assess 191 palliative cancer patients on admission and after 1 week of home care. Fifty-two (27%) had pain (mean 5.5+/-1.7) and 72 (38%) had no pain on admission [the middle group (n=67) had VAS 1-3]. Activity was more severely affected (5.4 vs 4.2, p<0.01) and nausea less well controlled in patients with pain (2.3 vs 0.7, P<0.0001). Pain was associated with the diagnosis of prostate cancer (P<0.01) and the presence of skeletal metastases (P<0.001), whereas pain-free patients, with or without analgesics, more often had colorectal cancer (P<0.01) or melanoma (P<0.05). The medication profiles differed between the two groups: 22 (42%) of the 52 patients with pain were on step 3 of the WHO analgesic ladder and 24 of 51 (47%) were receiving antiemetics, whereas 42 (58%) of the 72 patients with no current pain had no analgesic prescribed and only 25% of them had antiemetics prescribed, indicating biological differences. If pain was present on admission a pain analysis was formally documented in 23 (44%) of the 52 cases and the medication was changed in 27 of the 52 (52%). The patients improved after 1 week (5.4+/-1.6 vs 3.9+/-2.3, P<0.001), and the improvement was significant even when a pain analysis was not documented or when medication was not changed. In conclusion, the results of this study indicate biological differences in pain alleviation and the need for a more structured way of working.

Cancer patients' interpretations of verbal expressions when given information about ending cancer treatment.

Cancer patients' interpretations of the meaning of words used when given bad news are not well studied in medical settings. The aim of this study was to ascertain what significance verbal expressions had for cancer patients when they were given information about ending active tumour treatment, and what message they felt they received. Tape-recorded semi-structured interviews were performed and analysed using a qualitative phenomenographical approach. Thirty patients with incurable cancer admitted to hospital-based home care unit in Sweden participated. Three main categories about the significance of words emerged: 1) words could indicate indirect warnings as being forewarnings, evasive or ambiguous; 2) words could also be perceived as emotionally trying, as threats or abandoning; 3) other words were fortifying and strengthened the patient in this situation. The overall message given during the information could be interpreted differently: either focused on treatment, on quality of life, or on threat and death. The understanding of the significance of words to tailor the information to patients helps the physician to use forewarnings and fortifying words and to identify and avoid the use of threatening words.

Patterns of referral to a palliative care unit: an indicator of different attitudes toward the dying patient?

In 1996 a specialized palliative care unit was opened at the Linköping University Hospital in Sweden and different patterns of referral from different parts of the district soon became apparent. The aim of this study was to investigate the mechanisms underlying these patterns. During the first 6 months, 133 referrals were analyzed. The stated reason for referral and the actual content of care were, in each case, classified into five groups: symptom control, terminal care, rehabilitation, respite care, and special treatment and investigations. The stated reason for referral and the content of care coincided in three groups: terminal care, rehabilitation, and special treatment and investigations. When symptom control was the stated reason for referral, it was the main content of care in only 33 of 78 cases, while terminal care was the actual main content in 28 of 78 cases. Variations in patterns of referral were also observed in the different hospital-based home care teams (HBHC). In our study differences in the three HBHC teams regarding knowledge, skill, and attitudes might be reflected in variations in patterns of referral. The results illustrate the need for further education regarding referral indications, improvements in documentation of reason for referral, improved communication between HBHC teams and the palliative care unit, and improved prognostication at the end of life.

Receiving Bad News: Experiences of Family Members

Little is known about how next-of-kin experience receiving bad news. The aim of this study was to explore the experiences of family members when receiving information about ending tumour treatment, with a focus on their role in this context. Semi-structured interviews were performed and analyzed using a qualitative phenomenographic method. Twenty family members of patients with incurable progressive cancer admitted to hospital-based home care were included in the study. Data showed that family members want to protect, represent, or act on behalf of the patient. Some described themselves as assuming prominent roles: the demander-of-truth role, the secret-keeper role, and the controller role. Others assumed more passive roles: the surrendering role, the considerate listener role, and the excluded outsider role. This study has revealed possible-explanations as to why family members are dissatisfied with information. The results of this study may help doctors in clinical practice recognize the different types of behaviour family members exhibit when receiving bad news.

Impact of a Hospital-Based Home-Care Program on the Management of COPD Patients Receiving Long-term Oxygen Therapy

To analyze the influence of a hospital-based home-care program (HCP) on the management of patients with COPD receiving long-term oxygen therapy. Randomized, controlled study in a 1,000-bed university hospital. The HCP applied to patients in the intervention group (HCP group) consisted of a monthly telephone call, home visits every 3 months, and home or hospital visits on a demand basis. Patients in the control group were given conventional medical care. Pulmonary function data, gas exchange, use of hospital resources (emergency department visits, admissions, and hospital stay) and the cost of medical assistance were investigated in both groups before and after 1 year of study. Quality of life was analyzed using the chronic respiratory questionnaire in the first 40 consecutive patients included in the study. Survival throughout the study was also assessed. One hundred twenty-two patients were enrolled in the study, and 94 patients (46 in the HCP group and 48 in the control group) completed the 1-year follow-up period: 83 patients (88%) were men, and mean (+/- SD) age was 68 +/- 8 years. During the follow-up period, there was a highly significant decrease in the mean number of emergency department visits (0.45 +/- 0.83 vs 1.58 +/- 1.96; p = 0.0001) and also a significant decrease in hospital admissions (0.5 +/- 0.86 vs 1.29 +/- 1.7; p = 0.001) and days of hospital stay (7.43 +/- 15.6 vs 18.2 +/- 24.5; p = 0.01) in the HCP group. Patients in the intervention group required a total of 221 home visits (mean per patient, 4.8 +/- 0.8) and 69 hospital visits (mean per patient, 1.5 +/- 1.07). In spite of the cost of the program, cost analysis showed a total saving of 8.1 million pesetas ($46,823) in the HCP group, mainly due to a decrease in the use of hospital resources. There was no difference in pulmonary function, gas exchange, quality of life, and survival between the two groups. Hospital-based home care is an effective alternative to hospital admission. It reduces the use of hospital resources and the cost of health care.

Comparison of the Home Care System for the Elderly in Japan and Korea: Towards an Advanced Home Care System

The purpose of this study is to provide the directions for the further development of the home care services in Korea, through comparison of the home care system and visiting nursing activities for the elderly in Japan and with those of Korea. The results of this study were summarised as follows: The major difference between the two countries was that Japan emphasised the development of home services by visiting nurse service stations (VNSS), especially in the community. In contrast, Korea has emphasised providing hospital based home care services and assuring the quality of services through the preparation of home care nurses before beginning services. And many elderly in Korea have used a public health center when they have health problems. According to the result, the establishment of a VNSS system and activation of a public health center in the community must be considered as the direction to advance home care systems for the elderly.

Met and unmet needs in hospital-based home care: qualitative evaluation through open-ended questions.

Met and unmet needs in hospital-based home care : qualitative evaluation through open-ended questions.

Acupuncture for Patients in Hospital-Based Home Care Suffering from Xerostomia

A total of 20 patients (17 cancer patients) in late-stage palliative care reporting dryness of mouth and associated problems were treated for 5 weeks with 10 acupuncture treatments. Ten patients were also evaluated for speech problems (articulation) and dysphagia caused by xerostomia. Subjective assessments used Visual Analog Scales (VAS). Acupuncture had a dramatic effect on xerostomia and, subsequently, on dysphagia and articulation, with subjects showing definite improvement after 5 treatments. Release of neuropeptides that stimulate the salivary glands and increased blood flow are possible explanations for the effects.

Optimizing hospital-based home care for dying cancer patients: a population-based study.

In many reports the percentage of home deaths in cancer is based on selected populations. In this population-based study all cancer patients who died within 12 months within a specified area were studied (n = 108). This area is covered by hospital-based home care (HBHC) on a 24-h basis, which doctors available by day and at night. Forty people (37%) out of the total cancer population died in their own homes. Another 11% would theoretically have been ideal candidates for home care at the end of life. Thus, a home death rate of about 50% of the cancer patients is a realistic figure, and much higher than the usual 5-15% reported, provided that an effective HBHC is offered.

Optimizing hospital-based home care for dying cancer patients: a population-based study.

Health-related quality of life (HRQL) is difficult to define and measure. It is a generic term that includes concepts such as physical health, life satisfaction, psychological well-being and self-integrity. Realizing and appreciating the importance of HRQL is crucial for physicians if they are to be in a position to offer appropriate suggestions in assisting patients and their families in the decision-making process regarding cancer treatment and terminal care. In order to determine whether Greek physicians take into consideration HRQL when assessing different therapeutic options, we conducted a postal survey. A total of 1500 Greek physicians (internists, oncologists and anaesthesiologists) were asked to complete a questionnaire. We received replies from 1280 (85%). In summary, we found that Greek physicians: (1) have already started taking HRQL into consideration when reviewing their therapeutic options; (2) increasingly include HRQL in research studies as an outcome measure; (3) do not yet have thoroughly sufficient training in the holistic care of cancer patients and their families; (4) mostly do not have the opportunity to work in interdisciplinary therapeutic teams where they can exchange ideas and consider different aspects of alternative therapeutic methods. It is concluded that HRQL has already been introduced as an important determinant of therapeutic choices in cancer care in Greece. However, efforts need to be made to allow HRQL to enjoy its appropriate place in cancer care.

Accuracy of recall memory in elderly patients in response to telephone support calls

During the Gulf War, 93 elderly patients (mean age 74 years) received telephone-based support calls from a hospital-based home care facility. Accuracy of memory recall of these telephone support calls was assessed 6 weeks after the termination of the war by means of a postal questionnaire. The relative accuracy of the recall memory of these patients or their caregivers to the telephone calls received exhibited a sensitivity of 75%, a specificity of 78%, a positive predictive value of 60% and a negative predictive value of 88%. Patients who had received four calls demonstrated better memory recall than those receiving less than four. Thus, relying upon patient’s memory alone may be insufficient for evaluating survey data in the elderly. In addition, we found that only patients who correctly remembered receiving four individual telephone support calls tended to exhibit a decrease in the anxiety level. This study emphasizes the importance of repeated interventional telephone calls as a method of increasing recall accuracy and decreasing anxiety in aged patients.

Focused Nutritional Intervention in the Home Care Setting

In order to determine whether more efficient diabetic management could be achieved by focused application of resources in a Hospital Based Home Care (HBHCJ program, a nonrandomized prospective intervention was made during 1995-1996 in the HBHC program of the New Orleans VA Medical Center. Greater flexibility in application of personnel resources appears to increase the benefits of the nutritional interventions. Even with focused interventions, it appeared that lack of compliance was often a barrier to improved diabetic control. Obstacles to improved diabetic management in this HBHC setting often were due not to lack of objective knowledge, but to patient and caregiver difficulties in accepting life-style changes. Nutritional intervention was particularly useful in improving patient skills at grocery shopping, and appears a useful strategy to motivate smoking cessation.

The last month of life: continuity, care site and place of death.

A hospice ward was opened in 1991 at the Orebro Medical Centre Hospital (OMCH) in Sweden. Shortly afterwards, a research project was started, which aimed to describe different aspects of the final period of life of a group of cancer patients. This exploratory study is part of this project and aims to assess continuity in the site of care for a group of severely ill cancer patients during the final stages of their lives, and their place of death within different cultures of care. This prospective study involved 56 adults with cancer who had been admitted to six specialized departments at OMCH. Demographic and diagnostic data, documentation of when the patients changed from one care form to another, as well as place of death were obtained. The analysis of continuity in terms of care site involved care-oriented cultures (hospice ward, hospital-based home care, primary care-based home care and nursing home) and cure-oriented cultures (acute hospital wards). Considered as a group, the patients spent one-third of their time at home during their final month of life, with or without formal caregivers. For individual patients, however, there were great variations with regard to continuity of care site and care form. A pattern was found for the type of cancer the patients had and where they were during their final month. Ten patients died in their own homes, and of the 46 who died in an institution, approximately the same number died in a care-oriented culture as in a cure-oriented culture.

The benefits of in-home pharmacy evaluation for older persons.

To assess the potential benefit of a pharmacist performing in-home medication evaluations on frail older people. Prospective analysis with pre-post comparison. A hospital-based home care program at the Sepulveda Veterans Affairs Medical Center. Male veterans in a home care program who live within 15 miles of the medical center and take three or more prescription medications (N = 20, mean age: 75.1 years). Prescribed medications were documented from the medical records and compared with regimens actually being followed in the home. In addition, the home was inspected, patients were educated, and recommendations were made to the prescribing physicians when necessary. At first visit, patients had a mean of 6.0 prescribed daily medications but were only taking 4.7 of these regularly. Also noted were many potentially unnecessary medications (70% of subjects) and multiple problems with the medication regimen (e.g., incorrect drug frequency or dosage, expired medications, medication omission). Follow-up visit revealed a significant decrease in medication discrepancies and problems (P < or = .05). An in-home pharmacy assessment reveals many problems with drug administration not otherwise detected easily. These assessments can lead to potentially useful interventions that can improve medication regimens and compliance. Determination of long-term effects must await controlled trials.

A hospital-based home health diabetes education model.

For continuity in delivering healthcare across the continuum, an institutionally based home healthcare department was established at Georgia Baptist Medical Center, Atlanta, Georgia. The overall mission of home healthcare services is to maintain high levels of care while maintaining the lowest reasonable costs. Much of the department's patient care focuses on patients challenged with diabetes. This article describes the creation of a progressive, self-directed diabetes education model within this hospital-based home care program.

A45 Team managed hospital based home care: Design of a multi-site randomized trial

A45 Team managed hospital based home care: Design of a multi-site randomized trial

Serum glucose patterns of hyperglycemic patients receiving dietary and medical intervention in a hospital based home care program

Hospital Based Home Care (HBHC) is a multidisciplinary teaching program offered to veterans to improve their health status. The purpose of this study was to determine the effects of nutritional and medical management of hyperglycemic veterans in a home environment. Twenty-five male veterans, middle-aged (x̄ age = 55 years, 78% Black), low to middle income, diagnosed with non insulin dependent diabetes mellitus (NIDDM) and/or insulin dependent diabetes mellitus (IDDM) were selected from the HBHC caseload to study. The HBHC team comprised of nurses, a physician, Social Worker, and a Registered Dietitian conducted weekly and monthly follow up visits to the veteran's home to assess, teach and reinforce dietary and medical adherence. Dietitian taught veterans and/or caregivers dietary management using food models and conducted 24 hour recalls to assess dietary compliance. Weights and lab data were obtained by HBHC nurses. Monthly and quarterly chart reviews were held with the team physician for adjustment in diet and/or medication regimen. Results showed 34% decline in serum glucose levels for veterans studied the first month. After three months, 56% had serum glucose values within normal range (70–110 mg/dl). Within six months, 48% had serum glucose levels in normal range whereby 85% had normal serum glucose levels after nine months. This percentage remained the same after twelve months. The results showed a steady decline in serum glucose patterns of veterans participating in a HBHC program except during the six months follow up period. It was noted one veteran (4%) had a foot infection during this study period. The HBHC program may be a way of treating home bound veterans with hyperglycemia and requires further investigation.

Home bound patients on enteral feedings: A two year restrospective study of fiber vs non-fiber formulas

The Little Rock VA Medical Center Hospital Based Home Care (HBHC) program delivers primary health care to home bound veterans through a hospital based interdisciplinary team. The team's physician, nurse, social worker, dietitian, and rehabilitation therapist manage the patient's medical and social needs through an interdisciplinary approach to primary care with frequent visits to the patient's home. The objective of this two year retrospective study was to determine if enterally fed patients with constipation or diarrhea had a resolution of these complications by changing their enteral feedings to a formula containing fiber. Veterans admitted to the HBHC program were monitored to evaluate their tolerance to a one Kcal/cc non-fiber enteral feeding. During this period 25 patients were admitted to the HBHC program on the standard enteral formula. Twenty of the 25 patients (80%) developed complications of constipation or diarrhea as documented by a team member (six with diarrhea, 14 with constipation). Veterans who experienced diarrhea and/or constipation were treated pharmacologically by the physician with minimal relief in symptoms. Fifteen of the 20 patients had their formula changed to a fiber containing one Kcal/cc formula. All 15 of the patients receiving the fiber formula developed a regular power pattern within five days of initiation of the fiber formula. Five of the 20 patients did not have the financial resources to obtain a fiber containing formula.

Assessment of the oral health status of the medically compromised homebound geriatric patient: a descriptive pilot study.

This pilot study was designed to assess the oral health status of homebound elderly and determine their dental care needs. Fifty-one subjects enrolled in a hospital-based home care program were recruited for this study. Subjects were visited in their homes by both a dentist and a physician. Care plans and medications were reviewed for each subject. Initial assessments to receive informed written consent were conducted by the physician. Oral health assessments by the dentist included comprehensive examinations for soft tissue pathology, periodontal health, caries, restoration, and tooth condition, as well as existing prosthesis assessment, plaque index, and grip strength. A Physical Self-Maintenance Scale was administered in order to determine the level of dependence of this population for their oral hygiene self-care. The oral health status of these homebound elderly was found to be poor, with 84% of the subjects requiring dental care.

Hospital Based Home Care Registered Nurse Role

Hospital Based Home Care Registered Nurse Role