Reflections on Home Health: The Caregiver’s Perspective

I’ve been a physician for over 25 years. As members of my family age, I find myself increasingly in the caregiver role. Most recently, I have been assisting a family member following knee replacement surgery. It provided an opportunity to see the home health process from a perspective different than what I see as a physician.

Home health services were arranged before the patient left the hospital, and she was told to expect a phone call on the day of discharge to schedule the initial visit. This surprised me a bit because it makes a couple of assumptions about contacting the patient: that the patient will either be home to answer a landline call, or that they have a mobile phone and would be able to answer if they were in transit. By definition, patients receiving home health services under Medicare are “homebound” so they shouldn’t be anywhere else other than at a medical facility, at home, or in transit. However, hospital discharges can be unpredictable, which can create rework for scheduling phone calls if the patient is either not in the expected location or unable to take the call. In this situation, the patient’s discharge was delayed by a day due to medical complications, and I don’t think she was in the right frame of mind to take a scheduling call while she was being driven home had the call come at that time.

Although she’s older, the patient in this case is digitally savvy and she and her spouse regularly interact with a number of apps, websites, and communication tools on their smartphones. She’d be an ideal candidate for an asynchronous communication solution. Receiving a text on her smartphone, she or her caregiver could interact at the time of their choosing to schedule the first home health visit. We know that a high percentage of patients and their caregivers have access to smartphones, and although not every patient would be a candidate for this type of communication, even transitioning a fraction of scheduling calls to an asynchronous platform would help reduce the burdens of manual phone calls.

I was present at the initial intake visit, as well. The first fifteen to twenty minutes of the visit was taken up by administrative processes that were smooth but somewhat incomplete. For example, the patient was given a verbal summary of the forms she was being asked to electronically sign, and then her signature was collected using a tablet. However, she or her caregivers didn’t have the opportunity to actually read the forms they were signing. If she had asked to do so, that would have dramatically lengthened the visit and delayed the clinical assessment by the home health nurse. An asynchronous intake process could have mitigated this problem, allowing the patient and her caregivers the opportunity to review forms in detail prior to the arrival of the home health nurse. At that time, the nurse could have responded to any questions and collected any incomplete signatures if needed.

Following the administrative intake process, the clinical assessment began. This included a number of questions that could also have been answered outside the visit, using a technology solution. These included questions about the home environment such as whether there are grab bars or other assistive devices in the home, questions about the patient’s pain levels and appetite in the 24 hours prior to the visit, and whether a follow-up visit with the surgeon had been scheduled. Once those were completed, the hands-on clinical assessment began with vital signs collection and a physical exam. The nurse reviewed the importance of the patient keeping her leg elevated whenever possible, and commented that being seated in a chair for the duration of the visit so far was “just about at the limit” of the time she should be spending in a chair. Had she been given the opportunity to handle some of the administrative parts of the visit from her ideal place of comfort - such as a bed - prior to the visit, the risk of gravity-driven leg swelling from being up in a chair could have been reduced.

In hindsight, there are other things that incorporating asynchronous phone-based solutions could have added to these interactions. For example, a company I use for household repairs sends a text link to confirm appointments. It contains the name and picture of the person coming to my home, along with a link to a brief biography. It’s reassuring to have that in advance when someone comes to your home and it could easily be added to a home health scheduling process. That would make it more likely that a patient or their caregivers would admit home health personnel since they would have photo confirmation of the staffer’s identity. An online solution could have also provided additional instructions intended to protect the home health staff - such as a request to secure any pets for the visit and the opportunity to respond with any specific parking instructions or other helpful information.

Over the last twenty years, the length of time patients have stayed in the hospital has decreased dramatically. Many orthopedic procedures that would have resulted in multi-day hospital stays are now done as same-day outpatient procedures. This means that patients may return to their homes with different symptoms than they may have had in the past - including nausea, fatigue, disorientation, and incomplete pain control. They may be getting used to different equipment in their homes, whether it’s a wheelchair, a walker, or a bedside commode. They may be sleeping more or doing home physical therapy exercises at times and the ability to take care of administrative tasks (including scheduling and reading consent forms) at a time when they feel focused would enhance the recovery process.

A few days later, I was able to be present for another home health visit. Once again, it was scheduled via phone and the patient also received a manual confirmation call the day prior to the visit. Because there were fewer administrative tasks at this visit, the focus was almost entirely on clinical care. This time, since the postoperative dressing was removed, there were additional wound care instructions provided, including information on when the patient would be able to shower and how to gradually increase activity. For patients who may not be processing information well, asynchronous communication solutions could be used to send reminders on the new care plan as well as to obtain information on how the patient thinks their condition is progressing. Additional patient education documents could be sent electronically for the patient to review later or share with caregivers. For the long-awaited clearance to shower, patients could receive an alert that the day had arrived as well as reminders on how to proceed safely.

I’m looking forward to seeing my family member continue to make progress after surgery, but from the physician perspective I’m also looking forward to seeing how technology solutions can be fully integrated into patients’ care plans and recovery protocols. Now is the time to expand the ways in which we communicate with our patients and their families. Using these tools will in turn free the care team from administrative tasks and allow them to spend more hands-on clinical time with their patients.