1. Cueto, Cunanan, Dadgardoust, Daguman, Damo, David H.L., David H.A., De Guzman J., De Guzman R., De Leon, De Mesa, De Vera, Dela Cruz C., Dela Cruz F., Dela Cruz I., Dela Rosa, H., Delos Santos K. HOME CARE

2. Home Care Provision of comprehensive health services to individuals and families in their own residence -promote, maintaine or restore health - Minimize the effect of illness and disability Being prepared to become a member of the team caring for a chronically-ill or terminally-ill patient at home More people-oriented

3. Services Offered in a Home Care Program Medical Care Rehabilitation Counseling and health education Wellness program Diagnostic and therapeutic procedures Nursing care Spiritual care Support group Community resources Transportation Bereavement and respite care First aid

4. Therapeutic Procedures Transferred at Home Parenteral nutrition Home enteral nutrition (nasogastric tube) Intravenous antibiotics Blood transfusions Respiratory therapy Renal and peritoneal dialysis

5. Home care services must be able to provide comfortable transition to home, maintenance of optimal clinical condition, ongoing health education and reinforcement of learning and continuity of care

6. Role of the Physician Manager Acquisition of appropriate home care assessment skills Assessment of the adequacy of family caregivers and resources Knowledge of community resources Knowledge of home care technology Integration of home and hospital care for patients Ability to lead the home care team.

7. Preparations for Home Care

8. Multifaceted Assessment and preparation of both patient and home environment – facilitate safest and smoothest transition

9. Sharing information about diagnosis being considered Discussion of treatment plans and therapeutic options Assessment includes: Evaluation of physical conditions Functioning of extremities Sensory components Excretory functions Social factors

10. Prior to discharge, physical functioning must be enhanced by: Elimination unnecessary bed rest Physical activity must be encouraged Caregivers (trained) Safety measures Careful planning of mobility for bathroom, doors, and stairs

11. Organizing a Home Care Program

12. a. Get manpower Home care team consists of: Primary care physician Nurse Therapist Social worker Volunteers Effective Cost-saving manner to the patient

13. b. Train staff Assess hazards in the home Conduct functional assessment Monitor medications Assess caregivers

14. c. Prepare a home care program Includes the various services offered mechanics of implementation Set policies Issues on reimbursement or fees

15. d. Establish networking and linkages Help people deal with health and social problems Establish good lines of communication (agencies, communities, etc) Awareness of what they offer

16. e. Implement the program Diagnosis and prognosis should be clear Verify if the patient & family is informed about the referral Clarifications: Call the attending physician Meet and establish rapport, know their expectations, Do goal setting. Schedule-frequency of visits Checklist of gadgets and equipments Financial agreement

17. f. Evaluate the program Monthly health management meeting Determine if the planned care is effectively achieving its expected outcome Adjustments to be done

18. Guidelines for Home Visit Preparation Planning Coordination

19. Guidelines for Home Visit Prior to home care: Patient selection Admission criteria Review medical records – goal for a patient Take notes, form questions, make hypothesis Schedule visit

20. Guidelines for Home Visit Prepare a home care plan Medical Psychosocial Wellness Economic Environmental Including short and long term goals for the patient and his family

21. Guidelines for Home Visit During the visit: Establish rapport Brief review of medical history Exploration of psychosocial issues Living conditions Select a primary caregiver appraise his capabilities

22. Guidelines for Home Visit During post-visit: Write the report of visit – Problem list – Specific interventions performed Schedule follow-up visits – Check compliance – Render continuing care Refer to other disciplines and coordinate with them, if needed.

23. COMMON HOME CARE PROCEDURES AND INTERVENTIONS

24. NGT (Nasogastric Tube) Insertion Source: http://emprocedures.com/ngt

25. NGT (Nasogastric Tube) Insertion 1. Gloves, protective gown, and face shield 2. Nasogastric tube 3. 2% lidocaine jelly 4. Phenylephrine nasal spray 5. Atomized lidocaine or benzocaine spray 6. Cup of water with straw 7. Emesis basin 8. Towels, chux 9. 60cc catheter tip syringe 10. Stethoscope 11. Tape 12. Suction Source: http://emprocedures.com/ngt

26. NGT (Nasogastric Tube) Insertion INDICATIONS: a) Aspiration of stomach contents for either diagnostic or therapeutic reasons b) Feeding c) Administration of therapeutic substances Source: The Filipino Physician Today, 2 nd Edition, Maglonzo

27. CONTRAINDICATIONS: a) Esophageal strictures b) Facial fracture c) Comatose patients with unprotected airways d) Penetrating cervical wounds Source: The Filipino Physician Today, 2 nd Edition, Maglonzo

28. Mechanical Ventilation Indication: respiratory failure Recommendations – VT = 10-15 mL/kg – Rate = 60-80 breaths/min – FiO2 = 0.40 – Ventilator mode: assisted control – Inspiratory flow = 50% – Peak pressure = 50 cm H2O – I:E ratio = 1:2 – Humidifier temperature = 35˚C

29. 3. Tracheostomy Tube Suctioning and Cleaning Tracheostomy tube consists of: inner canula, obturator, ties and fenestrations Remove accumulated secretions to: facilitate patient comfort increase respiratory efficiency decrease risk of complete airway obstruction decrease the risk of infection Clean the inner cannula - done twice a day - done by immersing it in hydrogen peroxide and then rinse with normal saline Clean tracheostomy site with sterile cotton buds and normal saline Replace soiled ties

30. Catheter Insertion Female Catheterization Half the catheter must be inserted before inflating the balloon. Place it in the urethral meatus. From the urethral meatus, catheter advances towards the bladder as it proceeds in a slightly upward direction.

31. Catheter Insertion Male Catheterization Insert at least 24cm before inflating the balloon. Place the distal urethra in a slight stretch straight up to straighten the urethra. Catheter then needs only a single curve on its way to the bladder.

32. Intravenous (IV) Medications enter the patient’s bloodstream directly by way of a vein Appropriate when: rapid effect is required Medications are too irritating to tissues to be given by other routes

33. Take note! Assess caregiver’s eyesight & manual dexterity Check appearance of medication and expiration date Know which medications are unsuitable for IV administration Observe patients for any adverse reactions

34. IV Infusion Home Care IV Infusion For shortened hospital stays and the need to cut costs Peripheral IV lines are used for the maintenance of fluid balance, administration of medications and nutrition. The butterfly or catheter set may be used. Then it is connected to the tubing of the intravenous system.

35. IV Infusion Home Care IV Infusion Permanent access Long-term or home parenteral nutrition Achieved by placement of a catheter with a subcutaneous part for access, by tunneling a catheter w/ a substantial subcutaneous length, or threading a long catheter through the basilic or cephalic vein into the SVC. Temporary/ Short-term access Achieved w/ 16- gauge, percutaneous catheter inserted into a subclavian/ IJV and threaded into the SVC

36. Nursing Care Includes: Positioning and moving the patient in bed Perineal care Oral care Bed bath Transfers

37. Nursing care Positioning and moving the patient in bed

38. Nursing Care Perineal care Oral Care

39. Nursing Care Bed Bath

40. Nursing Care Patient transfers

41. Immunizations Most cost-effective form of disease control and the only form effective against many viruses 2 types: Active immunization occurs by administration of antigen, and requires an immune response. Passive immunization occurs by transfer of preformed immunoglobulin. “Booster” immunizations generate secondary responses and increase the strength of immunological memory. Home vaccination are provided by physicians themselves, including a pre- assessment Several factors needed to be considered before any patient is vaccinated: susceptibility of the patient, the risk of exposure to the disease, the risk from the disease, and the benefits and risks of the immunization.

42. Wound Dressing One of the most common services provided Wounds that are difficult to heal, usually because of underlying disease processes, anemia, poor nutrition, wound contamination, chemical irritants and other factors Chronic wounds: basic wound care including frequency of dressing change, type of dressing used, cleaning solutions, and topical medications, is generally determined by the physician Wound treatment and management include the following: – Prevention of further tissue destruction – Prevention of infection – Planning treatments as appropriate for the type of wound, condition and size of the wound

43. Lab Screening Yearly physical examination and home laboratory screening for undetected diseases at the confines of your home Complete with interpretation by a fully licensed physician Cholesterol screening, Blood pressure screening, Obesity screening, Diabetes mellitus screening Cancer screening tests

44. Ancillary Procedures Mobile x-rays Ultrasound

45. Caregiver Training Modules are designed to train family members, informal household carers, and caregivers on the proper management of patients Treatment plan that addresses needs of caregiver and the patient. Identification of caregiver burn-out or stress.

46. Issues in Home Care LEGAL ISSUES Home care policies must be properly drafted to avoid medicolegal risk Includes documentation of all examinations, conversations and care rendered Constant surveillance and attention to quality of care are the best preventive measures

47. Ethical Issues There must be an informed consent All risks regarding the procedure must be explained to the patient There must be an agreement before a procedure can be started If the patient is not competent to make a decision, the guardian or any family member can give the consent

48. Financial Issues The Philippine Health Care Insurance System does not have any provisions for reimbursement in the home care setting. Before entering the home care, the patient’s family should be informed regarding the financial agreement.

49. Legal Issues and Considerations on Home Care

50. Legalities of Home Care legal documents and formalities for completion Done ASAP Include the person/patient involve and his/her family in the decision making Only a very close friend or family member with no conflicting motives should be given these powers.

51. Letters of Instruction A letter of instruction provides important information and instructions a caretaker may need. It includes – the contact information for close family and friends, – a list of assets and liabilities, a list of insurance policies – and information on all financial accounts.

52. Will A will designates who will receive major assets after a person dies.. It also includes guardianship of any children under the age of 18. Smaller items such as heirlooms, furniture and other household goods, should be addressed in a separate testamentary letter. This letter should be referenced in the will.

53. Living Wills A living will is a clear statement about wishes regarding artificial life support. If a person's brain is dead yet the body remains functioning only with the help of life support, a living will directs attendants in what choice to make - to keep the machines functioning or turn them off.

54. Power of Attorney If the people under your care are unable to make decisions for themselves because they are somehow incapacitated, you will need to have power of attorney to make these decisions for them. Of course, they will need to create powers of attorney before they are actually needed

55. Two Types of Powers of Attorney Durable Power of Attorney Healthcare Power of Attorney

56. Durable Power of Attorney gives a person, or people, authority to manage finances and other legal affairs if the person needing care is not capable of managing these. It can be long-term or short-term. Allows the party that has power of attorney to use money to provide care, sign tax returns, handle investments and other important matters.

57. Healthcare Power of Attorney Allows the person designated to make healthcare decisions if the person being cared for is unable to make these himself or herself. For example, someone holding power of attorney may be able to decide against dangerous surgery if he or she feels that is in the patient's best interest.

58. Trust Establish financial resources for family members, especially for those who cannot easily do so themselves, or for those with a disability To protect assets in the event of an older person requiring residential care Organise your personal financial affairs Provide a form of protection for various beneficiaries Protection of assets against creditors Establish a Trust for charitable purposes

59. THANK YOU!