Home Care Medicine MELISSA VOURLITIS, DO MICHAEL BOWERSOX, MD

House Calls  “House calls” can be conducted at home, B&C, AL, RCFE.  Insurance coverage:  Medicare +/- secondary insurance  PPOs  HMOs (Arch health Partners, Scripps?, others?) *requires referral from primary care physician.  Private pay occasionally can be accommodated.

House Calls  Benefits to the patient:  Patients are in their own environment, waiting for the doctor is much easier.  “Home” environment can be evaluated for safety, other concerns.  Patients can have caregivers and family present at the appointment more easily in order to coordinate care effectively.  Reduces patient anxiety and confusion.  Reduces hospital readmissions.  Enhances doctor:patient relationship.

PREPARING FOR A MOBILE PROVIDER VISIT  NEW PATIENT Demographics Previous Medical Records/ Medications Contact Information Advance Directives Forms to be completed POLST 602-Physician’s Report for Admission Any assessments already performed Order pages

PREPARING FOR A MOBILE PROVIDER VISIT  ESTABLISHED PATIENT List of concerns Vital signs Medication list Refills needed Patient forms to complete Contact Sheet Orders to sign

Common Problems  Fall  Fever  Cough/SOB  Constipation  Nausea/Vomiting  Agitation  Urinary tract infection  POLST form is important when determining intervention.

How to report a concern:  Discuss with the physician the best method for communication:  Fax?  ?  Phone?  Text?  Other?  Keep in mind that the nature of the problem will dictate the urgency of transmitting information. Also, the time of day (or night) should be considered.

How to report a concern:  OPQRST mnemonic:  O ~ Onset  P ~ Provocation/Palliation  Q ~ Quality/Quantity  R ~ Region/Radiation  S ~ Signs/Symptoms  T ~ Temporal  SBAR reporting system  S ~Situation  B ~Background  A ~Assessment  R ~ Recommendation

Common Problems  Fall  Serious consequences of a fall:  Uncontrolled bleeding.  Major fracture or fracture that may require surgery.  Deformity of limb.  Acute change in neurologic status.  Epidural hematoma: rapid deterioration soon after injury.  Subdural hematoma: symptoms may occurs hours to days after fall. Patients with serious consequence of fall need urgent evaluation, 911 appropriate in most situations.

Common Problems  Other consequences of a fall:  Abrasions  Lacerations  Fractures, sprains, dislocations  Bleeding  What to do about this depends upon the severity of the situation. Stitches and splinting must be done at an office or urgent care. Other wound care can often be done at home.

Common Problems  Fever  Infectious Disease Society of America (2008) definition:  Single oral temp >100 F or 37.8 C (100.4 for non elderly residents).  Repeated oral temp >99 F.  Rectal temp >99.5 F.  Any single temp greater that 2 F over baseline.  Elderly people have a lower febrile response.  Serious, life-threatening illness can occur rapidly in elderly residents.

Common Problems  Cough/Shortness of Breath  Medical history important.  Asthma, emphysema, congestive heart failure, other?  Exertional symptoms or prandial symptoms versus symptoms at rest  Associated symptoms (edema, nausea, sweating, change in mentation)  Obtain basic vital signs, pulse and respiratory rate significant.  Pulse >100  Respiratory rate > 30  Fever?

Common Problems  Constipation  AVOID, AVOID, AVOID.  Monitor bowel habits, keep a log.  Review med list and ensure there is a prn medication available to use if needed.  Intercede at first signs of change in bowel habits.  Call if standing orders are ineffective.

Common Problems  Vomiting/Diarrhea  When did it start?  Others with similar symptoms?  How many episodes?  Associated symptoms?  Severe symptoms or symptoms that do not resolve in 24 hours, need medical attention.  In general: do not give food or drink for 2 hours after vomiting, trial of sips of water. BRAT diet for 24 hours once tolerating PO, advance slowly.

Common Problems  Agitation  Review potential causes ~ Ask WHY? Agitation is usually the result of an underlying, unrecognized problem:  Pain  Constipation  Urinary retention  Change in environment  Change in medication

Common Problems  Urinary Tract Infection.  Not all change in behavior is a UTI…Must have 1 and either A,B, or C, or Acute dysuria (painful urination). In males acute pain in testes. And one of the following symptoms: A. Suprapubic pain (lower abdominal pain) B. Gross hematuria (bloody urine) C. New or marked increase in one of the following: incontinence, urgency or frequency. OR 2. Fever with Costovertebral angle pain (back pain). **If indwelling catheter, criteria changes.

SERVICES AVAILABLE FOR PATIENTS IN THE HOME  Urine testing by physician collected at home, delivered to lab for evaluation  Blood testing collected at home by physician or mobile lab tech evaluate for causes of fatigue evaluate diabetic control evaluate levels of certain medications

 Mobile Diagnostic Services Radiology Studies Chest Spine Extremity Echocardiogram Electrocardiogram Ultrasound Abdomen Breast Thyroid Pelvis Evaluation for deep vein thrombosis Evaluation for peripheral arterial disease

Other available services  Home Health Agencies Provide the following types of services:  Skilled Nursing/Wound Care Nurse  Physical Therapy  Occupational Therapy  Speech Therapy  Dietitian  Social Worker  Behavior Health Specialist (in some cases)  Home health aid, once skilled service has been identified.