1. Chapter 57 The Patient Who Is Homebound “No matter how hard the past, you can always begin again.” Buddha

2. Homebound Patients  Residence  Home-based healthcare services  Institutionalized setting: hospital, nursing home, or residential facility  To classify for homebound 1) Limitation of one or more ADLs (Activities of Daily living) 2) ASA III-V 3) Be functionally dependent on caregivers

3. Common Oral Problems  Need for routine dental care  Difficulty biting and chewing  Weight loss due to oral problems  Toothache/pain and abscess/swelling  Trauma/fractured or loose teeth  Dental caries  Periodontal disease  Restorative issues  Loose dentures

4. Significance of Oral Health  Systemic conditions affecting oral status  Oral health affecting systemic conditions  Oral pain compromising nutritional status  Physical limitations and oral care abilities  Self-esteem and quality-of-life issues

5. Barriers to Access  Few on-site dental clinics in nursing homes  Lack of practitioners  Cost  Limited or no Medicaid coverage  Transportation  Fear  Patient attitude and beliefs  Patient daily pain/discomfort levels

6. Review Which of the following is not a barrier to accessing dental services for patients who are homebound? A) Lack of transportation B) High cost C) Ageism or negative attitudes of practitioners D) Large number of practitioners who provide home-based services E) Patient ’ s health attitudes and beliefs

7. Review Which of the following is not a barrier to accessing dental services for patients who are homebound? A) Lack of transportation B) High cost C) Ageism or negative attitudes of practitioners D) Large number of practitioners who provide home-based services E) Patient ’ s health attitudes and beliefs

8. Eliminating Barriers  Home health agency visits  Midlevel allied health professionals increasing  New models for healthcare delivery  Collaboration for onsite and supervisors  Web-based communication tools

9. Dental Hygiene Care and Instruction  Mobile dental clinics  Care objectives  EIOE to triage patient needs  Detecting pathology and care needs  Education interventions for prevention  Palliative care  Encouragement

10. Preparation for the Home Visit  Understanding the patient  Review med hx in advance for precautions  Consult MD if need to prior  Instruments and equipment  Portable  Routine with manual instruments  Appointment time  When best for patient (not during naps)

11. Approach to Patient  Communication  Empathy, understanding  Direct with gentle firmness  Depression common  Long-term painful illness  Introduce everything prior to performing  Move more slowly  Listen attentively  Avoid over-tiring the patient

12. Treatment Location  Chair best, avoid providing care in patient’s bed  Instability of patient ’ s head is the biggest barrier for the RDH  Patient in bed: pillow, adjust bed to correct height for you  Patient in wheelchair: portable head-rest, firm pillow

13. Review To provide dental hygiene treatment for a patient who is homebound and uses a wheelchair, which of the following techniques can be used? A) The patient should be moved to a straight chair B) Adjust the bed to a desirable height C) Dental hygiene treatment cannot be completed if the patient must stay in a wheelchair D) Attach a portable headrest to back of wheelchair

14. Review To provide dental hygiene treatment for a patient who is homebound and uses a wheelchair, which of the following techniques can be used? A) The patient should be moved to a straight chair B) Adjust the bed to a desirable height C) Dental hygiene treatment cannot be completed if the patient must stay in a wheelchair D) Attach a portable headrest to back of wheelchair

16. Additional Considerations  Tray for instruments near treatment  Adequate lighting  Headlamp  Floor lamp  May need to turn off over-head light to prevent glare

18. Assessment and Planning  Comprehensive patient assessment just like any other setting/patient care  Preventive strategies to meet individualized needs  Maintenance and continuing care  Education (Wilkins p.881, Table 57-1 Outlines protocols)

19. Unconscious Patient  Methods for head placement may be difficult  Instructions for caregivers  Try to motivate them to care for the patient’s oral cavity  Clean mouth @ least 3x/day  Prevent dryness and sordes (crust-like material that collects on lips, teeth, gingiva)  Soft tb, swabs, gauze for cleaning teeth  Electric tb with suction (next slide)  Cleaning removable appliances  Salivary substitutes

20. Toothbrush With Suction Attachment  Tubing connected from the end of the hollow tb handle to an aspirator outlet or portable suction unit  Bite block should be used  Dip brush in nonalcoholic, fluoridated mouthrinse, not toothpaste  Moisten brush frequently  Apply water-based lubricant to lips

21. Review How often should caregivers clean the mouths of their unconscious patients? A) Daily B) Twice a day C) Three times a day D) Weekly

22. Review How often should caregivers clean the mouths of their unconscious patients? A) Daily B) Twice a day C) Three times a day D) Weekly

23. Terminally Ill Patient  Provide comfort care, symptom relief  Thorough, gentle cleaning of teeth, tongue, mucosa  Dentifrice not necessary  Visual inspection for sores, ulcers, candidiasis, glossitis, xerostomia  79% terminally ill patient have candidiasis  75% terminally ill have pathologic changes to gingiva  Denture problems

24. Factors to Teach the Patient  Relationship of oral to general health  Oral wellness contributes to quality-of-life factors  Preventive strategies  Dietary modifications for caries control

25. Factors to Teach the Caregiver  Need to care for patient ’ s oral hygiene and oral infection control  Dental appliance care  Dietary strategies for caries prevention  Use of devices to accomplish home care