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Conducting a Home Visit
Whenever a nurse makes a home visit, the agency should know the nurse’s schedule and the locations of the visits. The nurse should learn about the neighborhood and obtain directions for reaching the expected destination. A plan of action should always be established in case of emergencies.Nurses are not expected to disregard their personal safety in an effort to make or complete home visits. If nurses encounter dangerous situations during visits, they should return to their agencies and contact their supervisors or law enforcement offi-cials, or both. Suggested precautions to take when making a home visit are presented in Chart 2-1.
The first visit sets the tone for subsequent visits and is a crucial step in establishing the nurse–patient relationship. The situations encountered can vary depending on numerous factors. Patients may be in pain and unable to care for themselves. Families may be overwhelmed and doubt their ability to care for their loved one. They may not understand why the patient was sent home from the hospital before being totally rehabilitated. They may not comprehend what home care is or why they cannot have 24-hour nursing services. It is critical that the nurse try to convey an un-derstanding of what the patient and family are experiencing and how the illness is affecting their lives.
During the initial home visit, which usually lasts less than an hour, the patient is evaluated and a plan of care is established to be followed or modified on subsequent visits. The nurse informs the patient of the agency’s practices, policies, and hours of oper-ation. If the agency is to be reimbursed for the visit, the nurse asks for insurance information, such as a Medicare or Medicaid card.
Safety Precautions in Home Health Care
· Learn, or preprogram a cellular phone with the telephone numbers of the agency, police, and emergency services.
· Let the agency know your daily schedule and the telephone numbers of your patients so that you can be located if you do not return when expected.
· Know where the patient lives before leaving to make the visit and carry a map for quick referral.
· Keep your car in good working order and have sufficient gas in the tank.
· Park the car near the patient’s home and lock it during the visit.
· Do not drive an expensive car or wear expensive jewelry when making visits.
· Know the regular bus schedule and know the routes when using public transportation or walking to the patient’s house.
· Carry agency identification and have enough change to make telephone calls in case you get lost or have problems. Most agencies provide cellular phones for their nurses so that the agency can contact the nurse, and so that the nurse can contact the agency in case of an emergency or unexpected situation.
· When making visits in high-crime areas, visit with another per-son rather than alone.
· Schedule visits only during daylight hours.
· Never walk into a patient’s home uninvited.
· If you do not feel safe entering a patient’s home, leave the area.
· Become familiar with the layout of the house, including exits from the house.
· If a patient or family member is intoxicated, hostile, or obnox-ious, reschedule the visit and leave.
· If a family is having a serious argument or abusing the patient or anyone else in the household, reschedule the visit, contact your supervisor, and report the abuse to the appropriate authorities.
The initial assessment includes evaluating the patient, the home environment, the patient’s self-care abilities or the family’s ability to provide care, and the patient’s need for additional re-sources. Identifying possible hazards, such as cluttered walk areas, potential fire risks, air or water pollution, or inadequate sanita-tion facilities, is also part of the initial assessment.
Documentation considerations for home visits follow fairly specific regulations. The patient’s needs and the nursing care given are documented accurately to ensure that the agency will qualify for payment for the visit. Medicare, Medicaid, and third-party payers require documentation of the patient’s homebound status and the need for skilled professional nursing care. The medical diagnosis and specific detailed information on the func-tional limitations of the patient are usually part of the documen-tation. The goals and the actions appropriate for attaining them need to be identified. Expected outcomes of the nursing inter-ventions must be stated in terms of patient behaviors and must be realistic and measurable. They must reflect the nursing diag-nosis or the patient’s problems and must specify those actions that are expected to solve the patient’s problems. If the docu-mentation is not done correctly, the agency may not be paid for the visit.
While conducting an assessment of the patient’s situation, the nurse evaluates the need for future visits and the frequency with which those visits may need to be made. To make these judg-ments, the nurse may find it helpful to consider the following factors:
· Current health status: How well is the patient progressing?How serious are the present signs and symptoms? Has the patient shown signs of progressing as expected, or does it seem that recovery will be delayed?
· Home environment: Are worrisome safety factors apparent?Are family or friends available to provide care, or is the pa-tient alone?
· Level of self-care abilities: Is the patient capable of self-care?What is the patient’s level of independence? Is the patient ambulatory or bedridden? Does the patient have sufficient energy or is he or she frail and easily fatigued?
· Level of nursing care needed: What level of nursing care doesthe patient require? Does the care require basic skills or more complex interventions?
· Prognosis: What is the expectation for recovery in this par-ticular instance? What are the chances that complications may develop if nursing care is not provided?
· Patient education needs: How well has the patient or familygrasped the teaching points made? Is there a need for fur-ther follow-up and retraining? What level of proficiency does the patient or family show in carrying out the neces-sary care?
· Mental status: How alert is the patient? Are there signs ofconfusion or thinking difficulties? Does the patient tend to be forgetful or have a limited attention span?
· Level of adherence: Is the patient following the instruc-tions provided? Does the patient seem capable of doing so? Are the family members helpful in this regard, or are they unwilling or unable to assist in caring for the patient as expected?
With each subsequent visit, these same factors are evaluated to determine the continuing health needs of the patient. As progress is made and the patient, with or without the help of significant others, becomes more capable of self-care and more independent, the need for home visits may decline.
As the visit comes to a close, it is important to summarize the main points of the visit for the patient and family and to identify expectations for future visits or patient achievements. The fol-lowing points should be considered at the end of each visit:
· What are the main points the patient or family should re-member from the visit?
· What positive attributes have been noted about the patient and the family that will give them a sense of accomplishment?
· What were the main points of the teaching plan or the treat-ments needed to ensure that the patient and family under-stand what they must do? A written set of instructions should be left with the patient or family, provided they can read and see (alternative formats include video or audio recordings). Printed material should be in the patient’s pri-mary language and in large print when indicated.
· Whom should the patient or family call in case they need to contact someone immediately? Are current emergency tele-phone numbers readily available? Is telephone service avail-able or can an emergency cell phone service be provided?
· What signs of complications should be reported immediately?
· What is the day and time of the next visit? Will a different nurse make the visit? How frequently will visits be made, and for how long (if determinable at this time)?
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