Jane Hanahan, RN, BSN, MHA; Administrative Director, Home Care/Hospice; Crozer-Keystone Health System
In today’s healthcare environment, home care plays an increasingly important role along the continuum of care as patients leave the hospital or rehab center and transition to life at home. In Home Care, we have two overriding goals: (1) to rehabilitate our patients to their full potential, helping them to become as independent as possible in managing their disease at home, and (2) to decrease the incidence of re-hospitalization and decrease use of emergent care facilities.
This is of particular concern with patients who are returning home from the hospital or rehab center after a recent stroke or heart attack. Any recently hospitalized patient has gone through a period of instability, which puts them at risk for complications. Home care nurses are highly experienced at assessing and monitoring patients to ensure that they continue to stabilize. The nurse plays a key role in observing changes in the patient and reporting them to the physician. In some cases, the nurse’s observations may lead to critically important changes in medications and treatment regimes.
Home care nurses also play an active role in recommending care for patients. In a stroke patient, for example, the nurse may recognize the need for physical therapy to facilitate ambulation and transfers, and occupational therapy to help with activities of daily living skills and re-acclimating to the home, especially if the patient has been in rehab for a while.
Patient education is one of the most important roles fulfilled by the home care nurse, particularly with heart and stroke patients. First and foremost, the nurse teaches them about medications. It isn’t unusual for patients to go home with 15 to 20 medications because of their co-morbidities. It is essential that they understand the purpose of each medication, how it should be administered, possible interactions and side effects, and how to recognize any problems that are developing.
We also teach patients about diet, activity and, most importantly, recognizing signs and symptoms to report to their physician, and knowing when to call the doctor or 911. If a congestive heart failure patient, for example, gains three pounds over two days, we make sure they know to call the doctor. If they wait much longer, they will probably end up going to the ER. If they call right away, the doctor might make a few adjustments to their medications to resolve the extra fluid and hopefully, prevent re-hospitalization.
In addition to nurses, the CKHS Home Care staff includes physical, occupational and speech therapists, home health aides and a social worker. Working together, they strive to remove any impediments to recovery and independence for the patient. Our staff stays until the patient’s medical status is stabilized and we feel they can function to their maximum potential.
The rewards of home care nursing are many. Our patients are so appreciative of the care and attention we provide, especially because the home care nurse is sometimes the only person the patient sees all week. It’s also gratifying to have the ability to work one on one with the patient and build a relationship of trust. Seeing the patient achieve independence at home is our ultimate reward.
Jane Hanahan, seated at the center, with members of Crozer's Stroke