Technology and care planning together should help support best practices and evidence-based care—but do they? When querying home care colleagues, many want the same things: a process that is fairly easy to learn and use while supporting practice in the real world. The bottom line is that the chosen technology and its applications work well (or work well enough that it is does not disrupt care and operations). This may not seem like such a hard thing to accomplish, but some days it sounds like it might be. On days when things are bad, like when things will not sync, or data entered cannot be “found” or devices seem to have their own minds; such frustrations are a very real problem. Additionally know that clinicians are making 6-8 “visits” a day and so are not in one place to “work through” or effectively address these concerns. With productivity standards and some very sick patients at home, the complexities and frustrations can grow.
Whether the patient information is data entered during the admission process or done the old-fashioned way—completed on forms and other written tools, care planning in home care should “look” or be practiced the same way. Because I practice and work in home care, and due to the very nature of home care, here are a few “wrinkles” that the setting alone contributes. And “alone” is the key word here. For those readers who are not familiar with home care, let’s spend a little time on the home care practice setting, which can have its own unique challenges. The following are some thoughts to help in better understanding home care and the challenges that are inherent in that practice setting.
- Try to see your community or city with “new eyes”—like you have never seen it before.
Imagine yourself being out in a community, perhaps 30 minutes to an hour (or more!) from the hospital or health system, and you are alone. The home care (or hospice) clinician admits and cares for all kinds of patients in the privacy and comfort of the patients’ homes. Now consider the variability of the word “home”. On your next drive somewhere, try to see your community with “new eyes.” Take into account such important health indicators as: Are there grocery stores? Are the homes maintained or neglected? Are the streets potholed or smooth? Are there streetlights at night? Is there a park? There are numerous indicators about the health of a neighborhood and zip code. Nurses and other clinicians providing care in homes are adept at such “windshield” assessments as this provides valuable information about the patients and their family members’ health and health care needs. Family members are mentioned here because in home care, the family caregiver is often recognized and valued as the “expert” about the person or patient needing home care.
- Imagine being able to talk to anyone about almost any health care problem, then “admit” them, assess them, provide care, coordinate care with the patient and caregivers, and more: all in one visit. This is what home care clinicians do every day.
Home care is holistic and must be as we are guests in the patient’s space or most sacred environment: their home. What this means is the nurse or therapist meets a person for the first time and may provide very personal care within that same time frame (visits may take 45 minutes to over 2 hours depending on the type of visit and the care). This care is person-centered and holistic—it must be, given that we are a guest in the person’s home environment. Because of this construct, which is very different from that of a hospital (or other inpatient care generally) there are no standard hospital gowns, there are no visiting “hours”, no restrictions on food choices or meal times, or anything usually. The patient is allowing us to come in as a guest, and in this way, we must function in their environment. At a glance, and across time the home care team understand socioeconomic problems: if a patient cannot afford the food or nutrition needed for their health problem, that there is no heat in the winter or no air conditioning in the summer in a patient with respiratory problems and other real-world examples that home care nurses identify and address.
Here is the usual case scenario for a visit: A clinician drives to the community for the first scheduled visit to a new patient. The clinician may have a tablet or a laptop to gather data and begin the assessment which becomes the basis for care and care planning. This is the time where technology interfaces and becomes the connector with the nurse and the patient. In home care, there is a large data set that is used for Medicare and some Medicaid patients that is called OASIS. OASIS is an acronym for Outcome and ASsessment Information Set, a discipline-neutral and mandated data set used by home care clinicians. The OASIS data items address sociodemographic, environmental, support system, health status, functional status, and health service utilization characteristics, and become the basis for measuring patient outcomes. The OASIS, a part of any patient assessment, is about 25 pages long, and the data are reassessed at defined time points. This is just one part of the data that home care clinicians must collect and enter to begin the care planning process. The good news is that these data elements are usually embedded, interwoven into a larger assessment, to help facilitate completion of the elements.
When viewed fundamentally, the care and care planning process can be broken down into or organized into distinct steps. These are assessment, analysis, problem identification and prioritization, more analysis and discussion, identification of the best interventions for the person, and the determination of patient goals or outcomes. Critical thinking occurs all along the way and throughout the process. Of course, the patient has input into the goals and priorities for their care. There is usually ongoing review and changes to the plan of care all along the way with reevaluation of the process and plan. Such changes might include medications, changes in visit frequencies, new medical equipment, and numerous other changes to the physician-ordered plan of care. By the time the clinician leaves the patient’s home, they have begun the care planning process and have usually provided care, such as wound care, observation and assessment of a new medication, and any number of other skilled services.
This is where the importance of effective technology takes center stage. Technology is critical to communications about the patient and their unique care needs. That communication and coordination with other team members, as well as physicians, is vital to providing the best patient care possible.
- Try to understand the regulatory complexity interfacing with the person and care and their unique home environment.
Medicare is the largest payer for home care services, and home care is very regulated. Though this is out of the purview of this article, suffice it to say that complexity and change will continue. (For more information about this, readers are referred to the book Home Care Nursing: Surviving in an Ever-Changing Care Environment.) Because of this complexity, the technology must be able to address these numerous complexities to support coverage rules, specific documentation requirements such as homebound, and have data flow across in a manner that replicates and supports the best home care and care planning processes. On the other side of the keyboard, (where there might be pets and sometimes creatures we do not usually think of as “pets”) at the patient’s home, the clinician must enter that data and other detailed information. This information should validate meeting regulatory requirements, such as medical necessity and have fundamental but very important frameworks to support the provision of individualized patient care. Similarly it should support “painting the picture” of the person receiving home care and the individualization of their unique health care problems.
- Have a grasp of the documentation requirements to meet numerous regulations and standards.
This is the area where an intuitive, effective and functional technology such as an EMR is worth its weight in gold. There are many kinds of documentation methods and systems. Many organizations have a blend of paper and electronic records. Of course it is intuitive and makes sense that systems integrate the fundamentals of care planning, as this is how care is accomplished in home care. Sadly, some organizations have devoted significant time, efforts and resources with one vendor, only to realize that there is not success operationally and so must switch vendors and systems (at great expense of time and money).
The Challenges Remain
There is always room to improve technology and its function from a performance improvement perspective. How is this best accomplished? The following are some ideas from working with EMR and other technologies related to home care. Ask yourself:
Are the end-users engaged in the technology and its usage? What has been done (or not done) to facilitate this? Like patient engagement, this is an important key for long-term success.
Are improvement ideas welcomed or is it met with “this is one more thing I need to do or change”?
Does the change support evidence-based care and/or meeting some standard that would improve patient care outcomes and clinician/patient/organization quality goals?
Is there a home care nurse leader on the team that can connect with your users and facilitate communications for effectiveness of the EMR or technology?
Is there sufficient effort made (and sustained when needed) to assist users in understanding the nuances and other processes to make the best use of the technology? I have seen good technology sit on shelves or otherwise not be functional or switched because of a lack of communication and education.
Consider how the process of (re) education is hardwired across time for success? Such as when needed for a significant staff turnover?
All health care settings have a “glossary of terms” that make them unique. Does the content of the EMR or other technology, directed toward home care clinicians and patients support home care practices and processes?
Is the nursing care planning or scientific process readily seen so that it follows that cycle and
mirrors how clinicians have been taught to think about care and care planning?
Is the library or content in the care planning process helpful? Does it reflect home care and best practices? Does it help clinicians document their care and have the ability to better individualize patient care?
Does the technology help with home care clinician and manager recruitment and retention? Does it in some way help improve the patient experience or quality goals and other safety and quality initiatives? Thinking this way may assist in innovation and differentiation.
Overall, is the feedback received, when asked, positive? These are just some questions to consider as technology in many forms and applications continues to expand as the home becomes the primary setting for health and heath care.
Though we may all strive for a truly “paperless” health care environment, there may continue to be forms that must be scanned (patient signatures on certain mandated forms come to mind). The dynamics of home care are very unique and different from any other health care setting. This is because the dynamics of providing care in a home environment. Care planning and EMRs should be congruent and “go” together. This is a very good thing as it can support the individualization of care and related process; but it takes a robust and informed EMR or other technologies to help the clinicians accomplish the goals of an effective care plan –meeting the identified goals of care for a special patient – a home care patient.