Home environment better atmosphere for learning

Observation aids in overcoming learning barriers

Education is the backbone of home health care, says Eileen McFadden, BSN, MN, manager of educational services at VNA Home Health Care Services in Spokane, WA. It is through education that the patient's goals and outcomes are met.

"It is the purpose of home health care to instruct and assist the patients in gaining the knowledge and skills to allow them to remain in their own homes and return to their prior health status," says McFadden.

The purpose of home health care is rehabilitation, says Jeanne M. Martinez, RN, MPH, CHPN, former quality and education specialist at North-western Memorial Home Health Care in Chicago, who now is a quality specialist with palliative care and home hospice at Northwestern Memorial.

Sometimes the rehabilitation is short term, in which case patients must learn a skill such as dressing changes while recovering from surgery. However, home care staff often work with patients learning to manage a chronic illness, such as diabetes, in which success has a long-term impact.

"Generally, the focus of home care is to rehabilitate the patient or at least get them to a point where they can continue their own care," says Martinez.

While the educational process is a continuum of the teaching that took place in the hospital, often the patient will learn better in familiar surroundings. "It is becoming well known that if you want a patient to recover get them back into familiar surroundings where the stress is decreased. The home is where the best teaching and learning take place," says McFadden.

There are many reasons why teaching in the home care setting frequently leads to better results than those achieved in the hospital setting. There is no better way to see the whole person than in home care, says McFadden.

"We in home care have a very special and unique role. We are allowed very close, intimate, and personal contact with the patient and families in their situation," she explains. By going into the home environment it is easier to assess what some of the obstructions and barriers to health and learning might be, as well as the patient's and family's values, interests, motivation, and real goals.

Connecting choices and consequences

The home environment is usually less distracting than the hospital where visitors and medical staff come in and out of a patient's room all day and education is interrupted for lab work or other patient care needs. If there are distractions in the home, such as small children running around or a loud television, nurses can work with patients to eliminate them, says Martinez.

When working with the patient at his or her home it is much easier to help them see the connection between the choices they make and the consequences of those decisions. "We can give patients direct feedback and support in order to correct their behaviors," says McFadden.

The feedback can be obtained by contracting with telemedicine companies that call the patients frequently to determine if they are making choices that will result in good health outcomes. For example, congestive heart failure patients learning to monitor their weight and determine what can cause a sudden weight gain might weigh each morning and report to a telemedicine company. If there is a sudden weight gain, home health would follow up to help the patients determine the cause and see the link between their food choices and the sudden spike in weight. Home health nurses are able to help patients sort out what may or may not be good choices for them, says McFadden.

"The home is where the actual change in the patient's behavior needs to take place so the clinicians are able to observe the patient's actual follow through, or lack thereof. By starting where patients are, allowing them to see their progress, and obtain observable goals, long-term results and sustained change are possible," says McFadden.

In a hospital setting, clinicians must rely on information provided by patients concerning such matters as the ability to purchase medications and nutritional food or whether patients have family support. When in the home setting, a team from home health can observe barriers to education and recovery. Home health nurses become very good at assessing situations quickly, says McFadden.

Family dynamics can be either supportive or challenging, she says. It is easier to know what would motivate a person to comply with treatment regimens and instructions when in a person's home, says Martinez. For example, they may be motivated to complete certain exercises so they will be able to walk because they have a garden with many walking paths they want to enjoy again.

Because nurses return to the patient's home time and again for repeat visits they are able to observe the patient's progress after he or she has had time to practice a technique such as insulin injection. Often people think they will not be able to master a skill but a home health nurse can help them through the process until they have a sense of control. In addition, patients can call the home health agency when they have problems, says Martinez.

Also, home health nurses can help patients become better organized to handle the changes in their lives that must occur in order for them to live with their illness or health problem. For example, taking 10 medications can be very overwhelming, yet a home health nurse can help patients organize them in a way that works.

In a two-story home, patients might keep the medicines they take at bedtime in the bathroom next to their bedroom and their morning medications downstairs.

"Nurses can do a lot with patients to help them become better organized in their home setting," says Martinez.

Successful teaching sessions

Teaching sessions can be very successful because the home health nurse sets up the time for the visit in advance and is able to discuss with patients what they will need to be ready to learn, as well as the information to be covered. For example, the nurse may want to go over the patient's ability to monitor his or her blood glucose levels.

Before a visit, the nurse will determine whether or not patients have been able to get the equipment they need, such as a blood glucose meter. If patients cannot get the equipment the nurse will find resources to help them obtain supplies.

Also, the nurse can make sure everyone who needs to be present at the time of teaching will be in the home. In home health it is important that a family member or other caregiver be in the home at the time of the visit to learn as well, says Martinez.

Valuable teaching sessions in the home setting also depend on accurate documentation of patient education. When multiple nurses are visiting the patient, as well as physical and occupational therapy, communication must take place so each discipline knows not only what was taught but also what teaching must be reinforced, says Martinez.

If educational needs are not well documented insurance companies may deny subsequent visits because the need is not evident, she adds. Indeed, in home health it is important to be goal- and objective-oriented and make every visit count because insurance companies can limit the number of visits, says McFadden. It is important for members of the health care team to know that a certain portion of the education has been completed and the objective has been met.

"Documentation of the education in the home is critical so we stay on task to help the patient reach these goals in as short a period of time as possible," says McFadden.

To help with documentation and make sure objectives are met, care pathways are often used at VNA Home Health Care Services. "Care pathways also help members of the team assess where the patient is and determine where he or she wants to go," explains McFadden.

It's important to communicate with the physicians who are seeing the patients as well, she adds. "We use liberal amounts of faxes to keep the physician apprised of the patient's progress. The physician is key in developing the plan of care," says McFadden.

Yet, communication is not limited to home health teams and the patient's physician. It begins at the point of discharge between home health care and discharge planners at the hospital. It's a good idea to have a copy of the written discharge instructions so there is consistency in what was taught at the hospital, says Martinez. It also is important to have the protocols from physicians on what they want their patients to be taught, especially for patients recovering from certain surgeries, such as hip replacement or undergoing certain treatments, such as chemotherapy.

When multiple services are involved with patient care it is helpful to provide patients with a folder to keep all their instructions and handouts together.

"The more the hospital and the home care agency or the physician's office and the home care agency can communicate the better it is for the patient," says Martinez.

Although hospital clinicians try to provide all the necessary instruction to patients before discharge, they do not always retain all they have been taught, says McFadden. Therefore, it is important for a home care agency to know what has been taught during the hospital stay so they can reinforce the teaching. In addition, it is important to know what triggered the hospital admission so the issue can become a focal point for teaching, she says.

"Our goal is to delay, reduce, or eliminate repeated hospitalization by helping the patient understand the process. Only by instruction and education can the causes of the changes in their health status become known to them so they can learn disease management," McFadden says.


  • Susan McMillan, RN, PhD, FAAN, professor, University South Florida College of Nursing, Tampa. E-mail: smcmilla@hsc.usf.edu.