This article is part of the HHCN+ membership
Most patients with complex medical needs, especially those relying on life support devices, are cared for at home by work-from-home equipment care providers. However, providing care to these patients presents unique challenges that require specialized skills and better communication.
To effectively care for medically intensive patients, home care operators need to integrate new technologies such as wearables and remote patient surveillance, while enhancing collaboration across the interdisciplinary care team.
“Ensuring continuity and consistency in care depends on effective closed-loop communication between care teams, caregivers, participants and families,” Patricia Connelly, CEO of the Center Light Health Care Program for Inclusive Care (Pace) for the Seniors, told Home Health Care News. “By reviewing documents, anticipating needs and maintaining clear and continuous communication, (caregivers) provide high quality, coordinated care between providers and shifts.”
Founded in 1985, Centerlight Healthcare is a non-profit long-term care organization run by the state of New York. We provide home health services to residents with age, disabilities and chronic disabilities in New York metropolitan areas.
Researchers at the Salt Lake City pediatric research company found that vision in hospitals has increased over time, and the severity and complexity of unresolved medical conditions at the time of discharge are also increasing.
Home care providers supporting medically intensive patients often face significant hurdles, such as labor shortages, financial burdens for both workers and patients, unsafe or inferior housing environments, complex care coordination among multiple providers, and complex care coordination resulting from high stress and demanding working conditions.
These issues can be difficult to manage patient safety concerns, poor communication, and the complex and changing needs of medically vulnerable individuals at home.
Patients with intensive medical needs require constant surveillance and care as conditions can change rapidly. This requires a high level of adaptability and support from the caregiver. Patients may feel that home care is a threat to independence and leads to resistance or violation. At the same time, a study from the University of Oslo in Norway shows that caregivers need to carefully balance the needs of patients with potential risks.
Patients can also face functional limitations that are often associated with technical dependence due to lack of access to life support equipment and reliable internet, or due to proper training to use digital health tools.
Given these challenges, home care providers need to develop and implement collaborative and coordinated care plans that address the patient's current health status.
According to Connelly, a comprehensive plan for caring for these patients begins with a thorough assessment of their needs.
At Centre Light, each participant is working with a dedicated care team that creates people-centered plans to address physical, behavioral, mental, emotional and social needs, she told HHCN. A comprehensive treatment plan provides a complete overview of an individual's medical condition, medication, treatment, dietary requirements, recreational interests and functional capabilities. It is updated regularly to reflect changes and timely intervention is ensured.
Jen Wirt, founder and CEO of Coral Care, told HHCN that while her company's standard care model is designed during weekly home sessions, the standard is not always optimal for all patients.
“Our goal is to provide the care that each patient really needs,” she said. “We start with a thorough assessment that explores strengths and challenges, and focus on family perspectives, taking into account previous notes and advice from other experts and centers. From there, we work with parents to create a care plan that meets both developmental and medical needs.”
She said providing care at home is a major advantage, as patients are supported in familiar environments where patients feel natural and parents can easily incorporate strategies into their daily lives.
Coral Care offers home-based pediatric speech and occupying therapy services for children in Massachusetts, Texas, Pennsylvania, Illinois and New Hampshire.
Wirt said in her organization, continuity begins with a way that matches family and providers. Each child is paired with a therapist who is the right clinical and personal fit, and the goal is to build a reliable, long-term relationship. When a child benefits from multiple disciplines, providers work closely to ensure that treatment is aligned with documented goals in the care platform and is strengthened through ongoing communication with parents.
In addition to support from healthcare providers, well-trained caregivers are important to ensure that patients remain safe, healthy and comfortable, as patients are often first aware of new problems.
According to Connelly, key skills for medically intensive patient caregivers include awareness and reporting on health changes, activities in daily life, support for mobility and safety, and monitoring nutrition.
“We look for qualities beyond qualifications such as adaptability, strong communication and the ability to build trust with children and caregivers,” Wirt explained. “Many of the families we support have children with complex needs, so we prioritize providers who have experienced multiple conditions.
Issues and new tools
Home emergency poses unique challenges for medically complex patient caregivers. Unlike hospitals, caregivers often do not have immediate access to all important medical devices. This lack of resources can be a major obstacle during serious circumstances and severe trauma, according to the National Institutes of Health.
Another challenge is that there may be only one caregiver in the house at a time, putting the burden on that individual with all their care. Collaboration is essential for healthcare. However, the reality of home care is that caregivers often have to rely solely on skills until additional help arrives.
In some cases, physical movement of a patient can be a hurdle, especially if the patient loses mobility due to illness or injury. Hospitals have many devices for safe and secure patient movement, but these are not always available in home environments. In emergencies, moving patients can be a challenging, important, time-sensitive task.
The hospital setting also provides immediate access to a wide range of professionals who can discuss cases within minutes. Researchers at Northeastern University in Boston say access to specialized services can be difficult, especially in rural areas, due to care, particularly in rural areas.
However, technology can alleviate some of these concerns.
According to Connelly, the use of technology enables efficient and effective communication between care teams, participants, and community providers and specialists, and care team members, allowing communication between care team members between care teams, community providers and specialists.
Tools and platforms help you manage medication, restock, schedule appointments, tracking calls, streamline service requests, and minimize disruptions in care. Technology also helps support accurate data storage and review, allowing errors to be identified and corrected as needed.
“We can use technology to provide and support services by employing electronic devices such as remote surveillance systems and personal emergency response systems (PERS),” Connelly explained. “Our remote participant surveillance program helps track vital signs, bathroom use and serves as a tool to prevent falls. Similarly, PES includes a necklace that includes a device that someone can push in the event of a collapse or an emergency at home, and operators activate emergency services.”
Providing home care to medically intensive patients during serious illness can be challenging, but it is feasible and often a preferred option. With the right provider, solid care plans and ongoing communication, home care providers can produce better results with higher satisfaction and lower costs compared to extended hospital stays.
