Med-Surg · chapter 36 · Home Health Nursing and Rehabilitation
Home Health Care
The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 3 practice questions with the reasoning.
Key points
Home health care scope
Home health care encompasses both medical and nonmedical services to address various needs and provide peace of mind for individuals, particularly older adults and those who are chronically ill or recovering from surgery or illness.
Home health outcomes
The Cleveland Clinic declared that the use of home health after an inpatient hospitalization decreases the rate of readmission hospitalizations, complications, and even death (National Association for Home Care Hospice, 2021).
Care plan elements
An important step in transitions of care, these plans should outline health-care needs, goals, interventions, and strategies that address conditions for patient health.
Preplanning assessment
To prepare for planning, nurses perform a detailed assessment of patient health status, which involves reviewing past medical histories and present conditions, medications, allergies, physical abilities, environmental factors such as home fall risks, and any support systems in place.
SMART goal setting
Based on assessment findings, nurses collaborate with patients, their family, and members of their health-care team to set realistic and obtainable goals that meet SMART (specific, measurable, attainable, relevant, and timely) criteria.
Culturally sensitive planning
Nurses consider each patient’s cultural background, beliefs, and values when creating care plans; this ensures care is culturally sensitive and respectful.
Patient participation
Nurses engage patients as active participants in care planning by including their input and preferences and acknowledging the patient has ownership over their own health care.
Care plan documentation
A registered nurse documents the care plan, detailing goals, interventions, expected outcomes, and changes made at subsequent visits. Accurate documentation ensures continuity of care and communication within the team.
Home visit purpose
A home health visit is an opportunity to conduct a nursing assessment in the patient’s home, documenting the patient’s health, monitoring their progress, and making sure they receive the care and support needed.
Health assessment monitoring
Nurses conduct thorough assessments of the patient’s health status, including vital signs, and monitor wound care, medication management, and chronic conditions. Regular assessments help detect changes in health and ensure timely interventions.
Medication management
Nurses educate patients and caregivers about medication regimens, administer medications as needed, and monitor for adverse effects or interactions. They play a critical role in ensuring medication adherence and preventing medication-related issues.
Patient education
Nurses educate patients and their families about the patient’s condition, self-care techniques, and lifestyle modifications to promote recovery and prevent complications. This education empowers patients to actively participate in their care.
Care coordination
Nurses serve as the point of contact between patients, their families, and other health-care providers. They coordinate appointments, facilitate communication among the care team, and ensure a seamless transition between different levels of care.
Personal safety
Personal safety is always a top priority. Trust your judgment if you feel your safety has been compromised during a visit to a patient’s home.
Terms to know
- community-based care
- A holistic approach, community-based care goes beyond typical medical treatments for specific conditions to address broader factors affecting health outcomes in a community.
- patient-centered care
- It is centered on delivering patient-centered care, which includes cultural sensitivity and considers the emotional, physical, social, and environmental factors that impact an individual’s health.
- home health care
- Providing community and health-care services within a home setting, often referred to as home health care or home-based care, offers numerous benefits for patients who require medical attention, rehabilitation, or ongoing support.
- SMART
- Based on assessment findings, nurses collaborate with patients, their family, and members of their health-care team to set realistic and obtainable goals that meet SMART (specific, measurable, attainable, relevant, and timely) criteria.
- home health visit
- A home health visit is an opportunity to conduct a nursing assessment in the patient’s home, documenting the patient’s health, monitoring their progress, and making sure they receive the care and support needed.
- medication regimen
- Review the patient’s medication regimen, which lists all medications the patient is currently taking, including over-the-counter medications and home remedies.
Practice questions
Stuck on select-all-that-apply? How to take them one option at a time.
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Every question here, with the answer
At 2:00 p.m., you finish a follow-up home visit. Changes in the patient's health status led you and the patient to revise the care plan. Which documentation approach best supports continuity of care?
- Document the interventions completed today and communicate the revised goals verbally to the team.
- Document the current assessment findings and leave the existing care plan unchanged until the next visit.
- Describe the revisions in a message to the primary care provider while retaining the original care plan.
- Update the care plan with the revised goals, interventions, expected outcomes, and changes made during this visit.
Answer: Update the care plan with the revised goals, interventions, expected outcomes, and changes made during this visit.
The section specifically calls for documenting care-plan goals, interventions, expected outcomes, and changes at subsequent visits. Assessment findings, verbal communication, or a separate provider message do not replace updating the care plan to reflect the revisions.
At 8:30 a.m., you review the medication regimen before a home visit. It lists prescribed medications, but the patient also reports currently using an over-the-counter product and a home remedy. Which actions would make the documented regimen consistent with the section? Select all that apply.
- Wait to add either product until the patient reports a side effect.
- Record both products only under lifestyle information rather than in the medication regimen.
- Keep the regimen limited to medications listed by the referring provider.
- Add the over-the-counter product to the medication regimen.
- Add the home remedy to the medication regimen.
Answer: Add the over-the-counter product to the medication regimen., Add the home remedy to the medication regimen.
The medication regimen includes all medications currently taken, explicitly including over-the-counter medications and home remedies. Restricting it to the referral list or placing these products only elsewhere leaves the regimen incomplete. Their inclusion does not depend on whether side effects occur.
At 11:00 a.m., you are documenting a home-care plan after discussing food preparation with the patient. The proposed approach does not fit the resources available in the home, and the patient has requested a different approach. What should the care-plan entry reflect?
- The agency's usual food-preparation approach, with additional education to help the patient follow it.
- The original approach, with the patient's concerns documented for consideration at a later visit.
- An individualized approach developed with the patient that fits the home environment, available resources, and personal preferences.
- The original approach, with a goal for the patient to obtain the resources needed to carry it out.
Answer: An individualized approach developed with the patient that fits the home environment, available resources, and personal preferences.
The section directs nurses to tailor care plans to the patient's home environment, resources, and preferences, with the patient actively participating. Deferring the concerns or relying on a standard approach leaves the current mismatch unresolved. Expecting the patient to obtain resources preserves the original plan rather than adapting it to the patient's circumstances.
Where every quote comes from
Section 36.1 Home Health Care of Medical-Surgical Nursing by Christy Bowen, Bridget Carey, Jessica Palozie, Maren Reinholdt, OpenStax, 2024. Read the whole section free at openstax.org.
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