Luis, 76, is injured in a car accident and admitted to the hospital. After five days of treatment, his team is ready to discuss his discharge.
His doctor feels Luis is stable enough to go home. The physical therapist who’s been working with Luis in the hospital believes he’s strong enough to continue his recovery at home. Luis just wants to be back in his house, wearing his own clothes and sitting in his favorite chair. His daughter, however, is unsure.
Luis is a widower and lives alone. His daughter is willing to stay in his house for a few weeks but is worried about what caring for him will entail. She doesn’t know how to clean a wound and wouldn’t be comfortable helping him shower. She tells the team, “Maybe my dad should stay at an inpatient nursing facility instead.”
Although Luis and his daughter are hypothetical, similar situations are happening daily as patients face the transition from hospital to home.
Isao Iwata, MD, who specializes in geriatric medicine at Penn Medicine Princeton Health, said it’s usually a family member who expresses concerns about taking care of the patient.
“In my experience, the patients themselves always want to go home,” he said.
What home care can offer
After a hospital stay, adults recovering from an illness, injury, or surgery can receive skilled nursing care and rehabilitation in the comfort of their home through Penn Medicine Home Health Princeton Health, one of several in-home programs offered by Penn Medicine at Home.
Under this program, Princeton HomeCare provides patients with hands-on assistance managing the next phase of their recovery, while giving caregivers (often family members) the training, support, and assurance they need.
Sandra Jost, RN, MSN, PhD, chief nursing officer and associate executive director for Penn Medicine at Home, explained that registered nurses, physical therapists, occupational therapists, speech therapists, social workers, or home health aides will come to your home for an hour or so, multiple times a week, to provide a range of services, according to your needs.
“There must be a skilled need that can’t be performed routinely by a family member or friend,” she said.
Skilled nursing services include wound care, from dressing changes to management of drains and sutures, as well as medication management. Patients often leave the hospital with their medication schedule switched around from what it was prior to admission. Home care nurses make sure the patient and family have the right medicines available and understand their timing and dosage. They also help patients manage newly diagnosed conditions like heart failure or diabetes.
“We may be there teaching you how to use your glucometer and making sure you understand your insulin regimen and diet,” Jost said.
Physical therapists come to the home and help the patient exercise the appropriate muscle groups to restore strength, balance, and range of motion. “The therapists do everything they would in an outpatient setting. It’s a full exercise program to help patients regain their function,” Jost added.
Occupational therapists work with the patient on activities of daily living (ADLs) like getting out of bed, using the bathroom, and changing clothes.
“Occupational therapy becomes very important for patients around their mental recovery, so they can do small tasks and hobbies around their home that were meaningful to them,” Jost said.
The home care team will also suggest any adaptations that can make the environment safer for the patient and arrange for equipment such as a hospital bed or commode chair to be brought to the home.
Deciding on home care versus an inpatient facility
Before a patient is discharged from the hospital, the care team must decide if they are ready to go directly home or if they need to transition to an inpatient skilled nursing or rehabilitation facility.
Recommendations are typically based on an assessment from the physical therapist, with input from the provider team, care team manager, and patient. The patient’s home situation is always factored into the decision-making. For example: the physical layout of the home (i.e., Must they climb stairs to reach a bathroom or bedroom?); how well the patient can get around; and whether there’s a friend, partner, or family member who can lend a hand with light meal prep, bringing them their medication, and ensuring they’re safe.
Iwata said that about half of the patients who are admitted to the hospital from pneumonia or some other illness become weaker during their stay and may be unable to perform the basic activities of daily living without assistance—another factor that determines if they’re ready to go home. If the patient’s breathing is unstable, for example, the team is more likely to recommend an inpatient facility.
In many cases, home care is the best option for the patient. Challenges such as a family member feeling nervous or overwhelmed can usually be overcome by talking to the hospital care team about the patient’s specific needs and what skilled outpatient support is available.
Serving today’s health care expectations
Since the COVID-19 pandemic, health care providers like Penn Medicine have expanded access to in-home options—from virtual visits to recuperation from illness. Home care services allow patients to recover in the safety, privacy, and comfort of their own homes.
Jost explained that the home care team is available 24/7 by phone to answer questions and discuss any problems. When appropriate, they also set patients up with a tablet device for telehealth visits and equipment for checking blood pressure, oxygen levels (pulse-ox) and heart rate. Nurses monitor the transmitted data and if they see anything unusual, will call the patient or dispatch a nurse to the home.
As part of Penn Medicine, the team at Princeton HomeCare has access to the patient’s electronic medical record and communicates with other providers to give updates on their progress and discuss when drains or stitches can come out.
“Many patients will do much better in their own surroundings,” Jost said. “If we can get their recovery going in their own environment, where it’s set up for them and safe, and they have the right support, they can regain their independence and achieve their health care goals.”