Transcription:
Home Care and How It Helps Patients

Scott Webb: As one of the first hospital based home care organizations in Massachusetts. Emerson Health Home Care offers a multidisciplinary team of nurses, rehab specialists, and home health aide to help you stay in the familiar comfort of your own home, during times of recuperation disability, or chronic or terminal illness. And joining me today to tell us more is Nicole Johnson. She's a rehabilitation supervisor for Emerson Health Home Care and a geriatric certified specialist. This is The Health Works here podcast for Emerson Health. I'm Scott Webb. Nicole, thanks so much for joining me today we're gonna talk about home care, and I got a bunch of questions for you, so as we get rolling here, what is home care?

Nicole Johnson: Home care is basically skilled clinical intervention and support services that allow patients to remain in their homes while receiving some level of medical care. Whether that's nursing care, rehabilitative care, personal care needs, on a short term basis. But it really promotes the patient's ability to stay in their home, be in the comfort of their own home, with their family, and with their personal caregivers, and promoting independence on the level of the patient.

Scott Webb: Yeah, I'm sure we can all probably identify with that. I'm sure it's nice. It is a comfor to be in their own homes. And I'm sure there's a bunch of folks, as you mentioned, a few of them there, what types of medical staff provide home Care?

Nicole Johnson: So at Emerson Home Care, we have a slew of clinical staff that are ready and able to assist the patients. We have skilled nurses, , which include registered nurses and LPNs. We have a home health aide that can provide self care or hygiene assistance to patients, showering, bathing, sponge bathing, dressing, that sort of stuff. We have a social worker, who can assist with community resources , difficult situations between family, difficulty managing the healthcare environment, that sort of thing. We have physical and occupational therapists, and they can provide specialized care for patients with a very broad range of disorders.

So vestibular disorders, we have a certified lymphedema therapist for patients that migh t have impairments with their lymphedema system. And then we also have a remote patient monitoring program, which basically is a telehealth system in which the patients can set up with a tablet at their home. And they record their own vital signs and then enter them into the tablet. And then that information is transmitted to the office and is reviewed by a registered nurse. And then that nurse may call the patient on the phone or have a video conference with the patient to kind of go over what the vital signs say.

Communicate with the physicians or the referring provider if there needs to be any changes in medications, if there's any concerning signs, if there are patients doing really well. And just seamlessly helping keep the community, patients, the physicians, and us all in the loop at the same time, and really helps with that kind of comprehensive patient assessment and guidance towards changes in their medical care.

Scott Webb: Yeah. That's really awesome. I think many of us have learned anyway the benefits of telemedicine over the last few years. So Nicole, who are the ideal home care patients? What are they recovering from and that kind of thing?

Nicole Johnson: So first and foremost is that any patient that is going to receive home care services must qualify as being home bound, which means it requires, the patient a taxing effort to leave their home. And a taxing effort is kind of a generalized term, but it can be, , inclusive of maybe they've had an orthopedic injury, a fractur e or a joint replacement. Or they get very short of breath, for example, leaving their home. And it's really difficult that for them to negotiate their stairs in and out of their home, but they need to have it be difficult for them to get in and out of their home for qualify for home bound status and to meet a home care requirement.

We see patients that, like I mentioned, have orthopedic injuries. So basically anything wrong with their bones. It can be arthritis, it can be after a joint replacement. It can be after a fracture, a broken bone. It can be a cardiovascular or a pulmonary issue. So an issue with your heart or your lungs. Heart failure, COPD. A lot of our patients have had covid or have covid, and we are fully capable of treating patients even that have active covid with the appropriate precautions. We see patients with, , skin disorders, so patients that have wounds. Our . Nurses are very capable and, patients that might be feeling dizzy and have any difficulty with their vestibular function. , and like I mentioned earlier, any patients that have a lymphedema problem, so if they have a lot of swelling in their legs due to an underlying condition, we now have a certified lymphedema therapist as well. And we want to help all these patients. We definitely, are willing and able to accept that very wide variety of diagnoses and clinical conditions and whatnot.

Scott Webb: Yeah, and you mentioned earlier some of the reasons why home care would be good for some people, some of the benefits, if you will, but I just kind of wanted to go back over that again. We've talked about, obviously being able to stay in their home, being able to do telemedicine having that slew of folks come into their homes. But overall, what are the home care benefits?

Nicole Johnson: Like I mentioned before, one of the main benefits is that the patients and their families can stay in the comfort of their own home while receiving some level of medical or rehabilitative care and that we're seeing is so important. Patients are really reluctant to leave their home, especially the geriatric population, and we are finding tha t they're the happiest in their home. They've lived there for however long. But it just creates a level of comfort that they can manage their own home environment. And the therapists, especially one of their main jobs, is to help them maximize their independence in their home environment. They wanna be able to do their own laundry.

They wanna be able to make themselves a meal. . And by having us go into their home, we can really customize the intervention, whether it be nursing or therapeutic intervention to that specific environment. So for example, the patient might tell us they're having difficulty getting on and off the toilet or getting in and out of bed instead of practicing in a rehab facility where it's a generic kind of set up, we are really optimizing that individualized, customized treatment in the patient's comfort of their own home to exactly what they're gonna be doing day in and day out.

Another one of the benefits of home care is that sometimes the home care can prevent a rehab stay. So you might have an issue in the hospital whether or not you have a heart failure exasterbation or you've had a joint replacement, knowing that you're going to have clinical care immediately in your home might prevent you from going to rehab. And Emerson does now have a Why Not Home program that we're running, at the Home Care Agency get a list of patients that really, the physicians in the hospital feel could meet their needs at home with our services.

And preventing that rehab stay and allowing the patients to be comfortable in their own home. Additionally, home care really has been shown to decrease re-hospitalizations. So a patient goes in with an acute issue into the hospital, they get discharged with home care, they have all these services set up that enable them to stay in their home, and it may prevent them from going back into the hospital again with an issue because we identify the issue early and reach out to the providers to address it before it becomes a bigger problem, requiring them to go back to the hospital.

Scott Webb: Sure. Well, it's been great learning about this today. It's like you see words, you think home care. Well, I have a pretty good sense of what that means, but apparently it means a whole lot more than I thought it did, and so many more benefits and so comprehensive and so convenient and everything. I guess my last question for you, Nicole, is if I want to get home care for myself or a loved one, how do I do that?

Nicole Johnson: Great question. So the referral process is fairly simple. , we need a referral from a referring provider, and that can be a physician or it can be a nurse practitioner. And the referrals are sent by usually fax. you can call in a referral to the line, but then the paperwork that is required does need to be faxed over. The referral phone line is 978-287-8361. And the fax number is 978-287-8399. And we do require some paperwork just so that we can bill the insurance company and make sure that we have everything that we need to follow the conditions of participation. And that paperwork has to include what's called a face to face encounter, which basically means that the physician has seen this patient at some point, either in the previous 30 days or is going to see them in the subsequent 60 days.

And can certify that they're home bound and make sure that all the needs are gonna be met. We need an active medication list. We need the provider's, most recent clinical note assessment of the patient. We need the specific orders, what they want us to provide. Do they just want nursing? Do they just want pt? , what specific services do they think that the patient needs. And then we need that provider to also say that the patient is home bound. So the physician just has to write, you know, the patient is home bound because, and fill in the blank.

Scott Webb: Well, this has been really fun and you are a wealth of information. You dotted all the i's, crossed all the T's. I really appreciate this today, Nicole. You stay well.

Nicole Johnson: Thank you, Scott. You as well.

Scott Webb: And visit emersonhealth.org/homecare for more information. And thanks for listening to Emerson's Health Works Here podcast. I'm Scott Webb. And make sure to catch the next episode by subscribing to the Health Works Here Podcast on Apple, Google, Spotify, or wherever podcasts can be heard.