WITH 100% CORRECT ANSWERS;
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Purpose of Home Visiting - ANS-} More accurate assessment of family - not healthcare provider domain
} Case finding and referral
} Identify barriers and supports
} Health promotion and illness prevention
} Health maintenance and restoration
Goals of Home Visiting - ANS-}Promote support systems
}Promote care of client with illness/disability
}Encourage growth & development; educate about health promotion & illness prevention
}Strengthen family functioning
}Promote a healthy environment
Transitional Care can reduce Hospital Readmissions - ANS-WANT TO REDUCE HOSPITAL READMISSIONS
BC THIS MEANS PATIENTS HEALTH HAS IMPROVED
the significant cause of this is poor communication and coordination from hospital to home (ppor
patient discharge instructions, medications, red flags about worsening conditions, and contact
information for questions)
Affordable Care act --> Medicare hospital readmission reduction program --> penalties are given to
hospitals if a patient is readmissted within 30 days discharge
Essential Principles
-home visit within 3 dyas
-care coordination with APRN or RN
-Communication between hospital team and PCP within 1 week of discharge
Risk factors for Readmission
- Older age
-Frequent ED admissions
-Lack of social support
,-weekend discharges
-Poor access to healthcare services
-Substance abuse
-Poor health literacy
-Functional limitations (lack of essential skills and confidence to engage in their own care)
NO SINGLE ACTIVITY HAS WORKED ON ITS OWN IT S A COMBINATION OF SO MANY OTHER THINGS
NURSES ROLE --> asses them for readmission risk and referred for transitional care services as needed,
educate them and get them involved in their own care, proper discharge planning, follow u[ with PCP,
How to prepare for a Home Visit - ANS-Preplanning
}Contact info, directions, map
}Phone # and itinerary for supervisor
}Agency and emergency numbers
}Referral source and purpose of visit
}Activity plan
}Pack paperwork, equipment and supplies
}Have community resources available
}Leave itinerary with agency
}Approach visit with self-confidence
Initiation - ANS-}Observe environment with regard to your own safety before and after entering home
}Knock and stand where you can be seen if a peephole or window
}Identify yourself and agency
}Ask for the client Introduce yourself to everyone present
}Sit where directed
}Discuss purpose of visit. On initial visit discuss services to be provided by the agency
}Have permission forms signed to initiate services
Implementation - ANS-}Complete database for the individual client
}Assess for changes since last encounter on return visits, was family able to follow up on plans, if not,
why not?
, }Wash hands before and after direct physical care
}Provide care
}Identify household members and their health needs, use of community resources and environmental
hazards
}Explore values, preferences, and clients' perceptions of needs and concerns
}Conduct health teaching as appropriate and provide written instructions
}Discuss referral, collaboration or consultation that you recommend
}Provide comfort and counseling as needed.
Termination - ANS-}Summarize visit with family
}Review goals with client
}Leave contact information with family
}Schedule next visit, if appropriate
Post home visit planning - ANS-}Documentation: In family record, other relevant databases
(immunizations, communicable disease registry, etc.)
}
}Referral Action: resource identification & contact information, form completion, direct
communications, other
}
}Consultation: with faculty, supervisor, or other members of the health care team
}
}Next Home Visit Plans: data collection, teaching, other direct care, and/or referrals
}
}Needed Changes: in equipment, asepsis, safety, approach
Factors that Influences Nurse/Family relationship - ANS--Focus on the family unit as everything
influences the patient
-HEALTH NEEDS AND ALL LEVELS OF PREVENTION
-family retains AUTONOMY
-NURSE IS A GUEST --> THEY DO NOT TAKE OVER EXCEPT(abuse/neglect, suicide/homicide and
communicable diseases)
-Caring presence (positive regard -->dont be judgmental, empathy, genuineness)
how to reduce potential problems
}Matching nurse's expectations with reality
}Clarifying nursing responsibilities
}Managing the nurse's emotions
}Maintaining flexibility in response to client reactions
}Clarifying confidentiality of data