Home health: The bridge between the hospital and 100 percent recovery

Patient Steve Caruso with therapist © UC Regents
Physical therapist Charlotte Norton helps post-surgery patient Steve Caruso navigate his stairs.

Posted Oct. 26, 2011

Steve Caruso had a difficult adjustment following hip replacement surgery at UC Davis Medical Center. He wasn’t prepared for the pain following his procedure or for the emotional strain of being homebound. The UC Davis home-health team is helping him regain his mobility – and more.

“I felt for a while like I was never going to get any better. It was frustrating because I had no similar experiences as a patient to compare it to,” said Caruso, who has been visited regularly at home by physical therapist Charlotte Norton and nurse Marianne Ciavarella since being discharged in September. “They have been very helpful in reassuring me that I am coming along fine, pushing me to go further with my therapy and never letting me think of myself as an invalid.”

UC Davis Home Health is a team of experienced nurses, social workers, physical therapists and home-health aides who, under the leadership of family and community medicine physician Don Zacharias, support patients like Caruso who are well enough to leave the hospital but not yet able to independently manage all of their medical needs. Home health fills those gaps in the healing process. The services are typically less expensive, more convenient and as effective as in-hospital care. They also help prevent rehospitalizations.

A 'dream team' recognized for quality care

The department’s hard work was rewarded this year with a 5-Star Patient Perception Award from Professional Research Consultants (PRC), an independent market research firm specializing in patient-satisfaction measurement. For 2010, 75 percent of patients surveyed rated the overall quality of care as “excellent,” placing the home health department in the 98th percentile relative to other home-health agencies in PRC's database. Home health was one of four UC Davis Medical Center departments that received such high marks.

Patient and nurse © UC Regents
Nurse Marianne Ciavarella supports patients' health needs while they recover at home. “It’s about being present with the patient and knowing what is truly needed,” she said.

“We know we have a ‘dream team’ in terms of experience and commitment. However, it was great to get this external validation that our patients appreciate what we do,” said Glenda Reckner, administrator of the home-health team.

Always interested in improving patient satisfaction, even when the scores are already high, home-health managers check in with patients and caregivers regularly to discuss their experiences and potential improvements.

“It’s our version of doing rounds,” Reckner said.

An important part of the dream team is Ciavarella, an R.N. case manager who helped establish UC Davis’ home-health program 16 years ago and has seen vast changes during that time.

“In general, we are more highly regulated and patient-outcome management is now the driving factor,” she said.

Addressing daily challenges to recovery

As a result, the team works together to develop specific care plans based on each patient’s particular needs and challenges. One patient, for instance, was an elderly man with a history of diabetes, cancer and chronic pain. His wife, also elderly, was experiencing challenges providing her husband’s care.

His plan included Ciavarella, who educated the couple about diet, medications and getting the patient’s blood sugars under control, and then worked with his physician to help with pain management. Vanessa Brown, a social worker, linked them with community resources for additional in-home support. Norton helped him improve his strength and abilities with a walker so he would need less assistance with bathing and transfers. She also recommended a ramp that would enable him to more easily leave home for medical appointments and enjoy his garden. As he began to do things for himself, it freed his wife from some of her responsibilities and stress.

Most important, this patient was able to recover at home, where he wanted to be.

Home Care department © UC Regents
The home health team includes nurses, social workers, physical therapists and aides who, under the direction of physician Don Zacharias (front row, center), support patients who are well enough to leave the hospital but not able to independently manage all of their medical needs.

“We help in ways that can’t be supported in the hospital,” Reckner said. “Once patients’ immediate medical needs are resolved, they tend to heal faster in familiar surroundings.”

Norton added that the team benefits from seeing patients in realistic environments, where they are more likely to face daily challenges to recovery.

“In the hospital, clinicians rely on what patients report,” she said. “A patient might say he has stairs at home, but may not say what condition those stairs are in – that maybe his feet go right through them. We can help find resources
to fix the stairs.”

About the home-health program

UC Davis home health provides opportunities for patients to receive skilled care and advanced therapies in the comfort of their own homes. The overall goal is to help patients achieve maximum health and self-care skills. To qualify for the service, UC Davis Health System patients must have medical needs that require ongoing attention and prevent them from traveling to health-care appointments. For more information, call 916-734-2458.

One has to be really resourceful and love home health to do it well, Ciavarella acknowledged.

“It’s about being present with the patient and knowing what is truly needed,” she said. “You are solely accountable for patient outcomes. There’s no doctor or nurse down the hall if the patient is ill. We have to become masters of many disease states and situations.”

Home-health providers visit four to five patients per day, five days a week, and spend 30 to 75 minutes with each patient. Travel comprises a significant portion of the day, with each care plan ranging in duration from a single visit to several months. They also coordinate community services, engage family members in care, help manage urgent medical issues and communicate with patients’ primary-care physicians.

“We do a great job of extending the excellent care UC Davis provides well beyond the hospital and into outpatient settings,” Norton said.