1. Cofer, DeLisa MSN, RN

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Home care is often viewed as the stepchild of nursing. Nurses who work in other areas of healthcare may assume that home care nurses have an easy job, and that our time is spent having lunch or making social visits with the patients. But, anyone who has had the opportunity to work in home care knows this is a myth. Home care nurses must be confident in themselves and their professional nursing skills, have the ability to exercise clear clinical judgment, and think quickly on their feet. They must also be knowledgeable of community resources and familiar with the populations they serve, so as to ensure the best clinical outcomes for their patients. When I enter a patient's home for the first time, I never know what situation I may encounter, but I know I am equipped to handle any circumstances.


My experience as a home care nurse has allowed me to provide care for a diverse patient population in several geographical locations in and around the Philadelphia metro area. My favorite area to provide care was South Philadelphia. I had the opportunity to work with patients of diverse ethnicities and social economic statuses. Yet, their differences did not dictate the level of care that I provided. All patients deserve to be treated with compassion, dignity, and respect.


I will never forget one particular day in my life as a home care nurse. I was to visit John (a pseudonym), who had recently been discharged from the hospital. After reviewing his information, I called John to schedule a time to visit and confirm his demographics. As we began to converse, I detected a tone in his voice which concerned me. John informed me that he had been discharged prematurely from the hospital. As we discussed his case in more detail, I learned that he had surgery to repair bilateral quadriceps; both knees were braced and had to remain in extension at all times. John was told by his surgeon that he would need to spend a few weeks in an inpatient rehabilitation center. The discharge planner had reviewed the process but things seemed to take longer than expected. John shared that he was ready to be discharged, but learned that he would be discharged to home instead of to an inpatient rehab, as he had been told.


Upset and confused, John was transported home via ambulance. He lived alone and had no additional support. He was unable to ambulate into his home, so the ambulance drivers log-rolled him onto his couch. John had no way of repositioning himself, he was unable to get his prescriptions refilled, and he did not have the ability to care for himself in the acute stages of his recovery. He knew this was a mistake. He called the ambulance transportation service and returned to the emergency room for pain medications. While there he discussed the confusion in his discharge from earlier that day and was told by staff that nothing could be done for him. He was given pain medications and transported home again via ambulance.


As I listened to John recall these events, I felt an urgency to help him. After hanging up, I asked my clinical manager if she would contact our medical social worker (MSW) and also send a physical therapist for further evaluation. We needed to find an inpatient facility for him immediately. It was Friday and I knew the odds were against us, but I was determined to get John the help he so desperately needed.


I arrived at John's home a few hours later. He was sitting on the couch in the same place and position where the emergency medical technicians had placed him. He was happy to see me, but very disappointed with his previous experience with the healthcare team. I assured him that I proactively reached out to my manager who had contacted providers from other healthcare disciplines, and that we would attempt to make the safest possible arrangements for him. I was honest with John. I told him that what we were trying to accomplish would be a challenge, especially because of the impending weekend. I assured him that our team was working hard on his behalf.


As I sat with John, my main concern was his safety. I could not imagine being in his position. He was unable to ambulate to the refrigerator or transfer to the bedside commode. In the case of an emergency, he would not be able to get out of his home without assistance. I thought about my loved ones and what I would do in that situation. I prayed that God would provide John with a miracle and I hoped that at least one facility in Philadelphia had an available bed for him. I did not feel comfortable leaving him alone.


During our visit, the physical therapist arrived to complete the home evaluation. He agreed that John could not stay in his home safely and needed to be transferred to an inpatient rehabilitation center. The MSW also completed her evaluation and contacted two inpatient facilities and John's surgeon-keeping John updated on any progress. I suggested that a phone call be made to John's insurance company so they would be "on alert" and could anticipate a request for authorization for an inpatient stay. It seemed like we were finally making progress.


As the 3-hour visit came to an end, John's niece and nephew arrived. With John's consent, I gave them a detailed report on his status. With his family in the home, I was less worried. Although their presence with John was temporary, it was a much better solution than leaving him alone. As I was preparing to leave the home, the MSW called. She found a facility that agreed to accept John that same day. This was exciting news!


As I informed John and his nephew about this amazing news, I was visibly overjoyed. I was very proud of our team for our display of teamwork and for utilizing our resources. I was able to identify John's needs and immediately connect with my team members in hopes of a favorable outcome. Later that evening, I called John to follow up on his status. He informed me he had been admitted to an inpatient facility around 8:30 p.m. He was appreciative and praised our agency's staff for our tenacity and the professionalism that was shown throughout this process.


From this experience, I learned that my assessment doesn't start when I enter a patient's home, but it begins when I make the previsit telephone call. I learned to be an effective listener; even though I was sympathetic, I was not overtaken by my emotions. I realized taking a team approach led to better outcomes for him-especially in light of the time restrictions we were under. My hope is that others will also see the importance of using the team approach to handle urgent situations, whether in the inpatient or outpatient setting.


Higher Daily Step Count Linked With Lower All-Cause Mortality

NIH: In a new study, higher daily step counts were associated with lower mortality risk from all causes. The research team, which included investigators from the National Cancer Institute and the National Institute on Aging, both parts of the National Institutes of Health, as well as from the Centers for Disease Control and Prevention, also found that the number of steps a person takes each day, but not the intensity of stepping, had a strong association with mortality. Previous studies have been done on step counts and mortality. However, they were conducted primarily with older adults or among people with debilitating chronic conditions. This study tracked a representative sample of U.S. adults aged 40 and over; approximately 4,800 participants wore accelerometers for up to seven days between 2003 and 2006. The participants were then followed for mortality through 2015 via the National Death Index. The researchers calculated associations between mortality and step number and intensity after adjustment for demographic and behavioral risk factors, body mass index, and health status at the start of the study. They found that, compared with taking 4,000 steps per day, a number considered to be low for adults, taking 8,000 steps per day was associated with a 51% lower risk for all-cause mortality (or death from all causes). Taking 12,000 steps per day was associated with a 65% lower risk compared with taking 4,000 steps. In contrast, the authors saw no association between step intensity and risk of death after accounting for the total number of steps taken per day.