1. Crossen-Sills, Jackie PT, PhD
  2. Bilton, Wilma MS, OTR/L
  3. Bickford, Michelle PT
  4. Rosebach, Jennifer RN
  5. Simms, Linda RN

Article Content

This clinical narrative was presented by a Norwell Visiting Nurse Association's interdisciplinary team to University of Massachusetts-Boston senior baccalaureate nursing students and faculty at the conclusion of their community health experience. Biannual Grand Rounds, an ongoing learning exchange since 1994, has proved to be a rewarding experience for both presenting staff clinicians and attendees. As the executive director, I consider it a "proud moment" and a reminder of how complex contemporary healthcare delivery can be. Yet every single day, talented home health clinicians continue rising to the occasion to achieve quality measurable clinical outcomes. The reported case highlights how veritable coordination of services, designed to meet the immediate and long-term needs of a family, were achieved through creative problem solving while maintaining safety and, most importantly, preserving human dignity. It is with great pleasure that we share this clinical narrative with our home healthcare colleagues. - -Meg Doherty, MSN, ANP-CS, MBA


The compassion and creativity demonstrated by home care clinicians continually rises to new heights. The following case reflects the depth to which an interdisciplinary team went to help both a patient and his family meet their ultimate goal-a safe discharge to home. This case was presented in December 2005 at a Grand Rounds symposium. It highlights the communication, teamwork, and dedication of a home care team committed to providing quality patient care.

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Home care has changed dramatically throughout the past 10 years. The population characterizing the home care clientele consists of the most frail and medically compromised patients. Many of these patients are asking local home care agencies to help them remain safely in their homes. Because patients and their families are seeking creative and complex discharge plans, the home care agency often must combine its services with those of other agencies to piece together a cohesive plan.


A home care team can use its expertise to assist acute care hospitals and skilled nursing facilities in developing the best home discharge plan for a particular patient. Discharge planners from various in-patient facilities may be unable to visualize and integrate the complexities of acute disease management in the home environment and family support services. Often, it is difficult to recognize the unique set of circumstances brought by each patient, and to anticipate each and every potential problem before the patient returns home. A home care discharge plan should include a safe and accessible home environment, a willing patient, and family or caregiver to assist the patient in activities of daily living (ADL) and instrumental activities of daily living (IADL) (e.g., laundry, cooking, cleaning, shopping, picking up medications). It also should include additional resources that can be accessed to supplement the patient and family as necessary.


The question was asked: Is it possible to organize a myriad of support services and thereby help a patient to remain in his or her home, avoiding rehospitalization? Local healthcare providers are expanding the resources available to offer comprehensive discharge planning. The objective is to mobilize various healthcare teams to deliver needed services. One method for accomplishing this is to link private and public organizations to achieve a comprehensive discharge plan for the patient and family.


The decision to stay in one's home, however emotional and personal for the patient and family, also takes a toll on healthcare providers. As caregivers, we regularly work toward helping patients reach their goals. The discharge plan must consider the amount of needed supervision and overall safety as well as the role of family members or the remaining spouse's ability to participate in the plan. The real question is: What is the most effective way healthcare agencies can develop safe home care discharge plans?


How important is a patient's goal to remain at home? Is there not an ethical principle that speaks to patient autonomy? Can a patient make a sound decision regarding safety when it comes to choices for a back-to-home discharge or a nursing home placement? Is it easier for an agency to say the discharge plan is unsafe and therefore not accept a patient for services when the only other option a patient may have is to be discharged to a local nursing home?


It is suggested that this shift may be a completely new arena for home care. Home care agencies are now offering hope and opportunity to seniors who once had no option other than nursing home placement.


Using the Grand Rounds Symposium to Share Best Practices

Grand Rounds presentations are commonly used in acute care and rehabilitation hospitals to showcase new practice and complex case management. This format also has been used in the home care environment as an opportunity to share best practices.


The Norwell Visiting Nurse Association offers Grand Rounds twice each year. The platform consists of presentations from both nursing students and staff on various aspects of home care. It provides an opportunity for student nurses and staff to meet and share a number of home care issues. The students identify and develop a project that is valuable to the home care agency, and the home care agency reciprocates by presenting a related patient case scenario. Diabetes, wound care management, prevention of falls, and heart failure are some of the areas covered in the past few years. Some cases are relatively routine, highlighting interdisciplinary care, whereas other cases are quite complex, highlighting communication, planning, and advanced skill.


In December 2005, an interdisciplinary team presented the case of a patient with complex medical conditions, a lengthy medical history, and an unclear future. It provided the audience with a profound realization that home care is no longer the "routine care" of yesterday. Caring for the complex medical patient who requires multiple professionals throughout a home care episode has always been a challenge of ensuring timely communication, coordination, and implementation of the home care plan.


Case History

Medical History

The patient chosen for presentation was an 82-year-old, 6-foot 6-inch, 250-pound man who lived with his wife in their own home. Before his chronic medical problems, the patient had been a successful businessman. The patient's medical history included a right cerebral vascular accident in February 2002, type 2 diabetes with peripheral neuropathy, coronary artery disease, heart failure, and atrial fibrillation. He had undergone several prior surgeries, including coronary artery bypass grafting and pacemaker insertion.


The patient was progressing well in the community, independently driving and caring for his elderly wife who had dementia. One day while on an errand, the he fell and hit his head, sustaining a traumatic brain injury. This unfortunate incident resulted in a prolonged hospitalization and rehabilitation before discharge home.


At the initial admission to home care in August, 2004, the patient's daughter and family moved back from Australia and into the patient's home to assist him in getting back "on his feet." The patient progressed well and was able to improve his overall functional mobility. The diagnoses at admission included hypertension, syncope, tremors, and methicillin-resistant Staphylococcus aureus (MRSA).


Over the years, MRSA in the home care setting has greatly increased. Staphylococcus infections, including MRSA, occur most frequently among patients in hospitals and healthcare facilities (e.g., nursing homes and dialysis centers) who have weakened immune systems. These healthcare-associated staphylococcus infections include surgical wound infections, urinary tract infections (UTIs), bloodstream infections, and pneumonia (Centers for Disease Control, 2006).


As the patient's time in home care progressed, he began to experience episodes of increased urinary retention and incontinence caused by benign prostatic hypertrophy and multiple UTIs. He was unable to use a urinal because of his left-sided weakness. Nighttime incontinence was a particularly difficult management problem for him.


Another concern the clinicians faced was the patient's insistence on sleeping in the same bed as his elderly wife. Despite toileting efforts, decreased fluid intake before bed, and use of adult diapers at night, the patient would wake up in the morning saturated, with leakage onto the bed. This placed his wife at considerable risk of infection and potential problems with skin integrity. Her confusion was a complicating factor as she also fought the delivery of a hospital bed for the patient.


Multiple attempts at medication management (Vesicare, Detrol, and Ditropan) by the urologist were unsuccessful at controlling the patient's incontinence, and the patient required rehospitalization. Once again, extensive patient and family education ensued regarding infection control through hand washing, linen care, use of protective equipment, nutritional management, and mobility training. With each new infection, a decline in the patient's strength and mobility skills occurred. Attempts by occupational therapy to educate the patient in the use of a urinal were ineffective because of the patient's left-sided weakness, poor coordination, and neglect.


The family requested a catheter to manage the incontinence, and in collaboration with the urologist, a urinary catheter was inserted. This allowed the nursing team to provide effective treatment for the skin excoriation that affected the patient's buttocks region. During one catheter change, the nurse experienced difficulty with the insertion. Consequently, the patient, at the request of the urologist, was sent to the local emergency room for catheter placement. The clinicians observed a regression of functional skills with each new UTI. The in-home support by live-in family members (the patient's daughter and her family) also was nearing the end because the daughter had plans to return to Australia at the end of the year (2005).


The home care agency conducted weekly case conferences to address the patient and family problems encountered. The clinical manager chaired the meetings to help the staff identify strategies to help the patient remain safely in his home. Despite the many safety devices and extensive family education provided, the patient experienced a fall because of a decrease in his endurance and strength. He then was transferred to a rehabilitation floor in a nursing home. While at the nursing home, the patient experienced another UTI. He was subsequently transferred to an acute care hospital, where a suprapubic tube was inserted in September 2005. The patient's functioning after the surgery was at his lowest level ever, now requiring two people for transfers and functional activities.


Was the Patient Capable of Returning to Home Care? The Preadmission Family Meeting

In October 2005, as the patient's discharge from the nursing home approached, a preliminary family meeting was conducted to develop a joint plan. The plan would focus on the steps that both the family and the home care agency would need to take to provide a safe discharge to home. At this time, the family had the options to accept, modify, or reject the plan presented by the home care agency. The family presented itself as a close-knit, supportive family willing to assist their father in any way to achieve his desire to return home.


All clinical specialists required for planning and coordination of care were present and involved in the discharge planning process. The overall purpose was to determine whether a safe plan could be developed to allow discharge of the patient home to be with his elderly wife. Four of the patient's seven children attended the meeting. The live-in daughter was able to share the amount of physical assistance and psychosocial support required to date. The daughter said that even before the most recent hospital admission, her husband had been providing moderate to maximal assistance for transfers. The home care team concurred that at times a second person was needed because of patient fatigue.


Four discharge scenarios were presented to the family for their consideration. Discharge to


* a nursing home with assisted living facility attached for the husband and wife


* assisted living facility set up with private duty assistance for the husband and wife


* a nursing home for the husband and wife


* home with modification and the hiring of private caregivers for the husband and wife.



The family decided that they would do everything within their power to modify the patient's home to keep both him and his wife in their own home environment. The family meeting proved to be a very emotional meeting. It was the first time the siblings had truly heard the detailed limitations of both their father and mother. At the end of the meeting, the family was committed to do whatever it took to keep their parents safe in their own home.


To accomplish this plan, the patient remained on a transitional care unit at the local nursing home. Here he worked with physical therapy and occupational therapy on functional mobility, balance, and strengthening. The family performed home modifications, which consisted of removing carpets, installing hardwood floors, and making the home wheelchair accessible for the pending discharge. During this time, the physical therapist from the home care agency worked with the nursing home staff to identify and recommend equipment necessary for the home discharge. The family hired private caregivers to work with the patient, and training of the caregivers was initiated in the nursing home.


After rehabilitation and home modifications, it was time for the patient to return home. The team recommended supervision and assistance for the patient 24 hours per day, 7 days per week. The family arranged for 12 hours of private help to assist the patient and his wife. Three children, who lived the closest, would provide the additional shift/assistance. One sibling provided evening time assistance; another sibling provided nighttime assistance; and the third sibling provided morning shift assistance for the patient's insulin management.


Home Situation

The patient's home was a multilevel town house. The town house provided the ability for first floor living, with a ramp installed to allow for wheelchair entrance and exit. A mechanical lift and a hospital bed were arranged. Other equipment in the home consisted of an elevating chair recliner, transfer tub handle, commode, tub seat, gait belt, and bilateral ankle-foot orthoses.


The Evaluation

Nursing Evaluation and Goals

After the patient had returned home from the skilled nursing facility, the nursing focus was on family and caregiver education to prevent skin breakdown and UTI, and on assistance with medication management. The patient remained very social, and at mini-mental examination was found to be alert and oriented, although he could at times present with some forgetfulness. The children were extremely involved in the patient's care, helping him to meet his overall goal of a safe return back to his home. The home environment consisted of the patient, his wife, and paid caregivers.


Medical Condition

The newly placed suprapubic tube required ongoing nursing intervention for monitoring and changing every 5 weeks. The hope was that the patient's problems necessitating frequent hospitalizations would be resolved.


The nursing staff provided extensive education to the family and private caregivers. This included care for the new tube site, measures to prevent UTIs, recognition of signs and symptoms of UTIs, and infection control in the home. Caregiver education consisted of dressing changes, catheter tube care, prevention of complications related to immobility including positioning, pressure reduction education, skin care, deep breathing and coughing, and bowel regimen management. It also included diabetic instruction to the patient, family, and caregivers concerning nutrition and blood glucose level monitoring through proper use of the glucometer.


The nursing staff provided ongoing assessment and intervention for cardiopulmonary, endocrine, neurologic, integumentary, and gastrointestinal systems. A home telemonitor system was installed, which provided daily transmission of the patient's vital signs to a central station at the Norwell Visiting Nurse Association for analysis of daily changes. A personal response system was installed to allow the patient to contact emergency services at any time during the day or night. In addition, the family and caregivers were instructed in the use of the on-call system to access a nurse if any potential questions or problems arose.


Physical Therapy Evaluation and Goals

Before the home discharge, the home care physical therapist worked closely with the nursing home's therapist to identify what equipment would be required at home. The nursing home and home care team worked to coordinate the care and discharge planning with vendors and private caregivers to allow the safe transition to home.


After the patient had returned home, he received home physical therapy. Weekly case conferences conducted with all team members ensured consistency, follow-through, and success with the plan.


At the patient's initial admission for home care services in 2004, he was able to ambulate with a contact guard using a rolling walker for approximately 60 feet (in and out of doors). At this admission to home care, functional ambulation was not feasible. The physical therapist's evaluation of the patient consisted of cognitive, physical, social, and home assessments. Initial problems identified were impaired mobility; declining physical status; decreased strength, flexibility, and balance; and ongoing equipment needs. The impairment in mobility was the greatest difficulty. The patient presented with variable skills from day to day.


The physical therapist's goals for the patient's safe home discharge also were established at the family meeting. The goals were to improve safe mobility in the home; to strengthen and improve static and dynamic balance in sitting, standing, and transferring; and to assist in identifying and ordering needed equipment. The therapist trained caregivers in the use of the medical equipment, assisted the family in identifying and modifying the home environment for safety, and provided on-going family training and support.


The transfer and mobility plan implemented for the patient included the use of a mechanical lift called the LYKO lift. This system allowed the home care staff and caregivers to transfer the patient safely from one position to another within the confines of the limited space.


Occupational Therapy Evaluation and Goals

The initial occupational therapy evaluation indicated impaired upper extremity strength and poor coordination affecting self-care and transfer abilities, as well as impaired mental status including decreased attention to the left side. Goals set at the time of the evaluation included a home exercise program designed to increase strength and range of motion and to improve attention to the left side. The patient and family goals were to achieve independence in toileting skills and transfers.


Occupational therapy intervention provided education and training primarily for the caregivers and family members to implement the daily upper extremity home exercise program. Occupational therapy also worked on functional transfer training related to toileting and transfers of the patient from the wheelchair to the commode.


The Team: Interdisciplinary Development of the Care Plan

Communication and coordination in this case allowed all professionals to be aware of the complex aspects of care (Slettebo & Bunch, 2004). The clinical manager for the team established ongoing meetings to address issues before they became problems. Using the strengths of all the caregivers, the team brought the nurse, home health aide, physical therapist, occupational therapist, and social worker together.


In addition, a plan was established that spaced the clinicians' visits throughout the week, ensuring that the patient would not be overwhelmed with too many professionals coming on the same day. The clinical interventions were designed on the basis of the patient's goals and medical needs, with each discipline focusing on function and safety within the home. The family education was disbursed throughout the episode of care, teaching family members and caregivers incrementally about how to understand and assist the patient effectively.


Ethical Considerations: Whose Life Is This Anyway?

The ethical principles of autonomy, beneficence, nonmalfeasance, and justice were put to their highest tests for this patient. Examining the principle of autonomy, that of the moral obligation to respect the sovereignty of our patient, was one of our challenges (Mueller et al, 2004; Gillon, 1994; Moran & Pouya, 2004). The patient expressed his strong desire to stay in his own home with his wife. Throughout the discharge planning process, every effort was made to encourage the patient to express his desires and needs. It was the healthcare team's role to attempt to meet those needs as long as the patient's desire allowed equal respect for the autonomy of his family and caregivers. The key to honoring the patient's autonomy was rooted in our ability as an agency to provide open channels of communication between the patient and his family. Looking back, we believe we met this standard.


Other ethical principles addressed were beneficence and nonmalfeasance. As healthcare workers, we must consciously work to do no harm to patients and to recognize the need to provide a net medical benefit to them (Munson, 2000). It has been suggested by some that empowerment-doing things to help patients be more in control of their health and healthcare-is essentially an action that combines the two moral tenants of beneficence and respect for autonomy. We believe we also met these ethical standards.


The final ethical principle is that of justice. This very often is equated with fairness and is summarized as the moral obligation to act on the basis of fairness between competing claims (Gillon, 1994). Fair distribution of scarce resources (distributive justice) allowed us to examine whether the services we provided to this patient and family were consistent with the services we would provide to any similar family in the same situation. The answer was "yes." This patient and family had the financial resources to pursue major home renovations and private duty services to augment the care and the services the home care agency could provide. Did we respect the patient's rights (rights-based justice), his right to choose his own medical care and discharge plan? Once again, the answer was "yes."



The goal of a home discharge is to provide services to assist the patient in living safely at home. The "one-size-fits-all" approach does not apply today in home care. The uniqueness of our patients, their individualized family structure, their available resources, the available community resources, and the overall safety and supervision for the plan must be considered. Most importantly, our healthcare ethical principles must allow for autonomy, beneficence, nonmalfeasance, and justice.



The reported case highlights the communication, teamwork, and overall courage of a home care team committed to providing quality patient care. The internal collaboration provided timely skilled interventions in the home. The external collaboration coordinated the family, private caregiver organizations, skilled nursing facilities, acute care hospitals, and specialty and primary care physicians around the same goal.


Outcomes of Care

A coordinated educational plan for the family/caregiver included instruction in MRSA precautions, standard precautions, safe transfers, skin assessment and skin care, nutrition, hydration, urinary assessment, suprapubic catheter care, donning and doffing of ankle-foot orthoses, telemonitoring, blood sugar monitoring, and ongoing bowel regimen (Table 1).

Table 1 - Click to enlarge in new windowTable 1. Clinical Goals, Interventions, and Outcomes


Through the winter (December 2005 to March 2006), the patient successfully remained in his home with both home care services and private-duty services. On one occasion, the patient was admitted to a skilled nursing facility for respite care when the family was concerned about a pending snowstorm (the snowstorm never arrived).The family has learned to anticipate and respond. Most importantly, they have honored their parents' wish to be kept safely in their home.




Centers for Disease Control (CDC). Community-associated MRSA information for clinicians. Retrieved April 19, 2006 from[Context Link]


Gillon, R. (1994). Medical ethics: Four principles plus attention to scope. BMJ, 309,184. [Context Link]


Moran, D., & Pouya, P. (2004). Caring for the frail elderly: Ethical considerations. Topics in Emergency Medicine, 26(1), 14-18. [Context Link]


Mueller, P. S., Hook, C., & Fleming, K. C. (2004). Ethical issues in geriatrics: A guide for clinicians. Mayo Clinic Proceedings, 79(4), 554-562. [Context Link]


Munson, R. (2000). Physicians, patients, and others: Autonomy, truth telling, and confidentiality. In Intervention and Reflection: Basic Issues in Medical Ethics. (7th ed., pp. 100-176). Belmont, CA: Wadsworth/ Thomson. [Context Link]


Slettebo, A., & Bunch, E. (2004). Ethics in nursing homes: experience and casuistry. International Journal of Nursing Practice, 10(4), 159-165. [Context Link]

AHRQ and Ad Council Encourage Patients to Ask Questions and Get More Involved With Their Healthcare


HHS' Agency for Healthcare Research and Quality joined with The Advertising Council to launch a national public service advertising campaign designed to encourage adults to take a more proactive role in their healthcare.


The new "Questions Are the Answer: Get More Involved With Your Health Care" Patient Safety Awareness campaign aims to encourage all patients and caregivers to become more active in their healthcare by asking questions. The campaign includes a toll-free number (1-800-931-AHRQ) and a comprehensive Web site,, to obtain tips on how to help prevent medical mistakes and become a partner in their health care. The site also features an interactive "Question Builder" that allows consumers to generate a customized list of questions for their health care providers that they can bring to each medical appointment.


The Web site features tips for patients to become more involved in their health care, including: bring a list of questions to each medical appointment; take notes in the examination room; make sure you receive the results of medical tests; and, upon leaving the hospital, make sure you understand instructions regarding follow-up care and medications.


The Agency for Healthcare Research and Quality ( is part of the U.S. Department of Health and Human Services. AHRQ's mission is to improve the quality, safety, efficiency and effectiveness of health care for all Americans. The Ad Council is a private, nonprofit organization that marshals talent from the advertising and communications industries, the facilities of the media, and the resources of the business and nonprofit communities to produce, distribute and promote public service campaigns on behalf of nonprofit organizations and government agencies.