Help! Having hard time transitioning from acute to HH

paddler · May 29, 2011

When I first started HH I remember thinking the same thing. "But, what am I DOING for this person?" in a task oriented manner. You are right, there really is only so much teaching a chronic diabetic can receive. They either know it all already, aren't interested, don't care, or are not very teachable. In these cases I think often HH is the last resort for a doc who sees unstable diabetics in their practice and just can't figure out what the problem is. Sometimes it's an access to medications issue, the patient can't get their meds or test strips or can't afford it. Sometimes they can't see or even feel their fingers to do the glucose monitoring. Sometimes they are on 45 other medications and just are overwhelmed with them and insulin is just too much to handle. Sometimes there are cognitive issues which are difficult to identify. Doctors don't often see this because they are not seeing patients in their own environment. Being a set of eyes for the doc can be helpful. Reviewing meds and finding out what the patient really is or is not taking and reporting that to the doc helps too. Sometimes the doc needs to pare down on all those 45 pills and get it to a reasonable list of 10-15 if possible. Sometimes the patient would benefit from ONE insulin injection daily instead of a QID sliding scale. Whatever the case often the doctors want to hear this from us. What they have tried isn't working, and you can be of assistance to help try to improve the situation and advocate for the patient.

That's just an example for a diabetic, but there are lots of situations like this where at first glance it appears we are not doing anything useful or skilled. But, that is not always the case, we have to be detectives... often identifying the problems/needs ourselves (because the doc really doesn't know), and figuring out our own answers, and presenting it to the doc for an order.

Home Health is very creative... not in a sketchy way, but in a "real world" nursing kind of way. I ask myself what is the doctor's goal and what is the patient's goal and how can I help be in the middle to achieve goals for both? That's where I get my nursing goal.

KateRN1 · May 29, 2011

Most of home health is teaching, not task based, as you've already discovered. Start off each episode thinking, "How can I change this person's way of life over the next 60 days?" Identify what the issues are and how to address them, including what issues need to be addressed by other disciplines, such as PT, OT, ST, MSW, etc. Talk to the patient, ask him/her or family members what things they feel needs to be improved. You *must* have buy-in from the patient or all your teaching will be in vain--this is where the docs often fail. They prescribe, but they don't investigate. Very few docs ever see the patient in their natural habitat. They don't know who is a hoarder, who spends all their money on cat food instead of meds, who has kids who are stealing from them, etc. Patients show up to the doc's office in their Sunday best and on their best behavior and it is up to us to do the sleuthing. Sometimes they don't want to believe us, but nothing we can do about that.

There are a lot of older books about home care. Check the used books on Amazon and you may find some titles that can help you out. Keep reading the forums here and you will pick up many good ideas. Ask for a mentor at your agency, if you can. See if they have someone who has been doing HH for several years who can help you puzzle things out. And be willing to be humble and learn--that is often the hardest part. When you move from an area of confidence to an area that is new to you, it takes a great deal of humility to learn to ask for help. You're off to a great start!