Teamwork in Home Care Reduces Hospitalizations and Improves Patient Comfort

Home-Based Palliative Care: A Scalable Solution for Cancer Patients in Under-Resourced Areas

A recent study highlights the effectiveness and affordability of a team-based home care model for patients with advanced cancer, particularly in regions with limited healthcare resources.The “Better at Home” program in Brazil, which utilizes registered nurses (RNs) and nursing technicians (NTs), demonstrates a powerful approach to enhancing the quality of life for individuals nearing its end.

Palliative care plays a vital role in managing symptoms like pain and dyspnea, which were prevalent in nearly all of the 471 patients studied. These patients, with an average age of 70, received care thru the SAD-caratinga Program (SAD-CP). Over an average of 48 days in the program, the interdisciplinary team focused on providing comprehensive support.

The study, published in the American Journal of Hospice and Palliative Medicine, examined 10 years of medical records and evaluated the nursing interventions within the SAD-CP. In this model, RNs took charge of complex procedures, supervised NTs, and educated caregivers. Meanwhile, NTs managed routine clinical tasks and provided daily care. A cornerstone of the program is the mandatory structured caregiver education based on the CARES model – Comfort, Airway management, Restlessness and delirium, Emotional and spiritual support, and Self-care. This model aims to promote a peaceful death and equip families with the knowledge to navigate the dying process.

To ensure continuity, each patient was assigned a dedicated RN for consistent supervision, while the number of NTs varied based on need. The team operated on a 40-hour per week schedule with rotating shifts, guaranteeing continuous patient coverage.

The outcomes were important. Almost all patients died at home, a key objective of palliative care, suggesting that this model effectively supports patient preferences. The interdisciplinary, intensive home-based approach not only improved symptom management but also notably decreased hospital deaths.

Researchers from Faculdade de Ciências Médicas de Minas Gerais, the University of Texas MD anderson Cancer Center, and Independent Biostatistics consulting concluded that the SAD-CP model, with its reliance on RN leadership and trained NT support, is both feasible and impactful in resource-limited settings.

“The SAD-CP model, structured around the leadership of the [RN] and supported by a trained NT workforce, offers a scalable and resource-efficient framework that could be adapted to other under-resourced regions,” the researchers stated. “It illustrates how even in the face of structural constraints, multidisciplinary care, when strategically organized, can ensure continuity, safety, and dignity at the end of life.” This innovative approach offers a beacon of hope for improving end-of-life care globally.

How does the interdisciplinary team approach to home healthcare contribute to reducing unneeded hospital readmissions?

The Interdisciplinary Home Care team: A Collaborative Approach

Effective home healthcare isn’t a solo act. It’s a carefully orchestrated collaboration between various professionals,all focused on the patient’s well-being. This interdisciplinary team approach is proving to be a powerful tool in reducing unnecessary hospital readmissions and considerably improving patient comfort and quality of life. the core team frequently enough includes:

Registered Nurses (RNs): Providing skilled nursing care, medication management, wound care, and patient/family education.

Licensed Practical Nurses (LPNs): Offering essential nursing services under the direction of an RN or physician.

Home Health Aides (HHAs): Assisting with activities of daily living (ADLs) like bathing, dressing, and meal readiness.

Physical Therapists (PTs): Developing and implementing rehabilitation programs to improve mobility and function.

Occupational Therapists (OTs): Helping patients regain independence in daily tasks and adapt their environment.

Medical Social Workers (MSWs): Addressing psychosocial needs, connecting patients with community resources, and providing emotional support.

Physicians: Overseeing the overall plan of care and providing medical direction.

Dietitians: Providing nutritional guidance and support.

How Teamwork Directly Impacts Hospitalization rates

The synergy created by this team directly addresses factors that often lead to hospital readmissions. Consider these key areas:

1. Proactive Monitoring & Early Intervention: Regular communication between team members allows for the early detection of changes in a patient’s condition. A home health aide noticing increased shortness of breath, for example, can immediately alert the RN, who can then consult with the physician – possibly preventing a trip to the emergency room. This is crucial for managing chronic conditions like heart failure and COPD.
2. Medication Reconciliation & Adherence: A collaborative review of medications by the RN, pharmacist (if involved), and physician ensures accuracy and minimizes the risk of adverse drug interactions. the team can also work with the patient and family to improve medication adherence, a major factor in preventing complications.
3. Complete Care Planning: A well-defined care plan, developed collaboratively, addresses all aspects of the patient’s needs – medical, functional, emotional, and social. This holistic approach ensures continuity of care and reduces fragmented services.
4. Improved Patient education: Consistent messaging from all team members reinforces patient understanding of their condition, treatment plan, and self-management strategies. This empowers patients to actively participate in their care and make informed decisions.
5. addressing Social Determinants of Health: Medical Social Workers play a vital role in identifying and addressing social determinants of health – factors like food insecurity, housing instability, and transportation barriers – that can significantly impact a patient’s health and contribute to hospitalizations.

Enhancing Patient Comfort Through Collaborative Care

Beyond reducing hospitalizations, teamwork profoundly impacts patient comfort and overall well-being.

Personalized Care: The team takes the time to understand the patient’s individual preferences, values, and goals, tailoring the care plan accordingly.

Emotional Support: The MSW and other team members provide emotional support to both the patient and their family, helping them cope with the challenges of illness and maintain a positive outlook.

Pain Management: A collaborative approach to pain management, involving the RN, physician, and potentially a pain specialist, ensures that patients receive appropriate and effective pain relief.

Reduced Anxiety & Fear: regular communication and a consistent presence from the care team can alleviate anxiety and fear, creating a sense of security and trust.

Promoting Independence: PT and OT work together to maximize the patient’s functional abilities, promoting independence and allowing them to maintain a sense of dignity.

The Role of Technology in team Communication

Modern home health technology is streamlining communication and enhancing collaboration.

Electronic Health Records (EHRs): Allow all team members to access the same details in real-time, ensuring everyone is on the same page.

Telehealth: Enables remote monitoring of patients and virtual consultations, expanding access to care and reducing the need for in-person visits.

Secure Messaging Platforms: Facilitate rapid and efficient communication between team members.

* Remote Patient Monitoring (RPM): devices that track vital signs and other health data, alerting the team to potential problems.

Benefits of a Team-Based