In my first installment, I talked about why you should at least potential hazards and dangers of doing home health. In this home health survival guide, I will tell you how you can manage your patients, avoid common mistakes, and make your experience as smooth as possible.
Home health might not require as much differential diagnosis and manual therapy as orthopedics, or as much knowledge of neuroanatomy as inpatient and neuro rehab. But it certainly presents its challenges, and you have to be adept in other ways. You need to be able to juggle your patients, respond to their needs and preferences, work with or manage other PTAs, keep detailed notes, communicate with MDs, look for signs and symptoms of disease exacerbation, and you also need to know a thing or two about gait and balance.
When I started home health, I was a new grad with absolutely zero experience. Imagine going from PT school to a rural, underserved area where you know nobody, and half the people don’t even speak your language! There was no “survivor’s guide” back then. Over the last two and a half years, I’ve refined my process to be as efficient as possible. First, we’ll start with logistics. If you don’t understand logistics, you are going to have a hard time in home health.
Notebook: Keep a notebook with all of your patients’ information. Each day I make a list of all the patients I see that day. I include the name, the type of visit, the phone number, alternative phone number, address, and any other pertinent information. I also record the date of birth and diagnosis if it’s an eval or a patient I haven’t seen before. This makes it easy to Record your mileage and time on the back. I keep one page per day. I keep all my evaluation information in the notebook too. When I do a reassessment, I have all of my information in one spot. Keep this information in one place for reference. Don’t forget to have an extra pen in case you lose a pen or run out of ink.
Scheduling: I used to call all of my patients the night before every visit. There’s a better way. Schedule the next visit at the end of the previous visit. Use text messaging to confirm times later. Even in rural areas, the majority of your patients in the year 2018 should have text messaging. I’ve texted 90 -year-old patients! So much for the idea that old dogs can’t learn new tricks. Sometime patients have appointments they don’t remember, or they go to the hospital, or they feel sick. The schedule needs to be flexible. Always obtain a best phone number at your first visit and ask if you can send text messages.
During the eval, get the number of the gatekeeper or the decision maker. Sometimes the patient’s phone number isn’t the best number and it’s best to call the patient’s family member. The home phone number often isn’t the best number, so get a best number at the eval and communicate with the gatekeeper. Don’t bypass the gatekeeper!
If you have a really busy week, consider doing two or three visits or an eval on Sunday. It can make your Monday and Tuesday a lot more manageable. Believe me, they won’t take up your entire Sunday. You can see a couple of patients before noon and then enjoy the rest of the afternoon. If you have a patient in a remote area, consider doing that on the weekend to make the rest of the week less hectic.
Driving: Driving goes with the territory. You will spend half your day in your car and you will live and die by your phone. Still, I highly recommend that you keep your backpack and phone in your hatch where you can’t touch it. I know this sounds inconvenient, but the temptation to text and drive at the same time is too much. Very few phone calls are urgent. Trust me, you don’t need to keep your phone with you while you drive. If you miss a call, call the person back.
Documentation: I highly, highly recommend you complete all your documentation while you are with the patient. This has several advantages. First, you don’t fall behind. I’ve known RNs and PTs who are one week behind on documentation. RNs have more to document, and I do feel sorry for them, but PT documentation is not as intensive, so there is no excuse to not have all your notes done the same day. If you complete all documentation with the patient, you can leave the home with the satisfaction that everything is complete and you don’t have to do anything later. The most devastating thing is to go home with two more hours of documentation. There are too many distractions at home. Get it done.
The second advantage is that the patient is with you when you do documentation in the home so if you have another question you can ask right there. This is especially important for evals. You don’t want to go home and realize that you forgot to ask a few questions.
The third advantage is that you don’t confuse your patients. Do you expect to remember the assistance level of all five of your patients when you go home? You can’t and you won’t. Expect errors if you do your documentation later in the day. I remember working with an acute care PT who saw up to 10 patients a day, and then did all of her documentation in the afternoon. Don’t do this.
Masks and gloves: These should be provided by your agency, but you should keep a large box of gloves in your car and a few face masks at all times. Some homes, well, stink, and it’s hard to treat your patient, talk, and breath through your mouth at the same time. If you don’t want to offend your patient, you can do one of two things: 1) say you’re sick; 2) say you have allergies; 3) say you can’t tolerate pet hair. Either one will suffice. Just don’t tell the patient that his home smells really bad!
CPR mask: Forget mouth-to-mouth cardiopulmonary resuscitation (CPR). It’s unsanitary and it’s hard to keep a tight seal around the mouth. You can buy an adult and pediatric mask at the American Red Cross or American Heart Association website. An automated external defibrillator (AED) would be nice, but it is a lot more expensive (an automatic AED is about $1000). For now, get a mask and a baggie.
Don’t forget to renew your Basic Life Support (BLS) CPR. The certificate expires after two years but you should do it every year.. A typical four-hour course is $80 and your employer will probably pay for it.
GPS: I mentioned in my previous installment that using your phone as a GPS was a potential hazard. Staring at your phone while trying to drive is as dangerous and reckless as texting and driving. Fortunately, GPS devices are cheap these days. You can buy a reliable one for $100. I recommend Garmin. It mounts to the windshield and it has 95% accuracy. In rural areas it has a hard time pinpointing the entrance of a home, but after the first visit, I save the exact location of the patient’s home and finding the home the second time is never hard.
Sackpack or handbag: Keep your “toys” in one bag: blood pressure monitor, pulse oximeter, thermometer, washable surface, gait belts, measuring tape, dog treats, etc. When you enter a home, you should have your tablet or laptop (or if your agency is more old school, forms), and your sackpack. Clean your sackpack and all of our tools at least once a day to avoid cross-contamination. Most agencies and JCAHO (Joint Commission on Accreditation of Health Organizations) require you to clean it after every visit, and even require you to use on sanitizing wipe for each piece of equipment, but sometimes this isn’t always possible.
A backpack: If you don’t already have a good backpack or the backpack you were using in grad school is worn out, then invest in a solid backpack that will last 10 years. I recommend Samsonite and Swiss. These two brands make excellent backpacks with plenty of pockets and storage, and they’re durable. Spend more now, or buy a new backpack every 3-4 years. You will need to keep your computer or tablet and other tools in your backpack. When you walk into a home, you will usually have your backpack and sackpack.
Dog treats: I buy a huge bag of dog treats and keep them in my car. Pets are part of the job, and the majority of your patients will have at least one animal in the house. I’ve seen donkeys, pigs, parrots, dogs, cats, gerbils, and even owls. Yes, owls! The most common pet is dogs, and they are also the most intimidating. Some of my patients have had Great Danes. Throwing them a piece of bacon can pacify most dogs and help develop rapport between you and the dog. However, you can develop a Pavlovian response in them, and the dog will expect a treat every time you see them.
Gait belts: You should have at least one from PT school, but I recommend the Lift Aid, which you can buy on Amazon. It has a buckle, which means the belt won’t get loose. It also has several handles on the sides to hold the patient. I can hold my patient much better with this belt than a traditional gait belt. The only problem with the LIftAid is that it’s a little bulkier so you might not be able to fit it into your sackpack.
Water bottle: I have a Klean Kanteen. It’s 800 ml and it’s a lot better than putting water in a plastic bottle that will sit in the hot sun all day. It fits nicely into the sleeve on the side of my backpack.
Blood pressure monitor and other vital sign tools: I used to use a blood pressure cuff (syphgmomonometer if you want to be technical) and a stethoscope. But often there is too much background noise or the patient isn’t in the correct position. I can’t believe it’s 2018 and we’re still using these tools. Get a blood pressure monitor that wraps around the patient’s arm. I don’t recommend the wrist devices. They’re very inaccurate and inconsistent.
You will also need to measure O2 saturation with a pulse oximeter (referred to as “pulse ox”). The agency should provide this, but if they don’t, buy one. Buy a case with it too so you don’t lose it. I also recommend a tympanic (forehead) thermometer. You point the thermometer at the patient’s forehead and it gives you a reading. It’s a lot better than putting the device under the tongue at each visit.
A 4” step with risers: I don’t know what I did before I had a step. It’s a simple and inexpensive piece of equipment but it’s effective and versatile. I use it a lot with patients who have poor endurance or exercise capacity. Since you can’t carry a treadmill or exercise bike with you in home health, you have to find a portable way to do cardio. You can also use a step to build lower extremity strength and improve step height. I don’t want to get into home health treatment, but suffice it to say that a 4” step is an indispensable part of your arsenal.
Stretching strap: You will have your share of knee replacements in home health, and a stretching strap can help your patient improve range of motion. It’s also effective with total hip arthroplasties (hip replacements, or THAs) who can’t lift their leg to do a straight leg raise or get into bed. This is another low-cost intervention ($15-$20) and it’s easy to store in your sackpack.
Cones: I use cones to improve standing balance. I put them on the counter and make the patient reach across the counter. I also put cones on the ground and make the patient walk through the cones like a slalom. It’s almost like geriatric Olympics in the home. Again, it’s another low-cost intervention that will make you shine as a PT.
Canes: I have a single-point cane and a quad cane. I prefer the quad cane as it provides more stability without sacrificing gait quality. Single point canes are more challenging. Patients almost always have a walker so there is no need to buy a walker.
This should be a good start for a new home health therapist. Don’t be like other PTs who only use the green resistance band that the agency provided to them. See these tools as an investment in your job. You will enjoy your job more, you will be more efficient, and you will get better results.
You can buy all of these tools for less than $300. It shouldn’t cost a ton of money. If you’re concerned about cost, ask your agency if they’ll reimburse you for it. Whether or not they do, you should have most of these tools in you car. You don’t need a large car to store all of these tools. None of these tools, except the step, take a lot of room. With these tools, there’s no patient you can’t treat.
Keeping these tools should keep make your home health experience as comfortable, efficient, and healthy as possible. Invest a little today to make sure you get superior results with your patients, and so that you’re prepared for any situation at any time.
Thinking ahead and being prepared isn’t a good idea, it’s a duty of the job.
Bonus Survival Item
Coolers: An easy solution to junk food is to have a cooler in your car. This is especially useful in the summer when it’s hard to keep anything cool, including perishable goods. Even a lunch box would be better than nothing. Packing your lunch is far more economical and healthier than stopping at fast food chains. You can pack as much as you want in the cooler. You can pack prepared meals, vegetables, fruits, nuts, sandwiches, energy bars, etc.
I also recommend you buy some ice packs to keep everything cool, especially in the summer. If you want to keep something warm, you can leave it out of the cooler and keep it in the sun if it’s warm outside!