Tender Care Home Health prides itself in implementing an Enhanced Care Model to help our patients get better. Rather just prevent them from getting worse, we combine an in-depth patient assessment in their home and an invaluable partnership with a patient’s doctor to work toward a patient’s goals of independence and better quality of life.
What you’ll experience with Tender Care Home Health's approach to patient care is different from any other agency. We’re committed to a patient’s health goals and truly improving their quality of life. Our ultimate priority is getting our patients living fuller independent lives at home, avoiding future trips to the hospital. Reaching that goal starts with an in-depth at-home assessment and continues through a patient’s treatment and recovery. Here’s how we do that:
First, a patient's eligibility for home health care is verified and orders are received from the patient’s doctor. Based on their treatment requirements, a Registered Nurse is sent to the patient’s home within 24-48 hours to complete an extensive assessment of the patient and their home environment. Our nurses are trained to look and listen for things that may be of concern and gather information pertinent to each patient’s needs and goals. It takes about 1-2 hours, and helps our team further detail a treatment plan for that individual patient.
A Medication Reconciliation — The key to successful medication reconciliation is seeing it as part of a larger medication management system with clear executive leadership owning that system, a robust quality improvement process integrated [into that system], and staff education. Also, getting the best possible medication list from multiple sources, understanding how the patient takes their medication, and having the best possible patient or caregiver interview regarding medication history.
Another area is pharmacotherapeutic interventions when appropriate and targeting the correct population for those interventions, such as the elderly or patients that are returning or going to, or coming from, a skilled nursing facility, long term acute facilities or hospitals. Certain populations and drug categories should have explicit attention paid to them from admission through intra-facility transfers and to discharge. Some of those medications would include anticoagulants, opioids, and hypoglycemic medications among others. Antibiotics can be problematic. The home health nurse will complete a true medication list of what the patient is actually taking to include over the counter medications. This list will be compared with any discharge instructions and the physician will be notified of any discrepancies identified to include drug interactions.
A nurse’s Physical Assessment will address a complete head to toe assessment which includes the condition of a patient’s skin, heart, lungs, etc. to determine the individualized needs of each patient and how our team members can help improve them.
Functionality and Home Safety is investigated to determine how independent a patient is, including if they can dress themselves, prepare meals, bathe, etc., and how safely they can accomplish these tasks. Tender Care nurses are trained to do things in a different way, meaning it’s not enough that a patient is capable of accomplishing daily tasks, they are trained to look for signs that the patient can do things safely. It includes having a sixth sense to be able to identify exactly what’s happening in the home that may be keeping them from getting better.
Education — By teaching our patients to manage their own chronic disease, and working closely with them as they improve, we offer them a chance to become more independent. For example, they’ll learn to take their own blood pressure, and we’ll celebrate with them as they learn to do it. This process instills confidence as they become able to do more and more on their own.
Behavior Modification — The techniques we use to improve self-care management help patients to alter their habits, in turn helping them lead healthier, fuller lives because they no longer need to rely on someone else to do things for them. By taking the time to understand each individual patient's priorities and values, we can help modify the attitudes about their disease and treatments, and inspire more positive and productive behavior.
Once our assessment has been completed, a Plan of Care is written and submitted to the patient’s doctor. This may include a recommendation that additional healthcare providers be included, such as occupational, physical or speech therapists, social workers, etc.
Finally, the agency gets the physicians’ orders to go back out to the home. Tender Care Home Health works closely with the doctors, collaborating to provide proactive care that helps patients actually get better, rather than just simply prevent them from getting worse.
One we’re in the home, we enact the Enhanced Care Model, which helps us work alongside the patient toward his or her goal. We teach them to manage their own disease, inspiring self-efficacy, we identify behaviors and attitudes to better assess how we can reach those goals together and we watch and learn from the patient, growing with them to reassess how we can get toward preventing those future hospital visits and enjoying life.
The bottom line – our patients are in the best of hands and never alone, as Tender Care is a true advocate for their patients. We serve as the central care coordinator for the patient, so they, and their families, can relax confidently knowing we will help them get better.