The home as a centre for health and social care operations

Jordi Varela
Editor

 

@varelalaf

People, while enjoying independence, receive health care services in accreditated facilities, where professionals work in an appropriate environment and they manage everything that influences the quality of their work: noise, lights, computers, clinical devices, waiting rooms, etc. On the contrary, when people become dependents, their home takes centre stage. It is, however, an alien place for professionals, often with difficult access and full of unforeseen events. The point is that many doctors and nurses prefer not to have to step out of their comfort zone and, probably, for this reason, home care programs weaken whenever there are budget constraints or overly packed schedules.

Home visits, an observatory that we ought to hold on to

The Americans, when they launched the Accountable Care Organizations (ACO), an initiative linked to Obamacare, explained (in "Eyes in the home") that they have recognized the importance of home visits, precisely to capture first how people live, observe if there are signs of neglect and dirt in the house, how they have the medicine cabient, how they have the refrigerator, what do they eat, what family climate is like, what benefits do the caregivers (if any) bring, how are they neighbours, etc. All this, they say, gives clues to adjust clinical strategies to each situation. The same study indicates that knowledge of the home environment, on the part of primary care, is essential to properly manage transfers of complex patients when they are discharged from hospitals.

According to the AQuAS Results Centre, in Catalan primary care centres, in 2015, 10.5% of people over 74 years of age benefited from the home care program, a figure that, unfortunately, has dropped to 8.2 % in 2018, with variability between centres ranging from 3.7% to 16.1%. These data confirm the tendency to neglect home care programs, another evidence that primary care is too overwhelmed by the pressure of demand and too inattentive to the reality experienced by people who are most sensitive to proactive actions.

Integrated home services, a model with a future

Beyond home visits, the services provided in the homes of people with complex social and health needs, if they want to be effective, require the work of multidisciplinary teams that, based on the comprehensive evaluation, develop individualized joint plans between health and social care services, can manage the necessary resources and, besides, offer a continuous provision that avoids the gaps of weekends and holidays.

The current situation is far from the desired comprehensive model. While primary care is obfuscated with impossible agendas, we see how all kinds of services are deployed in the homes of sick people, from those of the primary care nurses, those of home hospitalization, palliative care, family workers from town halls, oxygen therapy, physiotherapy, etc. Regardless of the intrinsic value of each of these services, which have it, there is no doubt that there is an urgent need to coordinate the services offered.

In Canada, concerned about this same problem, they are evaluating the effectiveness of various models that force the integration of services. From the document "Integrated Home Care and Primary Health Care. A Pan-Canadian Perspective", I want to highlight the model proposed by Winnipeg Regional Health Authority.

Notice that in the graph everything starts with a small team (micro team), one derived from primary care, which uses a methodology they call C.A.R.E. (an adapted "Chronic Care Model"), which has territorial support for mental health services, social support, nursing homes (when necessary), etc. The strong point of the model is that the patient and the small team, with the home as the centre of their activities, hold the key to the use of support services.

Neglect home work has costs

A team of Johns Hopkins researchers, in an observational study, estimated that in 2015 Medicare would have spent more than 4,000 million dollars as a result of insufficient home support for older people with difficulties in exercising their activities of daily living.

In summary, primary care teams should better understand how the elderly, frail and vulnerable people live to more appropriately adjust their clinical activities and, when dependencies appear, they should be able to organize all the services required, the only way to avoid so much environmental fragmentation, in addition to reducing unnecessary expenses.