Our expert care team helps our patients to maintain independence in their own homes and to recover from an injury, surgery or illness, all while reducing the risk of unplanned hospital visits. Our staff undergo continuous training to ensure the highest level of care and attention. Most importantly, we value the significance of providing an environment filled with love and respect.
We do this through the following services:
The physician is a key member of the home care team and plays a critical role in the patient’s Plan of Care (POC). Medicare and other health insurance plans cover or pay for “medically necessary” care. They require that the physician certify that the patient needs the services and sign the POC supporting the care. All care, changes in the POC, and significant changes in the patient’s condition are reported to the physician and documented in the patient’s clinical record. From legal, quality, and standards-of-practice perspectives, it is essential that the home care team members communicate and coordinate care with the patient’s physician(s).
A Skilled Nursing service is provided by a registered nurse (RN), or a licensed practical (vocational) nurse (LPN or LVN) under the supervision of a registered nurse.
In order to determine whether a service requires the skills of a nurse, the following factors are taken into consideration:
Some services may be classified as a skilled nursing service on the basis of complexity alone, e.g., intravenous and intramuscular injections or insertion of catheters, and if reasonable and necessary to the treatment of the patient’s illness or injury. However, in some cases the condition of the patient may cause a service that would ordinarily be considered unskilled to be considered a skilled nursing service. This would occur when the patient’s condition is such that the service can be safely and effectively provided only by a nurse.
Certified Home Health Aide (CHHA), or Certified Nursing Assistant provides probably the most important service for many patients. Home health aides are the “eyes and ears” of the organization. They often visit the patient the most, especially in the initial stages of home care, providing personal care and assistance in the Activities of Daily Living (ADLs) as the patient becomes more independent, or supporting the patient in these activities to maintain them comfortably at home.
Medicare standards and most state regulations require that home health aides be specially trained and proficient in several subject areas. Home health aides are closely supervised by the Registered Nurse (RN) or other appropriate team members to ensure their competence and comfort m providing the best home care to patients.
Physical therapist (PT) has an important role as member of the rehabilitation team. The PT assists home care patients to attain the maximum level of safety and independence in physical function. This is accomplished by addressing strength, range of motion, pain, balance, and neuromotor deficits. Cardiopulmonary re-conditioning, transfer and gait training, and wound care are other physical therapy interventions that may be provided at home. PT also serves as the case manager with patients who require therapy services only.
The PT, like other team members, provides input into the Plan of Care and any necessary revisions, prepares clinical documentation, and participates in in-service programs.
The Physical Therapy Assistant (PTA) is a technically educated healthcare provider who assists the PT in the provision of physical therapy. The Physical Therapy Assistant, under the direction and supervision of the PT, is the only paraprofessional who provides physical therapy interventions.
The Occupational Therapist (OT) is another important member of the home care rehabilitation team, with expertise in maximizing the patient’s safety and independence in functional activities of life, including activities of daily living (ADLs) such as bathing and dressing, and instrumental activities of daily living (IADLs) such as meal preparation or doing laundry. In optimizing functional performance, OTs may use interventions such as upper extremity hand therapies, sensorimotor training, energy conservation, modification of the home environment, and training in the use of adaptive devices or compensatory techniques. The OT can be an excellent partner for the agency’s home health aides to ensure that, whenever possible, patients maximize their functional abilities rather than increasing their dependence on others.
The OT, like all members of the interdisciplinary team, prepares clinical documentation, attends case conferences, and participates in care planning.
The Occupational Therapy Assistant (OTA) is a technically educated paraprofessional who can provide selected OT interventions under the direction and supervision of the OT.
Speech-Language Pathology (SLP) or Speech Therapy (ST) services are an important part of therapy for patients with various speech and swallowing problems and often include cognitive therapy. Home care patients who may need specialized speech-language pathology services include those with cerebrovascular accidents (CVAs); tracheostomies; laryngectomies; post-radiation for throat cancers; various neurologic diseases such as for Alzheimer’s disease, amyotrophic lateral sclerosis, and multiple sclerosis; and any who experience communication, swallowing, or cognitive-linguistic deficits.
Like all of the team members, the SLP creates clinical documentation, provides input into the Plan of Care, and attends case conferences about the patient’s status and progress on a regular basis for effective care coordination. The SLP also case manages in certain situations.
Respiratory Therapist (RT), also known as respiratory care practitioner, provides evaluation, treatment, management, and monitoring services for patients with acute and chronic respiratory and cardiovascular problems (e.g., chronic obstructive pulmonary disease [COPD], asthma, emphysema, Cerebrovascular Accident [CVA]). Care provided by respiratory therapists: may include administration of oxygen, management of mechanical ventilators, administration of respiratory drugs, and measuring and monitoring cardiopulmonary function.
Respiratory therapists also provide education and training materials for other home care clinicians related to oxygen and cardiopulmonary care needs.
A spiritual assessment is a part of the comprehensive assessment that is performed upon evaluation and admission to home care. The spiritual care services provided should be consistent with the belief systems of the patient and family. Many home care programs have a network of community clergy who provide support and spiritual care to patients, and Homeliving Health Providers, Inc. has its own chaplain team who work with the local community spiritual representatives. Responsibilities of the chaplain team may include providing bereavement counseling, serving on ethics committees, supporting staff and attending team meetings, performing sacraments for the sick, and intervening in other ways.
The chaplain provides services that span the life continuum from birth through death. The chaplain, like the professional nurse, interacts with patients and their families and friends at some of the most difficult times of their lives. The struggle with the meaning of life, experienced by many who have significant health concerns, is the work of the chaplain, regardless of any formal religious beliefs. The role varies based on the setting, the patient and family, and other needs. It may include bereavement counseling, ethics committees, home care staff support, and sacraments for the sick. The chaplain facilitates the patient’s movement toward his or her resolution of life’s questions.
Patients who may benefit from chaplaincy services include those for whom the North American Nursing Diagnosis Association-International (NANDA-I) nursing diagnosis, spiritual distress (distress of the human spirit), has been identified as an appropriate nursing diagnosis. Other patients may have a need for spiritual care based on their health problems. For example, the older adult patient who is temporarily home-bound due to a recent fall and fracture and cannot attend church services may need a call made to the priest or minister to arrange visits to the home.
Depending on the state and licensure requirements, the dietitian may be a licensed dietitian or registered dietitian. Accreditation standards require that the patient’s nutritional status be assessed and nutritional interventions implemented as appropriate. Many home care programs have dietitians available to make home visits and provide consultative services for conditions such as anorexia, mouth sores, wounds, pain, swallowing disorders, diarrhea or constipation, nausea/vomiting, and weight loss or gain. The dietitian may also make recommendations related to enteral and parenteral nutrition therapy. Other services include teaching about complex diets, identifying educational materials for use with patient teaching, and acting as an in-service educator and resource related to nutrition services.
Personal Care Giver (PCG) maintains the patient care area so that safe and effective home care can be provided.
Personal Care Giver services may include light housekeeping duties such as cleaning, vacuuming, and grocery shopping.
Durable Medical Equipment (DME) is any equipment that provides therapeutic benefits to a patient in need because of certain medical conditions and/or illnesses.
Durable Medical Equipment (DME) consists of items which:
DME includes, but is not limited to, wheelchairs (manual and electric), hospital beds, traction equipment, canes, crutches, walkers, kidney machines, ventilators, oxygen, monitors, pressure mattresses, lifts, nebulizers, bili blankets and bili lights.
Social Worker (MSW)
The Social Worker (Master of Social Work [MSW] or Bachelor of Social Work [BSW]) is an important member of the home care team. Support, active listening, and resource identification are just some of the services that social workers provide to patients and firmly/caregivers. Problems addressed by social workers include financial concerns, housing issues, caregiver support concerns, and other patient/caregiver issues. Most home care social workers have master’s degrees and clinical expertise in the counseling and other needs of home care patients and their families.