Chronic Conditions (Review)

You will find in this section, the information needed to prepare for the Home Health Aide In-Service exam. You can view, download and print for better preparation.

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CHRONIC CONDITIONS 

Overview

Home health patients often have chronic conditions. Chronic conditions are long-term conditions or diseases that often require complex treatment and care management plans. According to the Centers for Disease Control and Prevention (CDC), "chronic diseases and conditions - such as heart disease, stroke, cancer, diabetes, obesity and arthritis - are among the most common, costly and preventable of all health problems."

Home health aides (HHA) have a responsibility to help manage chronic conditions and prevent a decline in patients' conditions. Mismanagement of chronic conditions often results in rehospitalization when earlier intervention might have prevented the costly occurrence. HHAs need to be astute and observant to notice when someone involved in a patient's care - the caregiver or the patient - is not following the care plan, or when the patient's chronic disease seems to be declining.

Patients can be noncompliant in their care for a myriad of reasons. HHAs can help a patient with chronic conditions manage his or her care through patient and caregiver education and engagement. Understanding why a patient is noncompliant with the care plan is critical to improving overall care. 

Facts

Chronic conditions are long-term conditions that are often difficult to treat. Many patients often have more than one chronic condition. This makes the chances high for a bad medication interaction and for patient noncompliance and/or confusion over what to take and when.

Chronic conditions are a major contributor to health care costs and hospital readmissions. Chronic conditions develop for many reasons - sometimes they develop over a period of time of poor nutrition or lack of exercise, such as diabetes or heart disease, but those conditions can also have a genetic component to them. Some chronic conditions, such as obesity, increase the risk of other chronic conditions, such as stroke.

KEY TERMS TO AID YOUR UNDERSTANDING

Chronic condition: 

A long-term disease or condition that usually requires complex care.

Medication compliance: 

Medication compliance occurs when a patient follows the physician's instructions exactly while taking medications.

Patient engagement: 

Interaction between patient and caregiver or home health aide that involves a patient who takes an active role in his or her own care.

Rehospitalization: 

When a patient is readmitted to a hospital (any hospital) as an inpatient within 30 days after his or her last discharge from a hospital.

Teach-back: 

A method of reviewing and assessing education in which the learner explains to his or her teacher, in his or her words, what was just reviewed.

Common Chronic Conditions

There are many types of chronic conditions. The following sections highlight the most common chronic conditions, risk factors, and prevention and management methods. The HHA is best suited to care for patients if the aide's own education is ongoing. When aides are educated in chronic diseases, they are more properly prepared to care for their patients. Knowledge of common conditions, including symptoms, expected behaviors, frequently used medications and treatments, is imperative in order to be able to identify important changes when they occur.

One of the key responsibilities of the HHA is to observe, document and report. Any change in condition must be identified by observation. The next step is to report the change to the case manager or you supervisor and, of course, document your findings in your notes submitted to the agency.

The HHA often has the advantage of being the closest caregiver to the patient. With that comes the responsibility of being alert and aware of changes in your patient. Some changes may seem small to you but are actually significant and must be reported. The goal is to prevent worsening of chronic conditions and to keep the patient in the home and out of the hospital.

Heart disease

Heart disease describes a range of conditions affecting the heart. Risk factors for developing heart disease include:

• Age. Aging increases a person's risk.

• Sex. Men are generally at greater risk of heart disease. However, women's risk increases after menopause.

• Family history.

• Smoking.

• Poor diet. A diet that's high in fat, salt, sugar and cholesterol can contribute to the development of heart disease.

• High blood pressure.

• High blood cholesterol.

• Diabetes.

• Obesity.

• Physical inactivity.

• Stress.

• Poor hygiene, which can allow viral or bacterial infections to invade and put a patient at risk for heart infections. This includes poor dental hygiene.

Some of the things that cause heart disease can't be easily changed, such as diseases caused by viruses or birth defects. Many of the causes and risk factors, however, can be improved with diet and activity changes.

Everyone can benefit from the following guidelines for a healthy heart:

• Eat a variety of foods.

• Engage in regular physical activity.

• Achieve and maintain a healthy weight by controlling calorie intake.

• Limit total salt (sodium) consumption to less than 2,300 milligrams (approximately a teaspoon) per day.

• Eat foods low in saturated fat and cholesterol.

• Limit sugar intake.

• Eat plenty of vegetables, fruits and whole-grain products.

• Consume no more than one alcoholic drink per day.

• Do not smoke.

• Monitor blood pressure and keep it within healthy limits (ideally below 120/80); blood pressure at the 140/90 range is considered pre-hypertensive.

Cancer

Cancer occurs when abnormal cells divide in an uncontrolled manner and invade surrounding tissues. There are more than 100 different types of cancer. Often, cancer patients feel more comfortable being cared for in the home.

Reducing the risk of cancer is possible in some cases. Routine screenings for certain cancers may be recommended for some patients. Early detection of any cancer is key to cure and survival. Vaccines, such as the HPV vaccine or the hepatitis B vaccine, can also lower cancer risk. Receiving regular medical care, avoiding tobacco, limiting alcohol use, avoiding excessive exposure to sunlight (or any UV rays) and eating a healthy diet and living an active lifestyle also help reduce a person's risk of cancer.

Treatment for cancer includes the following:

Chemotherapy: Chemotherapy uses strong chemicals or drugs to kill cancer cells, stop their reproduction or slow their growth. There are many types of chemotherapy drugs. Some are given orally, while others are given by intravenous infusion. These may be given in combination with each other and in combination with surgery and radiation.

The amount of chemotherapy a patient receives depends on the type of cancer, the specific drugs used and the patient's response to treatment. This therapy may be given daily, weekly or monthly; it can continue for months or even years. Some drugs are given according to a pattern that includes rest periods between treatments to allow the body to recover.

Chemotherapy drugs affect normal cells in the body along with the abnormal cancer cells. Because chemotherapy affects fast-growing cancer cells, any cells that grow quickly (e.g., those in the stomach, intestines, bone marrow and hair follicles) may also be affected. Fortunately, most side effects from chemotherapy are temporary; they gradually disappear when treatment ends.

Side effects include the following:

• Nausea, vomiting and diarrhea: Chemotherapy affects the stomach and the intestines.

• Hair loss: Hair loss can occur on all parts of the body. Hair may thin or fall out completely. It usually grows back after treatment is completed. For some types of chemotherapy, hair loss on the head is prevented or minimized by the use of ice caps during administration of the drugs used.

• Fatigue: Chemotherapy affects the bone marrow and the body's ability to make red blood cells, which may cause anemia (lack of red blood cells). Anemia can make patients feel weak and tired. Medications are often given to boost red blood cell production, resulting in the patient feeling stronger.

• Infections: Chemotherapy's effects on bone marrow may lower the number of white blood cells, increasing the risk of infection. It is very important to avoid crowds during this time. It is also a good idea to avoid close contact with small children, who often are exposed to contaminants at day care or other social situations that could be passed on to the patient.

• Bleeding: Chemotherapy can affect blood cells called platelets, which may lead to easy bruising or bleeding.

• Mouth sores: The cells lining the mouth are affected by chemotherapy, and a patient may develop sores.

• Loss of appetite: Whether due to mouth sores, nausea or vomiting, many patients experience loss of appetite.

• Constipation: Chemotherapy patients may be given laxatives to prevent constipation.

Surgery: In some cases, surgery may be required to remove a tumor. (In other cases, tumors cannot be removed because of their size or location.) Infection and pain at the site of the wound and inside the body is a possible side effect of surgery and can take months to heal.

Radiation: Radiation therapy uses high-energy rays, similar to but stronger than x-rays, to kill or shrink cancer cells. It may be used in combination with chemotherapy and sometimes with surgery.

Radiation therapy is usually spaced over a number of weeks or months because the dosage needed to kill cancer cells cannot be given in a single treatment. The number of treatments a patient receives depends on the type and size of the tumor, the radiation dosage and how the patient responds to treatment. The newer methods of radiation therapy are quite precisely targeted, resulting in less trauma to surrounding tissues.

Depending on the specific plan for each patient, side effects from radiation therapy may vary. Common side effects include:

• Fatigue: Fatigue is the most common side effect of radiation.

• Eating problems: Nausea and loss of appetite may occur.

• Hair loss: Hair loss may occur on the part of the body undergoing radiation.

• Skin reactions: The skin in the treatment area may become dry, irritated and sensitive; it should be treated gently. It may appear sunburned or may peel. The affected area should be kept out of direct sunlight for at least a year after treatment.

Arthritis

People of all ages can have arthritis, but it occurs more often among older people. About 54 million Americans are affected by this condition. We do not know the cause of most types of arthritis.

There are six main signs of arthritis. They usually occur in or around a joint. They are:

• Pain

• Stiffness

• Swelling (sometimes)

• Difficulty moving a joint

• Redness around the joints

• Decreased range of motion

There are several things we can do to help most types of arthritis. First, anyone who has symptoms of arthritis should see a doctor for a correct diagnosis. Only a doctor can decide whether a person has arthritis and what kind it is. It is important to know the type of arthritis, because there are different treatments for different types.

Medication is important for reducing the pain and inflammation of arthritis. Doctors often prescribe the following:

• Aspirin-free pain relievers such as acetaminophen (Tylenol).

• Anti-inflammatory drugs such as aspirin, ibuprofen (Advil) and naproxyn (Aleve). These reduce the warmth and redness (inflammation) in the joints or skin and also relieve pain. Anti-inflammatory drugs can cause stomach pain and bleeding and can also thin the blood so that a person bleeds excessively. Nonsteroidal anti-inflammatory drugs (NSAIDs) taken long term or in large doses increase the risk for heart attack. Always report complaints of stomach pain.

• Sleep aids. There are many over-the-counter sleep aids available.

• Prescription medication, such as corticosteroids, may be prescribed to reduce inflammation. This can be given orally or by injection.

• Biologic medications were introduced in 1998; these includes etanercept (Enbrel), adalimumab (Humira), rituzimab (Rituxan) and others. Biologics work by interfering with the immune system signals and ultimately reducing inflammation.

Exercise is one of the best treatments for arthritis. Any form of exercise is helpful, from chair exercises to walking. Staying in motion, moving the joints, is very important. Even though the patient has arthritic pain, often the pain will lessen with activity.

Heat and cold applications can provide relief from some of the symptoms of arthritis. Heat relaxes aching muscles and can be applied with warm compresses and warm water soaks. Cold numbs the area and reduces pain and can be applied with ice or cold packs. Either heat or cold is fine to use, depending on the individual's preference.

When using either type of application, it's important to remember:

• Never use heat with rubs or creams. The combination of heat and creams can burn the skin. A patient should never go to sleep with a heating pad on.

• It is helpful to use heat or cold before exercising, to prepare the joints and muscles.

• Be safe! Don't leave a hot or cold treatment on the skin for more than 20 minutes at a time. Let the skin return to its normal temperature between treatments. Using a heat or cold treatment for more than 20 minutes at a time can actually have the opposite of the desired effect.

Pacing activities also saves energy, reduces fatigue and protects joints from stress and injury. Keep the following in mind:

• Alternate heavy or repeated tasks with easy tasks.

• Switch periods of activity with periods of rest.

• Change tasks often so the joints don't stay in one position for a long time.

Joint protection uses the joints in ways that avoid stress and can make it easier to do tasks. Pay attention to joint position and use the joints in the best way. Use larger or stronger joints to carry things, such as carrying a grocery bag with the forearms, not the hands. Use walking or assistive devices, such as canes, walkers and reachers to reduce stress on the joints and to make tasks easier. Use thick pens for writing, and only carry lightweight items.

Self-care skills involve taking care of oneself by planning activities for the best times, when feeling more flexible or in less pain. If mornings are the most pain-free hours, plan personal care and pleasurable activities during those hours. Patients should rest when they need rest; they should do enjoyable things and learn how to manage stress.

Stroke

A stroke is a "brain attack" - it occurs in the same way a heart attack does, only it affects the brain instead of the heart. A stroke occurs when the blood supply to part of the brain is suddenly cut off. This can happen when a blood clot blocks a blood vessel or when a blood vessel breaks and spills blood into the brain. In either case, brain cells in the affected area die, usually die within minutes to a few hours after the attack starts. When brain cells die, they release chemicals that start a chain reaction, killing even more brain cells in a bigger area.

When brain cells die, the abilities that are controlled by that area of the brain are lost. This can include speech, movement and memory, depending on where in the brain the stroke occurs and how many brain cells are killed. A small stroke might cause weakness of an arm or leg. A large stroke might cause paralysis on one side of the body or loss of the ability to speak and understand language. People can sometimes recover completely from minor strokes, but a severe stroke can be fatal. Immediate care is essential for the best outcome.

The five most common stroke symptoms include sudden:

• Numbness or weakness of face, arm or leg, especially on one side of the body

• Confusion, trouble speaking or trouble understanding

• Trouble seeing in one or both eyes

• Dizziness, trouble walking, loss of balance or coordination

• Severe headache with no known cause

Call 911 if you see any of these symptoms in someone.

Treatment is much more effective if given soon after the attack. Every minute can make a difference in preventing serious damage or death. Get emergency help even if the symptoms are painless or go away quickly.

Caring for someone after a stroke

There are challenges to recovering after a stroke. Many involve relearning how to speak, using aids to help with activities of daily living, using a wheelchair, etc. Changes may be needed to stay safe from falls in the home and bathroom, prevent wandering and make the home easier to use. Items (e.g., throw rugs) that may cause a fall should be removed.

As a stroke is a major, life-changing event, depression after experiencing a stroke is common. It can start soon after a stroke, or may occur months or years later. Increased social activities, medicines for depression and visits to a therapist or counselor can help.

It's important for a patient to avoid further complications, like pressure ulcers, after a stroke. To prevent skin or pressure sores:

• Clean up after incontinence.

• Change position often and know how to move in a bed, chair or wheelchair.

• Make sure the wheelchair fits correctly; a physical therapist can verify the fit.

• Have family members or other caregivers learn how to watch out for skin sores.

Eating healthy foods, controlling diabetes, lowering high blood pressure and potentially taking medicine to help prevent stroke are important measures to avoid a first or subsequent stroke.

Diabetes

In someone with diabetes, either the pancreas is not producing enough insulin or the body does not use its insulin effectively. The cells cannot turn sugar into energy, and the sugar builds up in the blood. The cells are starved for energy, and the blood carries dangerously high levels of sugar that can't be used. 

Importance of controlling diabetes

The goal of treatment for diabetes is to keep the individual's blood sugar as close to normal as possible for that person. Doing this will lower the person's chances of getting:

• Stroke

• Heart disease

• Kidney failure

• Stomach disease

• High blood pressure

• Eye disease, loss of vision or blindness

• Nerve damage, with pain or loss of feeling in hands, feet, legs or other parts of the body

A high level of sugar in the blood over a long period of time causes these problems.

Diabetic treatment

There are four parts to diabetic treatment.

Diet. There is no one diabetic diet designed for every diabetic person. There are guidelines to help diabetics with food choices. These guidelines are very similar to the kind of eating that is healthy for anyone. The following are the main rules that should be followed:

• Eat few sugary foods.

• Eat less fat, especially saturated fat and cholesterol (butter, margarine, oils).

• Eat a variety of fresh fruits, vegetables, lean meats and fish.

• Eat just enough calories to stay at a healthy weight.

Many people think that diabetics are not allowed to eat sugar of any kind. This is no longer a hard and fast rule. Sugar is a carbohydrate, like bread or potatoes, and can be part of a diabetic's food plan. However, most sugary foods provide calories without many vitamins or minerals, and they are often high in fat. It is better to eat more foods rich in nutrients, like vegetables and fruits, and very few fatty, sweet foods like ice cream and candy.

Exercise. Exercise usually lowers blood sugar and may help insulin work better. It helps control weight, it improves blood flow and it strengthens the heart. People with diabetes should exercise at least three times per week. Before a diabetic starts a new exercise program, a doctor should approve the type, length and frequency of the person's exercises. Elderly and disabled people need to exercise also and should be helped to find an exercise they can do. Any exercise is better than no exercise. Avoid prolonged sitting.

If a diabetic feels faint, sweaty, dizzy or confused while doing any activity, he or she should stop and immediately drink fruit juice or a sweet (not diet) soft drink. He or she must respond quickly to this feeling, because it means the blood sugar level is too low.

Medication. Diabetes can be treated with a variety of medications including oral anti-hypoglycemics, injectable insulin, and non-insulin injectable medications that help to stimulate the release of insulin. Only a doctor can decide what medication and how much of it a diabetic should receive. It can be very dangerous to change a diabetic's medication in any way unless ordered by a doctor. Diabetics must receive the exact amount of medicine their doctor has ordered, at the times the doctor has ordered. Timing of medicine and meals is important to prevent low blood sugar.

Monitoring. Close monitoring of a diabetic's blood sugar level is one of the best ways for him or her to prevent long-term complications from the disease. Diabetics check their blood sugar by pricking their finger with a needle and testing a drop of blood with a special blood glucose meter. The meter, also called a monitor, gives a number that tells the level of glucose in the blood. These monitors must be kept clean and should be checked for accuracy periodically.

Most diabetics need their blood sugar level tested at least once per day, usually in the morning before breakfast. Depending on the type of diabetes, the age of the person and other factors, a patient may need as many as five glucose tests per day. Sometimes insulin dosages are adjusted depending on the blood sugar level.

Diabetic emergencies and how to respond

Diabetes can cause both long-term and short-term problems. Blood sugar that is too low (hypoglycemia) or extremely high (hyperglycemia) can lead rapidly to unconsciousness and even death. You must know the symptoms of both conditions and know how to respond.

A doctor must set the acceptable ranges for each person, and they might differ from the normal ranges. When a blood glucose level falls outside the range set by the doctor, the doctor must be notified as soon as possible. If you are assisting a diabetic with monitoring blood sugar, be sure you know the correct range for the patient.

Another important part of monitoring is watching the feet and skin of a diabetic. Diabetes can turn a small sore or wound into a very large problem. Sores, blisters and wounds on a patient's feet and skin must always be reported to your supervisor or a nurse. As the HHA, you have the opportunity and responsibility to observe, document and report any changes in the patient's skin. Always look and observe for yourself; never just ask the patient if there are any sores or skin changes. Remove the patient's shoes and socks and look at the feet, including between the toes. Diabetics can have foot wounds and not even know it, as the feeling in their feet may not be normal; they may feel no pain.

Symptoms and treatment of low blood sugar

The following symptoms occur suddenly and without warning:

• Shakiness or nervousness

• Sweatiness and chills

• Pale, clammy skin

• Weakness and tiredness/drowsiness

• Sudden hunger

• Blurred or double vision

• Tingling of hands, lips or tongue

• Confusion

• Personality change

• Slurred speech

• Loss of consciousness

• Dizziness or a staggering walk

• Nausea

• Headache

• Fast heartbeat

• Itching

Note: Elderly people and people with other diseases and disabilities can be especially sensitive to low blood sugar, and it can be very dangerous for them. Some people may have a reaction even when their blood sugar is not below the normal level. Any diabetic suddenly showing any of the signs listed must receive immediate attention.

To treat low blood sugar, the person should drink a sweet drink, such as sugar-sweetened coffee or tea, orange juice, or non-diet soda. He or she could also eat sugar, corn syrup, candy or glucose tablets.

Symptoms and treatment of high blood sugar

The following symptoms occur gradually and get worse over time:

• Extreme thirst and/or hunger

• Rapid weight loss

• Frequent urination

• Vision changes

• Dry skin and mouth

• Fatigue, drowsiness

• Nausea

• Fruity-smelling breath

• Very deep, gasping breathing

• Unconsciousness

The first seven symptoms in this list should be reported to your supervisor or a nurse as soon as possible. Fruity-smelling breath, deep gasping breathing and unconsciousness are worse they are emergency symptoms that can lead quickly to death. Call 911 or access emergency medical care at once.

Obesity

Obesity is defined as having a body mass index of more than 30. Body mass index is a calculation of height and weight and may not be entirely accurate for everyone. Obesity is a chronic condition that needs to be cared for in order to reduce health risks and rehospitalizations.

According to the CDC, health consequences of obesity are:

• Coronary heart disease, stroke and high blood pressure

• Type 2 diabetes

• Cancers, such as endometrial, breast and colon cancer

• High total cholesterol or high levels of triglycerides

• Liver and gallbladder disease

• Sleep apnea and respiratory problems

• Degeneration of cartilage and underlying bone within a joint (osteoarthritis)

• Reproductive health complications such as infertility

• Mental health conditions

Controlling and reducing weight can be achieved by:

• Exercising regularly-exercising, no matter the weight, reduces the risk of many health issues related to obesity

• Eating healthy foods

• Monitoring weight

• Taking medications and vital signs to monitor health

Patient Engagement and Education

Engaging the patient in his or her care can be achieved in a number of ways. For example:

• Have the patient show you all of the bottles of medications he or she takes, including any daily vitamins.

• Ask the patient for the telephone number of his or her pharmacy and then place it in an easy-to-access area, perhaps on the refrigerator or at the bedside.

• Provide the patient with little-known information about his or her medications; this always seems to stimulate attention. In addition, stories about the medication help and may also serve as a memory aid.

• Encourage the patient to ask questions, especially if new medications are ordered or if the dosage is changed on a medication.

• Have the patient keep a daily log of when medications were taken. This provides the additional benefit of maintaining an accurate medication list.

• Provide the patient with handouts discussing his or her disease and the medications used to combat it.

• Use plain and simple terms to help the patient understand and feel more in control of his or her care.

• Use words that the patient can pronounce.

• Create a supportive atmosphere for the patient so he or she feels at ease in stating what is not understood or what is confusing.

A patient may feel more engaged during treatment if there is an easy and comfortable way for him or her to report discrepancies or errors.

Use the teach-back method, in which you have the patient explain to you what you've just taught him or her to assess whether the patient remembers and comprehends the information you've provided.

If a patient is in a high-risk situation, educate the patient and the family to make them aware of it. Provide them with the signs and symptoms of complications and with physician's orders that clearly state when to call for help and the parameters to follow for complications in the patient's disease or illness. For example, in cases of congestive heart failure, a weight gain of 5 pounds in a day can be alarming and may cause a physician or pharmacist to order an extra furosemide dose (diuretic to remove excess fluids) or draw digoxin levels. Create an environment for the patient with chronic illness that is supportive and reassuring. This will decrease patient and caregiver anxiety, as knowing what to do in an emergency is empowering.

Medication Compliance

Older adults frequently fall victim to medication nonadherence. There are many reasons for this, ranging from simple to complex. Whether patients are consciously skipping medications due to financial concerns or simply forgetting to properly take all of their medications, education is key.

A system of checks and balances should be in place, as the older adult can be especially vulnerable to the unintentional consequences of polypharmacy, missed doses, and accidental "adjustments" that may occur. The therapeutic range of many lifesaving medications may be very narrow, and monitoring by the home health staff should be frequent and thorough.

Keep tabs on medication habit and compliance. Be sure to:

• Ask the patient whether he or she is taking his or her medications, and if not, ask open-ended questions regarding why not (e.g., "Do you feel your medication is not working?"). You might also ask whether the cost of the patient's medications is presenting an issue.

• Document the patient's cognitive level, response to teaching, support system, and changes in conditions. (This should be ongoing.)

• Take action if you notice subtle changes in health, such as:

• Increased bruising

  
  

• Bleeding gums (indicating increased coagulation)

  
  

• Slight shortness of breath or pedal edema (indicating missed diuretics)

• Ask the patient to identify specific pills and reasons for taking them.

• Check to make sure the level of medication in the pill bottle is going down.

• Perform a simple physical assessment-is there weight gain or elevated blood sugars? Symptoms such as elevated blood pressures, headache or pain may dissipate if the patient is taking his or her medications.

• Help the patient remember medication by having the home caregiver organize a pill box.

If there are problems with the purchase of medications, refer the patient to a social worker in order to obtain Medicare Part D or other insurance coverage. Consult with the pharmacist on lower-cost medications that provide the same result. Ask the physician if he or she has samples.

Continue to monitor for adherence and medication side effects that could be present and may be keeping the patient from compliance.

Monitor laboratory work for the prescribed medications.

Educating the patient verbally or with documents won't be sufficient most of the time. To ensure the patient understands when to take medications or when to take action against a declining state (whether that is to call a doctor or go to the hospital), you must assess the patient's comprehension. An easy way to accomplish this is to use the teach-back method. After educating the patient, ask the patient to repeat what you've said in his or her own words. This helps the patient remember and understand the education. It often calls to attention important misunderstandings or overlooked points.

Outcomes and the ННА

When it comes to caring for patients with chronic conditions, HHAs must be prepared for a variety of considerations. For example, the HHA may help a stroke victim perform exercises under the direction of a physical or occupational therapist, following the care plan the therapist has prepared. This would include a home exercise program that is specific to the patient. Similarly, HHAs can assist in exercises for a patient with arthritis if the licensed therapist or nurse has included the exercises in the care plan. Note that HHAs are not permitted to perform exercises that a nurse or licensed therapist has not endorsed.

The HHA is also a key figure in supporting the monitoring and provision of care. For example, the HHA might be a primary caregiver to a diabetic patient, helping the patient remain healthy and decreasing complications.

Most important, the HHA's role is critical to managing chronic conditions. HHAs carefully monitor both patient health and patient compliance. This gives HHAs a window into the future, allowing them to take action or alert the nurse or physician that a problem exists, thus potentially preventing their patients from experiencing a serious health decline and/or a readmission to acute care.

Case Study

Marcus is an HHA who cares for an 81-year-old man, Mr. Louis. Mr. Louis has had diabetes and high blood pressure for 10 years. Marcus comes for a routine visit and asks Mr. Louis how he is feeling. Mr. Louis is in good spirits and says he feels just fine. Marcus asks whether Mr. Louis is taking his medications, and whether there are any problems. Mr. Louis says yes, he is, and that there are no problems.

Marcus draws a bath for Mr. Louis. While bathing, Mr. Louis complains about a cut on his foot he got while walking around barefoot, so Marcus ensures that it is washed thoroughly and reminds him to wear slippers.

During the entire visit, Mr. Louis is drinking soda, complaining that he is thirsty all the time and wishes he wasn't because it makes him have to use the bathroom often. Marcus suggests he try to schedule when he uses the bathroom so his body adapts to that schedule. As Mr. Louis walks to get a framed picture of his granddaughter to show Marcus, he knocks over a full pill bottle. He mentions that he forgot about those pills, then cleans them up, putting the lid back on the bottle and setting it back down in the same spot.

Marcus fixes Mr. Louis lunch. Mr. Louis asks for chips and soda to go along with his deli meat sandwich. After eating, Mr. Louis tells Marcus he's going to make an eye appointment because he thinks he needs stronger glasses. "The guide on the TV is blurry. I can't read it," he says. Marcus says this is a good idea, since he doesn't want Mr. Louis to fall.

THINK ABOUT IT

Answer the following questions:

1. What subtle clues did Marcus miss that might affect the management of Mr. Louis' diabetes?

2. What about this case study could have been changed to help Mr. Louis, who has high blood pressure, from developing more serious issues?

3. Are there any signs that Mr. Louis' diabetes is getting worse?

4. Did Marcus check in with the patient adequately? Does Marcus know that Mr. Louis takes his medication?

5. How could Marcus have asked Mr. Louis about his health and his medications in a more effective way?

CMS' Expectations

As a result of the Outcome and Assessment Information Set, the Centers for Medicare & Medicaid Services (CMS) reviews the quality outcomes and processes regarding the care an HHA provides. It also reviews potentially avoidable events. It expects that HHAs will use the information available for their quality improvement programs. CMS expects an agency's quality improvement efforts to take a multidisciplinary approach in meeting and improving the care needs of its patients.

CMS expects home health to play an important part in preventing rehospitalizations. With careful observation for changes in condition, plus appropriate and timely intervention, rehospitalization rates are reduced. This not only saves Medicare dollars but also reduces stress for patients and preserves their quality of life.

p. 55-70 Essential In-Services for Home Health, 2023

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