Home Care: Moving Beyond the Hospital

Podcast Transcript

Carol Pehotsky (00:04):

Nursing care has changed so much in the course of my nursing career as, as maybe it has for yours. I'm joined today by Heather Woodard and Suzanne Blankemeier today to talk more about the care we're able to provide patients in their own homes. Hi, and welcome to Nurse Essentials, a Cleveland Clinic podcast where we discuss all things nursing from patient care, to advancing your career, to navigating tough on the job issues. We're so glad you're here. I'm your host, Carol Pehotsky, Associate Chief Nursing Officer of Surgical Services Nursing.

Welcome back everyone. As we, our planning group thinks about what topics are interesting for our nursing essentials listening audience. We've taken a lot of twists and turns. We've spent some time talking about how to better take care of yourself. We've talked about professional development opportunities as a nurse, and we've spent some time talking to representatives with specialties. Now, there's numerous nameless numbers of specialties in nursing, and if you're in one of those thinking you need to do an episode with me, the answer is, yeah, gimme a call. Let's figure it out.

But what we've tried to do so far is really think about where do we not know enough about that specialty? Or where does it touch so many of us in so many ways? So that's why we're actually gonna talk about home care today. So it was a long time since I've been in nursing school, but even 20 years ago, I remember early in my career and, and even in nursing school really being taught, you know, discharge planning begins at admission. But thankfully, our patients have a lot different options now than they did 20 years ago in terms of what it means at discharge, am I healthy enough to go and where can I go? Right?

And well, let's face it, these days there's no shortage of patients, but sometimes there are shortages of capacities. Our EDs are bursting with patients, our ORs are taking care of patients. We have folks coming in who unfortunately sometimes have waited a little bit longer, and so they come in a bit sicker. And so we don't wanna send anybody out prior to being ready, but how do we make sure that they have a safe place to go? What better place than our own homes with that right supportive care. And so that's why I'm so excited to introduce you all to Heather Woodard and Suzanne Blankemeier. Heather is the Director of nursing at the Center for Connected Care at Cleveland Clinic, and Suzanne is the Assistant director of Cleveland Clinic Home Care. Welcome ladies.

Suzanne Blankemeier (01:44):

Hello.

Heather Woodard (02:22):

Thank you. Thanks for having us.

Carol Pehotsky (02:23):

Yeah. It's first time. I've had two guests on at once, so, uh, this is gonna be fun. So I'm hoping you can give our audience a general overview. What is home care nursing about?

Heather Woodard (02:33):

Yeah, so home care is taking care of our patients in their home.

Carol Pehotsky (02:33):

Mm-hmm.

Heather Woodard (02:37):

It's skilled nursing at home. It's-

Carol Pehotsky (02:39):

Oh, okay.

Heather Woodard (02:40):

Yeah. So it's-

Carol Pehotsky (02:41):

That's a difference (laughs).

Heather Woodard (02:41):

Yeah. So it's everything that you see as far as trach care, IV care, wound care, med education. It's those things that we're doing inside-

Carol Pehotsky (02:42):

Mm-hmm.

Heather Woodard (02:51):

... the hospital setting, but doing in the comfort of the patient's home, helping them age in place, helping them be in the comfort of an environment that they're most familiar with, and helping them be successful in that environment.

Carol Pehotsky (03:03):

Thanks, Heather. Suzanne, any additional thoughts?

Suzanne Blankemeier (03:05):

I think one of the benefits of nursing in home too, having been in the hospital and you know, going to home care was just really being able to assess the whole family, right. Or the environment at home.

Carol Pehotsky (03:16):

Oh, sure.

Suzanne Blankemeier (03:16):

And seeing that big picture, the social determinants of health that come into play, that might affect their outcomes as well.

Carol Pehotsky (03:23):

I was very fortunate in nursing school. I had the opportunity to spend a little bit of time with the home care nurse as my last semester, but that was 20 years ago. Things look a lot different now, I would imagine. So here we are, fast-forward 24 years later, what does a typical home care visit look like?

Suzanne Blankemeier (03:39):

Well, we start with a comprehensive assessment.

Carol Pehotsky (03:41):

Mm-hmm.

Suzanne Blankemeier (03:42):

So when we open a patient for home care, the nurse or the therapist, if it's a rehab only case, goes into the home. And really just a thorough assessment of that patient.

Carol Pehotsky (03:42):

Mm-hmm.

Suzanne Blankemeier (03:50):

And again, looks at the social situation, the caregiver support they may have at home, all of those things. And then they come up with an appropriate visit frequency for that patient-

Carol Pehotsky (03:50):

Hmm. Okay.

Suzanne Blankemeier (04:00):

... so how many times we plan on seeing the patient that can, you know, if a patient's coming out of the hospital, it's a new diabetic that needs insulin education, we might see that patient daily for a few days-

Carol Pehotsky (04:10):

Oh, sure.

Suzanne Blankemeier (04:10):

... until they can demonstrate that they're independent with that. Other times it might be two or three times a week-

Carol Pehotsky (04:10):

Mm-hmm.

Suzanne Blankemeier (04:16):

... at first. We try to front load the patients when they're coming out of the hospital.

Carol Pehotsky (04:20):

Okay.

Suzanne Blankemeier (04:20):

Just to make sure we have our eyes on them for that first 10 days when they're at highest risk of readmission.

Carol Pehotsky (04:25):

Okay.

Suzanne Blankemeier (04:26):

And then oftentimes back down a little bit and just reinforce the education and monitor them. And then also we do a, a lot of skills in the home. Much of what we do is teaching and education. But you know, as Heather said, we do catheter care, ostomy care, trach care. We take care of LVADs, all kinds of things. So most of what you would do in the hospital, we can do at home as well.

Carol Pehotsky (04:46):

That's amazing. So that assessment is done though in the home.

Suzanne Blankemeier (04:50):

Correct.

Carol Pehotsky (04:51):

So what does that look like to get referred into home care to really hear that, you know, Mrs. Pehotsky is going to be part of home care? Do you have the opportunity to look at my chart in advance or figure out if this is appropriate?

Suzanne Blankemeier (05:03):

We have the benefit here at Cleveland Clinic-

Carol Pehotsky (05:03):

Mm-hmm.

Suzanne Blankemeier (05:06):

... to where we share an EMR with inpatients.

Carol Pehotsky (05:09):

Ah, wonderful.

Suzanne Blankemeier (05:09):

So we are able, able to look at records from the hospitalization, or if it's an MD office referral-

Carol Pehotsky (05:14):

Mm-hmm.

Suzanne Blankemeier (05:14):

... looking at that last visit summary. So we do have that benefit of digging a little deeper.

Carol Pehotsky (05:19):

Okay.

Suzanne Blankemeier (05:20):

I have, I have worked at smaller agencies that were not hospital affiliated in the past.

Carol Pehotsky (05:24):

Okay.

Suzanne Blankemeier (05:24):

And oftentimes you might get an after visit summary or discharge summary from the hospital or an H&P from the provider along with the med list. And then it's kind of our job as home care nurses to assess the situation and determine what services are necessary and what the care plan needs to look like.

Carol Pehotsky (05:40):

So hopefully not completely blind of the situation.

Suzanne Blankemeier (05:42):

Correct.

Carol Pehotsky (05:42):

But (laughs)-

Suzanne Blankemeier (05:42):

Yes.

Carol Pehotsky (05:43):

... could be walking into something that looks a little bit different than-

Suzanne Blankemeier (05:43):

Right.

Carol Pehotsky (05:46):

... what you might expect.

Suzanne Blankemeier (05:47):

Correct.

Carol Pehotsky (05:48):

So there's a certain comfort in working in a hospital, a doctor's office, a blank based healthcare where you can hit a button and somebody else comes. So Heather, can you tell us a little bit more about how savvy a home care nurse needs to be about thinking about it's them, there's not a button to hit to say, I need more help?

Heather Woodard (06:07):

Yeah. Our nurses really need to be on top of their critical thinking. Right?

Carol Pehotsky (06:08):

Absolutely.

Heather Woodard (06:11):

So they're the only ones in the home. This isn't like, to your point, the inpatient area where you can just look down the hallway and say, "Hey, come here, here and-"

Carol Pehotsky (06:11):

Right.

Heather Woodard (06:18):

"... help me with this. Or, I need a second set of eyes on this."

Carol Pehotsky (06:18):

Yes.

Heather Woodard (06:20):

They really need to have good critical thinking skills-

Carol Pehotsky (06:20):

Mm-hmm.

Heather Woodard (06:23):

... and good assessment skills. However, they're also not alone. You know, we still have leadership that's a phone call away.

Carol Pehotsky (06:29):

Mm-hmm.

Heather Woodard (06:29):

You know, there's mentors for them. There's their fellow caregivers. And then we also have unique to Cleveland Clinic Home Care is our Virtual-Ass Program.

Carol Pehotsky (06:37):

Oh, what's that?

Heather Woodard (06:37):

So that's essentially like a phone a friend, phone a doctor. Right.

Carol Pehotsky (06:41):

(laughs). Okay.

Heather Woodard (06:41):

If I notice a change in my patient, so maybe I have a heart failure patient and we have a weight gain-

Carol Pehotsky (06:45):

Mm-hmm.

Heather Woodard (06:46):

... or we're noticing a little bit of shortness of breath for them, I can go ahead and call the Virtual-Ass and say, "Hey, these are the symptoms that I'm seeing with this patient."

Carol Pehotsky (06:46):

Okay.

Heather Woodard (06:52):

"I think we probably need an intervention that could potentially result in an ED visit if I don't intervene now." And this physician could give us orders. If they think that it's really urgent, they might even send out an APP.

Carol Pehotsky (07:03):

Oh gosh. Okay. Yeah.

Heather Woodard (07:04):

And do like an urgent dispatch. Or they might come out that day and provide IV Lasix or at some other interventions at the home in that day. So I think that that's pretty unique to our home care.

Carol Pehotsky (07:13):

Sure.

Heather Woodard (07:14):

But it's definitely helped us with our readmission rates and kept the patients-

Carol Pehotsky (07:14):

Absolutely, yeah.

Heather Woodard (07:17):

... in that, in that home environment.

Carol Pehotsky (07:18):

Sure. So if somebody's thinking about home care and through that interview journey or et cetera, probably a great question to ask is of that agency is what supports are available if I do need to escalate a concern?

Heather Woodard (07:30):

Yes. Yes. And we always try to tell the, you know, any of our applicants when they're interviewing, these are the supports that are available to you in the home, making sure that they're aware that while you are alone, you are not alone-

Carol Pehotsky (07:40):

Right.

Heather Woodard (07:40):

... at the same time.

Carol Pehotsky (07:41):

Right. So what does the inside of a home care nurse's car look like to make sure that they're prepared? (laughs), I can't even imagine. (laughs).

Suzanne Blankemeier (07:49):

Oh, their trunks are very interesting.

Carol Pehotsky (07:50):

Yeah.

Suzanne Blankemeier (07:50):

(laughs), we do carry what we call trunk stock or car stock.

Carol Pehotsky (07:55):

Okay.

Suzanne Blankemeier (07:55):

So the nurses try to make sure they have all those supplies that they may need at that first visit prior to the delivery from the supply company. So our nurses do a great job of keeping everything organized and going through periodically on a regular basis, checking for expiration dates and so forth-

Carol Pehotsky (07:56):

Sure.

Suzanne Blankemeier (08:12):

... to make sure they're getting rid of expired supplies.

Carol Pehotsky (08:13):

Again, a great point. You know, where in a hospital, hopefully somebody's checking for out dates, it's restocking cabinets, it's, that's all them.

Suzanne Blankemeier (08:19):

Right. But it is hard to go grocery shopping with your home care (laughs). Yes.

Carol Pehotsky (08:24):

So that nurse goes out and they've got their car full of stuff and it's organized. And certainly that's a whole different set of skills. There's time management organization, what it looks like in a hospital or in an operating room, or an ED. How does that skill change or evolve if instead I'm a home care nurse and my time management is still important, my organization is still important, my documentation is still important, but it's different?

Suzanne Blankemeier (08:49):

Home care is very different. It definitely requires some time management skills. You know, they have a expectation as far as how many patients they see a day. Sometimes patients don't wanna get up real early.

Carol Pehotsky (09:00):

Sure.

Suzanne Blankemeier (09:00):

So that can be a challenge to try to schedule your day. But we really work closely with them to try to teach them those skills to make sure they're managing their schedule. It's patient preference as to what time they like to be seen, but yet working that into their schedule. It is very different from inpatient. Going into home care, you do have an expectation as far as how many patients you need to see in a day. So they call their patients typically the night before to set up-

Carol Pehotsky (09:01):

Oh, okay.

Suzanne Blankemeier (09:26):

... those appointments. Keeping in mind patient preference what time they like-

Carol Pehotsky (09:27):

Sure.

Suzanne Blankemeier (09:30):

... to be seen throughout the day. But sometimes we have to ask them to be a little flexible with our schedules as well, based on the acuity, the patients, if there's lab draws that need to be done in the morning-

Carol Pehotsky (09:39):

Mm-hmm. Okay.

Suzanne Blankemeier (09:39):

... and, and so forth. But it definitely is a skill that they develop.

Carol Pehotsky (09:43):

There's some negotiation skills involved there.

Suzanne Blankemeier (09:45):

Yeah. Yes.

Carol Pehotsky (09:45):

Well you think about, in a hospital, I, I lose so much control, right? It's, here's the physical therapist at 9:00, or the lab draw at whatever time that here comes, the nurse with all these things. And so, one of the beauties of home care is that there is a little bit more control and autonomy, but again, working with those caregivers that are coming in to make sure that it all aligns perfectly.

Suzanne Blankemeier (10:04):

Right.

Carol Pehotsky (10:04):

So we spent a lot of time talking about what home care can do. What are some things that either one of you would say, a referral comes in and you would say somebody needs a higher level of care than what we can provide in a home care setting?

Heather Woodard (10:15):

Our intake department definitely reviews the referrals that are coming in just to make sure that they're appropriate for the, for the-

Carol Pehotsky (10:15):

Hmm. Yeah.

Heather Woodard (10:20):

... home care setting. And, you know, there are some times that we have to have some challenging conversations with some of the referrals that are coming in just to say, "Hey, you know, this patient's gonna require more care than what our home care agency can provide."

Carol Pehotsky (10:34):

Okay.

Heather Woodard (10:34):

Or, this patient's, maybe the expectations are not realistic for what our home care services-

Carol Pehotsky (10:40):

Oh, okay.

Heather Woodard (10:40):

... can do as well. So even just making sure that the family understands that home care is not there 24/7 in the home-

Carol Pehotsky (10:47):

Hmm.

Heather Woodard (10:47):

... that we're just doing, you know, a 45 minute to an hour visit, 1, 2, 3 times a week too.

Carol Pehotsky (10:53):

Mm-hmm.

Heather Woodard (10:54):

And that we're not gonna be there from the time that they wake up in the morning till the time that they're going to bed. That, you know, we're not helping them use the restroom, helping them get cleaned up in the morning. You know, that we're really there for those skilled needs in the home-

Carol Pehotsky (10:54):

Mm-hmm.

Heather Woodard (11:05):

... to help them with that dressing change, to help teach the caregiver or themselves to learn the skill with the goal-

Carol Pehotsky (11:05):

Sure.

Heather Woodard (11:11):

... of eventually helping them be independent and discharged from the agency, the short term aspects of care.

Carol Pehotsky (11:11):

Mm-hmm.

Suzanne Blankemeier (11:17):

I agree with that, Heather. Sometimes we can work together with patients and families for other resources that are available. So there's-

Carol Pehotsky (11:24):

Sure. Just because it isn't nursing care doesn't-

Suzanne Blankemeier (11:26):

Right.

Carol Pehotsky (11:26):

... mean they can't get other types of care.

Suzanne Blankemeier (11:27):

So there's non-medical home care.

Carol Pehotsky (11:27):

Okay.

Suzanne Blankemeier (11:29):

Like, we're skilled home care, but there is non-medical that provides aids in the home-

Carol Pehotsky (11:33):

Okay.

Suzanne Blankemeier (11:34):

... when we work with agencies that do provide those services to help keep our patients at home. But if that isn't an option, oftentimes we're having the conversation around, uh, skilled nursing facilities-

Carol Pehotsky (11:44):

Sure.

Suzanne Blankemeier (11:44):

... and even hospice for some of our patients.

Heather Woodard (11:46):

We've also seen too, patients that are really complex, you know.

Carol Pehotsky (11:46):

Yeah.

Heather Woodard (11:50):

Patients with IV lines, feeding tube, but maybe they're bed bound, complicated wounds, and you just think, "Wow, I, I don't know how this family's going to manage this-"

Carol Pehotsky (11:58):

Sure.

Heather Woodard (11:58):

"... in the home environment."

Carol Pehotsky (11:59):

Yeah.

Heather Woodard (12:00):

But they're so determined.

Suzanne Blankemeier (12:01):

Yeah.

Heather Woodard (12:01):

And they end up being successful.

Carol Pehotsky (12:01):

Okay.

Heather Woodard (12:03):

You know, and you're like, "Wow, I, I never would've thought or-"

Carol Pehotsky (12:03):

Yeah.

Heather Woodard (12:06):

"... you know, seen that." And then you have those patients that go home in that same capacity and they don't maybe have the same family support and they're-

Carol Pehotsky (12:06):

Sure.

Heather Woodard (12:12):

... not successful. But you have to almost see that through to let the family-

Carol Pehotsky (12:17):

Give 'em a, give 'em a chance to really [inaudible 00:12:19].

Heather Woodard (12:18):

... give them a chance to then realize where they need to go.

Carol Pehotsky (12:18):

Okay.

Heather Woodard (12:20):

And sometimes that puts our home care nurses in a tough situation when they-

Carol Pehotsky (12:20):

Sure.

Heather Woodard (12:24):

... go in there and they have to do the education, kinda watch that situation fail before they have to intervene, call 911. Sometimes we even have to reach out to Adult Protective Services-

Carol Pehotsky (12:24):

Oh, gosh. Sure. Yeah.

Heather Woodard (12:35):

... and get, you know, get them involved. So it's often very challenging for our RN case managers when they're put in those situations too.

Carol Pehotsky (12:41):

Absolutely. Yes. And it's, it's a great point. And, but for all of us as nurses, no matter what we do, is really assessing the situation, meeting the patient and the family member where they're at-

Heather Woodard (12:42):

Mm-hmm.

Carol Pehotsky (12:51):

... and not trying to set expectations of whether they can or can't do this, but also being able to know when it's time to say, we need additional help here.

Heather Woodard (12:59):

Correct.

Carol Pehotsky (12:59):

Gosh, that's gotta be tough.

Heather Woodard (13:00):

Mm-hmm.

Carol Pehotsky (13:00):

That's, that's a whole different set of skills that, yeah, not all of us have. So, going back to the comment about discharge plan, it begins at home. So for those of us who do work in a hospital setting, who want to advocate for our patients in their next journey, what are some signs to me that should say this patient might be a really good referral for home care?

Suzanne Blankemeier (13:19):

If there's been medication changes (laughs).

Carol Pehotsky (13:21):

Okay. Okay.

Suzanne Blankemeier (13:22):

Medications are a big reason for re-hospitalization-

Carol Pehotsky (13:25):

Okay.

Suzanne Blankemeier (13:26):

... patient's not taking their medications correctly.

Carol Pehotsky (13:28):

Mm-hmm.

Suzanne Blankemeier (13:28):

You know, they often need a lot of reinforcement. They're overwhelmed coming home from the hospital-

Carol Pehotsky (13:29):

Yeah.

Suzanne Blankemeier (13:33):

... they're not feeling good still-

Carol Pehotsky (13:34):

Sure.

Suzanne Blankemeier (13:34):

... coming home from the hospital. So just someone to go in and make sure that their meds are in order, that, and sometimes things need clarified. I know everyone does their best, but sometimes what's ordered on a discharge med list isn't what's in the home. And, you know.

Carol Pehotsky (13:34):

Right.

Suzanne Blankemeier (13:48):

So it's our job to-

Carol Pehotsky (13:49):

And 15 pages of discharge instructions later.

Suzanne Blankemeier (13:51):

Right. Exactly.

Carol Pehotsky (13:52):

Yeah.

Suzanne Blankemeier (13:52):

So it's our job to clarify those meds, reconcile those meds, and again, just make sure that patients are taking what they need to and understand the frequency and what they're for and all of those things. So, you know, I would say anyone who's been hospitalized, who of, of course they would need to meet home bound criteria for, um-

Carol Pehotsky (14:09):

Sure.

Suzanne Blankemeier (14:10):

... for most of our patients. But most people with med changes or who, who have been in with an acute illness could benefit from some education and reinforcement.

Carol Pehotsky (14:17):

Well, and like you said, it doesn't have to be seven days a week.

Suzanne Blankemeier (14:20):

Right.

Carol Pehotsky (14:20):

It's what does that look like that's appropriate for that patient.

Suzanne Blankemeier (14:20):

Right.

Carol Pehotsky (14:22):

Okay.

Suzanne Blankemeier (14:23):

Yeah.

Carol Pehotsky (14:23):

There are nurse case managers that help out with home care. So can you tell us a little bit more about what that role looks like?

Suzanne Blankemeier (14:28):

Really the role of the case manager is to ensure that the patient is progressing toward their goals.

Carol Pehotsky (14:33):

Okay.

Suzanne Blankemeier (14:33):

You know, at that start of care visit, we really work with the patient and the family to come up with what, what is their goal out of this? You know, we might have our goals as nurses, "I want the patient to do X, Y, and Z."

Carol Pehotsky (14:43):

Mm-hmm.

Suzanne Blankemeier (14:43):

But that may not be their goal. So the case manager, you know, keeps tabs on each patient's case to make sure, again, they're progressing towards the goals. And sometimes the patient's condition changes, you know, whether it's for-

Carol Pehotsky (14:43):

Hmm. Sure. Yeah.

Suzanne Blankemeier (14:55):

... the worse or for the better, but we may need to update that care plan along the way-

Carol Pehotsky (14:58):

Okay.

Suzanne Blankemeier (14:58):

... and change our interventions to make sure that we still meet those goals. And then really to act as a liaison between the patient, the family, the provider, making sure that appropriate community referrals are being made, whether that's Meals on Wheels or here at Cleveland Clinic we have chronic care clinics where patients can follow up as outpatient, you know, if they have CHF or hypertension or renal disease, any of those things. So we try to make sure our patients are referred, so whether, when we discharge, they can continue follow up with the chronic care clinics.

Carol Pehotsky (15:29):

Sure.

Suzanne Blankemeier (15:30):

Really, ultimately they're responsible for just making sure we're providing the appropriate services at the appropriate time.

Carol Pehotsky (15:37):

Yeah. Right.

Heather Woodard (15:38):

I think what's in, what's unique though, to the home care world is that our nurses aren't just responsible for the aspect of the patient care though too. There is a financial responsibility too.

Carol Pehotsky (15:38):

Mm-hmm.

Heather Woodard (15:48):

So they need to be cognizant of how many visits we're making too-

Carol Pehotsky (15:52):

Sure.

Heather Woodard (15:53):

... you know, 'cause there's that-

Carol Pehotsky (15:54):

Yeah. Thinking about that coverage.

Heather Woodard (15:55):

Yeah. Thinking about that coverage.

Carol Pehotsky (15:56):

Yeah.

Heather Woodard (15:56):

So when therapy's involved, you know, so they're also dictating like, "Hey, you're in, on service here too. So if I'm going to see this patient on this day, how many visits are you doing? And how do we make sure that we're covering and not there-"

Carol Pehotsky (15:56):

Sure.

Heather Woodard (16:08):

"... at the same time?" Right. So there's that coordination-

Carol Pehotsky (16:10):

And coordinating that care.

Heather Woodard (16:10):

... of care.

Carol Pehotsky (16:10):

Okay. Yeah.

Heather Woodard (16:11):

There's also a quality aspect of it too.

Carol Pehotsky (16:11):

Mm-hmm.

Heather Woodard (16:13):

There's a lot of, you know, documentation requirements and conditions of participation that we have to meet in the, in home care. You know, they need to make sure that they're ensuring that all of that is complete and that that documentation's correct. That our initial assessment, that that is all reported correctly in the system too, because that has a financial piece of it-

Carol Pehotsky (16:30):

Sure.

Heather Woodard (16:30):

... between admission to discharge. So I feel like that the responsibility of the nurse, it looks a lot different than that-

Carol Pehotsky (16:31):

Right (laughs). Yes.

Heather Woodard (16:37):

... that inpatient responsibility that you see.

Carol Pehotsky (16:39):

Documentation's important, but it takes a different spin [inaudible 00:16:42].

Heather Woodard (16:42):

Yes. Mm-hmm.

Suzanne Blankemeier (16:43):

That's a, a great point-

Heather Woodard (16:44):

Yeah.

Suzanne Blankemeier (16:44):

... there.

Carol Pehotsky (16:45):

So when we think about hospitals, we know that unfortunately it, it's hit the news several times that there have been situations across the country that, where people didn't feel safe. At Cleveland Clinic, we spent a lot of time talking about workplace violence and thinking about ways that we can make sure all of our healthcare providers, regardless of role, are safe and protected and that our patients are safe, our caregivers are safe. What does that look like in home care when we're going into different neighborhoods and to, to people's actual homes?

Heather Woodard (17:14):

Yeah. So this is, you know, probably one of the most challenging things about-

Carol Pehotsky (17:17):

Yeah.

Heather Woodard (17:17):

... leading in this position is, you know, we are sending caregivers into environments that we cannot control-

Carol Pehotsky (17:23):

Right.

Heather Woodard (17:23):

... at all. They don't know what they're walking into when they do that start of care.

Carol Pehotsky (17:23):

Mm-hmm.

Heather Woodard (17:27):

And it can be their dog is out and it's a dog bite, you know?

Carol Pehotsky (17:30):

Right. [inaudible 00:17:31]. Yeah.

Heather Woodard (17:32):

Yeah. To a gun, to the patient-

Carol Pehotsky (17:32):

Yeah.

Heather Woodard (17:34):

... just has the gun laying on the counter and it's not-

Carol Pehotsky (17:34):

It's their home (laughs).

Heather Woodard (17:37):

... threatening to them because it's their home, but that's threatening to a caregiver.

Carol Pehotsky (17:40):

For sure.

Heather Woodard (17:40):

Two, we've had situations where there was an active shooter in the area and the nurse is in a, a, you know, locked down in a home and can't leave.

Carol Pehotsky (17:47):

Oh my God. Wow.

Heather Woodard (17:48):

So these are very, you know, scary situations that sometimes our caregivers find themselves in. But we have tried really hard to work, you know, as a leadership team to ensure that we support them in the best way that we can.

Carol Pehotsky (17:48):

Mm-hmm.

Heather Woodard (17:59):

So we have an active workplace violence committee-

Carol Pehotsky (18:02):

Oh, great.

Heather Woodard (18:03):

... which our caregivers sit on as well. Some of the work that has come out of there is improving the amount of workplace violence service that are reported in our system. Right. So encouraging our caregivers to come forward and say that, "Hey, this patient or family member was verbally, you know, abusive to us or physically abusive to us," and reporting that.

Carol Pehotsky (18:20):

Sure.

Heather Woodard (18:21):

If there is a situation, our managers follow up with the patient or caregiver and say, "Hey, this is not something we tolerate. This is in our admission book, and if this continues, we will be terminating services."

Carol Pehotsky (18:31):

It's that same limit setting like we would do in any setting.

Heather Woodard (18:33):

Correct.

Carol Pehotsky (18:34):

Okay.

Heather Woodard (18:34):

And then more recently we were rolling out the use of what is known as 911 cellular.

Carol Pehotsky (18:38):

Okay.

Heather Woodard (18:38):

And it's a device our caregivers are wearing that and they can easily push a button and the, they are GPS located by the police department.

Carol Pehotsky (18:39):

Wow.

Heather Woodard (18:46):

And they can send the, the police out to their location very quickly if they are feeling threatened or in harm's way.

Carol Pehotsky (18:51):

So it's like a, like a panic alarm.

Heather Woodard (18:52):

Panic alarm. Yeah.

Carol Pehotsky (18:53):

That's fantastic.

Heather Woodard (18:54):

Yeah. So that is new and that's rolling out this year and I'm really excited about that and hoping-

Carol Pehotsky (18:58):

That's wonderful.

Heather Woodard (18:58):

... that that will help, you know, reassure everybody of their safety.

Carol Pehotsky (19:01):

And, and it's another great question for, you know, nurses who are thinking about transitioning into this space, whether you're applying at Cleveland Clinic or somewhere else, is really being able to ask that question is what do you hiring organization do to make sure I am safe-

Heather Woodard (19:13):

Mm-hmm.

Carol Pehotsky (19:14):

... when I'm going into people's homes?

Heather Woodard (19:15):

Yeah.

Carol Pehotsky (19:16):

That's fantastic. So we all know that the last couple years have created a lot of turnover and tension and issues with staffing and we could spend a whole separate episode talking about that. But what does that look like in the home care world and what sort of creative things have you all done to overcome any challenges with nurse staffing?

Heather Woodard (19:36):

Yeah. You know, we had to get really creative in the last couple years because home care has a very traditional role, five, eight hour shifts.

Carol Pehotsky (19:45):

Right. (laughs).

Heather Woodard (19:46):

And that is very hard to staff. So we've tried a couple different things, you know, I'd like to just touch on our RN residency program. So traditionally, hiring of new graduate nurses was not something that's been accepted into-

Carol Pehotsky (19:58):

[inaudible 00:19:58] hurdle. Yeah.

Heather Woodard (19:59):

... and, you know, for multiple reasons that we've already talked about, you know, you're alone-

Carol Pehotsky (20:02):

Hmm.

Heather Woodard (20:02):

... you're brand new to this world, so how are you going to feel competent in your position-

Carol Pehotsky (20:02):

Right.

Heather Woodard (20:07):

... to be able to independently be in someone's home and, and do it right and safe?

Carol Pehotsky (20:11):

Sure.

Heather Woodard (20:11):

So working very closely with our education department and aligning with what Cleveland Clinic already has in place as far as their RN residency program.

Carol Pehotsky (20:12):

Okay.

Heather Woodard (20:19):

So starting with a really good clinical assessment upon hire, tailoring their orientation to what-

Carol Pehotsky (20:19):

Sure.

Heather Woodard (20:25):

... their, that assessment shows, a robust 12-week orientation with skills being the primary-

Carol Pehotsky (20:31):

Sure. Right.

Heather Woodard (20:31):

... focus because we need to make sure that they're successful at those skills. And then also looking at what does the next year look like for them, bringing them back in for classroom and learning time.

Carol Pehotsky (20:39):

Oh, okay.

Heather Woodard (20:40):

Because there is a lot of classroom and learning time to begin with-

Carol Pehotsky (20:40):

Right.

Heather Woodard (20:43):

... in home care and you can't learn everything in that short 12-week period.

Carol Pehotsky (20:46):

No.

Heather Woodard (20:47):

So just continuing to support them, you know, throughout the rest of that year. And, and we've had some pretty successful new hires in that.

Carol Pehotsky (20:47):

Yeah. Wonderful.

Heather Woodard (20:53):

And, um, and that's been one way we've been able to kind of bridge that gap. We've also had to try doing unique shifts in our areas.

Carol Pehotsky (21:01):

Okay.

Heather Woodard (21:02):

So three twelves, four tens. And Suzanne, I'll let you kind of touch a little bit on how we got creative there.

Suzanne Blankemeier (21:06):

Sure. So again, as Heather mentioned, traditionally home care has been [inaudible 00:21:10].

Carol Pehotsky (21:10):

Yeah.

Suzanne Blankemeier (21:10):

Because as a case manager, I mean, you need to have your-

Carol Pehotsky (21:14):

Sure.

Suzanne Blankemeier (21:14):

... hands in the chart every day and know what's going on with that patient. So in order to be able to provide, uh, different shifts-

Carol Pehotsky (21:21):

Mm-hmm.

Suzanne Blankemeier (21:21):

... we created a care coordinator role-

Carol Pehotsky (21:23):

Okay.

Suzanne Blankemeier (21:23):

... um, within home care. So we have four different care coordinators currently. They're basically in-office case managers.

Carol Pehotsky (21:24):

Mm-hmm.

Suzanne Blankemeier (21:30):

... with the larger caseloads.

Carol Pehotsky (21:31):

Oh, okay.

Suzanne Blankemeier (21:31):

So they're not out seeing patients. Sometimes they do video conferencing with patients and things like that. But that allows us to have visit nurses out in the homes that are working part-time.

Carol Pehotsky (21:42):

Oh, okay.

Suzanne Blankemeier (21:42):

So, um, they report back to the care coordinator. The care coordinator-

Carol Pehotsky (21:42):

Sure. Updates.

Suzanne Blankemeier (21:45):

... is case, managing everything from the office, then ensuring that continuity of care, you know, keeping their eye on goals and things like that. So that's been very helpful.

Heather Woodard (21:53):

Yeah. So that gave us the ability to then hire four tens, twelves.

Carol Pehotsky (21:58):

Sure. (laughs).

Heather Woodard (21:59):

You know, the, the two eights, two twelves that people wanna work and not stick with that traditional Monday through Friday, 8:00 to 5:00 rule. So.

Carol Pehotsky (22:05):

Sounds like a key there is really the right match.

Heather Woodard (22:08):

Yes.

Carol Pehotsky (22:08):

Really on both ends really ev- each party understanding what's involved and really thinking about the person that can be autonomous and has the potential for some really deep critical thinking skills.

Heather Woodard (22:18):

Correct.

Carol Pehotsky (22:19):

Right.

Heather Woodard (22:19):

Yep.

Carol Pehotsky (22:20):

So ladies, I'm hoping each of you will take a turn to answering this question. What draws people to home care nursing and what do they get from that to charge the nursing batteries?

Heather Woodard (22:29):

Yeah. So I think the joy of what home care nursing can bring a nurse is I think that one-to-one patient connection that you can make in the home. So you're watching a patient come out of usually a difficult situation, right. You know-

Carol Pehotsky (22:29):

Mm-hmm.

Heather Woodard (22:43):

... discharge from the hospital, they're sick, they're not feeling well, and now they're in their home environment and this is the place where they're typically the most successful. Right?

Carol Pehotsky (22:43):

Sure.

Heather Woodard (22:51):

This is the place that brings them joy. So you're able to sit there, provide that care for them-

Carol Pehotsky (22:54):

Mm-hmm.

Heather Woodard (22:54):

... watch them be successful or watch them in the environment of the reasons why maybe they aren't successful.

Carol Pehotsky (22:54):

Hmm.

Heather Woodard (23:00):

So maybe you walk into the home and you just see high sodium foods laying around. So they're definitely not compliant with their diet. And now we're doing some coaching and education around why that we need to modify those things. So you're really bringing everything together-

Carol Pehotsky (23:12):

Mm-hmm.

Heather Woodard (23:13):

... that maybe we were doing in the hospital and putting those restrictions in place, but now we're in the environment where there's no restriction-

Carol Pehotsky (23:19):

Right.

Heather Woodard (23:19):

... so how do we help them be more successful? So I think it's just the connections that you can make in that environment. I mean, these are sometimes some of the best relationships we see between our nurses and our patients.

Carol Pehotsky (23:19):

Sure. Yeah.

Heather Woodard (23:30):

And if they're on service for multiple periods-

Carol Pehotsky (23:32):

Mm-hmm.

Heather Woodard (23:33):

... uh, episodes, you know, I, I think that that is a long-term relationship that our patients and our caregivers make, and you just hear some really great connections and stories, so.

Carol Pehotsky (23:40):

Sure.

Heather Woodard (23:41):

I think that that's one of the benefits.

Carol Pehotsky (23:42):

Yeah.

Suzanne Blankemeier (23:43):

You know, I would agree. Nursing is my second career. I've been a nurse about 18 years now, but I went into nursing because of my own experience with home care and hospice for my father. So I know his nurses were just amazing and helped us in so many ways, not only my dad, but our family as well.

Carol Pehotsky (23:43):

Mm-hmm.

Suzanne Blankemeier (24:01):

So when I went into home care, I, I would agree, Heather. I mean, I, I loved inpatient nursing, but being in the home, you really do develop those relationships with people. I still get Christmas cards, (laughs)-

Carol Pehotsky (24:12):

Oh, that's wonderful.

Suzanne Blankemeier (24:13):

... from people from 15 years ago, you know-

Carol Pehotsky (24:14):

Yeah.

Suzanne Blankemeier (24:15):

... but they impact us, I think, as much as we-

Carol Pehotsky (24:17):

Sure.

Suzanne Blankemeier (24:17):

... impact them. But, um, it's just a special type of nursing.

Carol Pehotsky (24:21):

Wonderful. Well, I've learned a ton today, and I'm sure our audience has as well. I do like to ask all of our guests a little something about themselves that takes us out of the subject matter expertise phase, and just lets our audience get to know you a little bit better. So I'll pick on Suzanne first. Same question though, ladies. What brings you joy?

Suzanne Blankemeier (24:38):

Honestly, I've got two boys, um, 18 and 19 who love everything dirt related, whether it's dirt bikes or, you know, um, mountain biking or whatever. But I, I love being outside with them, watching them race and, and so forth. But kind of sad that they're will be leaving the nest relatively soon, but they bring me joy.

Carol Pehotsky (24:59):

Wonderful. How about you, Heather?

Heather Woodard (25:01):

So, I mean, outside of my family-

Carol Pehotsky (25:01):

Mm-hmm.

Heather Woodard (25:03):

... I have a, you know, a 15-year-old daughter and she's wonderful and I love her, but I do find joy in organization, so I am a neat freak.

Carol Pehotsky (25:10):

Oh.

Heather Woodard (25:10):

And I like, I like to organize closets, (laughs), and clean. Um, so, you know, when I'm having a rough day, I like to just get out there and run the vacuum or dust something or organize something. So that is, that is my joyful moment. Yes.

Carol Pehotsky (25:22):

Well, ladies, thank you so much for joining me today. As always, thanks so much for joining us for today's discussion. Don't miss out, subscribe to hear new episodes wherever you get your podcasts. And remember, we want to hear from you. Do you have ideas for future podcasts or want to share your stories? Email us at nurseessentials@ccf.org. To learn more about nursing at Cleveland Clinic, please check us out at clevelandclinic.org/nursing. Until next time, take care of yourselves and take care of each other. The information in this podcast is for educational and entertainment purposes only, and does not constitute medical or legal advice. Consult your local state boards of nursing for any specific practice questions.