By Beth Hoffmire Heideman, MSN, BSN, RN, WCC, DWC, OMS
Fifty shades of wound care at home refers to treating the whole patient and the patient’s caregiving supporters—not just the wound. Only by understanding the nuances, or shades, of a patient and his or her environment can clinicians best achieve desired outcomes.
Differences between home and facility
Both a home and a facility create an environment that focuses on healing, but how each accomplishes that task differs.
In a facility such as a hospital, clinicians direct patient care, from the timing of meals to the delivery of medications. The expectation is that the patient/caregiver relationship follows the established plan of care in an environment that is controlled 24 hours a day. Access to ancillary support such as pharmacy, radiology, dietary, and laboratory is easy. All equipment, products, and staff conform to established standards, which promotes consistency in care.
The home, on the other hand, is an uncontrolled environment where care is delivered on a short-term, intermittent basis, as directed by the patient’s insurer and based on Medicare guidelines. The expectation is that either the patient or caregiver will learn the treatment plan. Clinicians are expected to be self-reliant with the understanding that immediate clinical support will be via a phone call.
The patient is living in his or her chosen home environment, whether that is an assisted-living apartment, under a bridge, or in a mansion. This means that clinical staff never know what they will face at the patient’s home: Will there be a large dog, running water, working lights, feuding family members, or durable medical equipment? In addition, the patient or caregiver may or may not follow the practitioner’s plan of care.
Another important difference is patient options. In a facility, healing is directed by controlling the setting and patient options. If a patient chooses to ignore the practitioner’s directions, that individual can be asked to leave the facility. In the home, the patient can choose to ask the clinical staff to leave. That’s why it’s important to know that healing in the home is directed by understanding how the individual and caregiving constellation—friends, community, and family—function within the living situation. The home care staff works within those parameters to promote healing.
Delivery of care in the home
How are 50 shades of wound healing performed in home care? Care is provided based on the mandated Medicare/Medicaid Outcome and Assessment Information Set (OASIS) and includes assessment, evaluation, and observation.
The first action taken by the clinician is to assess the patient and caregiver’s life skills. The clinician determines the patient’s, family’s, and caregiver’s life skills and how they handle change in their lives. Next, the clinician evaluates the patient’s understanding of the clinician’s role in promoting wound healing.
The knowledge from these two steps guides the clinician’s development of a plan of care based on the patient’s coping mechanisms and personal goals. In developing the plan of care, the clinician observes the home setting and resources available to the patient or caregiver, including both material (for example, chairs and beds) and people (caregivers) that will be helpful in implementing the plan. See Care delivery in the home for a summary of clinician actions in delivering care in the home.
When the patient is nonadherent
Nonadherence occurs for multiple reasons, including treatment costs; mobility restrictions; diet limitations; mental health issues, such as feeling depressed, helpless, or hopeless; and inappropriate use of wound treatment products. Reasons for nonadherence that are specific to the home setting include declining to adapt the home to promote healing (such as offering a commode when the only bathroom is not available to the client), refusing to remove trash, and unwillingness to use durable medical equipment to promote turning and repositioning because of the effect of the equipment on home décor.
The multidisciplinary team, with representation from nursing, rehabilitation, social work, and nutrition, meet to uncover reasons for nonadherence and develop interventions to promote compliance. The team also evaluates the wound assessments, comorbidities, and lab results.
One of the primary interventions is to promote empowerment. Empowered patients feel valued, and people who feel valued become active in their lives. Physical activity increases nutrition, endorphin release, oxygenation, and blood flow, all of which promote wound healing at the tissue and cellular level.
Techniques to promote empowerment include:
• Teach the patient or caregiver how to do the wound care.
• Deliver information in small packages; don’t try to cover too much at once.
• Offer genuine praise.
• Restructure thoughts by rephrasing negative statements. For example, a patient says, “I’m not skilled enough to do the wound care.” You can say, “You may feel that way, but look how you have been helping me with the care.” Another example is the caregiver who says, “I’m not good enough to help my husband.” In this case, you might reply, “You have been making his bed, making sure he has nutritious meals, and calling the nurse when there is a problem. These things demonstrate how worthy you are to help him heal.”
• Let the patient and caregiver do what they can.
• Help patients and caregivers to work through any issues encountered and learn skills to promote healing.
Fifty shades of wound healing will occur when clinicians encourage patients to maintain their individuality and when clinicians adapt wound care to fit an individual’s personality and caregiving support system. Clinicians should be nonjudgmental, use positive humor, and promote independence. They should continually seek methods to adapt the plan of care as needed. Through this process, the patient receives quality care and healing time can be reduced.
Centers for Medicare and Medicaid (2012) Outcome and Assessment Information Set Oasis-C Guidance Manual, A clinician’s Pocket Guide: Briggs Healthcare. https://www.google.com/search?q=Outcome+and+Assessment+Information+Set+Oasis-C+Guidance+Manual%2C+A+clinician%E2%80%99s+Pocket+Guide&ie=utf-8&oe=utf-8&aq=t&rls=org.mozilla:en-US:official&client=firefox-a. Accessed November 25, 2013.
Johnson RJ. Finding Health, A Search for Wellness and Longevity. Create Space; 2011.
Medicare/Medicaid Benefit Policy Manual – section 7. rev. 144 (5/6/2011). cms.gov. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.html. Accessed November 25, 2013.
Taylor SG, Rennpenning K. Self-Care Science, Nursing Theory and Evidence-Based Practice. New York, NY: Springer Publishing Company; 2011.
Watson J. Human Caring Science: A Theory of Nursing. 2nd ed. Burlington, Vt: Jones & Barlett Learning; 2011.
Beth Hoffmire Heideman is a wound nurse at McAuley Seton Home Care in Cheektowaga, New York.
DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.