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ONWARD ~ and ~ UPWARD
Judith Florian, R.N.
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Featuring articles and
discussion of diverse topics and issues, including:
Disabilities, Home
Health Care, Sexual Abuse of Children, and Advocacy.
HOME CARE ISSUES
| Patients have no
representative body to turn to when there are problems in receiving
home care. There is NO national agency for consumer
issues. I repeat this, because it is so important (and
disgraceful)! |
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There is NO national office that serves as a
clearinghouse of information, or as a national office of advocacy
for home health care consumers (consumers = patients and their
families). |
As a patient, do you know what your
home health aide should know
if they are a "home health aide"? Some background is needed first before going on to
answer that question.
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Agencies are usually paid through State and/or Federal monies, such as
Medicaid and / or Medicare. Almost all agencies are
"certified" by Medicare, and so, these agencies must comply with
Federal guidelines and standards. Very simply, this means that
all home health aides must be trained in compliance of certain guidelines
that the federal government has mandated. Most websites state that
federal law suggests at least 75 hours of classroom and practical training
supervised by a registered nurse. All training and testing programs
must meet the standards of the Health Care Financing Administration,
regardless what agency or company offers the training and testing.
Training programs vary depending upon State regulations. And
home care employees must pass a competency test that covers 12 basic areas
of care. Competency Tests must be passed within 4 months of employment
generally, and Aides must be re-tested yearly.
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The 12 areas of competency are in these areas:
Communication skills;
observation, reporting, and documentation of patient status and the
care or services furnished;
reading and recording vital signs;
basic infection control procedures;
basic elements of body function and changes;
maintenance of a clean, safe, and healthy environment;
recognition of, and procedures for, emergencies;
the physical, emotional, and developmental characteristics of the
patients served;
personal hygiene and grooming;
safe transfer techniques;
normal range of motion and positioning;
and basic nutrition.
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These 12 areas form the
benchmark of a qualified employee. Let's look at each area
separately and talk about what each means for a patient.
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Communication skills...
Communication skills are more than the gift of gab or simply talking.
It includes understanding how people react to certain comments, statements
and replies, and what things shut down communication and what enhances
communication. It includes verbal and non-verbal skills.
Verbal is usually what is and is not said and so, it is pretty
straight-forward. But non-verbal messages can actually contradict the
words a person says. For example, a patient may hear an Aide say "I
don't mind dumping your potty," but sees the Aide grimace, hold their
breath and scowl every time they are asked to take care of that task.
Communication is not only talking, but actively listening, and responding.
It is a two-way action, not just one-sided.
Observation, reporting, and documentation of patient status and the
care or services furnished...
This seems so obvious, but the fact is, many people are NOT very
observant. OR, they do not know or understand WHAT they need to be
observing. If an Aide cannot observe and recognize the importance of
what they observe, there can not be "reporting," which is a
necessary part of working in a medical team (patient plus doctor, nurse, and
other aides). An Aide is trained to observe a patient's
physical, emotional, and psychological status, and to recognize changes in a
patient which are different from that patient's "normal"
well-being.
Reading and recording vital signs...
Vital signs consist of Temperature, Pulse, Respiration, and Blood
Pressure. These duties require practice and skill to do accurately,
since vital signs can be one very important indicator of health or illness.
Most Home Health Aides do not perform these duties and instead, these are
done by Licensed Practical Nurses or Registered Nurses. But, a
good home care aide often recognizes changes in a patient even when they are
not permitted by their agency to actually take vital signs, so again,
observation comes into the foreground. An Aide who recognizes a
difference in the patient can report those changes to a nurse who can then
take vitals. Or it might be suggested that the patient contact their
doctor.
There are "skilled cases" in which a nurse or LPN performs
certain nursing duties. The nurse is responsible for reporting
changes in a patient's vital signs or overall status to the doctor.
Basic infection control procedures...
As reported on many news programs in the past year, basic infection
control demands knowing good hand-washing technique and actually doing
it.
Unfortunately, many health care workers skip this basic step, either
because they forget or are just lazy - or they were not properly trained.
When working in a patient's home, a worker must be more aware of
reducing the spread of illness and promoting sanitary conditions, especially
if there are children in the home or elderly.
This includes proper food refrigeration and storage, proper food
preparation, and personal and environmental cleanliness. In very basic
terms this means, storing and cooking foods the right way, washing counters
and hands in between handling raw foods, and cooking food well. But,
to the discredit of home care companies, a new applicant is rarely
questioned about their knowledge of hand-washing techniques or their
knowledge of food preparation. Somehow it is just assumed
that Aides, who are mostly female, already know HOW to cook and clean a
kitchen. But, often, they don't know. And their personal hygiene
may be lacking.
Basic elements of body function and changes...
"Body functions" covers a vast area. Aides must
recognize changes in elimination (bowel and bladder), changes in skin color
or temperature, changes in skin integrity, etc. They must know some
level of "normals" to recognize "abnormals."
And the Aides must then use good documentation and good communication to
alert the supervisor/nurse of any changes.
Maintenance of a clean, safe, and healthy environment...
This goes hand-in-hand with basic infection control procedures, but also
includes safety, which includes every aspect of home, patient, employee
safety, and good body mechanics. A short list of what is
included in this section is that an aide should know
- to not block walkways, doorways, or stairs;
- to keep side rails up on a frail or disoriented patient;
- to lock doors, and keep the home safe;
- to use good body mechanics to protect the patient as well as the
worker;
- to properly use and assist a patient who uses a walker, wheelchair,
cane, crutches, Hoyer-lift, or any other assistive device.
Again, those are just a few areas of safety. This category overlaps
though with infection control, basic sanitation, and cleanliness in the home.
Again, it is usually assumed that Aides know these things (when many Aides
do not).
Recognition of, and procedures for, emergencies...
In Nursing Homes, Personal Care Homes, or other institutional situations,
there is an evacuation plan that covers all emergencies, especially fire.
These plans are posted with the exits clearly marked on the paper (posted in
the hallway usually) and exit doors properly marked in the building.
In home care, there is usually no specified "plan" so home
health aides must recognize emergencies and must know what actions to take.
Patients (or the family / caregiver) must assist in the planning for
emergencies, such as having working smoke detectors, carbon monoxide
detectors, and fire extinguishers. An Aide should know what
actions to take first if there is a fire, or other
environmental emergency (flood, tornado, power outage, etc).
Additionally, Aides are required to have CPR (Cardio-Pulmonary
Resuscitation) and training for Choking incidents (important for all ages of
patients, from children to elderly).
They should know basic first aide (what to do to control
bleeding, such as applying pressure and keeping the affected part above the
level of the heart); initial care of sprains (ex. having a patient sit and
stay off an ankle, keeping it elevated), and should recognize emergencies
which require additional care at a hospital. Therefore, an Aide coming
to a new patient (since Aides often go to different cities and localities)
should look in the phone book for phone numbers to the fire department and
police department if there is not 911 service in the area (some cities do
not have 911). Patients should be encouraged to keep emergency numbers
posted, including next of kin, doctor, pharmacy, in addition to the
emergency services numbers.
The physical, emotional, and developmental characteristics of the
patients served...
Folks say all people are the same, and yes, we all share the basic human
emotions, needs etc. We all have need for food and water, to be safe,
to have privacy, and to avoid undue embarrassment or ridicule. But,
different ages, races, impairments, and even ethic background can change how
an Aide should approach care giving. Some examples follow (but I
could write about many other examples).
- Physical needs and diseases change as one ages.
- There are cultural differences that affect diet and foods eaten
(Muslims and Jews don't eat pork or shellfish, or some people are
vegetarians).
- A patient who has a short term condition, like a broken leg or recovery
from surgery, is likely to have different emotional needs than someone who
has been chronically ill, or who is terminally ill. Likewise, families
may need support in acute phases of illness (ex. an accident, or a heart
attack), but may need more support from others when an illness had
progressed over years and has taken a toll on everyone.
- The most obvious developmental differences is when one thinks of a
child versus an adult. And as one ages from teen to young adult to
middle age to elderly there are changes in life perspectives, coping skills,
as well physical and emotional capabilities. A recently retired
worker who has had few medical problems will be different to work with than
a person who is in the late stages of Alzheimer's.
Overall, this category means that Aides should have a high level of
"people- skills." But, as obvious as this seems, many Aides
lack interpersonal skills and some end up treating their adult patients as
children rather than as patients - or as adults - even when these patients
are quite competent and have good communication!
This category also includes that Aides
need to know, understand, and use good personal boundaries. A
worker should know to not "borrow" money from clients, nor accept
gifts. Aides must keep their own emotional or life problems out of the
patient's home. The ideal employee should be able to interact in
a caring - but always very professional manner.
Personal hygiene and grooming...
Some patients may wonder if this means the personal grooming and hygiene
of the worker - or of the patient. Actually, it should include both,
given that some Aides do not present themselves in clean clothes and their
own hygiene appears to be lacking! Aides should not be dressed in any
way that interferes with your care. This includes excessive jewelry,
perfume, and extra-long fingernails. An Aide should be dressed
appropriately.
However, this category of personal hygiene and grooming is
more about the patient. It means that an Aide knows how to provide
total care or assist a patient in personal
care, grooming, and dressing. They should already know how to do a
"stand-by assist" where a patient needs only some help versus
"total care" like a bed bath. Good skin care is needed
for patients who sit for many hours or who are bed-bound. Aides should
be able to recognize that skin discoloration (reddened or grayed skin) and localized warmth on a body
area might indicate the very beginning of a pressure sore (a decubitus ulcer).
As well, Aides should be able to deal with any number of unpleasant
situations without any emotional reaction or negative statements to
the patient, such as cleaning a patient who has urinated or defecated in
bed. A patient should never be reprimanded or ridiculed for
soiling the bed or their clothes. An Aide should perform their duties
with the utmost compassion, professionalism and high regard for the
patient's physical and emotional well-being, and to maintain a patient's
privacy while attending to their needs.
Safe transfer techniques...
It is never so scary for a patient as when they must rely on another
person physically to assist them in transfers, standing, walking, or even
turning in bed! Aides must know correct body mechanics,
which means not only how they manage the patient's physical body but also
how an Aide positions their own body during any assistance being given.
Aides should place their feet in a wide stance to maintain their own
balance. They should bend their knees when lifting from a lower
position to a higher position (e.g. chair to standing), rather than using
their back. They should know to never pull or grab a patient
in the underarm area, and must never wrench a person's arm out away from the
person's body -- children especially can receive bad arm/shoulder damage,
but adults can also suffer significant nerve injury when grabbed like that.
Aides need to know the proper way to help patients who use assistive devices
(walker, cane, wheelchair, Hoyer lift) to keep the patient and the worker
safe.
An aide should also recognize when it would be unsafe for
them to attempt to assist a patient or to move a patient who is unable to do
any movements without help. Rather than attempting to move (or assist)
a patient in an unsafe manner or in unsafe circumstances, the worker should
know to stop and call a supervisor for instructions and to get additional
help.
Normal range of motion and positioning...
Positioning goes along with other physical safety measures. When a
patient is "safely" in a chair or bed, they are at more risk for
skin breakdown or even long-term problems like muscle atrophy or foot drop.
Positioning and care begins with simple things, like keeping sheets or
pillows free from food crumbs and wrinkles in the material, both of which
can cause skin irritation and can lead to skin breakdown. One study
showed than the skin can be affected within just a few hours, with the
discoloration caused by bony areas pushing against surfaces (including
another part of the body).
The recent events of hurricane Katrina showed one elderly man being
rescued who, over about 10 days, had become totally dehydrated. He had
been of average weight and generally good health before the storm, but lost
most of his body mass and fluids before being found in his living room.
He had laid on the side of an upturned couch, his head against a end table
or coffee table, with one arm resting across his chest. As he lost
weight, and being weak and not moving his body on his own during those days,
he was unable to prevent skin irritation (along with everything being
soaking wet and the fact he was unable to wash and have clean and dry
clothes). He had skin breakdown where his elbow had laid against his
chest, and the top of his head already had a sore beginning.
This was a very tragic event, but it is an example of how fast even a
healthy person can suffer from the effects of starvation, dehydration, lack
of sanitary and dry conditions, and the inability to move one's own body.
In hospitals, nursing homes, and private residences, the elderly and ill are
susceptible to these same effects to their bodies and skin, especially those
who are not eating or drinking much, who are left sitting or laying for long
hours, left sitting or laying in wet or soiled areas, and who are not moved
frequently throughout every day. Re-positioning a patient should be done
every 2 hours, regardless of the "hassle" or inconvenience to the
Aide.
Range of motion (ROM) exercises are necessary to prevent problems with
joints and muscles. It also improves circulation to muscles, bones,
and skin, and helps prevent skin breakdown (movement of any kind helps
this). Generally, ROM follows standards that have long been used in
hospitals. It involves moving every joint within it's normal
"range". For example, healthy people in normal everyday life
move their arms up and down, or forward/backward, or out and in.
Persons walk, moving their hips and knees, as well as ankles.
Assistive or total ROM is simply having a caregiver (Aide) move those joints
(or assist the patient to move) in a similar manner, even though the patient
is in a chair or bed. Nursing homes often build ROM into other
activities, such as music therapy where residents are encouraged to clap
their hands, reach above their head, tap their feet or gently
"kick" their legs forward. But, in home care, there are no
scheduled activities like in nursing homes, and Aides must arrange their
schedule to include ROM into everyday care. It is often recommended to
do or assist with ROM during bath time, when a patient is already moving
their limbs (or an Aide is moving the body parts). Creative
Aides might turn on music during part of their day and encourage the patient
to sing and "dance" according to the patient's ability and safety
level. (It *is* possible to get some good "dancing" done
even in a wheelchair or in bed! Swing those arms, move those
toes/feet, "bounce" a little. Movement and music are not
only good for the body, but excellent for the mind, emotions and spirit!)
And, basic nutrition....
Medical persons use of the word "diet" is different than how
many lay- persons use that word. Rather than
"dieting," medical staff refer to the "diet" as the kind
and amount of food usually consumed by that person. So "one's
diet" might be "normal" - meaning a person can and does eat
whatever they want. A "low salt diet" is often prescribed by
a doctor when a patient has heart, kidney or fluid retention problems.
The "diabetic diet" is specific types of food and portions which
attempt to control the blood glucose ("sugar") levels [although
this diet is not just about restricting sugary foods]. There are
other diets prescribed for other types of medical conditions. Patients
who are elderly, or who have dental or oral conditions, or who are very
debilitated, may be on a "soft diet" to assist them in getting as
much nutrition without having to spend as much time and energy in chewing
the food. Other patients may receive types of "supplemental
nutrition" - by mouth or through tubes inserted for nutrition.
Aides should know the basics of what these "diets" mean and the
importance of following a doctor-prescribed diet. Workers should
recognize that some medical conditions do not allow for any
"cheating" - or that a patient's medical problem may become worse!
Also, an Aide should be able to see changes in a patient's intake and
output [one reason patients are asked those intrusive questions about how
often and when they've had a bowel movement and urinated :-/ ].
Sometimes intake and output [ I & O] are measured and recorded on an I
& O form, which assists the nurse and doctor in evaluating the patient's
current physical state.
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One website states:
"The National Association for Home
Care* offers national certification for home health and personal
care aides. The certification is a voluntary demonstration that the
individual has met industry standards.
Successful home health and personal care aides like to help people
and do not mind hard work. They should be responsible,
compassionate, emotionally stable, and cheerful. Aides should
also be tactful, honest, and discreet because they work in private
homes.
Home health and personal care aides must be in good health. A
physical examination including State regulated [medical] tests such
as those for tuberculosis may be required.
Advancement is limited. In some agencies, workers start out
performing homemaker duties, such as cleaning. With experience and
training, they may take on personal care duties. The most
experienced home health aides assist with medical equipment such as
ventilators**, which help patients breathe."
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Cleaning services...
Agencies differ about what types of cleaning they allow aides to do.
Most exclude anything that would be considered "spring cleaning."
Most agencies forbid moving furniture, or climbing ladders, onto chairs, or
onto short step-stools to do cleaning. Some agencies allow Aides to clean
the inside of the refrigerator or defrost the freezer -- other agencies
forbid this. (Reason: some Aides have forgotten to return food to the
freezer or refrigerator! )
Almost all agencies allow vacuuming, light dusting,
bed-changing, laundry, dumping/cleaning bedside commodes [considered part of
personal care], things like grocery shopping and errands, and meal
preparation/clean-up.
Additional requirements to become a Home Health
Aide...
BACKGROUND CHECK
Home Health Aides usually have to
submit to a background check, including
police records (most companies may accept a person with a Misdemeanor charge
but most companies reject an applicant who has had a Felony).
Prospective workers are normally fingerprinted for the background check.
HEALTH CHECK
Health checks include a physical and TB testing. Applicants should
obviously be in good health to work in any healthcare situation. Some
companies reserve the right to do drug testing, but not all actually DO any
kind of routine drug testing.
Applicants might be able to
hide their active drug use during the interviewing phase, which can turn
into a huge problem for patients who end up with an Aide who is using drugs.
Some patients report that their Aides are falling asleep on the job, due to
suspected or observed drug use.
Falling asleep on the job may have other causes, such as being up with
young children or if a worker has a second job (like working nights in a
hospital on rotating shifts, then trying to work day turn in home care).
Employers need to know when workers are moonlighting or have
responsibilities at home that might affect their work, versus the use of
illegal drugs while on the job.
EMOTIONAL AND PSYCHOLOGICAL SUITABILITY
The emotional and psychological well-being of applicants is mostly
determined through good interviewing skills. This may miss documented
conditions an applicant has, which may range from slight to severe
depression, manic-depression, violent tendencies, or personality disorders.
While having a mental health condition does not automatically exclude a
person from working in the health field, it is important that a home health
aide is stable emotionally. Workers who show an unstable personality
or emotions should be carefully screened by employers. Unfortunately
this does not always happen.
IN CONCLUSION......
While the 12 areas of testing are the Guidelines set by the Federal
government, the truth is that often Home Health Aides receive little training
and little-to-none of any kind of in-service training. Many, many employees get OJT - - "on the job
training" or are trained for each individual patient to whom they are
assigned. Obviously, OJT is *NOT* a satisfactory substitute for real
training in the areas covered by Federal Guidelines!
Given what you've read here, how would you evaluate your Home
Heath Aide Worker? Do they show through their actions and words that
they have received training? Does the training seem adequate for YOUR
needs and your situation?
Far too often, patients receive inadequate
care, by incompetent Aides, and many patients are at risk of neglect,
outright and subtle abuse, theft, and workers with unstable personalities
and emotions. Additionally, many patients are at the mercy of not only
the agency but also the aides in regards to inadequate staffing.
Patients put up with Aides who call off, or who are no-shows, simply because
there is no family or friends who can regularly give the person care or get
meals for the person. Patients who should receive
excellent care are treated worse than what law-makers demand of pet-owners!
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Facts....Do You Know...
* NOTE: The National Association for Home Care is a
body established to assist home care agencies, NOT THE
PATIENTS/CONSUMERS OR FAMILY/ CAREGIVERS. The NAHC assists
agencies/ companies in influencing legislation (or fighting legislation that may
not be favorable to agencies/ companies within States or Nationwide). From
the NAHC
website.
* Most home health aides employed through State programs that pay for home
care do not take care of "skilled services" such as ventilators. LPNs or RNs must attend to these cases.
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Coping Index...
Coping
through Writing... Coping
Through Music... Coping
Through Dreams
Coping
Through Inspiration-1 (large photo)... Coping
Through Inspiration-2 (small pictures)..
Coping
Through Inspiration-3.. Coping Through Day-Dreaming...
On-Frustrations...
On-Rejection...
On-Encouragement...
Life-Coaching...
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The title "Onward ~ and ~ Upward" is a
"motto" I used as a teenager and young adult --- then forgot about for
a number of years. I feel it is a fitting motto to strive for and a
fitting title for the topics of this website.
(c) Judith Ann Florian
159 E. Main St.
Girard, Ohio 44420
Disclaimer: This website is intended to convey
information and discussion ONLY, on a variety of topics, and reflects the
views of this author and submitters to this website. The information
provided on this website is not intended as a substitute for a medical opinion
or diagnosis. If you are suffering from an illness, injury, pain or
other symptoms, please seek help and diagnosis from a medical professional.
If you are feeling suicidal or are thinking of harming yourself, in any way or
by any means, call your therapist, your local 911, your local police
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This page was last updated on Saturday, April 22, 2006 15:24
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