Article by Jordan Rosenfeld

Dr. Amarish Dave’s patient claimed to take her seizure medication, but that didn’t explain why her blood level for the drug was zero one week, and normal the next. With time and gentle probing, Dave, a DO, learned that she was in an abusive relationship and forced to move into temporary shelters several times per year, where it wasn’t possible to get her medication.

In another instance, a patient with multiple sclerosis who had no nearby family or close friends became temporarily homeless after job loss, though she still had health insurance and eventually found a new job. “Fortunately she didn’t end up back in the hospital, but she was right on the edge,” he said.

Dave, a neurologist and Associate Medical Director for Mercy Health, in Woodstock, Ill. has become keenly aware of the ways that social determinants of health play a role in his patients’ overall health.

“Social determinants of health are not necessarily medical, technically, but they clearly have a major impact on cost, care, quality and safety,” Dave said. Detrimental factors can range from being unable to afford air conditioning, which exacerbates conditions like asthma and COPD, to social isolation and loneliness after the loss of a spouse, a leading cause of depression and increased risk of illness among seniors.

Research shows that addressing social determinants of health, which are often overlooked in patient care, can not only improve health, but may also reduce disparities in health care.

Get to know the patient’s individual variables

All people want to be treated as individuals, not just a set of symptoms, said Mikki Firor, a gerontologist and CEO of Trovato, LLC, Dementia Services in Annapolis, Md.

Patients will have a wide range of skills and cognitive function, depending on age and medical conditions. “You’ve got your textbook version of a disease but then there’s a personality that goes with it. Getting to know one another, talking to the client is important,” Firor said.

She makes an effort to share information about herself, as well. “People want that human connection,” she said. “Telling them about your favorite food or family or showing them pictures are ways to make the interaction more human.”

Support and foster self-determination

It’s important to avoid doing everything for the patient when with a little practice or training the patient can regain some activities, said Eduardo Suarez, manager of Better Support Service, a home health company in Miami, Fla. If somebody is getting weaker, for example, instead of putting them in a wheelchair, it might be time to try physical therapy. If they can’t use utensils anymore, maybe switch to finger foods.

“If a patient is able to do some of the activities of daily living such as toiletry, transferring, bathing, and feeding, that will improve his independence,” Suarez said.

Even when a patient cannot do these things by themselves, Firor points out ways to preserve their dignity, such as plastic bathrobes they can wear in the shower, or moving a commode to a more private location.

“It’s about finding those ways to allow patients to be independent but working within their limitation,” Firor said.

Support healthy eating habits

Dave said some of his patients struggle to eat healthy. He has patients who think fruit juice is as healthy as a vegetable and others whose nutrition is limited by what they have access to. “We often think of food and nutrition as a choice for so many,” he said, “but for some people, it’s not a choice.”

Dave urged home health providers to help their patients search for and access nutrition resources, from programs that deliver or offer free food to low-income people, or nutrition education to improve the quality of their meals.

Sometimes, Firor added, patients with neurodegenerative diseases and the elderly simply eat less, or only want to eat sweet foods. Better nutrition may require creative solutions, such as adding ice cream to ensure for a protein-rich milkshake that’s tasty and easy to eat.

Be vigilant for medication errors

In the home environment, patients’ medications are not supervised as they are in the hospital. Firor recommended care managers help patients utilize a fill kit, pre-filling medications for one or more weeks at a time. “I’d also recommend keeping it in a safe place out of reach of the client so it helps the caregiver stay on track, too,” she said.

One study in Patient Safety and Quality found that the most successful interventions for medication problems in home health patients included patient education delivered by telephone or videophone with nurse follow-up; education tailored to the individual; and a medication review and collaboration among providers.

Develop rapport with family members

Improving a patient’s home environment is only as effective as the support network in place for the patient.

Suarez finds that sometimes simply communicating the goals of a particular treatment or intervention to the family member can increase the likelihood of their support or compliance. “I tell the family, ‘I’m going to do X. If you help me, you’ll get Y result,” he said. For example, by training a patient to increase his physical strength, they will eventually be able to use the toilet without help.

Identifying the patient’s support network is also crucial to discovering any gaps in their treatment or care, and to ensure emotional support. Dave said that some of his patients only have a friend or neighbor to help transport them to appointments or pick up prescriptions, but that one person can make all the difference.

It might also require some cultural or socioeconomic sensitivity, said Emily Reilly, DHS, an occupational therapist at Purposefully Home, in Scottsdale, Ariz. “You really have to learn or better understand what realistically happens when patients go back to their homes,” she said.

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