Home Care

A S S I S T I N G S E N I O R S W I T H C O N G E S T I V E H E A R T F A I L U R E T H R O U G H I M P R O V E D H E A L T H

L I T E R A C Y A N D S E L F M A N A G E M E N T

Jaime Hadley – Communication II – July 2014

Executive Summary

Many seniors who require home care battle with chronic illnesses such as chronic obstructive pulmonary disease, diabetes, and congestive heart failure. These illnesses lead to hospitalizations, health degeneration, and emergencies. However, seniors may decrease the risk of these negative occurrences by helping to manage their own health at home. Home care providers have the opportunity to aide and enable seniors in this self-management by facilitating open communication among the heath team (the individual, family members, and professional care providers) to increase the senior’s health literacy and by utilizing recommended tools and techniques to track and improve health at home. This paper explains the concepts of health literacy and self-management for seniors and provides guidance for home care providers concerned with managing congestive heart failure in the home. Points of Note: Though health literacy is an apparent issue across demographics, seniors pose

significant risk due to the wide breadth of ability and understanding associated with mental and physical degenerations of aging and chronic illnesses.

Multiple studies show a correlation between low understanding levels of chronic illnesses and increased avoidable health complications and hospitalizations.

Home care providers can work to open lines of communication between seniors, physicians, home health, and family caregivers.

Open communication and clearly explained/understood information about a senior’s illness can lead to better self-management at home and overall better senior health, especially when facilitated by a home care provider.

Home care providers should be familiar with and able to teach steps to controlling congestive heart failure in the home.

An effective and educated in-home care provider can make a great difference in the health of a senior with congestive heart failure through increased health literacy and assisted self-management.

http://selecthomecare.com/

Introduction

“When patients are in doctor’s offices, they (might) hear 50% of what’s being said and maybe their relative hears another 30%, but they walk away without 20%” (Evans 2013)

Of that 80% actually heard, how much is understood?

Joanie, a 67 year old woman, has just been told by her physician that she has congestive heart failure. She knew with her diabetes, progressive weight gain, and recent shortness of breath that this possibility existed. But the diagnosis still comes as a shock. Her mind wanders, focused on those words – Heart Failure; the terms heart and failure together filling her with concern. While she processes her emotions, the doctor continues, unaware of the loss of attention from Joanie. He explains the symptoms of CHF, her options going forward, and his recommended changes in her medication and lifestyle. Joanie tunes back in to hear “Do you have any questions at this point?” Her mind still muddled, she answers “No.” The doctor hands her pamphlets, information on diet and general health, warning signs. He tells her to call immediately if her condition worsens. Joanie thanks him and leaves the clinic.

The premise of effective health care relies on the patient understanding and following the advice of the physician. Unfortunately, many factors may impact the patient’s understanding and follow-through: money, emotions, and particularly a concept known as “health literacy”. In Joanie’s situation, one common for many seniors, the doctor assumes not only that Joanie hears his instruction, but also that she understands how to follow through with his prescribed care plan. Even if the physician takes the time to ensure she has heard, he has very little power of follow through and accountability with Joanie. He must depend on her ability to monitor and regulate her own health, known as “self-management”. Self-management can be especially difficult for seniors.

“Seniors are totally reliant on their physician – an individual they see only occasionally – to explain their basic health condition. In appointments, seniors will nod ‘yes’ but don’t necessarily understand what is being said.” (Gynn 2013)

An effective home care provider steps in to help the senior overcome these obstacles, to increase the senior’s health literacy and aid the senior in self-management of their condition. For seniors with congestive heart failure, an informed home care provider can prove an essential leader at the bedside, utilizing the unique ability to make observations about their clients that no other care provider can and report subtle changes to decrease the need for unnecessary hospitalizations. (Harris 2014)

According to Mary Gynn, RN and experienced Senior Preventive Health Advocate, seniors face many unique challenges when it comes to their health. (Gynn 2013)

• They don’t fully understand what the doctor is talking about;

• They don’t understand their role in receiving prescriptions;

• They don’t understand explanations of their condition, medications or treatment;

• Physical limitations restrict understanding (e.g. Many seniors have hearing problems); and

• Mental limitations restrict understanding (e.g. Complex information is communicated quickly yet seniors are expected to grasp this in a 15-minute visit) (Gynn 2013)

http://www.aplaceformom.com/blog/unlikely-connection-between-utis-and-dementia/

For many people, the term “health literacy” may be unfamiliar or vague. According to the American Medical Association, health literacy encompasses “…a constellation of skills, including the ability to perform basic reading and numerical tasks required for functioning in the health care environment.” (Cook et al 2006)

Rosie Harris, MSN, RN, defines health literacy as “the state at which clients and health care professionals understand each other.” (Harris 2014) Improved health literacy influences the way professionals communicate with patients and the way patients or individuals understand their overall health. All levels of home care – from family and companion caregivers to Certified Nursing Assistants – can increase the effectiveness and quality of care by understanding and improving the health literacy levels of the seniors they serve.

The impact of poor health literacy extends beyond immediate health consequences. Patients with low health literacy, those who “read at lower reading levels,” “are more likely to incur higher medical costs that those patients who read at higher reading levels.” (Cook et al 2006) In one study done on the subject, 1 in 5 Americans were shown to read at half the level required for understanding most health care material (Cook et al 2006). Unsurprisingly, in 1998, it was reported that “an excess of $29 billion dollars in additional annual health care costs” could be “attributed to poor health literacy skills.” Lack of health literacy affects the entirety of the health care system, and should be a priority for every care provider as well as patient.

Defining Health Literacy

“Patients over age 60 are more likely to have both poor health literacy skills and suffer from chronic conditions, such as cardiovascular disease.” (Cook et al 2006)

Defining Health Literacy (cont.)

With seniors being at increased risk for poor health literacy consequences, home care providers must be prepared to aid the senior one-on-one and advocate on behalf of the senior in communications with other members of the health team. Recalling Joanie’s situation, a home care provider serving as an advocate could help Joanie to overcome obstacles of miscommunication. Physicians often “do a poor job of assessing their patient’s health literacy skills and overestimate their abilities.” (Cook et al 2006) In addition, many patients feel uncomfortable asking questions about the physician’s recommendations. (Cook et al 2006) One study found that “when asked to determine how well their patients understood what they said… [these] physicians were correct only 2% of the time.” (Cook et al 2006) The presence of a home care advocate in these doctor’s appointments can help to avoid this misunderstanding. Home care providers advocating on behalf of the patient remain uninhibited by emotion or embarrassment, and may ask questions and take notes about the patient’s prescribed treatment or condition.

As part of an Innovations Project for Medicare and Medicaid, The Schmieding Center of Northwest Arkansas offers a course for advanced caregivers that focuses on helping seniors stay healthy at home and thereby decrease healthcare costs and unnecessary ER visits, hospital visits, or LTC visits. Addresses: • Health literacy • Chronic condition self-management • Communicating with Emotional

Intelligence • Motivational Interviewing techniques • Increasing medication awareness • Advocacy • Creating healthcare teams that

encompass ALL parts of the team (Harris 2014)

Role of the Home Caregiver The individuals comprising a health care team come from different levels of expertise and involvement. Family members, physical therapists, general physicians, home health nurses, specialists, and home caregivers together comprise the health team surrounding a senior. The home caregiver typically spends the most day-to-day time with the senior they serve, and can be essential in connecting all the members of the ‘team’. When facilitating effective communication on behalf of the senior, the home caregiver must remember to work towards the goal of the patient. “It is important for all people [involved] to understand what is important to the client and base decisions on that persons individual needs.” (Harris 2014) For a caregiver to be effective in increasing a senior’s health literacy and self-management, the senior must determine for his or herself that personal health is important.

Consider Joanie’s scenario, and how a home caregiver could advocate for her in the doctor’s appointment to thwart instances of poor understanding: 1. When Joanie tunes out, an accompanying home care professional can remain undistracted by

emotion and able to listen attentively to the doctor’s words. (More so than an accompanying family member)

2. Joanie’s home care advocate can be prepared to make a list of medications prescribed by the doctor, and make note of any special instructions, avoiding the common “bag of medications” – jumbled and possibly expired prescriptions that many seniors take without understanding (Gynn 2013)

3. The home care advocate can take a moment to gage Joanie’s understanding by asking Joanie to repeat back what the doctor has said in her own words. The doctor can then clarify any misconstrued points.

4. Joanie’s advocate can gather materials provided by the doctor and later review the information with Joanie.

5. The home care advocate can make note of the doctor’s contact number and reassure Joanie that any questions that occur to her can be answered at a later time.

With a prepared home caregiver present, Joanie can leave her doctor’s appointment assured that all of her bases are covered. This type of information intervention has been shown to improve the health of seniors with heart disease. “Careful consideration of health literacy elements within a heart failure disease management program (written patient education material, oral communication approach) is associated with improved self-care behavior and clinically significant improvements in heart failure symptoms. In one study, 23 patients with heart failure and low health literacy received an education booklet specifically designed for them as part of a disease management program. Patients were tested on their knowledge before and after the three-month intervention. After the intervention, 100% of patients reported weighting themselves daily compared to 32% baseline. They also scored a mean improvement of 9.9 points on the Minnesota living with Heart Failure scale.” (Cook et al 2006)

Self-Management for Congestive Heart Failure

Many seniors like Joanie are daunted by a diagnosis of congestive heart failure. They may already employ a home caregiver, but be unaware of the increased help they could be receiving by utilizing a home caregiver with knowledge of health literacy, self-management, and advocacy. The right caregiver will assist the senior in learning about CHF, understanding their medications, and managing their lifestyle to prevent early progression of the illness.

Stuart D. Katz, MD, professor of medicine at New York University School of Medicine and director of the heart failure program at NYU Langone Medical Center in New York City states “Heart failure is a progressive disease, but the rate of progression varies a great deal. At least three-quarters of patients who practice self-care can help themselves in very meaningful ways.” (Freeman 2007)

In a comprehensive guide to congestive heart failure management, professionals at The Washington Home Center for Palliative Care Studies offer steps for the home caregiver to assisting a senior with CHF in self-management. (Schuster et al 2002) 1. Keep a daily log 2. Home caregivers may ease the seniors burden by

keeping a log of the senior’s breathing (difficulties, coughing), medications and side effects, diet and activities, and additional symptoms.

3. Know When to Call the Doctor 4. Not only should the caregiver know when and who

to call, but the information should be made easily accessible to the senior.

5. Be Prepared with Information the Doctor Will Want

6. Chest Pain, Weight Gain, Swelling, Difficulty breathing, Decreased urination, Feeling dizzy, Nausea or vomiting, Increased fatigue, Muscle cramps, etc.

7. Have an Action Plan A. Don’t Panic B. Call C. Follow Instructions

The most important step a home caregiver can take to help a senior with congestive heart failure is to record weight “at the same time every day and report significant changes.” (Harris 2014) Roseanne Harris, MSN, RN, recommends seeking additional knowledge from experts, specifically at the American Heart Association or the Mayo Clinic. (Harris 2014)

Conclusion

Anyone can be confused by health care information. Seniors face more obstacles than other demographics when it comes to health, and a well-informed home caregiver can make a significant difference in the overall health and wellness of a senior.

“Healthcare is a very complex system. It is easy to get lost and be pushed around, not heard. It’s about taking an active role in meeting [one’s] own needs.” (Harris 2014)

The home caregiver carries great responsibility when acting as an advocate for a senior, and may, through improved health literacy and self-management techniques, aid a senior in achieving better overall health and avoiding hospital readmissions and illness progression.

Resources

Resources Cooke, Catherine, Jann Keenan, and Richard Safeer. Dec 2006. "The Impact of Health Literacy on Cardiovascular Disease." Vascular Health Risk Management.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994011 /Accessed June 15, 2014. Evans, Melanie. December 2013. "Providers Help Patients Address Emotion, Money, HealthLiteracy."ModernHealthcare.http://www.modernhealthcare.com /article/20131207/MAGAZINE312079983 Accessed June 15, 2014. Freeman, David. 2007. “Living with Advanced Heart Failure.” WebMD http://www.webmd.com/heart-disease/heart-failure/features/living- with-advanced-heart-failure?page=3 Accessed June 6, 2014. Gynn, Mary, RN. 2013. "Health Literacy for Seniors." The Florida Nurse. Harris, Roseanne, MSN, RN, Instructional Development Specialist UAMS. Personal Interview. June 18, 2014. Hines, Patricia, Kevin Yu, and Michael Randall. Mar/Apr 2010. "Preventing Heart Failure Readmissions: Is Your Organization Prepared?" Nursing Economics Schuster, Janice, MFA, Carol Spence MS, RN, Michelle Jacobs, MPH, Anne Wilkinson, PhD, Casey Milne RN, BSN, Suzanne Pieklik, and Sarah Myers, MPH. 2002. “Living with Advanced Congestive heart failure: A Guide for Family Caregivers.” The Washington Home Center for Palliative Care Studies.