Basis of Medical Care in Home Medical Care

Needless to say, everything the physician says or does influences the patient and the family, which is true even in home medical care. This article outlines the general points to remember at the time of home visit in home medical care, what should be done in the first and a few subsequent house calls, and how to deal with the family’s anxiety when initiating home medical care.

General Points to Remember at the Time of Home Visit

The physician may or may not wear a white coat. However, if he/she is expected to perform a medical procedure, it is appropriate to wear a white coat. It is also preferable for the physician not to dress casually even when he/she is not wearing a white coat. Therefore, wearing T-shirt or sandals should be avoided.

When the physician is at the doorstep, ringing the doorbell several times as if rushing the individual(s) inside is inappropriate because, if the caregiver or the patient is elderly, it may take some time (approximately 1–2 min) for him/her to reach the front door even if he/she is inside.

The physician should consider that the patient/caregiver may sometimes be using the toilet or the bathroom.

When “the family is out having the front door unlocked,” the decision on whether to enter the home is sensitive. Doing so should be avoided until certain agreement that “the physician may get in the home” without a greeting or any response from the patient or the family, after a trusting relationship with the patient/family is established through repeated medical care.

Obviously, this is not true if the patient’s condition is expected to be exceptionally unfavorable.

Additionally, if the patient who is alone at home and is supposed to be unwell, sometimes “the physician should get inside (even through a window) to ascertain his/her condition even if the front door is locked.” These decisions are made considering the strength of the trusting relationship with the patient as well as the preference or life style of the patient/family, but mostly it will be appropriately determined based on the physician’s experience.

It is preferable even for a physician to neatly place his/her shoes at the entrance way before getting inside. More often than not, having entered the home, it is wise not to look around too much until reaching the patient’s room. The physician should be aware that “they do not want some room (or some part of the home) to be observed by the physician.” However, if there is something for a display, such as an ornament, a work of flower arrangement, or a framed testimonial, in most cases the physician may look at it because his/her looking at these things not only provides psychological satisfaction to the patient and the family but also is useful to know the interests or the past achievement of the patient/family. Before entering the patient’s room, the physician should knock the door or tell him/her something like, “I am here for house call. I’m coming in.”

After entering the room, the physician starts medical consultation, at which time he/she should pay attention “whether the sight of consultation can be seen or the conversation can be heard from outside the room.” For instance, if a window curtain in the room is open, the physician should draw it before initiating the consultation. If a window is open, the physician should shut it before starting the consultation, as the conversation may be overheard from outside.

The First and a Few Subsequent House Calls

What the physician says and does in the first house call provides a strong impression to the patient/family, exerting substantial influence over the trusting relationship thereafter. It is ideal that the patient/family “cotton to the physician’s visit and begin to look forward to it” during the first few home visits. To achieve it, the physician should perform the consultation remembering what is described in the above section. During the first few visits in particular, the physician should try to ask the patient’s life history and the current situation of daily life to grasp his/her character.

Sometimes the family offers tea/sweets after consultation. In the first house call, the physician may have them expressing gratitude, at which time he/she may tell, “Essentially, no consideration is necessary from next time on,” thereby releasing the family from unnecessary consideration as well as reducing the time of consultation. In fact, taking tea/food will become painful for the physician if he/she has to be entertained at every home he/she visits. The reason for having stated “essentially” is that some patients/families look forward to chatting with the physician/nurse over tea/sweets. Further, offering tea/sweets may sometimes be a message, i.e.,

“I need someone to share my stories as I am tied up with caregiving all the time.” In these instances, accepting the offer itself is useful for mental care for the patient/family; therefore, in most cases, it is wise not to decline it.

Addressing the Anxiety of the Family Who Initiated In-home Daily Care

It is no exaggeration to say that, when in-home care is initiated, the family who has just begun to provide care is constantly struggling with anxiety. However, usually the realization, “probably we can do it,” comes as they are taught the caregiving method in detail by earnest professionals including nurses, gaining caregiving experiences, and get used to the life while providing care.

Until the caregiving family reaches the realization, the physician should intently work on the

“reduction of the family’s anxiety.”

The author would suggest that the physician provide positive encouragement to the family as much as possible. For example, he/she may say, “I hear your husband saying, ‘it’s good to be back home’ many times. It owes entirely to your efforts. He can do what he wants to do and eat what he likes. Your husband appears to be feeling safe and comfortable because everyone in your family is helping him so much,” or “Cancer is believed to be a painful disease, but your wife appears to have almost no pain now. It is probably because you and your family have been so devoted to taking care of her. It’s a real blessing.” The author believes that words such as these will bring out and enhance the family’s capability.

When in-home convalescence is started, additional home-visiting nursing or house calls are often required to counsel the family about their concern. In these instances, the family will obviously be relieved if a nurse or physician visits the home—even though knowing there is not necessarily medical urgency—instead of responding on the phone, and assures in front of them that there is no criticality in the patient’s status. Through a few dialogues with the physician (or the nurse) like this, the family acquire their own way of care and often come to feel “it’s all right”

except in “the matters that really require urgent procedures.”

Therefore, there should be much deliberation before demanding a decision that bears a greater psychological burden such as “whether we have the intent to look after the patient until the end of his/her life” of “a family who has just begun to provide care with trepidation.” At first, as in-home care was initiated, it mostly produces a good result not to provide a psychological pressure of determining “whether we will continue care through the patient’s final moments” to the family, and just have them “experience caregiving for the time being.” As far as the situation allows, it is wise not to interview them on such intent until the family get used to caregiving. Sometimes

it is not even necessary to hear what they have to say about the issue because, even if health care professionals do not find it out deliberately, a mutual understanding is often spontaneously built between the medical staff and the family as they gradually become “determined.”

Physical Examination in Home Medical Care

Because only limited diagnostic testing measures are available in home medical care, the physician needs to assess many things through physical examination. The key points are to examine not only the vital signs and the status of consciousness but the whole body closely as necessary, and to take accurate information from the family.

A. Necessary Medical Equipment

In the ordinary home medical care, the equipment for consultation may be simple. The minimum equipment would be a stethoscope, a sphygmomanometer, and a pulse oximeter. Additionally, a flashlight, a disposable tongue depressor, and a reflex hammer should also be prepared. An otoscope and an ophthalmoscope are added as necessary.

B. Medical Interview and Obtaining the Patient’s Clinical Condition from the Family In home medical care, unless especially prepared in advance, the medical interview and physical examination are the sole approaches to know the clinical aspects of the patient’s condition. The medical interview in home medical care has advantages over outpatient medical care because it ensures that the physician can obtain information from the family, who are directly giving care to the patient, and allows him/her to directly observe the patient’s life and convalescent environment. Given that home medical care largely deals with patients with severe disorders, it relies on the information mainly obtained from the family (care service employees) for patients who have lost the ability for verbal communication.

C. Physical Findings

Physical examination weighs much in home medical care. Comparison with usual conditions matters; therefore, accumulating the data obtained in each examination is important. In the usual physical examination, the author always carries out an interview regarding any changes in conditions, checking of vital signs including oxygen saturation, auscultation of the chest, and examination of lower extremities. Additionally, the author observes urine in patients with a urethral catheter and check wound in patients with a tracheostomy or gastric fistula.

(1) Observation of body movement at home

The consultation starts as the physician enters the home. Closely observing the patient’s movement at home in usual circumstances enables the physician to easily notice a change occurred during the illness. Sometimes mildly disturbed consciousness can be detected by observing the patient’s movement.

(2) Examination of the abdomen/chest/lower extremities

In home medical care, most patients are usually in the “ready-for-immediate-examination status,” and are usually lightly dressed so that their chest/abdomen can be easily exposed, are lying in bed or at bedside, wearing no shoes and examining their lower extremities and feet is easy. For patients who are lying in bed, the examination of the abdomen and lower extremities can be immediately started.

(3) Auscultation of the chest

In older adults and those who are in bedridden status for a long time, the physician usually hears various cardiac murmur or pulmonary sound in auscultation of the chest.

Murmur over lung field is often heard in the back/lower part of both sides of the chest. Unless these auscultation findings are recorded when the patient’s condition is stable, the physician

occasionally performs close auscultation when the patient’s condition is stable, and record the findings. For patients lying in bed, examining murmur in the back may require much work, but auscultation in the back must be done if complication such as lower respiratory tract infection/pulmonary congestion is suspected.

(4) Check of pressure sore

Pressure sore is prone to develop if the family are not used to providing sufficient caregiving.

In the first house call as well as when the patient’s condition was aggravated, the physician must perform visual examination of the sacral region/the iliac crest region/the greater trochanter region/the back/around ankle joints, even though no information has been provided by the patient/family. When it turned out that the family got used to caregiving enough, or a home caregiver or home-visiting nurse is routinely observing the patient’s skin, the early detection of pressure sore may be entrusted to them.

(5) Examination of the lower extremities

The lower extremities provide a lot of information, including the one about edema or peripheral circulatory disorder. Particularly in older adults, who are mostly affected with mild cardiac failure, observing lower extremities in every house call is of great significance.

D. Other Physical Findings

(1) Examination of conjunctiva/fundus

In home medical care, the physician is often asked to examine conjunctivae. For conjunctivitis, as long as the severity is mild, the house call physician may perform assessment.

House call physicians do not necessarily need to be capable of examining fundus, but those who have techniques to examine it at the patient’s home can release him/her from the stress of going out for outpatient visits.

(2) Examination of ears

Sometimes the physician is asked to examine ears or remove cerumen of the patient. General assessment of external auditory canal/tympanic membrane may be performed by the house call physician.

(3) Orthopedic examination

Many patients have low back pain; therefore, it is desirable for the house call physician to have basic skills for identifying pain in muscles, bones or joints, as well as neuralgia (sciatica).

There are also many occasions to see patients who presented with fall. In regard to femur fracture, it is desirable that the physician is able to make a potential diagnosis before having the patient transferred to the orthopedic department. Femur fracture should be suspected if the lower extremity on the affected side sustain no load and coxalgia is experienced by supination of the lower extremity in dorsal recumbent position.

(4) Skin

Skin examination is also frequently requested. The physician should consciously learn dermatologic findings of scabies in particular.

(5) Rectal examination

It is desirable for the physician to be able to perform general assessment of anal/rectal membrane and prostate gland.

Positioning of Diagnostic Testing in Home Medical Care

A feature of home medical care is the absence of testing equipment that requires facilities. What is of importance is to wisely carry out the tests that can be done on the spot in home-care settings in accordance with the patient’s clinical features and, simultaneously, have major collaborating hospitals in place and perform diagnostic testing, switching between home medical care and these hospitals as necessary.

A. What Tests Are Carried Out in Home Medical Care?

“Absence of testing equipment” is an aspect of home. Because of this restriction, clinical tests in home-care settings are performed using a methodology different to the one used for the tests performed in medical facilities. That is to say, usually, clinical tests are selected based on the criteria of what is most useful to make accurate diagnoses, in which being quick-and-easy-to-perform is taken into account when determining the order for carrying out the useful tests. On the other hand, what matters in home-care settings is “what can be most easily done at home.”

Basically, the house call physician continues medical care, cleverly optimizing the tests on blood, urine, and collected stools/sputum/pus, as well as electrocardiograms.

B. Obtaining Information When Initiating Home Medical Care and Regular Diagnostic Testing

Certain homebound patients are introduced to home medical care by hospitals. Therefore, it is crucial for the house call physician to obtain as much test data as possible from the physician who made the referral at the time of discharge. If any information provided in the referral letter is insufficient, inquiries should be persistently made.

Additionally, if the patient “has an opportunity to visit the hospital (an opportunity to be admitted to the hospital) and if the hospital is a small hospital (which is not using the DPC/PDPS [Diagnosis Procedure Combination/Per-Diem Payment] system), the house call physician should request the hospital to perform additional test(s) that will provide the information he/she wants, besides the patient’s original purposes of going there. It is also useful for the patient to undergo examination at a hospital approximately once a year on a same-day basis or by a 1–2 day hospitalization. The test information should be aggregated in this way on the side of the house call physician, in the hospital-clinic collaborative alliance.

C. Tests on Acute Diseases

The most important test in home medical care is the blood test. In home medical care, the most common acute aggravation occurs as pyrexia, for which the blood test alone can provide valuable information. The most useful information provided by the blood test are white cell count, hemogram, and C-reactive protein (CRP), followed by electrolytes, and renal functioning panel.

It is recommended that both complete blood count and hemogram be checked because sometimes a relative increase in neutrophil count is found without a rise in white blood cells (WBC). It is wise to include the hepatobiliary function panel because it is effective to make a diagnosis of hepatobiliary infection.

In addition to the blood test, a urinalysis, and a bacterial culture test should be combined as necessary. Additionally, blood gas analysis, electrocardiography using a portable electrocardiograph, and Holter monitoring are also possible.

Some house call physicians perform conventional radiography at the patient’s home.

Development in computed radiology (CR) has now made performing in-home diagnostic testing easier than before. Besides, the ultrasound testing device has also been miniaturized, so physicians who have skills to use the equipment may perform the test.

(Tadashi Wada)