I’ve been honored to have worked with my CHAMP colleagues since its inception in 2004. They are a phenomenal group of professionals who are as diverse as our participants. Many live and work in NYC, CHAMP’s home.  Some of us live in Boston, a city unlike any other, strong….wicked strong! Some of us live in the heartland and another on the west coast. Our common bond has been to strive for excellence and to honor our mission to help you provide the best care for our aging patients.

Home care clinicians are among the realm of the unsung heroes in our society. I’ve always said that there’s nothing ‘sexy’ about being a home care nurse. We don’t have crash carts or work in hospitals, which are often the settings for prime time TV shows. Home care nurses and therapists go through their day in solitude, knocking on doors and walking into apartments, shelters, homes that are as neat as a pin and homes that house hoarders. Patients have asked me if I’m a home care nurse because I “flunked out of the hospital.” My response is always that I’ve chosen to do this work because it’s an honor to be allowed to enter into one of the most intimate relationships in healthcare – providing care in the place where a patient lives.

On behalf of the CHAMP Program Faculty, I wish you all the best.  Keep providing the best care you can and remember that you are creating a legacy for those to come and may someday become the beneficiaries of your labor, as we all grow old someday.

Take Good Care,

Debra Bertrand, CHAMP Facilitator

One team’s test
In an early experience, one team tested a “Red Flags” tool to prevent an ED visit and/or hospital admission through early detection of deterioration in a patient’s condition (click here to see “My Action Plan,” as we called it.  Plus there’s another “Red Flags” tool, “My Emergency Plan,” in the CHAMP Toolkit).   Many of the patients on their team were older adults who lived alone and were at high risk for rehospitalization.  When they came home from the hospital, despite being relieved to have made it through their front door, they were often exhausted and had limited ability to absorb all the interventions and guidance aimed at keeping them safely at home.  These nurses asked “How could patients, especially those who were alone and overwhelmed, be helped to know when to call for help, especially since the nurse was only intermittently present in the home?”

Involvement of the Home Health Aide
The team’s test started with their patient, “Mr. J”:

Mr. J. was a 78 year old patient admitted to home care after a hospitalization for an exacerbation of heart failure.  This was his third admission in the past six months.  Mr. J. lived alone since his wife died five years earlier.  He was fiercely independent, minimized his need for assistance, and told the nurse his goal was to remain in his home.  However, after this hospital stay, Mr. J. was physically weaker and reluctantly accepted the service of a Home Health Aide (HHA) until he regained his strength.  The nurse used Mr. J.’s goal in a discussion about how the HHA would help him carry out his personal care activities but also help him learn how to be alert to when he might need to call the doctor or nurse, so he could remain home – out of the hospital.  During the episode, as the nurse taught Mr. J. about his medications, and monitored his symptoms and his weights, the HHA was involved in those sessions, preparing to coach Mr. J. in observations about his condition, or how he was feeling with his medications.

This led to the creation of the tool, “Home Health Aide Action Steps to Reduce Hospitalization” (also in the CHAMP Toolkit)  The nurses on the team tested and refined the questions as they worked with HHAs to coach patients to be alert to signs and symptoms and get help before it became necessary to call 911.  The testimony to the success of optimizing the role of the HHA was a patient who with the help of the HHA noted her symptoms, and called the nurse who was able to intercede with changes to avoid a hospitalization.  The patient told the nurse, “my home health aide didn’t mop the floor, but she saved my life!”

Resources in CHAMP’s Geriatric Care Transitions Toolkit that include the broader patient care team (such as paraprofessionals or family caregivers) can be particularly beneficial to improving transitions in care. The network of people around the patient can be a “safety net” for patients, and help in promoting safe transitions.

Sally Sobolewski
Director, Practice Improvement
Visiting Nurse Service of New York

Because this question comes up so often, here’s a quick summary of the HMG-CoA reductase inhibitors (statins) that can interact with GFJ, and the advice/recommendations about the interaction generally given in the U.S. and Great Britain (UK):

HMG-CoA Reductase Inhibitors (Statins)*

Atorvastatin

• In the US: Advise that GFJ can increase atorvastatin concentrations
• In the UK: Recommendation given that large quantity of GFJ should be avoided (no more than 1 to 2 small glasses daily)

Simvastatin

• In the US: Recommendation that large quantities of GFJ should be avoided
• In the UK: Recommendation that GFJ is to be avoided

Pravastatin

• Studies have demonstrated that grapefruit juice has no significant effect

Although the GFJ question seems to come up most frequently about statins, other drugs that can be impacted include amlodipine, cyclosporine and carbamazepine.

I contacted a drug information specialist colleague who said that the clinical impact of the grapefruit interaction differs greatly depending upon which drugs are involved. His take? It can make a difference if we’re talking about cyclosporine, but it’s not such a big deal if we’re talking about atorvastatin or amlodipine. The FDA just wants to raise our consciousness and make sure we read the labels.

SO, remind your patients to talk to their pharmacist or prescriber about grapefruit!

Dennee Frey, CHAMP Pharmacy Expert

P.S. To find other tools that can help you and your team teach patients which foods and food groups may need to be avoided with certain medications, visit our Tools page, choose “Medication Management” from the “All Topics” drop-down list, type “food” in the “Text search” box, then click “Search”. Also, see the University of Florida web site www.druginteractioncenter.org, where consumers or professionals can check which medications interact with grapefruit.

* Both the FDA’s advisory and the information about statin-grapefruit interactions in this blog post are based on a 2010 review article Grapefruit-drug interactions (Seden K. Dickinson L. Khoo S. Back D. Grapefruit-drug interactions. Drugs. 2010; 70(18): 2373-407), which outlines the mechanisms of grapefruit-drug interactions and presents a comprehensive summary of those agents affected and whether they are likely to be of clinical relevance.

As I dipped into the toolkit, here are some of my thoughts:

1. Evaluation and Screening Tools

• “The ARMOR Tool” could be helpful to agencies with nurse practitioner, physician, and/or pharmacist support, or as a training tool for staff nurses.
• The “HbL Medication Risk Questionnaire” could help to identify high-risk clients and those who might benefit from further medication review. CMS is encouraging beneficiaries with Part D Medicare to have an annual Comprehensive Medication Review (CMR) that’s part of their Medicare benefit. Clients screened with this instrument can follow-up with their Part D Pharmacy Benefit Manager plans, or ask their dispensing pharmacist how they can schedule a CMR. A number of large managed care health plans like Humana and Kaiser Permanente now have Medication Therapy Management pharmacists.
• The updated Beers Criteria can also be beneficial for identifying high-risk patients (Click here to read my previous blog post about the 2012 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults).

2. Intervention Tools

• The American Geriatrics Society has really stepped up to address medication management issues with their updated Beers Criteria and tools oriented to patients/caregivers. Their tools may be more appropriate for high-literacy homecare patients/caregivers and could have a place in staff training.
• I’ve used patient/caregiver tools from the National Council on Patient Information and Education (NCPIE) for years. They are oriented to lower-literacy level consumers and are translated into numerous languages.
• For medication/pill lists, I suggest the materials disseminated by the Agency for Healthcare Research & Quality (AHRQ), including “How to Create a Pill Card’.

3. Communication Tools

• “Your Medications – What to Ask” might be more useful for higher literacy patients/primary caregivers.  I suggest looking at NCPIE’s materials for lower literacy patients and caregivers, such as “NCPIE Questions to Ask Before You Leave the Doctor’s Office” (included in the Toolkit).

Please come back and post a comment below to let the CHAMP team and Community know what you think, and what you’ve found to be useful!

Dennee Frey, CHAMP Pharmacy Expert

P.S. Be on the lookout! CHAMP’s partners at the Home Health Quality Improvement (HHQI) National Campaign are scheduled to release a Medication Management Focused Best Practice Intervention Package (BPIP) in a few months, and it will be a great complement to this Toolkit! In the meantime, you can find many useful free resources by registering with the Campaign at www.homehealthquality.org.

My fortieth wedding anniversary is this year.  Where did the time go?  There are times when I look into my husband’s eyes and think about a future when one of us is no longer here.  He’s been my Valentine for so many years.  When I was a very young nurse, listening to a patient talk about the loss of a spouse made me feel uncomfortable.  Finding the words to give them solace didn’t come easily.  I also worried that my words wouldn’t help much anyway; that my youth would make these words seem insincere.  During home visits, the subject always seemed to come up.  I’d nod my head and listen to their heartbreak, feeling helpless and frustrated knowing that I couldn’t bring back their spouse.   As an older nurse, words of comfort roll off my tongue now.  Many years of experience with love and loss, personally and professionally, have helped.  But, deep down I know that I’m rehearsing for the day when I may be alone on Valentine’s Day.  I joke with my husband that I’m going to die first and he’ll be dating someone younger than our kids before I’m cold in the ground.  My husband says that he hopes that I die in the winter <guffaw>!  He’s rehearsing too, I guess.

Happy Valentine’s Day!
XXXOOO

Debra Bertrand, CHAMP Facilitator

Home Care Insecurities

Describing the Visit
I suggested that the three of us meet and review a patient care situation that the new nurse had managed well.  We met, and the new nurse described the care she had provided to a man with heart failure.  She described how she read the notes from previous visits and planned for her visit before leaving the office.  She then described the visit.

• She arrived at the house, introduced herself and ensured that the patient was the man she was supposed to be visiting.
• She asked him how he was and reviewed with him what she saw as the purpose of the day’s visit.  She assured him that she’d read through the notes of his regular nurse and knew that his goal was to learn how to avoid high salt foods.  She told him she was going to save time to review his food log with him later in the visit.
• She conducted a cardiac assessment: vital signs, lung sounds, dyspnea assessment, edema and weight check.
• She queried him about his medications and any recent doctors’ visits.
• She went over his Emergency Response plan and asked him for a Teach Back about how he used this tool (click here for the Teach Back tool, and click here for a video showing how it can be used).
• She then gave him a summary of her assessment, and moved on to review his food log. After looking the log over she congratulated him on his many good choices and noted that he appeared to enjoy bologna, and then talked with him about the salt content of bologna and asked if he could think of another cold cut that might be satisfying but less salty.  She and the patient concluded their discussion with the plan that the patient was going to try low sodium turkey breast instead of bologna.
• She documented the visit while still in the home, asking the patient if he had other questions as she entered information in the computer.
• She concluded the visit saying that she anticipated his regular nurse would visit him within in 5-7 days, and that he was managing his illness well.

The Preceptor’s Feedback
I asked the preceptor how she thought the new nurse had done with this visit. She replied, “She was fantastic.  She conducted an excellent visit.  She is just wonderful with patients.  She is an A-plus.”

Feedback on the Feedback (Using S-B-I)
After our meeting, I used the Situation-Behavior-Impact (S-B-I) approach to give the preceptor her feedback.  I started, “In today’s meeting with your preceptee (Situation), I noted that you used a lot of superlatives to describe her as a nurse, but did not identify specific behaviors or elements of her practice that she used in this visit that you considered excellent (Behavior).  This left me wondering if the new nurse knew what she had done well, and if perhaps your general feedback isn’t specific enough to help her build confidence (Impact).”

Then I sat quietly as the preceptor reflected on what I had said.

Get Specific
The preceptor acknowledged that giving feedback was not a skill she was comfortable with, so she gave the new nurse lots of general praise when she did well, and said nothing when her practice was less than stellar.  This opened up an opportunity to talk about giving feedback and how new nurses need specific feedback in order to adopt good solid practice habits, and that confidence comes from knowing you are competent in those habits.  I was able to teach the preceptor about the S-B-I method of giving feedback, and we role played a couple of situations so she could practice giving both specific positive feedback and “need for improvement” feedback using S-B-I.

Adele Pike
Director, Center of Excellence & Education
Visiting Nurse Association of Boston & Affiliates

Note: CHAMP’s new CE hour-conferring course Techniques for Improved Clinical Coaching will help you learn and practice new skills for motivating clinical practice change among clinicians and patients (including the S-B-I approach).

Taking the time to explain what a fall is and then asking your older client to share if they have fallen in the past 12 months can be a powerful start to falls risk reduction intervention in the home. If any fall has taken place, find out more about the circumstances of that fall, such as:

• The time of day of the fall
• The location of the fall
• What activity the client was doing at the time of fall
• Possible contributing factors to the fall, such as environmental factors (clutter, wet or uneven surfaces, footwear, etc.), not using assistive devices, distractions, rushing, the impact of others (people or pets), etc.

My client is in his eighth decade, and had experienced two other falls prior to the one in the parking lot. His first fall was about two months earlier – on an escalator (he was lucky to have been able to hang on to the rail and come back to standing during his ride down). A second fall occurred a few weeks later in his home. He landed on an ottoman that broke the fall and supported him. So what was up? After debriefing, we discovered that prior to each fall, he had either bent down or put his head down and was light-headed when moving his head back up. The same culprit was responsible for each of these posturally related hypotensive incidents – his medication regime. During his hospital stay, his medication was adjusted to eliminate that side effect.

If a fall has taken place in the past year, research indicates that there is a higher risk to fall again. Knowing this, any positive falls’ history offers an opportunity to open a dialogue with the client, demonstrate understanding, and create a better care plan that addresses needs and reduces the risk of a fall

The new Geriatric Falls Prevention Toolkit on the CHAMP web site offers home care clinicians helpful tools that highlight proven risk reduction efforts.  Falls are a health concern for everyone – especially those age 65 and older – but assessment, education and intervention coupled with tips for adherence can minimize the likelihood of history repeating itself!

Eileen Bach, PT, MEd, DPT, COS-C
Director of Rehab Quality Assurance and Education Services
Visiting Nurse Service of New York

Grouchy folks get angry when you tell them that they have to take their arm out of their multiple layers of sleeves. “Just give me the damn shot!” they exclaim. There are the very, very thin patients who have an almost non-existent deltoid muscle. Hitting the bone isn’t good technique J. There are the very large patients. Deep down, you know that you’d need a needle that’s 6 inches long to get the vaccine anywhere near a muscle.

Here are some flu questions I’ve heard over the years:
“Why do I need to get this every year?” (From Irritated Sorts)
“Is it OK to get a shot if I have the sniffles?” (From Worried Sorts)
“What’s the recipe for this year’s vaccine?”  (From Traveling Sorts)

And some flu comments:
“This shot made me sick last year.  BUT my doctor told me to get it again.” (From Compliant Sorts)
“I hate needles.” (From Tattooed Sorts)
“I love eggs!” (From Rotund Sorts)

I don’t understand why some healthcare workers resent and resist getting a flu shot. You would think that they would understand the concepts of ‘herd immunity’ and their obligation to protect their patients. I get pretty irked with people who love to spread nightmare stories ‘they heard about.’ I recently heard callers on a local talk radio station talk about a conspiracy theory that the government is duping everyone into getting vaccinated. “Left-wing liberals are trying to take over my body!” or “This flu stuff is just a way to line the pockets of the big pharmaceutical companies and to give big government something to do!” Yikes!!

The CDC has announced this week that flu cases are widespread in 47 states. Are you sick of hearing about the flu? Well it’s better than being sick with the flu. So get a flu shot if you haven’t had one. And if you’ve already had one, good for you!

Debra Bertrand, CHAMP Facilitator

The Visit

During the visit, the nurse carefully checked the woman’s vital signs, and had the patient check her blood sugar. It was 256. The memory feature of her glucometer showed a blood sugar range of 231-346 over the previous 7 days. The nurse queried the woman about her medications and her diet.  The woman demonstrated knowledge of her medication regimen and said she was taking them as prescribed.  She said she was doing her best to adjust her diet, but her food choices remained high in carbohydrates. She appeared to be eating large amounts frequently.

The nurse set about to change the dressing on the patient’s foot wound.  The wound did not show signs of infection, but the tissue was pale with scant serous drainage. Its size was slowly but steadily increasing. After taking measurements and cleansing the wound, the nurse applied a new dressing.  She then sat down next to the patient and said, “I am really worried about you. Your wound won’t heal if your blood sugars are over 200. It will just keep getting bigger and then infected, and then you’ll have to go into the hospital and you could lose your leg.  This is very serious and I don’t see that we are making progress. You have to get your blood sugars lower.”

The nurse then scheduled her next visit, and we left.

Using Coaching to Teach Coaching
When we returned to the office, I wanted to engage this nurse in thinking about alternative approaches to the patient’s care. Specifically, I wanted to motivate her to use adult teaching methods. I thought for a moment about having her read something about adult learning, or sharing a power point handout I had on adult teaching/learning. But I opted for a coaching approach.

I started our review session by asking her to describe a learning experience she had had that she had found really effective. She described a time when she had made a mistake and her manager had helped her correct it and learn from it. I asked her if she thought such an approach might work with this patient. The nurse was quiet. I sat with the silence, metaphorically biting my tongue. I really wanted to tell her how to do this but I knew that it would be so much better for her to discover her own answers to this question.

“I guess so,” she finally said. “What would that look like?” I asked.  “Well, she’s making mistakes in what she eats. Well, maybe not a mistake, but she makes bad choices.”  “How could you work with her to help her understand the connection between what she eats and her wound healing – like your manager worked with you when you made a mistake?” I asked to engage her in critical thinking and reflective practice.

And so the conversation went, until she came up with a plan to ask the patient if she’d like to keep a log of her blood sugars and then together they would try to identify blood sugar patterns and causes of hyperglycemia.

If I had done what was more comfortable and efficient for me – telling her what to do – I would have only been replicating her prescriptive approach to teaching that I’d witnessed during the joint visit. Using open-ended questions that engaged the nurse in solving the problem herself resulted in a better plan than I could have prescribed, and role modeled a collaborative, patient-centered approach to patient teaching.

Adele Pike
Director, Center of Excellence & Education
Visiting Nurse Association of Boston & Affiliates

Note: CHAMP’s new CE hour-conferring course Techniques for Improved Clinical Coaching will help you learn and practice new skills for motivating clinical practice change among clinicians and patients.

Over the years, I’ve broken into song when caring for patients with dementia. I learned that singing old familiar songs help to allay anxiety for some of these patients. It’s heartwarming when I look into the eyes of someone who is happily singing with me when, moments ago, those same eyes were fearful and agitated. There have been times when my nursing colleagues have asked for my singing help.  I’ve softly sung into a previously combative patient’s ear, while an IV was being inserted.  During my pediatric home care days, singing was a first line of defense with some of my patients.  One 4-year-old wouldn’t stay still long enough for me to check her heart sounds.  After a few rounds of singing “I Think We’re Alone Now” from Tommy James and the Shondells, we had our own music video, which included a moment of auscultation during the lyrics “the beating of the heart is the only sound.”  Remember the ‘lub-dub’ in the chorus?

I had a young man in his 20’s in my home health aide supervision caseload.  Once a month I would visit him and attempt to take his blood pressure.  Despite the able assistance and cajoling of his aide, it was next to impossible to corral him for a BP.  I realized that pumping the cuff was too much for him.  During my next visit, I played Technotronic’s “Pump Up The Jam” and sang along.  Later on in the visit, I sang as the BP cuff was inflating.  Voila!  He stayed still long enough to get a reading.  From that visit on, when I came into his room, he would clap his hands and squeal “Pump Up The Jam!”

The holiday season is a wonderful time to bring some joy to your homebound patients with song.  How about breaking into a chorus of “Let It Snow! Let It Snow! Let It Snow!” as you’re dusting yourself off from a winter snow squall?  Try singing a few bars of “Santa Claus Is Coming to Town” with a recalcitrant patient.  The “Oh, you better watch out” line could be disarming at the right time.  Humming “Silent Night” during a painful dressing change may be soothing for some.  Jingle bells are fun to wear during the holiday season. They can also be good accompaniment with the “Jingle Bell” song while a patient does his/her strengthening exercises.

Some nurses tell me that they are too self-conscious to sing or they can’t hold a tune.   Here’s my response, taken directly from a line in the Joe Raposo song, “Sing”:

“Don’t worry that it’s not good enough for anyone else to hear…Just sing…sing a song!”

Debra Bertrand, CHAMP Facilitator