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Perhaps an elderly friend or relative has had major surgery or an illness, needs additional care, and wants to recover at home. When is a person best served by having professional assistance at home? When would an assisted living facility or nursing home be the most appropriate care option?

Mary Jo Castrale, R.N., M.S., Executive Director of CareGroup Home Care, the home care department at Mount Auburn Hospital in Cambridge, a teaching hospital of Harvard Medical School, says there are basically four criteria, approved by Medicare, for receiving care at home. In addition, most insurance companies will cover home care if these same conditions are met. These are the criteria:

1. The person is homebound which means they have difficulty leaving home due to functional limitations.

2. A physician has ordered home care.

3. There is a need for skilled service: nursing or therapy care.

4. The need for home care is intermittent. (Either the patient may become independent again or will secure more permanent care, such as a family caregiver or a professional caregiver, or care will be secured in a facility.)

Ms. Castrale emphasizes that for care at home to be effective, a safe plan of care is needed. Always, when a patient is being discharged from a hospital, an assessment is made about whether the patient can be safe at home with only intermittent care, such as what is provided by Home Care. Many elderly live by themselves—no one to oversee medical care, to help in bathing or personal care, or to help with such daily tasks as cooking. Home Care is most appropriate and works best when patients need short-term care that can help them reach the point of being able to stay at home independently, possibly with the support of community resources, such as Meals on Wheels, a program that delivers prepared meals. Ms. Castrale points out that part of home care’s goal is to connect needy patients with appropriate community resources and services that will help them remain independent.

Ms. Castrale says, “We work closely with the patient’s family to maximize the patient’s potential and, if at all possible, return the elderly person to a more independent life.”

Mount Auburn’s home care program takes care of patients who have medical needs while they stay at home. Last year the program serviced nearly 6000 patients, a large majority of them over 65 years old; many patients are ninety and over hundred years old. Some patients are recovering from surgery or an illness and may be able to move to an independent state again. For other patients with chronic illnesses, that may not be possible.

Ms. Castrale says, “We provide the whole range of services, including skilled nursing, physical therapy, occupational therapy, and speech therapy. For those who cannot manage the activities of daily living, we can also provide home health aides for personal care.” Since home care services provide intermittent skills, social workers are also available to help connect patients with more permanent resources in their communities. Psychiatric nurses are also available for patients who have behavioral health needs. The most effective home health programs, such as Mount Auburn’s, stay in close communication with the doctor about the patient’s condition and progress.

CareGroup Home Care also has specialty programs. For instance, one focuses on wound care and involves specialty nurses working with the patient’s doctor to try to accelerate the wound-healing process. There is also a program focusing on symptom management, which involves a variety of interdisciplinary clinicians who work with patients who are not ready for hospice yet but who need significant support for pain or other symptoms.

Another important area of focus is safety. Ms. Castrale says, “We assess how safe a patient is at home and recommend changes if necessary. For instance, are there scatter rugs on the floor that may lead to falls? Can the patient safely handle cooking or bathing? Does the patient know their medications and how to take them properly? We do a complete evaluation, establish a safety plan, and communicate our findings with the patient’s caregivers and physician.

Ms. Castrale says, “In helping people remain at home rather than going to a skilled nursing facility or nursing home, we are providing an important service to the elderly community. Most older people definitely prefer to stay at home if they have the choice. One of our goals is also to prevent patients from having to return to the hospital.”

In the next few months, CareGroup Home Care of Mount Auburn Hospital will be launching a program called Telemonitoring. This program uses monitors in people’s homes for daily monitoring of key clinical parameters: blood pressure, respiratory rate, blood oxygen concentration, and weight. A major goal of this program is for home care personnel to have daily information on patients instead of only at the time of the visit, which may be several times a week. This information can help with proactive interventions and hopefully decrease patients' need to go to the hospital for treatment. Physicians can have current clinical information to make treatment plans with the nurses.

Ms. Castrale emphasizes that to participate in Mount Auburn’s home care program, there has to be a skilled care need: for example, an elderly patient has had a stroke or is recovering from surgery. Nurses and /or therapists will treat the patient based on physician orders. If the patient is unable to bathe themselves during this time, a home health aide can be placed in the home to assist. If there is no skilled need, there are private agencies in the area to help with personal care.

Ms. Castrale says, “Home care is a wonderful option for many elderly people for a variety of reasons. Most people recover more quickly and comfortably in their own homes. They also feel that they have more control over their lives when they can be in a familiar environment. This feeling of control or independence is important in maintaining a positive attitude .”

For a free Mount Auburn Hospital pill box, please call us at 617-499-5094.