Safety Strategies and Interventions in the Home
Safety interventions in home care are challenging for professionals since they question usual assumptions and approaches. Priority is given to avoiding hospitalisation while increasing autonomy, and mental and social wellbeing. In this context, where there is often a trade-off between autonomy and safety, the best and safest care is a 'mastered compromise' in which a team of the patient, health and social care professionals and relatives each brings their own perspective and together arrive at a negotiated way forward. We believe however that, in addition to the thoughtful negotiation with patients and families, that it will also be valuable to consider broader strategic approaches to safety.
Optimization Strategies in Home Care: Best Practice and System Improvement
Optimization strategies are challenging to implement in the home especially with frail older people and people with mental health problems. The opportunities to directly implement evidence based medicine or to improve the delivery of care within the home are limited. Direct improvement of care can be difficult, time consuming and to reach only a proportion of the target group as the example in Box 8.1 shows.
Box 8.1. Difﬁcult Challenge for Optimisation Strategies: Lessons from a Centralised Nurse-led Cholesterol-Lowering Programme
Lowering low-density lipoprotein (LDL) cholesterol in patients with diabetes
mellitus (DM) and cardiovascular disease is critical to lowering morbidity and mortality. A team-based quality improvement programme attempted to improve compliance with evidence based medicine; registered nurses followed a detailed protocol to adjust cholesterol-lowering medications. General practitioners agreed to enrol 74 % of potential eligible patients. Thirty-six per cent of approved patients could not be reached via phone and 5.3 % declined enrolment. Of patients enrolled, 50 % did not complete the programme. Of those enrolled, median LDL decreased by 21 mg/dL and 52 % (33/64) achieved the LDL target.
The resources required to identify, enrol and continually engage eligible patients raise many concerns regarding efficiency and highlight the challenges of implementing clinical guidelines in the home and community.
Adapted from Kadehjian et al. (2014)
There are however important examples of successful initiatives which fall into the optimisation approach. Studies have examined the effectiveness of particular approaches to treatment at home, covering areas such as skin care and integrity, behaviour management, pain management and incontinence. The results of such research in nursing homes often show that “what works” involves simple, low-technology solutions that may increase staff time with patients (Stadnyk et al. 2011). In other words, the time staff spend listening to patients and carers, explaining, and coordinating may be one of the best ways of improving safety in the community and home care.