Friday, August 26, 2016

Best Practices for Home Visits to People Aged 65 and Over

I am a social worker.

I have worked in community health care for the past 16 years. I have made at least 2,000 visits to people in their homes. Most of these people are aged 65 and over. The first ten years of visiting was as a Home Care Case Coordinator and the last six have been as a Geriatric Mental Health Clinician. Most of my visits are one-time only visits, and it is to conduct in-home assessments of an individual. On occasion there are follow-up or reassessment visits. I am also doing private counselling and I meet people wherever works for them.

My experiences of these home visits has lead me formulate “best practices.”

I have never actually written down what works for me in terms of home visits. I was never really trained in this, it's just something I have developed over the years. My workplace has had a few rules implemented, so these have also become part of my daily practice. The goal of these best practices is to conduct a safe and successful experience for not only myself but also for the people I have to meet with.

Some of these best practices come as a result of trial and error and I know I probably have some more things to learn. 

I have come up with a list of 19 “best practices” and procedures that always (most of the time, anyways!) results in a positive experience.Generally speaking, these are my tried and true professional approaches to ensuring a safe and successful visit. I hope they can offer you some tips to make your home visits more productive and positive. 

Things to bring or have on hand:
  • Client file/forms
  • Cell phone
  • Water bottle
  • Hand sanitizer
  • Booklets and resources
  • Lined paper
  • Business cards
  • Clip board
  • Indoor shoes
  • Booties (for bedbugs)
  • Extra pens and pencils
  • Compassion, smiles and compliments
After you have determined the request is appropriate and is within your catchment area, here are some tips to take note of.

1. Determine if I need an interpreter. Is there anything on the referral or consult that indicates the person does not speak a language you are fluent it? For example, if it says the person speaks Mandarin, do you know Mandarin? Or do you need to enlist an interpreter? Sometimes family members are able to help out and are very used to doing this. For more serious or complicated situations, you may want to obtain the services from an official interpreter.

2. Figure out who to call about making the appointment. The referral source should indicate if you should call the client him or herself, or if it’s better to call a family member. Preferably it would be someone that is already very involved in the person’s care and one that is trusted by the client. If there is no indication of such person, call the client direct and then find out if he/she would like you to call or involve any other family member. Most older people have one or two family members who are involved in their care and would prefer to have their loved one involved in the assessment. On occasion, there are people who prefer to not have anyone else involved, and this has to be honoured as well. Privacy issues must be respected at all times.

3. Make sure the person is agreeable to having you come to their home. Sometimes people do not agree with the need for assessment. They may agree initially, but then change their mind. For example, a person in hospital may agree to a home visit just so they can get out of the hospital. Perhaps the person’s doctor mentioned he/she was going to send a referral and the client forgets about it. They say yes to a daughter who is nagging them to agree just to get her to be quiet. One of the biggest hurdles for me is to explain in a simple and favourable way who referred me, why, what I do and what I hope to do for them. If they refuse the visit, it’s important to report this back to the referral source (the doctor for example) and to help problem solve how to get the visit done. Sometimes it means involving a family member or the referral source may have to encourage the visit.  However, if the person does not want you to come, don’t go. I have been in situations where the family member really, really wants me to come to the home to do the assessment, but when I arrive, the person does not want me there. I was actually physically pushed out the door once! My services are voluntary, so I explain this fact to the person. I advise that I will leave if I am not wanted, however, their doctor, Home Care Case Coordinator, etc. wanted this in order to provide the best care possible. I make sure I talk to the client on the phone before I go if at all possible.

4. Always confirm the home address. There have been times when the person moves or the address on the referral form is incorrect. This saves a lot of grief in the end. Sometimes I ask about parking if I am unfamiliar with the area. If the person lives in a secured building, I ask if there is a special code to buzz when I arrive and I write it down.

5. Ask if there are any smokers or pets in the house. If no one has been to the home before, and there are no previous records, I ask about smoke and pets. If the person or someone in the household smokes, I ask if they could refrain from smoking while I am there as second-hand smoke has been proven to be harmful. If there are any pets in the home, I ask if the pet could be put into another room while I am there so there are no issues with allergies, jumping up, biting, etc.

6. Ask if there are any bedbug issues in the home. If there are bedbugs, or have been bedbugs, find out what stage of treatment they are in. To be safe, take as little as possible into the home. Don’t put anything down on the floor. Keep your jacket on. Watch where you sit. Avoid couches and fabric chairs. Remain standing if you can. You can also wear protective gear like little disposable blue booties that go over your shoes if you need to. One time I met with a woman outside of her apartment suite, and I witnessed a bedbug crawling on her shirt. I made the visit as quick as possible.

7. When booking an appointment, give the person options. I ask if he/she would prefer a morning or afternoon appointment. Research I have read states mornings are a better time for most older people, after they have had a good sleep. This is when they are functioning at their best. Afternoons are often nap time and this wouldn’t be a good time to do a cognitive assessment or ask questions that require a lot of brainpower.  

8. I always call before I leave. When I initially book the appointment, it is usually for a few days or a week ahead. I offer to give him/her my phone number and I also tell the person I always call before I leave to confirm our appointment. The problem of “no-shows” is easily solved by using this simple technique. Sometimes people forget about the meeting, or they conveniently have something else come up so they have to cancel. It is very rare that the person cancels on me, but sometimes the visit is delayed because of something that held them up.

9. I bring my cell phone. This is a great tool to have. If the person doesn’t answer the door you can call them on the phone. Some people can’t hear you knocking for example, or they have their TV up loud. A cell phone also offers safety. I have also used the cell phone to call the person to say I was caught up in traffic. Once I had to cancel my visit enroute because it was raining so hard the streets were flooding!

10. When I arrive, I always take off my outdoor footwear, unless the client or family member is adamant that I leave my shoes/boots on. This is a sign of respect. After I have introduced myself, and confirm I am in the right place at the right time, I put on my indoor shoes.

11. When they ask where I would like to sit, I often suggest a table, like the kitchen or dining room table. This offers me the most comfortable seating arrangement, and I can write down things easily enough. I make sure I have a clipboard with me in case I don’t have access to a table. This is also handy when my client has to do cognitive testing and they are sitting in a chair or on a couch.

12. I always ask about the client’s hearing and if he/she has a “better side.” This helps me determine how close to sit and on what side. 

13. I make sure I have extra pencils, pens and paper with me. I never know when my pen will run out. I have been in a situation where I didn’t have any scrap paper with me for writing notes and I had to ask the client for a piece of paper. That is embarrassing.

14. When offered a cup of coffee or glass of water, I politely decline, advising that I brought my own bottle of water with me. I had a situation in the past where I spilled a cup of water. Now I always carry my own water bottle, and keep the lid closed. No more spills for me.

15. Bring resources and giveaways. People tend to like it when you can leave reading material for them to look at after you are gone.

16. I always give lots of time at the end of my visit for questions. I explain next steps so they know what to expect. I make sure I have left my business card and encourage them to call me if anything comes up.

17. I always thank the client for answering all of my questions. I also thank the client and family member for their time.

18. I try to say something positive in the end, something that will leave the person with a good feeling. For example, I might say, “You have a beautiful family” or “We are going to get you some help.” I may compliment his/her environment, such as, “You have a beautiful home, there is so much light,” “Look at the view!” or “I love the artwork.” If there are family photos around the home, I ask “Who is in this picture?” The person usually lights up and it makes them feel good. I may also ask about framed awards and certificates, as these are hung up on the wall because they are important to the person.

19. I sanitize my hands. I always have hand anti-bacterial hand sanitizer in my car, so I make sure I sanitize my hands before and after each visit (preferably I would be washing with soap and water). I don’t want to transfer any germs from one person to the next. I shake hands with people so I want to ensure cleanliness.

Do you have any best practices or other tips for home visits you would like to share? Any comments or questions on what you have read here? Please do so in the comments below.

Angela G. Gentile, MSW, RSW

Additional reference: Safe Practice Procedure, Sample Policy 2:

Wednesday, February 18, 2015

Online Dementia Caregiver Support Groups

Support groups are often recommended for people who share a common problem. Talking with others who "understand" what you are going through can help end isolation. It can make you feel better just knowing you are not alone. Sharing with people who have similar feelings and frustrations is a great way to help alleviate some of your own fears and doubts. You can learn a lot from those who have been there. Being part of a group offers you an opportunity to provide support and helpful advice to others. Social connection is an important part of maintaining good mental health. It can help alleviate stress.

     If you are a struggling caregiver to someone with dementia, or you want to connect with others, you may find it difficult to get out to a support group offered by your local Alzheimer's association or other agency or program. It may be hard just to leave the house for an hour or two because your loved one is unsafe. You may have trouble finding someone to provide respite while you go out.

     An alternative is to join an online group through websites such as Facebook. I have found a few groups that you may want to check out to see if they suit your needs or not. Most of these groups are "Closed" and you must be approved by an administrator to join. You can be a part of the group and decide if it meets your needs or not. If it's not for you, it is easy to leave the group and move on to something else.

Facebook Groups (you need a Facebook account) for caregivers of people with dementia:
This listing is not exhaustive, and the availability of groups can change at any time. Please do your own search to see if there are any new groups for you to check out.

Please comment below if you have any other groups or information to share.

- Angela G. Gentile, MSW, RSW
Specialist in Aging

Thursday, May 22, 2014

As a Social Worker...

Edited by Angela Gentile, MSW RSW. Please share freely.

Wednesday, March 12, 2014

That One Client

I came across a quote on Facebook, and it said, "Every Nurse has that one patient that they'll remember forever." It also had a "red cross symbol" on it.  It immediately made me think about my career as a social worker, and the fact that there is also that one client that I will remember forever.

I don't think I'll ever forget a certain young male. He was in his early 20's. It was a very complex case, and this young man had a terminal illness. I learned a lot about hope, culture, Multiple Sclerosis, family dynamics, stigma, shame, the health care system, financial stressors, the social system, allied health care professionals, death, and so much more.

It made me think about changing that quote about nurses, so I made my own quote: "Every Social Worker has that one client that will be remembered forever." I am also wondering if this is true for every helping professional? I believe it is an honour to be part of people's lives in their times of need, and we learn so much about ourselves and others. Some of those people and families will never be forgotten.

Warm regards,

Angela G. Gentile, MSW RSW
Specialist in Aging

Tuesday, March 4, 2014

35 Techniques Every Counselor Should Know (Book)

Book Review:  35 Techniques Every Counselor Should Know, by Bradley T. Erford, Susan H. Eaves, Emily M. Bryant and Katherine A. Young (2010)

Here's a great book full of counseling techniques.  A brief origin of the technique is described, "how to implement" and an example is provided for each one.  Each chapter ends with a "usefulness and evaluation" of the technique.

Techniques based upon brief counselling approaches:

1.  Scaling
2.  Exceptions
3.  Problem-Free Talk
4.  Miracle Question
5.  Flagging the Minefield

Techniques based upon Adlerian or psychodynamic approaches:

6.  I-Messages
7.  Acting As If
8.  Spitting in the Soup
9.  The Mutual Storytelling
10. Paradoxical Intention

Techniques based upon Gestalt principles:

11. Empty Chair
12. Body Movement and Exaggeration
13. Role Reversal

Techniques based upon social learning:

14. Modeling
15. Behavioral Rehearsal
16. Role Play

Techniques based upon cognitive approaches:

17. Self-Talk
18. Visual/Guided Imagery
19. Reframing
20. Thought Stopping
21. Cognitive Restructuring

Techniques based upon behavioral approaches using positive reinforcement:

22. Premack Principle
23. Behavior Chart
24. Token Economy
25. Behavioral Contract

Techniques based upon behavioral approaches using punishment:

26. Extinction
27. Time Out
28. Response Cost
29. Overcorrection

Techniques based upon cognitive-behavioral approaches:

30. Rational-Emotive Behavior Therapy (REBT)
31. Bibliotherapy
32. Deep Breathing
33. Progressive Muscle Relaxation Training (PMRT)
34. Systematic Desensitization
35. Stress Innoculation Training

I don't see mindfulness here, or Dialectical Behavior Therapy.

Great resource for counselors.

- Angela G. Gentile, MSW RSW
Specialist in Aging

Wednesday, June 12, 2013

Professional Development for the Professional

I have come across a few companies that provide professional development in the field of health and mental health.  I will add to this list as I find new resources.  If you have any others to add, please let me know.

(These are Canadian resources).

Achieve Training Centre - Promoting Leadership and Organizational Performance

HQS Professional Development - Committed to organizing quality conferences and contributing to the professional development of health care providers in our community

Jack Hirose and Associates - Mental Health and Educational Seminars

-- Angela G. Gentile

Sunday, March 17, 2013

A Prayer for Social Workers

Bless them in the work they do for our patients, residents and clients across the system. They are advocates for those we serve and their families with the staff and physicians. 

Social Workers lend themselves to listening not only with their ears but with their hearts to determine the myriad of needs to be filled. They are educators and provide direction to those in need as our residents, clients, patients and families attempt to maneuver through the complexities of health care.

As an integral part of the team they provide the bridge to outside resources and services so that those we serve may benefit from uninterrupted care and are enabled to continue their healing.

We ask You to protect each of them to provide them with sufficient grace to be your hands and feet as they care for our mothers and their children, the elderly, the sick and dying and all Your children with special needs.

Written by the Pastoral Care staff at Holy Redeemer Hospital.