Nurse practitioners have traditionally practiced within the comfortable confines of a hospital or clinic setting. That is changing. New opportunities have expanded into the home, where NPs monitor patients and complete comprehensive assessments. I found little guidance in how best to navigate these waters. After nearly 2 years of trial and error, I have developed key pieces of advice that I follow and would recommend to others for a successful home visit.
1. Call the patient. Place this call 24 to 48 hours prior to the visit. This call is a gentle reminder that the visit has been scheduled. It also provides the patient the opportunity to cancel or reschedule the appointment if circumstances change. It is important that you identify yourself, who you are working for, what (if anything) the patient needs to have available for you during the visit, the approximate length of time the visit will take, and a confirmation of the location of the visit. If there is no answer to the call, leave a message with the above information as well as the call-back number in case the patient needs to change or cancel the appointment.
2. Assess the patient's response. A lot can be determined about the condition of the patient from his or her phone response. Conditions such as hearing loss, frailty, hyperactivity, depression, aberrations in thought process and cognition may be present. This becomes invaluable when preparing for the visit.
3. Assess risk. Use the phone call to assess potential environmental and safety risk. Is the home located in a neighborhood that is potentially unsafe? Are there pets in the home? Who, if anyone, will be in the home during the visit?
4. Know where to go. Map out your visit addresses; I like to use Google Maps. If you are in unfamiliar territory, print out the location of the address as well as directions. I also document mileage from home to each location. Many agencies reimburse for mileage. I also use a portable GPS device, such as Magellan or Garmin, when driving. Many automobiles are also equipped with navigation direction services. Finding some patients can be a challenge.
5. Review information for each patient. This may be the first and only visit with this patient. Review whatever medical information is provided to you, as well as medications. Also be aware of any previous past history of violence, agitation or previous incarceration. This may give you a heads up to possible interactions with the patient. Determine what educational materials you may want to bring with you.
6. Review your equipment. Make sure everything is in working order, and that batteries are charged and usable. Do you have sufficient supplies to carry you throughout the day as well as personal protective equipment (gloves, N95s, sharps container)?
7. Let someone know where you are. Leave a copy of your schedule with someone in your home.
1. Be on time for the visit. If there is a delay, call the patient and explain that you will be a little late. Give an approximate time of arrival. Being late leaves a bad first impression that may be hard to overcome.
2. Assess the area as you drive up to the address. Look around the neighborhood. Do any safety issues concern you? Are you in an unsavory area? Trust your instincts. If anything suggests you might be in danger, drive on and call the patient to inform them that the appointment will need to be rescheduled. Call the company that hired you and report your concerns. Your safety is paramount.
3. Leave valuables in the car. Take only what you need to the visit; it is best to keep valuables in the trunk, or out of view in a locked vehicle.
4. Dress professionally. Some Nurse Practitioners wear scrubs. That is fine. If that is not the case, then dress comfortably, yet professionally. This is not the time for fancy dresses, expensive jewelry or high heels. Expect that you may be performing assessments in the kitchen, in the bedroom, in the living room, on the front porch, or other unlikely areas that will require you to bend, reach and get down on your knees. Wearing nice slacks has served me well.
5. Wear your name badge. It is important that you identify yourself with a company name badge and also have a company business card with you.
6. This is not a social call. You are there for a special purpose. Many folks are ecstatic to have someone come visit them; they will offer you coffee, breakfast, lunch, dessert or the grand tour of the house. I have found that accepting a glass of water works well. Locate a well-lighted area to work from, usually the kitchen. You may need to adjust this depending upon the condition of the patient.
7. Include family members. This is their home. You are entering their territory and their family dynamics. Encourage input from family members and include them in your discussions and education. Be respectful and nonconfrontational. Be aware that many homes have multiple generations living under the same roof.
8. Be nonjudgmental. People may live differently from you. You will see all sorts of living situations and home conditions.
9. Address medical emergencies and safety situations. Be prepared to call 911, the patient's usual provider, the case worker, or the police if the situation warrants it.
10. Take time to answer questions. Always ask if the patient has any questions or concerns. Answer them if you can, try to find the answer for them, or direct the patient to where he or she might call for the answer.
11. Thank the patient for his or her time. As you leave, thank the family for allowing you to come into their home.
12. Check your vehicle. Always check the back seat and under the vehicle before entering, to make certain you are safe.
After the Visit
1. Complete assessment. Whether on paper or in digital format, complete and forward to the appropriate person. Document any verbal or physical abuse, witnessed illegal activity, blood or body fluid exposure, or personal safety issue.
2. Privacy. Always keep patient information private. If you have information in paper form, keep in a locked cabinet and shred information with a high-quality shredding device. If using a digital format such as an iPad, always use the security codes and keep the device with you and out of view in your vehicle.
A successful home visit requires pre-visit preparation, the actual home visit and post-visit completion. Following these suggestions and general safety precautions will help you transition from the traditional practice area into the home.
Rosemary King is an adult nurse practitioner who provides home care to Medicare Advantage plan members of Optum Health Services. She also provides health coaching and hypnotherapy at her business, Focused Wellness Solutions (www.FocusedWellnessSolutions.com) in Green Valley, AZ.