Home round: a strategy for improving community health

INTRODUCTION

A trained community health practitioner working at a primary healthcare center in Nigeria is expected to give an account of the health of patients who visit their health centers from catchment areas.¹ To improve community health, the community health practitioner must be skillful in identifying complex health needs, offer safe, high-quality treatment, and provide necessary health education or referral services.² This can only be done when the home round is in place. Home rounds are crucial for community health improvement and real-life experience for community health practitioners allowing them to understand community needs and identify appropriate resources.³

Home round conducted in primary health care settings has the same concept as ward rounds conducted in hospitals, however, home round is conducted in the community and at the home of the patient.⁴ A home round is different from a home visit, though sometimes they are used interchangeably. Home rounds and home visits are both essential strategies of primary healthcare, but they serve different purposes and involve distinct approaches.¹ While a home round is initiated on outpatient still on medications especially since most primary healthcare facilities don’t admit patients, a home visit is conducted after the patient has been discharged from a hospital or on a patient who could not visit the health facility.^1-12 Understanding the nuances between these two practices is crucial for healthcare professionals to provide comprehensive and effective care. This enhancement, and impact on patient care and the community. Just as in ward rounds, clinical diagnosis is revised, a clinical examination is undertaken, decisions about future investigations and treatment options are made, and written and verbal communication is undertaken.¹³

Home round is a systematic process conducted by a team of community health practitioners in primary healthcare facilities, supported by community physicians, pharmacy technicians, nurses, and social workers, to assess and monitor the health and well-being of patients or clients who receive healthcare services from the primary health care facility at the home of the patient in the community.⁶ Home rounds are typically organized regularly, and they aim to assess the progress of the health of the patient, compliance with prescriptions, identify other health issues, and provide preventive care, or referral if need be.⁷

The primary goal of home rounds is to proactively manage health concerns and enhance the overall quality of care for individuals who receive health care services from the health facility. Home rounds are essential for ensuring the holistic care of patients who visit the health facility. During these rounds, healthcare professionals from various disciplines come together to discuss the patient's condition, treatment plan, and progress.⁸ This collaborative approach enables a comprehensive assessment of the patient's needs, leading to better-informed decisions and coordinated care. It also allows for the identification of any potential issues or complications, ensuring that appropriate measures are taken promptly.⁹ In addition to their impact on patient care, home rounds also serve as a valuable learning experience for interns, students, and junior primary health care staff.¹ Observing senior health workers during home rounds provides an opportunity to learn about different conditions that can be managed at the primary health care level, treatment strategies, and patient management, and when to refer the patient to specialist care. It also offers insights into the decision-making process and the importance of effective communication within a multidisciplinary team. As such, home rounds play a crucial role in the education and professional development of future primary healthcare professionals.⁹

Furthermore, home rounds contribute to the efficient functioning of primary healthcare institutions. By bringing together healthcare professionals, these rounds facilitate the exchange of information, ensuring that everyone involved in the patient's care is on the same page. This shared understanding promotes effective teamwork, enhances communication, and reduces the likelihood of errors or oversights.¹⁰ Moreover, home rounds provide a forum for discussing challenging cases, seeking input from colleagues, and refining treatment plans or referrals, ultimately leading to improved patient outcomes.¹

Objectives of home rounds in primary health care centers

Home rounds are an essential aspect of providing comprehensive and personalized healthcare to patients who receive healthcare services from the primary healthcare facility.^12,13 The primary objectives of home rounds in healthcare are to: 1) To provide specialized care: Home rounds enable healthcare providers to offer personalized and specialized care to patients in the comfort of their own homes. This allows for a holistic approach to healthcare that takes into consideration the patient's living environment, lifestyle, and support system. 2) To monitor and manage chronic conditions: Home rounds are particularly beneficial for patients with chronic conditions that require ongoing monitoring and management. Healthcare providers can assess the patient's condition, adjust medications, and provide necessary interventions to ensure optimal disease management. 3) To prevent hospital admissions: by conducting regular home rounds, healthcare providers can identify potential health issues early on and intervene before they escalate, leading to emergency room visits or hospital admissions. This roactive approach to healthcare can help improve patient outcomes and reduce healthcare costs. 4) To ensure medication adherence: Home rounds allow healthcare providers to assess the patient's medication regimen and ensure proper adherence to prescribed medications. This can prevent medication errors, drug interactions, and misuse of medications, ultimately improving patient safety and health outcomes. 5) To provide prompt referral of unprogressive cases to appropriate hospitals for specialized care. 6) To provide emotional support: Home rounds also offer an opportunity for healthcare providers to offer emotional support and counseling to patients and their families. This can be particularly beneficial for patients who may be experiencing isolation, loneliness, or anxiety due to their health condition. 7) To educate and empower patients: Home rounds provide a valuable opportunity for healthcare providers to educate patients and their families about their health conditions, treatment plans, and self-care practices. By empowering patients with knowledge and skills, healthcare providers can help them take an active role in managing their health and improving their quality of life.

The initiation and conclusion of a home round for a community health practitioner depend on several factors, including the specific practices of the healthcare institution, the needs of the patients, and the complexity of the cases being managed.

METHODOLOGIES OF CONDUCTING A HOME ROUND

Generally, the methodology for conducting a home round can be outlined as follows.¹²

Preparation: Before starting the home round, the CHP typically reviews the medical records, test results, and relevant information about the patients under their care.

This helps the CHP to have a clear understanding of each patient's current status and any changes that may have occurred since the last home round.

Assembly: The CHP may gather a team, which could include other healthcare professionals in the primary health center such as community physicians, nurses, students, or residents, to accompany them on the home round. This team-based approach allows for a more comprehensive assessment of patients and facilitates interprofessional communication and collaboration.

Patient assessment: The CHP goes from home to home, visiting each patient who received health services from the health facility within the week, reviewing their charts, conducting physical examinations, and discussing their condition and treatment plan. During this time, the CHP may also address any immediate concerns or issues raised by the patients or other health staff.

Decision-making: Based on the information gathered during the home round, the CHP makes decisions regarding ongoing care, treatment adjustments, diagnostic investigations, and referral plans as necessary. The CHP may also update the patient's family on the care plan and answer any questions or concerns.

Documentation: Document all findings, observations, and recommendations.

WHEN TO INITIATE AND END HOME ROUNDING

Just as in ward rounds, home rounding commences three days into patient treatment or clients’ counseling sessions and continues until the patient is well. Home rounding on patients/clients typically begins in the morning, around 8 am or 9 am. However, the specific time may vary depending on the patient's availability, and the preferences of the healthcare team. Similar to ward rounds, a patient's home round may last for about ten minutes. This excludes instruction and family house inspections.¹⁴ The frequency of home rounds can vary depending on the healthcare facility and the specific client/patient's needs. In general, home rounding is typically conducted at least once a day by a healthcare team. This allows for effective communication, assessment of client/patient progress, and coordination of care among community health providers. However, the frequency may be increased or decreased based on the client/patient's condition and the healthcare provider's judgment. It is important to follow the specific protocols and guidelines set by your institution regarding home rounding practices.¹⁴

ACTIVITIES AT HOME ROUNDING

Discuss the patients' diagnoses, progress, and response to treatment. Conduct physical examinations, review lab results, and discuss any concerns or issues the patients may have.

Inspect patients'/clients' homes (kitchen, toilets, source of drinking water, waste disposal technique, living environment) to identify any issues that may impact their health negatively and provide health education.

Refer cases that cannot be handled at home to the primary health center, secondary or tertiary levels.¹

INSTRUMENT FOR HOME ROUNDING

During home rounding, CHPs may use various instruments and tools to assess patients, monitor vital signs, and provide appropriate care.¹⁵ Some commonly used instruments for home rounding include. Stethoscope used to listen to the heart, lungs, and other internal body sounds. Blood pressure monitor measures blood pressure to assess a patient's cardiovascular health. Thermometer used to measure body temperature and identify fever or hypothermia. Pulse oximeter determines the oxygen saturation levels in a patient's blood. Sphygmomanometer measures blood pressure using an inflatable cuff and pressure gauge. Penlight provides a focused beam of light to examine the eyes, throat, and other body parts. Glucometer measures blood glucose levels in patients with diabetes or suspected hypoglycemia, mid arm circumference, and referral form.

ELEMENTS OF HOME ROUND

The elements of a quality home round by a CHP may include assessment; evaluation of the patient's health status and any chronic conditions; education on self-care management and preventive measures; coordination of care with other healthcare providers and resources; collaboration with the patient and their family to develop a personalized care plan; follow-up to ensure that the patient is following through with recommendations and to address any barriers to care, and quality referral to the health center

These elements help to ensure that the patient receives comprehensive and holistic care in the comfort of their own home.

STEPS TO CONDUCT HOME ROUNDING

To conduct home rounding of a patient/client, follow these steps.

Schedule the home round: coordinate with the patient or their caregiver to schedule a convenient time for the home round. Consider factors like the client/patient's availability, the caregiver's availability, and any specific needs or preferences.

Prepare necessary equipment: gather any medical equipment or supplies that may be required during the home rounding. This can include things like a stethoscope, blood pressure cuff, thermometer, and any specific tools or devices relevant to the client/patient's condition.

Review the patient's medical records: familiarize yourself with the client/patient's medical history or counseling history, current medications, and any recent test results or lab reports. This information will help you provide appropriate care and monitor the patient's progress during the home rounding.

Communicate with the healthcare team: if you are part of a healthcare team, keep them informed about the home rounding. Discuss any concerns, questions, or specific instructions related to the client/patient's care.

Follow infection control protocols: before entering the client/patient's home, practice proper hand hygiene by washing your hands thoroughly or using hand sanitizer. Wear personal protective equipment (PPE) as necessary, such as gloves, masks, or gowns, depending on the patient's condition and any infectious risks.

Assess the client/patient: Begin by assessing the patient's general well-being, vital signs, and any specific symptoms or concerns they may have. Use your professional judgment to determine the appropriate approach for each client/patient.

Conduct physical examinations: perform any necessary physical examinations based on the patient's condition. This may involve listening to their heart and lungs, checking their pulse or blood pressure, examining wounds or incisions, or assessing other specific areas of concern.

Address medication management: review the patient's medications, including dosages, frequency, and any changes made since the last visit. Ensure the patient understands their medications and any potential side effects or interactions.

Communicate with the patient and caregiver: engage in open and clear communication with the patient and their caregiver, addressing any questions or concerns they may have. Provide education and recommendations for maintaining or improving the client/patient's health.

Ask if anyone in the family has any health issue: Engage in open discussion to identify any health condition that could be referred to the health facility for medical attention or counseling.

Inspect client/patient’s home and surroundings: inspect the home of the patient (environment, kitchen, toilet facility, source of water supply, refuse disposal, etc.) for cleanliness, orderliness, and void of becoming a source of infection.

Document the home round session: make accurate and thorough notes about the home round. Determine if additional visits or interventions are needed. Communicate with the patient's primary healthcare provider or other members of the healthcare team as necessary to coordinate ongoing care and ensure appropriate follow-up.

It's important to note that the specific steps for conducting home rounding may vary depending on the patient's condition, the purpose of the visit, and any specific instructions or protocols in place in your healthcare setting. Always adhere to your organization's policies and procedures and consult with your healthcare team for further guidance.¹

DOCUMENTATION OF FINDING

Documenting home rounding findings is an important part of the session. Here are some steps to help you effectively document home rounding findings.

Gather necessary information: start by collecting all relevant patient information, including medical history, laboratory results, and any recent interventions or treatments.

Use a structured format: use a standardized template or electronic medical record system to document your findings (David and Wendy). This helps ensure consistency and makes it easier for other healthcare providers to review the information.

Include client/patient’s identification details: begin each documentation with the patient's full name, date of birth, and hospital identification number. This helps prevent confusion and ensures accurate identification.

Summarize the client/patient's condition: provide a brief overview of the patient's current condition, including their chief complaint, vital signs, and any notable findings from physical examination.

Document assessment findings: detail your assessment of the patient's symptoms and physical findings. Include information about any abnormalities or changes from previous assessments.

Include diagnostic test results: document the results of any diagnostic tests or imaging studies conducted, along with your interpretation and any follow-up plans.

Note medication changes: if any changes were made to the patient's medication regimen during the home rounding, clearly document the specific changes and reasons for them.

Mention ongoing care plans: describe the recommended plan of care, including any further investigations, treatments, or referrals. Make sure to include any discussions with the patient or their family regarding the care plan.

Be objective and concise: use clear and objective language when documenting your findings. Avoid vague or subjective terms and focus on factual information.

Sign and date the documentation: always sign and date your documentation to indicate who completed the home round and when it took place. This helps with accountability and legal requirements.

A guide for documentation during the home round (DAVID and WENDYD)

During a home round, documentation can be done using DAVID AND WENDYD's approach. Although Ward-round employs other frameworks, such as SOAP, David and Wendy's approach seems to be easier to use in home rounds.¹⁶

Diet: what are they allowed to have?

Activity: are they resting in bed, or are they walking around? Is mobilization/sitting being encouraged?

Vitals: normal/abnormal, need to clarify, trending?

Investigations: reviewing old ones/new ones, planning to order.

Drains and lines: cannulas, central lines, abdominal wound drains, Check and record output. Clean if needed and look for infections (cellulitis)/ NA.

Wounds: check wounds/dressing and their progression, N/A.

Examinations: your typical examination where they must be focused (This depends on the condition).

Nursing concerns: A medical doctor can join you and raise concerns which is helpful as the whole team can be used. Problems get fixed faster.

Drugs: complying with prescriptions?

Y Is there no improvement? Are they unwell, still pending, social point of view such as having nowhere to go.

Decision: Refer/change of medication/completely well/revisit.

HOW TO ENHANCE THE CONDUCT OF A HOME ROUND?

Home rounds can be a valuable tool for improving community health by providing personalized care and support to outpatients in their homes.¹⁷ Here are some recommendations for conducting home rounds effectively:

Develop a comprehensive plan

Before conducting home rounds, it is important to develop a comprehensive plan that outlines the goals, objectives, and strategies for the visits. This plan should include a schedule for the rounds, a list of patients to be visited, and a checklist of items to be addressed during the home round.¹⁷

Build relationships with community members

Build relationships with patients by contacting them and seeking their permission to visit. This is essential for the success of home rounds. Tell them your purpose of visiting, listen to their concerns, and show empathy and understanding.

Collaborate with other healthcare providers

Home rounds should be conducted in collaboration with other health practitioners in the health facility. This collaboration can help ensure that individuals receive comprehensive care and support.

Respect privacy and boundaries

Respect the privacy and boundaries of the patients or family. Ask for permission before entering certain areas of the home and be mindful of cultural or personal sensitivities.

Provide education and resources

During home rounds, provide education and resources to individuals on topics such as healthy living, disease prevention, and medication management. This can help empower individuals to take control of their health and make informed decisions.

Follow up and monitor progress

After conducting home rounds, follow up with individuals to monitor their progress and address any concerns or issues that may arise. This ongoing support can help individuals stay on track with their health goals and make positive changes in their lives.

IMPACT OF HOME ROUND ON PATIENT AND COMMUNITY HEALTH

Home rounds have been a longstanding practice in healthcare that involves healthcare professionals visiting patients in their homes to provide follow-up medical care and support. This practice has been shown to have a significant impact on both patients and community health.¹⁸

One of the key benefits of home rounds is the personalized care and attention that patients receive

By visiting patients in their homes, healthcare professionals can gain a better understanding of the patient's living environment, lifestyle, and social support system. This allows for more tailored and holistic care that takes into account the patient's individual needs and circumstances.

Home rounds also have a positive impact on patient outcomes

Studies have shown that patients who receive home rounds are more likely to adhere to their treatment plans, have better medication management, and experience fewer hospital readmissions. This is particularly important for patients with chronic conditions or those who are homebound and have limited access to healthcare services.

In addition to benefiting individual patients, home rounds also have a broader impact on community health. By providing care in the home setting, healthcare professionals can identify and address social determinants of health such as housing instability, food insecurity, and lack of access to transportation. This can help to improve overall community health by addressing the root causes of health disparities and promoting health equity.

Furthermore, home rounds can help to reduce healthcare costs by preventing unnecessary hospitalizations and emergency room visits. By providing proactive and preventive care in the home setting, healthcare professionals can help manage chronic conditions more effectively and prevent complications that may require costly medical interventions.

CHALLENGES OF HOME ROUND

Understanding home health care from a human-systems viewpoint is beneficial because it highlights the important individual components of the system, such as people, tasks, settings, and equipment/technology.¹⁹ Some challenges of conducting home rounds include: 1) Limited resources and funding for home-round programs. 2) Difficulty in accessing homes that are located in remote or unsafe areas. 3) Lack of proper training and support for healthcare providers conducting home rounds. 4) Privacy concerns and issues related to confidentiality when conducting home rounds at patients’ homes. 5) Time constraints and scheduling difficulties for healthcare providers. 6) Challenges in coordinating care with other healthcare providers and agencies involved in the patient's care. 7) Difficulties in obtaining accurate and up-to-date medical information and history from patients in their home environment. 8) Shortage of manpower. 9) Insecurity

CONCLUSION

The home round is a valuable tool for community health practice. CHPs with the support of other health workers in the primary health care setting can conduct home rounds on outpatients and clients who visit the health facility. It involves assessing the health of the patient, checking compliance with prescriptions, identifying any health problem in the family, providing health education, and changing the medication or referral for proper management of care. The CHP may also engage in further discussions with the healthcare team to address any outstanding issues or to provide teaching and learning opportunities for trainees. It's important to note that the specific timing of the commencement and conclusion of a home round may vary based on the size of the patient population, the acuity of their conditions, the presence of complex cases, and other institutional factors. Additionally, emergent situations or unexpected developments may extend the duration of a home round. Flexibility and responsiveness to patient needs are essential throughout the process. Some of the challenges militating against the successful conduct of a home round include limited resources, shortage of manpower, insecurity, lack of proper training on how to conduct home rounds, privacy issues, tradition, time constraints, and challenges coordinating with health care providers.

Recommendations

The government and non-governmental organizations should support home rounds by making logistics available and conducting training to improve the skills of health workers. CHPs at the primary healthcare center should understand that the task of conducting home rounds is sacrosanct to improve the health of the outpatients and community health. Other health workers in the primary healthcare centers should be supportive to make the home round successful. An adequate number of CHPs and other health workers should be engaged in line with the primary health care requirement. The families and communities should corporate and protect health workers during home rounds.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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