Home Health

Engaged Across the Continuum

I and many of my friends and relatives are caring for elderly individuals we’re close to. All around me, I see how challenging it is—even for those who are otherwise fully “engaged” patients and family members—to manage the abundance of clinicians, pharmacies, service organizations, assisted living facilities, and so on. It’s a big job to figure out what’s needed, how to find appropriate service providers, where to access reliable information and to what degree insurance will cover the cost. Whether sharing a home with an elder who needs daily, hands-on care or supporting someone from a distance, staying engaged in the process and navigating everything involved in elder care is a challenge. I’m familiar with the elderly population; I imagine the same applies to individuals of any age who need help with daily living and home health care.

Engaging with home health is challenging for all

Turns out, physicians and other professional caregivers have trouble with this, too. For all of the attention paid to improving communication and follow-through across the “continuum of care,” there is still tremendous need for education and process improvement related to care at home.

I recently listened to a podcast episode designed to help clinicians understand and consult about their patients’ needs for help at home. The episode betrays how confusing the world of home health is for professionals, as well as patients and families. Although the focus is on paid, professional home health workers, the information is relevant for family caregivers as well and is presented in accessible, non-technical language.

The episode is one in a series focused on interprofessional health education, produced by CORE IM, a biweekly podcast about a wide range of medical topics. CORE IM is produced by a large community of doctors, residents and other health professionals, most of whom have day jobs in medical centers across the country. Episodes offer continuing medical education credits for members of the American College of Physicians.

The episode about home health covers different kinds of workers, their scope of practice and options for Medicare, Medicaid and other insurance coverage. Supporting graphics on the related website are very helpful, as is a transcript of the podcast that links to journal articles and other resources for diving deeply into these topics.

In addition to providing practical information, the physicians and medical student featured in the episode cover “pain points” and “pearls” of advice for better collaboration in home health. For example, they advise always asking the patient during an office visit if there is someone with them (i.e., sitting in the waiting room) who they’d like to have join them for part of the visit. Home aides or family members can often supply crucial information and a unique perspective but may need to be invited and encouraged to participate. The podcast also points out that the power dynamic especially when the patient is also the employer, may mean that communicating openly is difficult for the worker.

This episode, and likely others on CORE IM, provides a huge amount of information and food for thought. I especially appreciate that it’s done in a way that works for clinicians, patients and family members across the continuum.


Susan Carr Susan Carr is a medical editor and writer specializing in patient safety and engagement. In addition to curating the EngagingPatients blog, she produces publications for the Betsy Lehman Center in Boston and the Society to Improve Diagnosis in Medicine. Susan lives and works in Lunenburg, Massachusetts.

Susan Carr has 185 post(s) at EngagingPatients.org

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