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 Current Programs:

1 - Palliative Care Program

2 - Transitional Care Program

3 - Gestational Diabetic Program

4 - Wound care Program

Patient referrals:

Referrals to Home Health Care are initiated by physicians who have hospital admitting privileges.  Patients are initially assessed by the Home Health Care referral nurse,  either on an inpatient or on an outpatient basis,  prior to being accepted into the program.  Ideally 24 – 28 hours notice is required for inpatients so a timely visit can be scheduled upon discharge.  Once accepted to the program a family member is required to supply a map and give directions to the patients home to enable HHC staff to co-ordinate the first,  and subsequent home visits.

In order to be accepted into the HHC program the following criteria must be met:

Patient must live within 50 km of King Faisal Specialist Hospital and Research Centre

The referring doctor remains responsible for the patients care for entire stay on the program

If not self caring the patient must have a reliable caregiver available 24 hours per day that is willing to look after the patient and be responsible for their care

The male head of family must understand that a Home Health Care nurse and male medical Interpreter will make home visits and must agree to allow them to enter the house

The Caregiver:

Requirements:

Must be responsible and available 24 hours per day to care for the patient

Able to administer prescribed medications in the correct dose and at the correct time

Inform the Home Health Care nurse when a prescription refill or new supplies are required

Be available when Home Health Care staff visit to provide details regarding the patients condition and to answer questions as needed

Inform the Home Health Care nurse of any unexpected events  (i.e  hospital admission,  emergency room visit,  death)  

The first home visit:

The first home visit is arranged between the family and Home Health Care staff.  Ideally this visit takes place as soon as possible after discharge from hospital or an outpatient clinic visit.  Each patient is visited by a nurse and male interpreter team.  Subsequent visits may include physician,  social worker,  physiotherapist,  respiratory therapy or nutritionist as needed.

The aim of the first visit is to:

Assess the patient’s physical and psychological needs.

Assess the facilities available in the patient’s home

Meet caregiver and other family members

Discuss,  plan and implement care required from a team approach

Review and explain medications,  doses and administration times

Discuss the Home Health Care Program,  services offered and frequency of visits 

Services provided:

Patients are visited by a Home Health Care nurse and Saudi male interpreter and this must be agreed upon to continue receiving home visits.  The number and frequency of home visits will depend on the condition of the patient and will be assessed at each visit.  The Home Health Care medical interpreter will contact the patient and/or the family member on the morning of the visit to confirm the appointment for that day.  A definite time cannot be given as the nurse’s schedule  is subject to change at anytime.

Social worker:

The role of the social worker is to assess patient’s and/or family’s psychosocial and economic status.  They can arrange for the loan or purchase of medical equipment and collaborate with the Ministry of Labor and Social affairs and community resources to obtain necessary financial assistance for the patient.  They are also available to assist the family unit during grieving or bereavement.

Medications:

All current medications prescribed by the physician will be reviewed at each home visit.  If a new prescription is required the Home Health Care nurse will obtain this for the patient.  The caregiver or a male family member can collect this from the Home Health Care office at 5pm each afternoon (4pm on Wednesdays) and have the prescription filled in the outpatient polyclinic pharmacy.  If medication runs low prior to a scheduled home visit the patient or designated caregiver is requested to call the Home Health Care office well in advance for a prescription refill.

On-Call Service:

Occasionally patients become sick after office hours.  A nurse and interpreter are on call from 1800-0800 on weekdays and 24 hours on Thursdays and Fridays.  To contact the Home Health Care nurse patients or caregivers are requested to call the hospitals switchboard operator on 464-7272 and leave the patient’s name,  medical record number and their phone number.  The operator will contact the nurse who in turn will call the interpreter if an Arabic speaker is required.  If a patient or family member speaks English the nurse will be able to directly contact the house.  When the return call is made it is requested that the following information be available:

The specific problem

Events leading up to the current problem

Measures taken to alleviate the problem

Medications given if any

In most cases problems may be solved over the phone with advice from the nurse.  If necessary the nurse and interpreter will make a home visit or send the patient to the KFSH & RC emergency room if the problem remains unresolved.  If able,  families are requested to transport the patient themselves,  have the Home Health Care nurse arrange for a KFSH & RC ambulance or call Red Crescent Ambulance Service on 997 to bring the patient to hospital.

Resources:

Supplies

If required the hospital will provide supplies to help care for the patient at home.  During a home visit the nurse will assess patient’s needs and complete the medical stores requisition which can be collected from the Home Health Care office the same day.  When supplies run low the caregiver is requested to call and alert the nurse to refill the order.

Equipment

The Home Health Care department has a limited supply of equipment which is loaned out to palliative patients on a short term basis.  When no longer required families are requested to return any equipment to the Home Health Care office as soon as possible. 

Home Health Care data base:

The Home Health Care data base is a pioneering project which has never been carried out in Saudi Arabia until now.   The data-base is used to measure productivity of service and also for documentation of the patients requirements.   Lap-tops are taken out every day and updated daily,  they are brought back to HHC where the information is downloaded into the computer.  This catalyst for change is to improve quality of care and to improve communication across the hospital to link with Home Health Care.

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