Introduction

Health care delivered in the home or outpatient setting has continued to increase. According to the latest figures in 2018 and 2017, over 11,500 home care agencies treated 4.9 million individuals in the United States.¹ As the aging population increases, the nuances of optimal wound care delivery in the home health setting should be examined.

Wound Assessment and Monitoring

As in all wound care settings, care within the home setting begins with a thorough head-to-toe assessment of the patient and the wound. This assessment is followed by closely monitoring the wound during each home care visit. Handheld electronic wound measurement devices and digital photographs are useful tools for wound evaluation and monitoring in a home care setting because of their accuracy, portability, and ease of use.²

Infection Prevention: Across Home Health Settings

In addition to monitoring the wound, clinicians must strive to prevent any onset or spread of infection. In the home care setting, thoroughly washing one’s hands is the first step. The presence of certain devices, such as Foley catheters or IV lines, may put patients at a higher risk of infection.³ Various care items—such as a computer/tablet, bag, or other supplies—that wound care professionals carry with them may become infection vectors. To prevent contamination between homes, providers might place a barrier down before setting an item in the patient’s home. To further minimize risk, wound care professionals may also switch the order in which they visit patients. For example, a nurse may visit a patient with a weakened immune system before they visit a patient with a severe infection.³ It may also be wise to familiarize oneself with safe and effective disinfecting methods for such equipment to use between home visits. In the home health setting, patients or caregivers may have a larger role in the care plan than in inpatient settings. They may find themselves changing bandages, for example. For this reason, patients and caregivers should receive education on proper hygiene practices associated with wound care.³

Home Wound Care–Related Issues

The following issues, although not exclusive to wound care across settings, are particularly essential to successful wound care in the home care setting:

• Patient education: When caring for the patient’s wound, clinicians should explain what they are doing and why and show the patient or caregiver how to care for the wound between home care visits. The teach-back technique, in which the patient demonstrates what the clinician has taught, can give the patient confidence in their ability to follow the wound care plan or, conversely, may reveal the need to modify the between-visit wound care protocol.⁴ For example, some patients and caregivers may find certain products, dressings, or advanced wound care systems too complex or difficult to use.
• Financial concerns: Wound care professionals should be aware of the costs to the patient associated with home care. If the patient cannot afford the prescribed supplies, the clinician should advocate on the patient’s behalf for less expensive alternatives, if available.
• Pain management: If the patient experiences pain from the wound itself, debridement, or other treatments, ensure that pain is managed appropriately and adequately.⁵ Unmanaged pain is a potential factor in patient nonadherence to wound care.
• Environmental issues: If the wound care plan includes offloading, carefully inspect all offloading equipment, key home surfaces, and devices, and make adjustments and recommendations as needed. If turning and repositioning are part of the care plan, remind patients and caregivers to avoid friction and shear forces, and demonstrate the correct technique.

Benefits and Challenges of Home Wound Care

The home care setting has several clinical and logistical advantages and disadvantages. One advantage is that patients don’t have to travel to receive care. This setting minimizes environmental stressors, which is especially vital for patients with obstacles to mobility or transportation. Home care also gives wound care professionals a unique window into the patient’s world that may provide a deeper understanding of the patient’s preferences, lifestyle, and circumstances. One disadvantage of wound care in the home setting is that it may be challenging from a clinical standpoint. Some of these obstacles to clinical wound care may include the following:

• Limited space for wound assessment and treatment
• Variable lighting (it may be dim)
• Sanitation level of the environment
• Human and animal residents potentially interfering with care (despite the best of intentions)

Wound care professionals must be prepared if the above issues arise and resolve them as flexibly as possible. To list another disadvantage, clinicians must bring all supplies needed for each visit and supplies to be left when applicable with the patient for self-treatment between visits. The patient or caregivers may have difficulty with that intervisit care and may need additional monitoring, possibly through telehealth or a modified wound care plan.

Looking Beyond the Wound

Wound care professionals should take a holistic approach, bearing in mind the adage, “treat the whole patient, not the hole in the patient.” A wound does not exist in isolation, so it is essential to ask open-ended questions, actively listen to the patient, and carefully consider their responses empathically. This process may take time because some patients may be unable, reluctant, or simply too exhausted to engage right away. The following information, which may already be included in the patient’s electronic health record, should be documented. It is vital for the provider to consider the unique applications of each of these topics to the patient's home care plan, as they can impact coverage of services, available treatment options, available ancillary services, or the necessity of additional professionals on the team.

• Care coverage: Does the patient have an additional home health provider? Family or caregivers? A care coordinator?
• Comorbidities: Is the patient under medical care for comorbidities? How well are these conditions being managed?
• Mobility: Is immobility an issue? If so, would the patient benefit from modifications to the living space, such as grab bars or ramps, if they are not already in place? Would the patient benefit from a consultation with an occupational therapist? Does the patient have a physical therapist?
• Cognitive function and mental health: Is the patient’s cognitive function adequate? Can the patient understand the wound care plan? Does the patient have mental or behavioral issues that may complicate the patient’s care?
• Access to care: Is the patient able to travel to medical appointments when necessary? If not, is the patient registered with a local agency, volunteer group, or social service that provides transportation?
• Social services: Does the patient receive or have access to local services (meals, transportation, help with utilities, help with cleaning, etc)? If not, would the patient want these services if they were free or affordable?
• Nutrition: Is the patient’s diet compatible with the needs of a healing wound? If not, is the patient unable to afford more nutritious food? Would the patient be willing to talk to a dietitian about possible options?
• Cultural factors: Is the patient’s care culturally appropriate? If not, what changes would be beneficial?
• Overall quality of life: What is the patient’s view on their health and quality of life? What improvements can be made? Remember that we all define quality of life differently.

Encouraging Patient Adherence to the Wound Care Plan

Patient engagement promotes a positive wound care experience, and this is where a solid patient-provider relationship is invaluable.⁶ Clinicians should use all the tools at their disposal to help patients understand their wound. Different strategies, like using various devices and/or photographs mentioned earlier, are beneficial for this purpose, and telehealth can be a great resource between in-person visits. Wound care professionals should explain all aspects of the care plan at each phase of the healing trajectory and empower patients to be informed participants in their wound care decisions.⁶

Conclusion

In home wound care, providers and patients are partners. Wound care professionals can work together toward healing by respecting the patient’s autonomy, using clinical expertise, and exhibiting agility in a unique setting.

References

1. Centers for Disease Control and Prevention. Home Health Care. National Center for Health Statistics. Updated December 14, 2022. Accessed January 4, 2023. https://www.cdc.gov/nchs/fastats/home-health-care.htm
2. Lucas Y, Niri R, Treuillet S, Douzi H, Castaneda B. Wound size imaging: ready for smart assessment and monitoring. Adv Wound Care (New Rochelle). 2021;10(11):641-661.
3. Dowding D, Russell D, Trifilio M, McDonald MV, Shang J. Home care nurses' identification of patients at risk of infection and their risk mitigation strategies: A qualitative interview study. Int J Nurs Stud. 2020;107:103617. doi:10.1016/j.ijnurstu.2020.103617.
4. Yen PH, Leasure AR. Use and effectiveness of the teach-back method in patient education and health outcomes. Fed Pract. 2019;36(6):284-289.
5. Coulling S. Fundamentals of pain management in wound care. Br J Nurs. 2007;16(11):S4-S6, S8, S10 passim.
6. WoundSource Practice Accelerator. Patient engagement: encouraging healing by involving patients in wound care. WoundSource.com. Published March 31, 2022. Accessed December 21, 2022. https://www.woundsource.com/blog/patient-engagement-encouraging-healing…