Home Care

HOME CARE, or domestic medical assistance, represents a special form of organization of therapeutic and preventive care at home for patients who, due to their health condition, cannot come to outpatient reception, as well as for patients who need hospitalization but cannot use hospital treatment due to lack of space in hospitals or because transportation of the patient would pose a risk to their health. H i s t o r y. Home care as a state organization of medical assistance in pre-revolutionary Russia did not exist. Medical home care was provided mainly by private practitioners; this assistance was completely inaccessible to the poor strata of the population and the broad masses of workers. Of the 224 cities for which Dr. Zhdanov collected data in 1912-1914 on medical assistance, home care existed in only 34 cities, but here it was provided in very limited amounts only to the poorest population in cases of severe illnesses. In the territory corresponding to the RSFSR, there were only 16 home care points in 1913: St. Petersburg, Yekaterinodar, Irkutsk, Kazan, Samara, Tomsk, Yaroslavl, Perm, Ufa, Krasnoyarsk, Yelets, Yalta, Bugulma, Verkhneudinsk, Minusinsk, Nikolaevsk (of Samara province). Where this form of assistance existed, it was provided either by municipal doctors (in St. Petersburg - 42 municipal doctors) or doctors for the poor (for example, Odessa) or district doctors and even sanitary doctors. It is not surprising that home care at that time was of rather low quality. In Moscow, the organization of home care in pre-revolutionary years was only planned, and in such major centers as Rostov and Saratov, the municipal authorities did not think at all about organizing it. Home care arose in cities mostly in connection with epidemics, when there was an acute need to provide medical assistance to those suffering from infectious diseases, in the form of temporary home care doctors. For example, the diphtheria epidemic that broke out in St. Petersburg in 1881 forced the organization of home care as a temporary measure, and the scarlet fever epidemic that appeared the following year did not allow the home care organization to be dismantled. Similarly, the typhus epidemic in Kharkov forced the invitation of district regional doctors to serve the population at home; this was also the case in other cities. To provide home care, the city was usually divided into districts, and municipal doctors serving certain areas made an average of 20 visits per day, and in large cities only 1-2 and only in rare cases 3-5 doctors served the population with home care (For the inaccessibility of home care in rural areas in pre-revolutionary years - see Medical district and zemstvo medicine.) Only after the October Revolution did home care begin to develop strongly in cities, industrial centers and also in rural areas. Already in 1926 in the RSFSR alone, there were 435 special home care points in cities and industrial centers, where 923 doctors worked; in 1931 there were already 2,801 doctors, and in 1932 - 3,582 doctors. In Leningrad, where there were only 42 home care doctors in pre-revolutionary years, there were already 356 in 1931 and 472 in 1932. But home care in the revolutionary years not only showed colossal growth compared to the pre-revolutionary period - the very form of providing home care and the content of all the work changed fundamentally. From a primitive, miserable organization, mainly of a philanthropic nature for providing home care to the poor, home care transformed into a powerful, inseparable link in the entire Soviet health care system, actively contributing to the protection and strengthening of the health of the broad working masses. H o m e C a r e A b r o a d. While in the USSR home care is a state form of therapeutic and preventive assistance, provided free of charge and accessible to all workers, in capitalist countries home care is provided in the vast majority of cases by private practitioners. This paid home care has to be used by almost all strata of the population due to the absence of state or communal home care organizations. The most qualified doctors serve only bourgeois circles of the population, and here private practitioners act as permanent "family doctors." In those European countries where there is state social insurance, insurance funds cover the costs of providing home care, mainly in cases where emergency medical assistance is necessary and in the most severe cases when for some reason it is impossible to be admitted to a hospital. There is no special institution of home care anywhere abroad. Only in a very small number of cities do municipal authorities provide home care to the poorest residents through so-called doctors for the poor, mainly in cases dangerous to life and in diseases suspicious of infection. In the USA, where there is no social insurance, the employed are deprived even of those miserable forms of home care which in some European countries are provided in one way or another by insurance funds to the insured. Home care occupies a very important place in the entire system of out-of-hospital care, representing a necessary complement to outpatient and hospital medical care. Home care, under conditions of insufficient hospitalization, plays an enormous role in providing therapeutic assistance, especially to those patients who for one reason or another cannot use the indicated hospital treatment. The work of home care is also very important in the fight against epidemics; it also has extremely great significance for the dispensary care of the population, contributing to the improvement of living conditions. In it, the synthesis of therapeutic, sanitary-preventive and social assistance is realized. T h e r a p e u t i c t a s k s o f h o m e c a r e. The home care doctor, while prescribing appropriate treatment to patients in a home setting, also establishes the necessary regimen, proper care, issues a sick leave certificate when necessary, and if hospital treatment is indicated (infectious diseases, the need to carry out a number of procedures in the hospital or any medical intervention possible only in a hospital setting, unfavorable living conditions, etc.), refers the patient to a hospital. When the patient is able to visit the outpatient clinic, he is transferred by home care under the supervision of the outpatient clinic or polyclinic, dispensary, etc. In cases of contagious diseases, home care is limited to one visit for diagnosis, referral to a hospital and taking measures to carry out disinfection. For the most part, the provision of home care is not limited to one visit; along with repeat visits, the organization of special care with the help of middle medical personnel is often required. A home care point must be supplied with necessary care items for temporary use by patients: bedpans, urinals, hot-water bottles, ice bags, rubber rings, etc. The home care doctor must have during visits test tubes for taking blood, test tubes with swabs for taking smears, slides, etc. for carrying out necessary laboratory analyses, and must be able to obtain from the home care point a stomach tube for extracting gastric juice for analysis or for washing the stomach. P r e v e n t i v e t a s k s o f h o m e c a r e. Along with providing therapeutic assistance, home care doctors carry out a number of important preventive tasks: familiarization with the living and working conditions of patients and their entire surrounding sanitary-hygienic environment, clarification of the causes and sources of observed diseases, especially contagious ones, and taking measures to prevent the spread of diseases (timely disinfection, isolation of patients, acquainting those around with measures of personal prevention, etc.). The home care doctor is the closest advisor to the patient and those around him not only on issues related to the treatment and care of the patient and measures to protect those around from illness and the instillation of sanitary-hygienic skills, but also on socio-legal issues (procedure for exemption from work, receiving benefits from the insurance fund and admission to a sanatorium, rest home, procedure for providing for children when their parents are ill, procedure for placing children in various children's institutions, etc.). The home care doctor contributes to the improvement of the entire home environment, takes the initiative to improve through the appropriate authorities nutrition, housing conditions and working conditions that adversely affect his patients. He is also a propagandist of sanitary culture in the homes of workers. He is a member of the commission for improving labor and living conditions of the corresponding polyclinic and participates in the distribution of socio-preventive assistance, caring for the proper satisfaction of the needs of the patients he serves. The district doctor, with a rationally organized system of providing home care by district, becomes a kind of "family doctor" of the patient. Home care plays a particularly important role in improving living conditions, spreading sanitary-hygienic knowledge and healthy hygienic skills. Familiarizing himself with the living conditions of the entire family, the health status of all its members, and all the questions that concern them, the home care doctor has the opportunity to give rational advice. The particularly great importance of home care in the fight against infectious diseases is S96.

Home care assists sanitary organizations in identifying contagious patients, takes measures to isolate them, send them to hospitals, carry out disinfection, informs those around the patient of necessary information for their protection from infection, and informs sanitary authorities of sanitary defects threatening public health: unsanitary housing conditions, yards, etc., of noted diseases caused by consumption of contaminated water, spoiled food products, etc.; at the request of sanitary authorities, it carries out necessary bacteriological research through laboratories, etc. Home care, with its sanitary-preventive functions, which often dominate its work, is a very important link in the entire system of Soviet prevention. Organization of home care. To provide home care, experienced therapists familiar with both contagious and childhood diseases are usually involved. They must be qualified not only in the field of curative medicine but also in prevention, as home care doctors must constantly quickly orient themselves in the surrounding domestic environment and carry out dispensary-consultative and investigative functions in the course of their work. When necessary, home care doctors invite consultants from various specialties who are on staff at the corresponding polyclinic or outpatient clinic to examine the patient at home and provide specialized assistance—pediatrician, surgeon, neurologist, otorhinolaryngologist, gynecologist, etc. The most common form of organizing home care in large cities and industrial centers is the combination of home care with outpatient care, i.e., the home care doctor conducts outpatient reception for a certain period, usually 2-3 hours; the rest of the time provides home care. Each home care doctor is attached to a specific area of a district, city, industrial center, and serves patients of their area with both outpatient care and home care. These are so-called outpatient-home doctors. With this form of organization, it becomes possible to provide the most rational systematic medical-sanitary service by the same doctor to patients of a specific area. Work of the home care point. In many cities and industrial centers, there are special home care points with a special staff of home care doctors who perform no other functions. Usually these special home care points, which were the predominant form of home care organization until almost 1931, are located at corresponding polyclinics or special outpatient clinics. With this form of organization, the entire territory served by the home care point is divided into separate areas to which home care doctors are attached. The standard norm is considered (for cities and industrial centers) 1 home care doctor per 4-5 thousand population, or 7-8 visits per day with a radius of the served area not exceeding 1 km. Depending on the availability of transportation, the number of home care doctors, the size and density of the population of the served area, and other conditions, the radius can be increased to 2 km. With a larger service area, the number of visits correspondingly decreases. The average norm for a home care doctor's work in cities and industrial centers should be considered 2,000-2,200 visits per year, but this norm correspondingly decreases with a large radius. The maximum norm is 3,000 visits per year, i.e., 10 visits per day with a workload throughout the entire workday exclusively on providing home care without any time spent by the doctor at the home care point, which is irrational. A home care doctor spends about 4 hours per day on work directly providing home care, and the rest of the time is spent at the point for communication with medical personnel and the population. In the case where a home care doctor also performs functions of an outpatient doctor, the duration of his work providing home care and the norm of visits correspondingly change, the size of areas served by individual doctors decreases, and the number of doctors increases. When calculating the required number of home care doctors, in cities and industrial centers they base it on 2 visits per year per insured family or 0.9 visits per 1 insured person, and on average for a region, province—on the basis of 1.72 visits per year per insured family (family coefficient taken as 2.3) and 2 visits on average per illness. The indicator of home visits per 1 resident was on average in the RSFSR in 1931 0.34, in 1932—0.4. Usually certain hours, morning and post-lunch, are established for calling doctors depending on local conditions, and these calls can be made by phone, but to avoid disruption of work on accepting oral applications, they are accepted at a different time than oral applications, except for emergency calls, which are accepted immediately. At home care points serving a large area with a large staff of doctors, applications are accepted all day continuously. Usually registration is conducted by the middle-level personnel working at the point, who during their time at the point registers patients, manages the referral of appropriate patients to hospitals according to the instructions of home care doctors, maintains contact with other medical-sanitary institutions, accepts all kinds of applications and issues corresponding certificates, etc. Doctors come to the point at a set time, usually 1-1½ hours before the end of registration, not only to receive the appropriate applications with addresses of patients but also to have the opportunity to maintain proper contact with the point's personnel and the population, giving necessary information to relatives of patients about the health status of the latter and about other issues of interest to them in connection with the illness. Patients registered in post-lunch and evening hours are visited on the same day if the nature of the illness requires it, by a separate doctor or one of the doctors working during the day, but for further observation these patients are transferred to home care doctors working during daytime hours. Evening home care in most cases amounts to providing only emergency care, and therefore it is mostly included in the organization system of emergency care. The home care point is staffed by special nurses who spend part of their time at the point and part on visiting patients at home according to doctors' instructions. The staff of home care nurses is established depending on the number of home care doctors and on the basis that on average 12-15% of patients (and in large cities up to 20%) served by home care use auxiliary help from home care nurses to carry out doctors' prescriptions, and that a nurse spends approximately half of her workday at the point (and on average spends about 1 hour per visit). Usually 1-3 nurses work at a home care point, and each often serves 2-3 areas. It is accepted that for 1 home care doctor it is necessary to have ½ unit of middle-level medical personnel. With a sufficient staff of home care nurses, they are also attached to specific areas of the corresponding district. At each home care point it is necessary to have 1 registrar. The duties of a home care nurse include: carrying out all of the doctor's orders—dressings, injections, cups, enemas, etc., and instructing the close relatives of the patient about the necessary care for the patient, the conditions for maintaining the room where the patient is located, observance of necessary cleanliness of dishes, linen, the patient's nutrition regimen, etc. The home care nurse has with her a syringe, cups, thermometer, dressing material, iodine, ether, vaseline, etc. The home care point is closely connected in its work with a number of medical-sanitary institutions. Polyclinics, outpatient clinics, dispensaries transfer to home care patients who need treatment at home, and in turn home care transfers to the aforementioned treatment institutions for further treatment those of its patients whose health has improved so much that they can continue treatment on an outpatient basis. In cases where home care doctors also perform functions of outpatient doctors, the said connection of home care with outpatient care becomes very close. The inseparable connection of the home care doctor with the polyclinic or outpatient clinic makes it possible to have a unified form of registering illness at home and in the polyclinic, i.e., a unified individual card with family records. Home care doctors are in close contact with the health center of the corresponding enterprise, from which they through the appropriate polyclinic or outpatient clinic receive all necessary information about the working conditions and previous morbidity of the patients they serve who work at this enterprise, and to which they in the established order report data on patients with loss of work capacity. Similarly, a connection is established between home care and the corresponding hospitals to which home care doctors direct their patients requiring hospital treatment, after which the patients with the corresponding hospital's conclusion come under the further observation of their home care doctor, if such is indicated, and this observation usually continues until the patients are transferred to outpatient treatment or until their complete recovery.

The same connection is established by the Home Care Service (P. n. d.) with institutions of the Children's Health Protection and Health Improvement for those patients who are constantly served by these institutions. Patients referred by the Home Care Service to hospitals are usually admitted to them in the first place, since in these cases it concerns seriously ill patients who need urgent placement in a hospital, or patients who cannot be left at home without the risk of significant deterioration of their condition or infection of others.

Special types of Home Care. In addition to the Home Care Service usually provided for internal diseases, infectious diseases, gynecological, pediatric, and surgical cases, there are also some special types of Home Care. These include: Home Care for mental patients, tuberculosis patients, venereal disease patients, obstetric Home Care, and emergency Home Care, as well as Home Care by sanitary organizations. -Psychiatric Home Care. Home care for mental patients is provided in large cities and major industrial centers by a special institute of physicians—district psychiatrists. The district psychiatrist carries out systematic observation of all mentally ill patients in the corresponding district, visiting them at home when necessary, providing them with the necessary medical assistance. Usually, nurses-attendants are assigned to assist the district psychiatrist, visiting patients at home. The district psychiatrist serves mentally ill patients under public patronage and patients discharged from hospitals to their nearest relatives. -Home Care for tuberculosis patients. In many cities, to provide home care for tuberculosis patients who cannot come to outpatient treatment due to their health condition, mostly bedridden and extremely weak, specially designated tuberculosis doctors, usually from the tuberculosis dispensary, are assigned to permanent work in providing Home Care. Tuberculosis patients are usually visited by the doctor once a week, more often if necessary. In some cities, tuberculosis doctors who conduct outpatient treatment in tuberculosis dispensaries also provide home care to their patients, which gives them the opportunity to directly familiarize themselves with the living conditions of the patient, with their domestic situation. -Home Care for venereal diseases. Home care for venereal disease patients has to be provided only in severe complications (epididymitis, prostatitis, etc.) and venereologists rarely have to visit patients at home, unless the patient does not come for treatment and does not bring his family for examination to the venereal dispensary. -Home Care for the protection of motherhood and infancy—see Consultation—home care. -Emergency, urgent, rapid Home Care—see Emergency medical care. Home Care by sanitary organizations. To combat infectious diseases, sanitary authorities have to carry out a number of anti-epidemic measures at home—disinfection, isolation, quarantine. In addition, municipal doctors, and where there are none, general sanitary doctors, have to visit residential premises to conduct housing and sanitary inspections and take measures to eliminate unsanitary conditions. -Home Care in the conditions of a unified dispensary. In a unified dispensary, where all main types of treatment and preventive care are united under a single plan in one center, under unified leadership, and where all medical work is closely linked with preventive measures, Home Care constitutes an integral part of the entire activity of the unified dispensary. Being mostly territorially connected with all the main links of the unified dispensary, Home Care develops its work on the indicated bases, relying on the corresponding institutions that are part of the unified dispensary. And here, the doctors of the Home Care point also conduct outpatient treatment; special types of Home Care become more accessible in the system of the unified dispensary, and the preventive work of the Home Care point is significantly facilitated. -Home Care in rural areas is provided by district physicians in cases where emergency care is necessary and it is impossible to bring the patient to the hospital. The staff of rural district medical institutions also includes functions for providing home care (see Medical district).

D- gorfin.