Polypharmacy and the Readmission Quagmire

Our homebound seniors belong to a growing population group that is vulnerable including unnecessary trips to the ER or hospital. When we implemented a quality improvement project looking into homebound seniors discharged from skilled nursing facilities, we found that more than. half of these seniors come home with 11 medications (the systematic definition of polypharmacy is 5 or more active medications).


By doing transitional care medical house call visit, we were able to significantly reduce polypharmacy to 7 medications. Polypharmacy is one of the quicksands in preventing readmissions to the ER or hospital.

Dementia and the Brain

The portion of the brain that gets preserved, according to Mary Cochran Abraham, GNP, in her presentation to the California Association of Long Term Care Medicine (CALTCM) this fall, includes the areas that control automatic speech and rhythm (circled in blue above). This explains why music can be an integral part of a dementia patient’s comprehensive care plan. It also explains why some of our dementia patients repeat words such as, “help me, help me, help me,” or repeats expletives over and over. 

Emergency Preparedness in RCFEs

AB 3098 is effective January 1, 2019

We cannot stop natural disasters but we can arm ourselves with knowledge: so many lives wouldn’t have to be lost if there was enough disaster preparedness (Nemcova).

AB 3098 was recently signed by Governor Brown, effective January 1, 2019. This bill requires all RCFEs to have additional elements within the emergency and disaster plan. 

… Care Home By RNs has geared up to meet this requirement.

A Picture is worth a Thousand Words

Conducting a fire drill at Aspen Meadows Care Home By RNs in Lincoln, Ca headed by Christina (house manager) and assisted by Mary Ann.

This bill requires all RCFEs to have additional elements within the emergency and disaster plan. In addition, this bill requires Community Care Licensing to confirm, during annual visits, that the emergency and disaster plan is on file at the facility, with required content. Violation of these provisions would be a crime.

Disasters in 2017

The year 2017 was a record year for disasters. Preparation is key, according to the Senior Community Learning.

More information about disaster preparedness can also be found in www.RedCross.org including disaster toolkits.

Look deep into nature, and then we will understand everything better… (Albert Einstein)

Care Home By RNs

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Caring in extraordinary circumstances

by Albert Wilson, RCFE Administrator (excerpts from a letter to state licensing)

As most of us probably notice, the hospitals of today are looking more like ICUs and so consequently the skilled nursing facilities (SNFs) are looking more like the hospital of years ago. Consequently, the Assisted Living Facilities including those of us who are in the 6-bed healthcare space are also seeing this change in the types of clients that are being referred to us.

PEG tube may be a way to continue nutrition when a person is unable to eat by mouth.

For example, we had three separate requests for PEG tube care in the last week alone. We let the families and discharge planners know we will work on developing a strategic care plan that will help address these needs. As we know, some of these PEG tube clients either do not have enough funding to afford SNF care at private pay or just are not able to thrive in a large-scale care environment that a focused care environment (that small homes) can provide may benefit them.

A reducted approval letter for PEG tube care at Care Home By RNs facility.  CONFIDENTIAL: Pls do not copy, print or distribute.

To worsen matters, some of our seniors are either clogged up in the hospital ERs or SNFs that worsen the hospital/ER readmissions problem. 

At Care Home By RNs, we are hoping that we would be able to meet licensing requirements and regulations (through exceptions) to take care of clients with PEG tubes in a small home-like environment. It’s been rightly told to us that regulations show PEG tubes are outside the scope of RCFE’s.

Care Home By RNs is continuously working on innovations in the care for seniors in the 6-bed residential care realm. A program/action plan in collaboration with a medical house call practice who can provide the medical and nursing oversight may be able to make the care in this extraordinary circumstance be a reality.

We have had success in getting an exception granted in a Care Home By RNs facility in the Bay Area. We’re open to new ideas on how to move forward now or in the near future to find a way to serve our community and families in need of PEG tube care.

Diabetes management options at Care Home By RNs

by Dr. Ron Billano Ordona, DNP, FNP-BC

According to an article in the American Family Physician, a comprehensive, collaborative approach is necessary for optimal treatment of patients with type 2 diabetes mellitus. Treatment guidelines focus on nutrition, exercise, and pharmacologic therapies to prevent and manage complications.

Nutrition plays an important role in diabetes management.

Care Home By RNs collaborates with the Senior Care Clinic Medical House Calls to provide both nursing and medical oversight to prospective residents needing diabetes care that involves injections. As a general rule (with exceptions), RCFEs are not designed to manage diabetes injections, let alone titrate the medication to a once-a-week treatment modality*, saving the family the expense (or hassle) of 2-3 times daily insulin injections. 

Advances in diabetes management provide options for once-weekly dosing especially for patients living in places of residence that has restrictions to using injectable medications. With careful planning and monitoring, though, a once-weekly dosing is achievable.

*not applicable in this case scenario to type 1 diabetes or Kaiser patients. 

Referenced in this article: Am Fam Physician. 2015 Jul 1;92(1):27-34

Improving Access to Care: APRNs in House Call Practice

by Dr. Ron Billano Ordona, DNP, FNP-BC

For us in the house calls practice, as soon as we see our first elderly, homebound patient of the day, we get the rewarding feeling that these vulnerable seniors would have ended up in the emergency department if not for our preventive care. For this vulnerable population group, APRNs in the house call practice provide the much-needed access to care.

As such, the American Association of Retired Persons (AARP)’s Campaign for Action1 supports changes that would allow APRNs to certify for home health services. Removing this barrier will mean that more Americans will have improved access to high-quality, affordable health care, when and where they need it. This is especially necessary for those who are homebound and vulnerable, as well as those in underserved areas or rural of the country.

APRNs, particularly those that do house calls for homebound seniors, act as a bridge to improving access to care for the growing population of seniors. An increasing number of homebound seniors are not able to see primary care providers in their offices but do need home health services. In some U.S. states, APRN practices have to wait for collaborating physicians’ signature on home health certification documents thereby, delaying the delivery of care.

It would be in the patient’s best interest that the provider who makes the house call to be the provider who certifies the need for home health services and communicates those needs to the Medicare-certified home health agency2.  

We would like to meet with more GAPNA members who do house calls. Please see us at the national conference in Washington, D.C. in September. The Housecalls SIG, which meets via telephone and video conference monthly every first Thursday at 5:30 PM (Pacific), would like to meet and greet September 28 at 4:30 pm (Eastern). Exact room will be announced at the conference. Please watch out for it or reach out in advance.


1 AARP Foundation. (n.d.). Improving access to care. Retrieved Aug 16, 2018, fromhttps://campaignforaction.org/issue/improving-access-to-care/
2 Brassard, A. (2012). Removing barriers to advanced practice registered nurse care: Home health and hospice services.Insight on the Issues, 1-10. Retrieved Aug 16, 2018, from https://www.aarp.org/health/medicare-insurance/info-07-2012/removing-bar…)

This article was published on the GAPNA website:  https://gapna.org/article/improving-access-care-aprns-house-call-practice

Care Home By RNs

Welcome to Care Home By RNs blog. Nurses are the most trusted professionals. Nurses as entrepreneurs is a concept that we support and nurture. Who would better serve an honored but vulnerable senior population but those who know caregiving from the get-go?

Founded by Nurses since 2006