Received date: April 17, 2016; Accepted date: April 28, 2016; Published date: April 30, 2016
Citation: Chen MJ, Chen CH (2016) Home Visits on Elderly in Public Housing in Taipei - A Team Leader's Observation. J Community Med Health 6:421. doi:10.4172/2161-0711.1000421
Copyright: © 2016 Chen MJ, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Purpose: The purpose of this study is to understand the health stakeholders’ characteristics who join the home visits.
Method: In this qualitative research, the data was collected based on team's leader observations.
Result: The personality traits of the health stakeholders included warm-heartedness, being passionate and
calmness. The team was professionally competent, enthusiastic and empathetic. There was an effective division of labor. All the members strongly approved of the interdepartmental arrangement. In our study, the pharmacist and dietician did not have younger staff (<5 years) to join the home visit.
Conclusion: It is an important to know that the characteristics of the health stakeholders who are willing to join home visit. The empathy training, communication skill and policy regulations should be included in the education programs.
Home visit; Qualitative research; Health stakeholder
Over a recent decade, the effect of different models of after-hours primary medical care services have been studied in the United Kingdom, United States, Australia, Germany and the Netherlands . Some studies focused on service satisfaction and reduction in healthcare expenditure [2,3], which have led health authorities in some countries to increase use of telephone counseling and triage [2,3]. Research in the United Kingdom found high satisfaction with home service despite a significant drop in the number of visits. However, patients complained about telephone counseling because they felt many symptoms could not be clearly described over the phone. In Denmark, after the new mode of service was introduced and centrally managed in 1992, the actual number of general practitioners’ home visits fell significantly while the patients remained satisfied .
To tackle the challenges of ageing population, weakening of family functions, and increasing cost of care and economic burden on families, Japan introduced long-term care insurance in 2000. A component of home medical care has been added since 2006, with higher remuneration than facility care. As of 2014, 13,000 cases received home medical care, accounting for 20% of general physicians’ total service volume. The multi-disciplinary program integrates medical insurance and long-term care insurance and provides patientcentered services including medical care, rehabilitation, home nursing care, daily care, etc . Care managers play a pivotal role of linking people’s needs and service. However, still more efforts are needed to improve the communication and coordination between medical care and long-term care providers .
Access to healthcare has been greatly enhanced in Taiwan since the national health insurance program took effect in 1995. The payment method for primary care physicians is based on fee-for-service and does not cover home visits. In other words, Taiwanese general practitioners do not provide home visits .
Physicians in the department of family medicine of Taipei City Hospital Heping Fuyou Branch form the backbone of the team and apply the chronic care model  to design the community-level home visiting services. The key to successful chronic care relies on whether healthcare providers are able to form a prepared, proactive team, and whether patients are well-informed and actively managing their own health [8,9]. Guided by the chronic care model and measured with health outcomes, an interdepartmental healthcare team is formed with a mission to develop positive therapeutic relationships characterized by congruence, accepting and empathy, according to Rogers .
Located in Wanhua District, Taipei, the Chung Cheng compound is low-cost public housing managed by Taipei’s social welfare department. Its elderly residents are of low or middle-lower income and live alone. The health stakeholders visited single-living residents 65 years of age and older who were in need of medical or welfare intervention in the Chung Cheng public housing.
Home visit and case management are seen as a type of service delivery system able to assist individuals or families in complex situations by evaluating their healthcare needs and referring them to necessary services, while taking into account their economic status and preferences. Care provided with continuity, appropriateness and in a timely manner brings several benefits, such as resource-effectiveness, patient satisfaction and cost-effectiveness [9,11].
The purpose of this study is to understand the health stakeholders’ characteristics who join the home visits.
Headed by the chief of the family medicine department, the heath stakeholders are composed of one case manager, eight family medicine physicians, three pharmacists and three social workers. To begin with, two weeks prior to home visits, the heath stakeholders meet and formulate strategies to work with high-risk cases as well as those who agree to accept the home visit. Second, the team spends 30 to 60 minutes each case going through every dimension from medical need, medication, nutritional assessment to role of social worker before reaching a consensus. In addition, all the heath stakeholders have to acquire full understanding about the program and information systems involved beforehand. The case manager is responsible for making appointments with patients.
The team arrives at a predetermined time and provides services such as dementia evaluation, identifying polypharmacy, malnutrition, or ageing associated diseases, and giving information to access social welfare. It also refers those with special needs to necessary services or agencies. A copy of post-visit report will be shared with social workers stationed in public housings.
Receivers of home-visiting services in this study are the elderly living in Chung Cheng public housing who agree to take home visits and assessment after the social worker’s introduction of the program. The study protocol has been approved by the Institutional Review Board of Taipei City Hospital (IRB -10410108-E). During July and August, 2015, the team made 112 home visits to 88 senior citizens, including 66 men and 22 women aged 81.66+/-8.68. The heath stakeholders were 7 physicians, 3 pharmacists, 3 dietitians and 3 social workers.
Study subjects and job descriptions
In the observation based assessment knowledge, attitude and practice of the heath stakeholders is observed and noted by the team leader, currently head of the family medicine department with a doctoral degree in health education and health promotion.
Working in the field for over two decades, she has gained experience in chronic disease management, community medicine, long-term care and health administration. Job description of the team leader includes duty assignment, quality management, convening coordination meetings, communication and coordination, crisis management and other administrative tasks.
Visiting physicians conduct comprehensive assessment, including dementia and depression assessment; pharmacists address medication literacy, adherence and storage; dietitians use Mini Nutritional Assessment to understand cases’ nutritional status and perceptions of healthy diet; social workers observe if cases need other social welfare assistance or intervention.
Observation-based assessment helps to identify the needs and characteristics of the heath stakeholders on one hand, and reinforces the concept of unconditional positive regard on the other.
In each trip, the team leader observes the heath stakeholders to gain understanding of their knowledge, attitude and practice. The team leader takes note of members’ regular and non-regular performance. The observation and field notes are the primary data source to construct a picture of the healthcare team’s experience.
Measurement and analysis
In this qualitative research, the data was collected based on team's leader observations.
The heath stakeholders consisted of 7 physicians (team leader excluded), 3 pharmacists, 3 dieticians, and 3 social workers. Data presents below exclude that of the team leader. Of the 16 members, the majority (10) are aged between 31 and 40, with a mean age of 37.88 +/- 9.75.
Fourteen of them have an undergraduate degree and the other two post-graduate degree. The majority have worked 6-10 years, with a mean of 10.19 +/- 8.00 years (Table 1).
|Age 37.88 ± 9.75|
|10.19 ± 8.00|
Note: The denominator of percentage is 16.
Table 1: Demographic analysis of the heath stakeholders.
Team leader’s observation and field notes were compiled in October, 2015 and then categorized into four main headings as follows:
personality traits, professional competence, attitude, and team identification (Table 2).
|Personality traits||Professional competence||Attitude||Team identification|
Treat cases in a friendly and professional manner
Have patience and bring in health education in response to case’s questions
|Clinical work tenure
1~5 year 
6~10 years 
>10 years 
Good attitude, friendly and concerned about case’s health
. A passion to serve
|Level of team identification 
Have a high level of identification with the work and find it meaningful
Ability to identify procedural problems and propose solutions
Ask questions and offer constructive solutions
|Providing professional guidance
Provide service in a way that is firm and professional
Actively promote and explain the program
Adhere to professional ethics and provide health education
Professionally trained, able to disseminate correct information
Show patience and provide health education in response to case’s questions
Good attitude, put oneself in other’s shoes.
|Division of labor 
Excellent division of labor, can learn a lot by working with different professionals
Stable and quiet
|Awareness of cases’ needs 
Understand cases’ needs and provide health education while adhering to professional standards
2. Well-trained but unable to initiate communication with cases
Gentle temperament, lacking confidence
|Workforce allocation 
Manpower allocation can be included in the agenda of pre-visit case discussion
Signs of nervousness in body language when case brings up questions
|Familiarity with referral procedures 
Provide service in a way that is firm and professional, make referrals when necessary
Have a good interaction with cases; have proper etiquette when addressing cases
Table 2: Four domains of observation-based assessment.
Descriptions such as warm-hearted, passionate, calm and nervous were coded under “personality traits”; clinical work tenure, certificates, providing professional guidance, and awareness of case’s needs were coded under “professional competence”; enthusiastic, sympathetic, hesitant and unconfident were coded under “attitude”; level of identification, labor of division and workforce allocation were coded under “team identification”.
Briefly, the observation-based assessment showed that the heath stakeholders were mostly warm-hearted, enthusiastic and calm; they were professionally competent; their attitude was active and sympathetic; all of them supported a division of labor and showed a high level of group identification.
The personality traits of the heath stakeholders included warmheartedness, being passionate and calmness. The team was professionally competent, enthusiastic and empathetic. There was an effective division of labor. All the members strongly approved of the interdepartmental arrangement. In our study, the pharmacist and dietician did not have younger staff (<5 years) to join the home visit.
Japan has started home medical care since 2006. Their experience shows that a visit made by professionals in medicine, pharmacy and nursing at the same time has achieved the highest efficiency . A pharmacist is always needed, especially in nursing homes, to prevent duplicate medication and improve drug safety. How to educate and motivate the junior pharmacists on home visiting did not be mentioned in the previous study in Taiwan.
It is not consistent for the nutritional evaluation of elderly in the community on age, singly, living with spouse, economic status and meal frequency in different countries [12-18]. The role in home visit is important as a dietician. Although the seniority and experience are the keys to some situation during home visit. To arouse the passions and to train the communication skills for new generation should be arranged in the regular curriculums and community courses.
In our study, one social worker seemed to be nervous and unconfident during home visit. She had the signs of nervousness in body language when case brings up questions. Otherwise, empathy has many different definitions that encompass a broad range of emotional states, including caring for other people and having a desire to help them; experiencing emotions that match another person's emotions; discerning what another person is thinking or feeling ; and making less distinct the differences between the self and the other . It also is an ability that we can be trained and be aroused.
The health stakeholders recommended that manpower training, inclusion of other specialists, more assessment, multi-channel marketing and health education, manpower and budget were factors to facilitate sustainable provision of home visit.
The impact of interdepartmental healthcare team on organizational culture was characterized by identification and coherence, and brainstorming. All the heath stakeholders noted higher degrees of identification and coherence, mutual respect and team workship. Home visits provided a platform for frequent cross-departmental interaction and collaboration, and understanding of the functions and strengths of other departments. On the other hand, due to a large number of cases, concerted efforts within the department have become a must in order to achieve targets.
As the population ages, the world began to pay attention to the integration of the health care and social care. "Aging in place" is the trend of the society. In Taiwan, the poor integration is not the result of redundant growth of services but rather, the departmentalism within agencies, particularly the social work administration and health administration. As a result, the management and scope of services are not well defined or clearly mandated. This is an issue repeatedly brought up in evaluation reports and one of the proposed solutions is case management .
The Taipei City Hospital initiated in April 2015 a pilot  “hospital-based family physicians outreach program,” providing a range of primary care services from health assessment for the elderly, medication assessment, vaccination reminder, telephone counseling to nutritional assessment for vulnerable population groups such as those in low and lower-middle income households, the elderly who live alone, those with medical need or disabilities, etc. Objectives of the program are to improve health status, health literacy and care-seeking behaviors of the target individuals.
Working with different health professions is not equal to the effective cooperation for healthcare. The interdisciplinary team still needs to learn the adjustment. In public housing, not all people had a good knowledge about resources made available. It is an important issue that the characteristics of the health stakeholders who are willing to join home visit . How to implement the empathy training and education is needed to be investigated.
There are a few limitations of the study. First, it only collected the team leader's observations. A better understanding can be achieved when data from more data collection are included for analysis. Second, the study did not analyze objective outcome measures such as cost analysis or patient satisfaction and therefore recommend them to be included in further research.
The trend of population ageing and change in family structure has witnessed late or no care among those who are elderly, disabled or recently discharged. It has also produced long-term hospitalization out of social, rather than physical needs. Home care can be one of the solutions to address the issue.
It is an important to know that the characteristics of the health stakeholders who are willing to join home visit. The empathy training, communication skill and policy regulations should be included in the education programs.
We thank all physicians in the department of family medicine, pharmacists in the department of pharmacy, dieticians in the department of nutrition and social workers in the social work unit of Taipei City Hospital Heping Fuyou Branch for their contribution.