According to a 2007 report prepared by Weimberg, Lusenhop, Hoffer-Gittell, and Kautz, it is found that home care preparation and practice can be improved significantly when there is strong relational coordination between the formal health care providers and the home caregivers.

The report has fond that the patients, especially the elderlies have reported that they enjoyed and experienced better care that involved different aspects such as:

  • Improvement and reduction in pain through better management and therapies
  • Improvements in their functionality and quality of life and
  • Overall improvement in their physical as well as mental health conditions.

This is what home care service is all about: meeting the expectations of their clients.

In this specific arrangement, the APNs or Advanced Practical Nurses do the major part of the job that involves different aspects such as:

  • Diagnosing
  • Planning
  • Treating
  • Organizing health care process across a variety of disciplines
  • Coordinating the care process across a variety of providers and
  • Communicating with the primary care physicians

 It is their recognizing the hurdles to self-management such as depression, apathy, or cognitive impairment that will make the home of the patient and ideal medical home in the future.

Primarily, it is their close and constant coordination, interaction and relation with the formal caregivers that will better the standard of Philadelphia Corporation for aging and create virtually endless opportunities for the APNs. This relation helps them to find out what is it that you are not getting currently and meet that need partnering with everyone, demonstrating viability and value, and thinking beyond the conventional lines of the care process.

Description of caregivers

The meaning of an informal or family caregiver is a friend, family member, or even a neighbor who is not paid for providing care to an individual patient suffering from a chronic medical conditions or any acute disease. They may provide constant assistance to manage and assist the patient in a variety of jobs such as:

  • Bathing
  • Eating
  • Taking medicines on time
  • Dressing and even in some cases
  • Ventilator care and tube feeding.

According to research on such caregivers, it is found that:

  • There are 44 million caregivers at present who are over 18 years
  • There is approximately one caregiver for every five adults
  • Their unpaid work accounts for $257 billion and
  • Most of them are women handling personal care.

However, the research also found that there is a growing number of male home caregivers as well but they are involved in more complex jobs such as managing finances, arranging for proper care and supplies and also in providing direct assistance to the patients with more complex personal care.

Long-Term support and services

The informal or family caregivers interact with the formal caregivers especially when an individual patient needs care services and support on a continual basis. Long-Term Services And Supports or LTSS is best provided when there is such coordination and the are service providers along with the informal family caregivers work as a team. This team may include different other players such as:

  • Nurses
  • Advanced nurse practitioners
  • Assistants of the physicians
  • Physicians
  • Social workers
  • Home care aides
  • Psychologists and

Though the family members form the backbone of health care and LTSS systems, the entire team will be entitled to look for the four major areas such as:

  • Proper assessment
  • Systematic identification
  • Gathering health information using technology and
  • Formulating the best health care and social service workforce.

The team may also consist of other direct care providers such as hospice workers, physical therapists, language therapists, and occupational therapists.

Home and community-based services

Formal and informal caregivers are found in both home and community-based services. They improve the quality of home care including dementia care quality with an array of services that are of the highest of standards. These types of services include:

  • Health promotion
  • Teaching the patient and their family
  • Providing curative intervention
  • Rehabilitation assistance
  • End-of-life care
  • Social integration and adaption
  • Support and maintenance and
  • Support and guidance to informal caregivers.

On the other hand, tasks that include supportive home care are professional health care and support services.

  • Professional healthcare services are those that are provided by nurses, social workers and therapists and
  • Support services include personal care, homemaking, making in-home meals, and providing respite services.

As far as the community-based care services are concerned it includes day programs, geriatric assessments, and transportation services. All these constitute home care system. It is due to the absence of a national home care standard and framework that warrants for such a mix of private and public service coverage to somewhat balances the inconsistent home care services.

Few recommendations to follow

In order to promote family and patient-oriented home care during the transition, there are a few recommendations to follow to build a specific framework. This will help in assessing and meeting with the family caregiver's needs and design a proper plan of care. These recommendations include:

  • Arranging for funds to develop quality measures for home care focusing especially on the family caregivers and their experience in transitional care.
  • Enrolling more informal caregivers in transitional home care studies that may include patients and family caregivers coming from different cultures, races, and ethnicities.
  • Conducting further research on the roles played by the hospital staff and other care providers as well as their attitude toward family or informal caregivers.
  • Urging for more attention to the role of informal caregivers in developing better and more effective transitional care programs and policies.
  • Following the set standards of the Joint Commission and other accreditation organizations as well as home caregiver organizations and institutions.
  • Making elaborate changes in the payment policies so that it supports and encourages more engagement from the patients and families.
  • Expanding informal caregiver engagement in the new programs according to the Affordable Care Act that includes refining transitional home care.

Apart from that, advocating for adequate funding for these programs is also recommended.


Therefore, the role of the informal or family caregivers should not be overlooked especially at this stage when the home health care industry is looking for ways to contain the cost and improving the quality of healthcare.

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