Patient handling in home and community care

Everything in this course so far has taken place in a building designed for care: a hospital with ceiling lifts, an equipment pool, biomedical engineering down the hall, and colleagues a call bell away. A growing share of patient handling happens somewhere else entirely. Northbridge Home Care's 42 nurses, personal support workers and therapists see about 310 clients in their own homes, in apartments, farmhouses, basement suites and seniors' buildings across the city and the rural area around it. Group homes, adult day programs and supportive housing add more. In each of these places, the worker arrives alone or in a pair, the home was not built for lifts, the equipment is whatever the client has, and the client and family decide much of what happens.

Home care workers have some of the highest injury rates of any group of health workers, and handling clients is the leading cause. This lesson covers why home care handling is different, how Northbridge Home Care assesses homes and clients, the equipment that makes home handling safe, working with families and with clients who refuse equipment, transfers in and out of cars, and how a home care program plans visits so that no worker is left to lift alone.

Why home care is different

Nadia Rahman, a home care RN who drives about 180 km a week, lists the differences she sees every day:

• The space. Bedrooms are small and crowded with furniture. Beds are low, soft and pushed against the wall so the worker can reach only one side. Bathrooms are narrow, with a tub instead of a shower, and doorways are too tight for a wheelchair. Carpet, rugs and steps make it hard to roll equipment.
• The equipment. There may be no lift, or a lift but no spare sling, or a sling that has never been inspected. The bed may be a double bed the client shares with a spouse. A hospital bed or lift has to be ordered and delivered, which takes days.
• Working alone. Most visits are by one worker, so a move that needs two people in hospital has no second person. The nearest colleague may be 30 minutes away by car.
• The client and family are in charge. It is their home. Clients can refuse equipment, decline to move the bed or furniture, or ask the worker to do things the way they always have. Family members may help, or may get in the way.
• Time. Visits are short and tightly scheduled, and a worker running late feels pressure to hurry the next one.
• The trip. Workers drive in all weather, carry supplies from the car, and in winter walk on icy steps and driveways. Home care staff carry ice cleats from November to April.

The law still applies. Under the OHSA, the home care employer is responsible for its workers' safety even in a client's home: it must assess the hazards of each home, provide information, instruction and supervision, and take every precaution reasonable in the circumstances. A worker who believes a move is likely to endanger them can refuse, using the process in Lesson 2. Ontario Health atHome care coordinators arrange home care services for many clients, and their assessments and care plans are one source of information about a client's mobility.

Assessing the home and the client

Northbridge Home Care does a home safety and handling assessment before or at the first visit for every new client who needs help to move, and repeats it when the client's condition changes, after a hospital stay, or when a worker reports a problem. The assessment is usually done by a nurse or an occupational therapist, and covers three things.

• The client. The same mobility assessment used in hospital (Lesson 3), adapted for home: can the client sit up, bear weight, stand and step, follow instructions? What is their weight? Do they have pain, confusion, dizziness or behaviours that make moves unpredictable? What can they do at their best and at their worst, for example first thing in the morning?
• The environment. Room sizes, bed height and access to both sides, floor surfaces, steps, doorways, the bathroom layout, lighting, pets and clutter. The assessor sketches the bedroom and bathroom and measures the clear space beside the bed.
• The people and equipment. Who lives in the home and can help, what equipment is already there, and its condition, rating and service history.

The result is a handling plan for the home that says, for each task (getting up, toileting, bathing, repositioning in bed, transfers to a chair or car), which method and equipment to use, how many workers are needed, and what to do if the equipment is not working. The plan is kept in the client's file and in a folder in the home, so that any worker who visits can follow it.

Equipment in the home

The same principle applies at home as in hospital: equipment does the lifting, not the worker. Because equipment takes time to arrive, the handling plan includes what to do in the meantime, which may mean extra workers, a different schedule, or a short stay somewhere with equipment rather than a manual lift.

The most common items in home handling are:

• A hospital bed. A height-adjustable bed is the single most useful item. It lets the worker raise the bed to hip height for care and lower it for the client to get out safely, and it can usually be placed away from the wall.
• A floor lift or portable ceiling lift. Floor lifts work in homes with hard floors and enough space; carpet makes them hard to push. Some homes have a freestanding gantry lift, a frame that stands over the bed without fixing to the ceiling. Permanent ceiling track can be installed in homes for clients with long-term needs.
• Sit-to-stand aids, transfer boards and slide sheets, as in hospital.
• Bathroom aids such as raised toilet seats, toilet frames, grab bars, bath boards and tub transfer benches. Bathing is one of the riskiest home tasks, and many plans switch to a sponge bath at the bedside, or a bath at a day program with a lift, rather than lifting a client in and out of a tub.
• Mobility aids such as walkers and wheelchairs, which the client uses between visits.

Equipment is paid for in several ways. In Ontario, home care can arrange some equipment and supplies for clients, the Assistive Devices Program helps pay for some mobility devices, and vendors and charitable loan programs rent or lend others. Clients may also have private insurance or buy equipment themselves. The handling plan notes who owns each item and who maintains it.

Equipment in homes is often owned by the client or a vendor, not by the employer, which creates gaps. Northbridge Home Care asks its workers to do a quick visual check of a lift and sling before each use, the same check taught in Lessons 4 and 5, and to report any damage to the office, which contacts the vendor or family. A lift that fails the check is not used, and the visit plan changes until it is repaired.

When the client or family says no

The hardest home care situations are not about equipment but about choices. A client may refuse a lift because it feels undignified, because it reminds them they are getting worse, or because they do not want a hospital bed in their bedroom. A spouse may insist that the worker help their partner up the way they always have. A family may refuse to move a sofa or remove a rug.

Clients have the right to make choices about their own care and their own home, including choices that carry risk for themselves. This is sometimes called the dignity of risk. But they do not have the right to require a worker to do something that is likely to injure the worker. Northbridge Home Care's approach is:

• Listen and explain. Find out why the client is refusing and explain why the equipment is needed, for them as well as the worker. Many clients accept a lift once they see that it is more comfortable and less frightening than being hauled up by two people. A trial with an occupational therapist often helps.
• Offer choices. There are often several safe options: a sit-to-stand aid instead of a full lift, a different time of day when the client is stronger, a hospital bed in the living room instead of the bedroom.
• Agree on what workers will and will not do. The plan states clearly which tasks workers can do safely without the equipment and which they cannot. Workers do not perform a manual lift because the client asks.
• Escalate and document. If no safe plan can be agreed, the nurse and the supervisor meet with the client and family, and the care coordinator is involved. In the end, the employer may have to limit or change the service, for example to tasks that do not involve transfers, while making sure the client is not left without care.

Family caregivers deserve attention too. They often do most of the handling between visits, without training, and are themselves at risk of injury. Showing a spouse how to use a slide sheet or how to let a client sit back down safely protects both of them, and many back injuries in home care happen when a worker and an untrained family member lift together.

Cars, stairs and the community

Some of the most dangerous moves in community care happen outside: helping a client into or out of a car for an appointment, up or down steps at the front door, or after a fall in the driveway. These moves are often unplanned and done in a hurry.

• Car transfers. The safest approach uses the client's own ability with aids: the seat pushed back and reclined slightly, a swivel cushion or transfer board on the seat, a handle that fits in the door latch for the client to push on, and the client sitting first and then lifting their legs in. Workers do not lift clients into cars. A client who cannot do this with aids needs accessible transport.
• Stairs. Clients who cannot manage steps with a rail and supervision need a ramp, a stair lift or an evacuation chair; workers do not carry clients up or down stairs. For emergencies, the plan says how the client will leave the home, usually with paramedics.
• Falls outside. The rules from Lesson 8 apply everywhere: stay, call for help, assess, and do not lift from the ground by hand. In winter, keep the client warm while help comes.

Workers also handle the equipment itself: a folding wheelchair, a commode or a portable lift into and out of a car trunk. Portable lifts split into pieces of a manageable weight, and workers lift them one piece at a time, close to the body, rather than all at once.

Planning visits so no one lifts alone

Because most visits are by one worker, the scheduling office has a key safety role. Every client's handling plan has a risk level and says whether tasks need one or two workers. Grace worked with the home care manager to make sure the schedule matched the plans, using a short script on a week's visit list.

# Check one week's home care schedule against each client's handling plan.
# need: workers required for the transfer tasks in the plan
clients = {
    "C-114": {"need": 2, "visits": [("Mon", 2), ("Tue", 1), ("Wed", 2), ("Thu", 2), ("Fri", 1)]},
    "C-207": {"need": 1, "visits": [("Mon", 1), ("Wed", 1), ("Fri", 1)]},
    "C-231": {"need": 2, "visits": [("Mon", 2), ("Tue", 2), ("Wed", 2), ("Thu", 2), ("Fri", 2)]},
    "C-305": {"need": 2, "visits": [("Tue", 1), ("Thu", 1), ("Sat", 2)]},
    "C-318": {"need": 1, "visits": [("Mon", 1), ("Thu", 1)]},
}
total = gaps = 0
for cid, c in clients.items():
    for day, booked in c["visits"]:
        total += 1
        if booked < c["need"]:
            gaps += 1
            print(f"{cid} {day}: plan needs {c['need']} workers, schedule has {booked}")
print(f"\n{gaps} of {total} visits are short-staffed for their handling plan")

C-114 Tue: plan needs 2 workers, schedule has 1
C-114 Fri: plan needs 2 workers, schedule has 1
C-305 Tue: plan needs 2 workers, schedule has 1
C-305 Thu: plan needs 2 workers, schedule has 1

4 of 18 visits are short-staffed for their handling plan

Four visits out of eighteen were booked with one worker although the client's plan needed two. Two of them were for C-305, a man whose plan had changed to two workers after a hospital stay, but whose schedule had not been updated. The fix was to make the scheduling system check the plan automatically, so a visit that needs two workers cannot be booked with one. Where a second worker is not available, the visit is moved, or the tasks are changed to ones a single worker can do safely, and the nurse is told.