Home health care (HHC) is that component of a continuum of comprehensive health care whereby health services are provided to individuals and families in their places of residence for the purpose of promoting, maintaining or restoring health, or maximizing the level of independence, while minimizing the effects of disability and illness, including terminal illness. (9) Even if HHC programs have been established as hospital-based programs for over the past ten years to solve the long-term occupancy of their hospital beds, it has just started in Saudi Arabia. There are no-community-based HHC services in the country.

The members of the home health care team may include: physician, nurse, medical social worker, home health aide, physician's assistant, psychologist, paid homemaker, dentist, rehabilitation personnel, dietician, optometrist, volunteer, friend, and family caregiver. Each professional from each discipline brings a special set of knowledge, attitudes, and skills to home care. The patient's needs and the requirements outlined in the home care plan are the bases of the level of involvement of each professional in the home care. There may be overlapping of functions because of patient's needs and the intermittent, part-time nature of professional home care services. (2) The home care professional is alone in the patient home with the patient, and must often provide, in addition to the planned professional interventions, a general view of the entire team's home care program. The shared tasks are brief assessment of the overall effectiveness of the comprehensive home care plan; assessment of patient and caregiver interactions and satisfaction with the home care program; identification of any new problem; notification of appropriate team member(s) for follow-up of new problems; and encouragement and reinforcement of instructions from other team members.(2) Each team's composition depends on each patient's needs and on its responsibilities to take care of these needs.

Key words. Home Health Care (HHC)

Home health Care (HHC) is a formal, regulated program of care provided by a variety of health care professionals in the patient's home. (1) The unique aspect of home care is the nature of the collaborative team effort.(2) Each professional from each discipline brings a special set of knowledge, attitudes, and skills to home care. The patient's needs and the requirements outlined in the home care plan are the bases of the level of involvement of each professional in the home care. There may be overlapping of functions because of patient's needs and the intermittent, part-time nature of professional home care services. (2) Unlike in hospital setting where other team members are readily around, the home care professional is alone in the patient home with the patient, and must often provide, in addition to the planned professional interventions, a general view of the entire team's home care program. The shared tasks are brief assessment of the overall effectiveness of the comprehensive home care plan; assessment of patient and caregiver interactions and satisfaction with the home care program; identification of any new problem; notification of appropriate team member(s) for follow-up of new problems; and encouragement and reinforcement of instructions from other team members.(2) Each team's composition depends on its responsibilities which each patient needs. A HHC team may include any of the following: physician, nurse, medical social worker, home health aide, physician's assistant, psychologist, paid homemaker, dentist, rehabilitation personnel, dietician, optometrist, volunteer, friend, and family caregiver.(2)

This article is a review of literature on the role of HHC team members.
According to Home Health Care websites, the home health care team consists of physicians, nurses, home health aides, medical social workers and therapists who coordinate care based on an individual's needs. (3,4,5,6,7)

The physician's role in the HHC team cannot be undermined.(8) Home visits very important to HHC for many reasons. They can help the physician gather information that may not have been uncovered in the office visit as evidence of neglect, incontinence, or use of multiple medications, understand better the environmental and family factors that might influence a person's health, and assess better pertinent activities of daily living and clarification of a situation that may have been perplexing in the office setting. Home visits serve as opportunities to monitor home care service. Physicians can act as administrators and active participants. By knowing the patient's baseline data, the physician can direct other health care professionals who are members of the HHC team. By understanding the role of each team member, the primary care physician will be able to provide more cost effective care. Another purpose of home visits is providing emotional support to the patient and the family. When a patient is seen by a physician in the home, fears of being abandoned will be relieved.(9)

There are two models for physician participation in the HHC team. The common model shows the physician relying on the home health care nurse to be liaison, team leader, and coordinator in addition to performing the regular nursing activities. (2) The second model is active physician participation in HHC. A mnemonic INHOME (9) (which stands for Immobility, Nutrition, Home Environment, Other home health care team members) was devised to help family physician remember its role. It expanded to INHOMESSS4 (which stands for Immobility, Nutrition, Home Environment, Other home health care team members, Medications Examination, Safety, Spiritual Health, and Services by home health agencies).

Corrective interventions can be made by physicians when proper assessment can be done of patient's mobility (daily activities of bathing, dressing, feeding, toileting, continence, shopping for food, paying bills, preparing meals, doing homework, etc.) and these can be properly evaluated more properly in the home. Corrected interventions can be made at any deficiencies noted. (9,10) Physicians can better evaluate the patient's current nutritional status and state of hydration as well as his capabilities for maintenance of proper nutrition. (9,10)

The patient's home environment should allow for privacy, social interaction and both spiritual and emotional comfort and safety. It can also reflect the patient's interests and hobbies. The physician can assess the patient's safety and sense of security in his home, and thus can recommend activities which the patient can do at home.(10)

Family physicians should evaluate and assess the other home health care team members' tasks. As the patient's social support system cannot be fully appreciated during office visit, the accessibility and helpfulness of family members and neighbors, especially in an emergency situation, need to be evaluated. Evaluation of the caregiver's needs and risk of burnout is critically important. (10) In the home, cues for caregiver stress or burnout are more evident and can be assessed easier, thus recommendations for respite care can be made more easily (9, 11)

The physician can assess the patient's medicine cabinet to be certain of the full extent of the prescription and nonprescription drug use by an individual patient, (9) and also allow a direct estimate of patient compliance, uncover evidence of "doctor shopping," and identify the use or abuse of over-the-counter medications and herbal remedies.(10)

The physician should be able to assess the patient's and caregivers' ability to manage the equipment at home such as ventilators, peak flow meter, self monitoring glucose levels, and others so as to teach them the proper use of each.(9,10)
Home safety assessment is done to assess the patient's environment as to his comfort and safety so that unreasonable injury is avoided. The physician should simply state the intention to identify and help modify condition to ensure safety. (10) Home safety elements are: furniture such as tables and chairs, stairs, bathroom, loose carpets and throw rugs, lighting and night lights, emergency actions and safety route, fire and smoke detectors, and fire extinguishers, water source, hot water heater, heating and air conditioning, gas and electric utilities.

The physician should well know that religion and tradition plays a strong role in Saudi Arabian society. The physician's ability to fast and to pray may be affected by his illness, and the physician should be able to assess this. He should be able to convince the patient on the medical aspect of health.

The nurse's role in the team is very important in the HHC since the most HHC service is provided by nurses. (10) The nurse collaborates with the physician to provide the patient with home care that he needs. Home care nurses also work with various personnel from ancillary disciplines to coordinate services designed to optimize a client's quality of life. A nurse determines the type and frequency of nursing interventions to be implemented and evaluates the patient for any needed ancillary services when performing a client's initial assessment. (10) The home care nurses primarily implement the medical and nursing care plans and identify needs for ancillary services and make recommendations to physicians. (12) Physicians revise treatment plans based on the nurse's report of changes in the patient since they see the patient frequently than the doctor. Developing comprehensive problem lists and assessment of care and goal plans are HHC nurses' responsibilities, too.(10, 11) All the HHC team personnel perform initial assessments, and subsequent assessment hereto after which all there services are based from; these they coordinate with the nurse. Case conferences are held wherein multidisciplinary team meets collectively to brainstorm strategies that will most effectively help patients to achieve their goals which the team members' goals are compatible with. The nurse coordinator establishes a schedule of visits with several people performing different interventions in rapid succession do not overwhelm patients. Lack of communication can cause unnecessary conflicts in treatment plans that send mixed messages to patients and lay caregivers, thus resulting in lay caregivers to lose trust in the home care team. The nurse coordinator sees to it that regular communication is important to ensure that interventions are complementary. (10, 11)

In addition, the nurse should provide the documentation, keeping all patient data (patient clinical assessment, diagnosis, HHC treatment plan, objectives, and goals) recorded. (10,12) Nurses must also stay in contact with different community services and organizations which will meet the comprehensive long-term needs of patients as: equipment, medical supplies, food, socialization, laboratory testing, and personal care. These organizations can facilitate and enhance the ability of patients to maintain independence in their own homes.(10,13)

The Pharmacist's role in the HHC team is guided by the American Society for Hospital Pharmacists' guidelines. He is responsible for willingness and ability of the patient or caregiver to be trained to properly administer medication; and appropriate indication, dose, route and method of administration of medication; and appropriate laboratory test for monitoring patient to medication orders. The appropriateness of whether the first dose of medication is to be given in the home should be guided by clinical judgment. The pharmacist should ensure that the patient or caregiver receives the appropriate education, training, and counseling regarding the patient's drug therapy. Pharmacist should be readily accessible in the event that problems or questions arise. The pharmacist should use clinical judgment for many procedures and equipment use and maintenance, home inventory maintenance, and procedures for securing additional supplies and medication when needed, potential adverse effects, drugs interactions, drug nutrient interaction, and their management; special precautions for the preparation, storage handling, disposal of the drug, supplies and biomedical waste, and emergency procedures. (13) The pharmacist with the patients or caregiver and other health care professionals is responsible for developing an appropriate pharmaceutical plan for each patient.

The physical therapist's role in the team is helping evaluate a patient's need for assistive devices (such as canes, walkers, crutches) and educate patients about their safe and appropriate use. He also assists patients to improve mobility and to reduce the risk of injuries resulting from accidents. He is most useful in putting up a plan for patients with mobility problems, difficulties with ambulation, transfers, or bed mobility and chronic pain, balance or coordination problems, or decreased range of motion and strength. He establishes the home exercise program to enhance or maintain a client's range of motion, muscle strength, and endurance. (9,10)

The occupational therapist's role in the HHC team is managing patients with diseases or disabilities affecting their functional status. Occupational therapists provide services to increase a patient's ability to perform activities of daily living such as: bathing, dressing, toileting, cooking, eating, and homemaking. They instruct clients on techniques on techniques, equipment, and aids that can help them to overcome their disabilities.(11) They also assist patients incapacitated by illness or injury with adapting their homes to improve functionality, as well as educate patients with reduced respiratory capacity (such as COPD, CHF) or with chronically compromised strength and endurance (such as muscular dystrophies) in energy conservation techniques. (10) They may recommend ways to adapt clothing that enable patients to dress themselves , use specially designed utensils or devices that will help patients maximize their autonomy, which can profoundly affect self-esteem and the ability to leave alone. (10, 11)
Occupational therapists develop exercise programs for home care patients who have decreased functions in upper extremity or hand because of impairment such as nerve or brain injury, or CVA. They can apply splints which are used to rest inflamed joints in optimal positions to prevent or to correct deformities. Occupational therapist also deals with applications for home adaptations, including stair lights or rails, grab rails, bathroom adaptation, widening door for wheel chairs, and positions of switches and extra heating appliances. (10)

In addition, the nurse should provide the documentation, keeping all patient data (patient clinical assessment, diagnosis, HHC treatment plan, objectives, and goals) recorded. (10,12) Nurses must also stay in contact with different community services and organizations which will meet the comprehensive long-term needs of patients as: equipment, medical supplies, food, socialization, laboratory testing, and personal care. These organizations can facilitate and enhance the ability of patients to maintain independence in their own homes.(10,13)

The Pharmacist's role in the HHC team is guided by the American Society for Hospital Pharmacists' guidelines. He is responsible for willingness and ability of the patient or caregiver to be trained to properly administer medication; and appropriate indication, dose, route and method of administration of medication; and appropriate laboratory test for monitoring patient to medication orders. The appropriateness of whether the first dose of medication is to be given in the home should be guided by clinical judgment. The pharmacist should ensure that the patient or caregiver receives the appropriate education, training, and counseling regarding the patient's drug therapy. Pharmacist should be readily accessible in the event that problems or questions arise. The pharmacist should use clinical judgment for many procedures and equipment use and maintenance, home inventory maintenance, and procedures for securing additional supplies and medication when needed, potential adverse effects, drugs interactions, drug nutrient interaction, and their management; special precautions for the preparation, storage handling, disposal of the drug, supplies and biomedical waste, and emergency procedures.(13) The pharmacist with the patients or caregiver and other health care professionals is responsible for developing an appropriate pharmaceutical plan for each patient.

The physical therapist's role in the team is helping evaluate a patient's need for assistive devices (such as canes, walkers, crutches) and educate patients about their safe and appropriate use. He also assists patients to improve mobility and to reduce the risk of injuries resulting from accidents. He is most useful in putting up a plan for patients with mobility problems, difficulties with ambulation, transfers, or bed mobility and chronic pain, balance or coordination problems, or decreased range of motion and strength. He establishes the home exercise program to enhance or maintain a client's range of motion, muscle strength, and endurance. (9,10)

The occupational therapist's role in the HHC team is managing patients with diseases or disabilities affecting their functional status. Occupational therapists provide services to increase a patient's ability to perform activities of daily living such as: bathing, dressing, toileting, cooking, eating, and homemaking. They instruct clients on techniques on techniques, equipment, and aids that can help them to overcome their disabilities.(11) They also assist patients incapacitated by illness or injury with adapting their homes to improve functionality, as well as educate patients with reduced respiratory capacity (such as COPD, CHF) or with chronically compromised strength and endurance (such as muscular dystrophies) in energy conservation techniques. (10) They may recommend ways to adapt clothing that enable patients to dress themselves , use specially designed utensils or devices that will help patients maximize their autonomy, which can profoundly affect self-esteem and the ability to leave alone. (10, 11)
Occupational therapists develop exercise programs for home care patients who have decreased functions in upper extremity or hand because of impairment such as nerve or brain injury, or CVA. They can apply splints which are used to rest inflamed joints in optimal positions to prevent or to correct deformities. Occupational therapist also deals with applications for home adaptations, including stair lights or rails, grab rails, bathroom adaptation, widening door for wheel chairs, and positions of switches and extra heating appliances. (10)

The primary objective of a caregiver for an aging or disabled individual is to provide a safe environment combined with the highest level of achievable independence. Fortunately, the home health care industry and medical products manufacturers have produced innovative products and equipment designed to help patients maintain independence, dignity and safety. Medical Supplies & Equipment is a reliable, established home health care supplier offering a wide range of physician-prescribed home health care.(14)

The speech therapist's role in HHC team is to help patients develop their remaining communication skills and to learn compensatory communication mechanisms through visual cues and cognitive retraining. He sets up a variety of communication aids and technology, assists patients with learning sign language, obtaining hearing aids or mastering the use of an electrolarynx, and teaches them to use a simple communication board that includes common messages they wish to communicate, which enable patients to point messages on the board indicating whether they are hungry, thirsty, hot, or cold. Recent advances in computer technology provide telecommunication systems for hearing loss patients which transcribe spoken words into written messages on a screen. (10)

The role of social workers in the HHC team is to provide invaluable assistance to the home care team by providing emotional and psychological supports. Sometimes HHC becomes stressful due to conflicts between the caregivers and patients, limited community resources, restrictions on the type and amount of care provided, and the challenges to patient autonomy that arise as a result of chronic and acute illnesses.
When patients inexplicably fail to comply with instructions outlined in their treatment plans and the refusal of care to participate in the care of a patient for reasons that are not apparent to the clinicians involved, social aspect of HHC management may appear. The social worker is the key figure in access to community care services for care of elderly patients or old age psychiatry. (15) When an extra support at home is needed, social worker will start a formal assessment procedure which varies from an initial assessment of mobility, personal care abilities, and current environment process involving input from other members of HHC team and including assessment of finances. (16) He links the patients also to formal and informal sources of support, and providing emotional support to help them resolve feeling related to loss, the burden of caregiver, and the need to readjust relationships in the face of illness and disability. (16) The social worker's community-based activities of care are coordination, health education, counseling, assessment, and skill in facilitating decision making related to ethical issues. To insure that standard are maintained the social worker will do regular inspection and monitoring unit visit (16). The social services departments provide 24 hour emergency call system for people who are: elderly or disabled; living alone or unable to use an ordinary or adopted telephone, which consists of press button and loud speaker installed in the phone or a portable pendant that is worn around the neck or as a bracelet or brooch.(16)

The role of home health aid in the HHC team performs services involving the personal care of the patient. The home health care assistant works under the direct supervision of the home care nurse to follow a course care outlined in the written care plan. (10) He may help the patient in bathing, transferring in and out of bed, grooming, dental care, exercise, and taking of medications. He may also help with light housekeeping chores, such as changing bed linens. (10) A trained paid housekeeper can take this role of the home health aid.

Family members can provide personal care, wound care and administration of intravenous medications.(17) Although HHC has the ability to lower the more obvious health care costs associated with hospitalization or long-term institutional care, home health care may also increase the personal cost to family member's emotional, social, physical, and financial well-being. (17, 18) If the patient's informal support network becomes unable to handle the increased burden resulting from disease progression, treatment intensity or depletion in available resources, home health care may collapse. A home health care team should consider the increased family caregiver burden and try to decrease it by looking for other alternative such as respite care. The aim of respite care is to ease the pressure of the caregiver by substituting an alternative method of care for a period of time which may be a few hours, days or weeks.(16)

In cancer care, home health care team members are composed of the following:(19,20) oncologist, rehabilitation specialist, nurse, psychologist, psychiatrist, social worker, dietary or nutritional service , and home health aides. The services of a rehabilitation specialist help people recover from physical changes caused by cancer or cancer treatment. It includes the services of physical therapists, occupational therapists, counselors, speech therapists, and other professionals who help you physically recover from cancer.

In Saudi Arabia, the results of the Al Hazmi study 21 showed that health care professionals had positive attitudes toward HHC services. Virtually all health care professionals agreed that there is a need for home health care services in Saudi Arabia because of their importance to patients. This was supported by almost all their answers to the important questions related to providing HHC to their patient. This reflects from their experiences from their professional day-to-day practice the actual patients' needs of home health care. It was also found out that no structured HHC services were available in government hospitals and PHHCs in Al-Khobar and Al-Dammam.

The quality of life of the terminally ill patients relies heavily on the psychosocial skills of health care professionals. The health care team consists of a physician, nurse, respiratory pharmacists, therapists, social worker, home health aide and volunteers. The team develops an individual care plan, which will provide an appropriate support system for the patient and their family up to and beyond patient's death. Weekly meetings allow the team to focus on the changing needs of the patient and make adjustments to their plan.(13)