Standard Operation Procedure for Home Health Care Services

1. Referral Sources:

• Family Medicine Outpatient’s Clinic
• Inpatient

2. Referral methods:

• Outpatient patients are referred to the home visit team by Family Medicine doctor.
• Inpatients are referred to Family medicine team by consultation.
• Emergency cases are referred to outpatient Family Medicine clinic after discharge.

3. Doctors in charge:

• Outpatients: by Family Medicine doctor at outpatient clinic
• Inpatient: attending physician on call

4. Criteria for application

• Patient can only maintain limited self-care ability, i.e. he or she is confined to bed or chair for more than half of the time he or she’s awake.
  • Patient’s performance status: ECOG (the Eastern Cooperative Oncology Group) score >=2, or Karnofsky score <=50
• Those require an obvious medical need, such as those with nasal gastric tube or urinary catheter etc
• In stable condition
• Within 30 minutes of commute time from Taipei Veterans General Hospital.

5. Evaluation and Assessment

(1) Application Rejected: Reasons for rejection will be stated.

(2) Application Accepted:

        a. Filled out application form

    b. Sign consent form

    c. Create patient’s profile

d. Arrange the first home visit by the nurse

e. Filled the National Health Insurance application form

f. Arrange doctors visit (once every 2 months)

g. Arrange nurses visit (once every fortnight)

6. Closing Cases

(1) Case assessment and evaluation meetings are held regularly

(2) First evaluation will be held after 2 month, to assess whether case can be closed.

(3) The case may be closed if

1. the patient’s condition become stable,
2. The nasogastric tube or urinary catheter being removed successfully ,
3. Family can provide proper care to the patient,
4. The patient moved to nursing home/care facilities or out of service area

(4) If case cannot be closed, then application for extended home visit care will be sent to NHI.

7. Charges:

• Patient need to pay 10% of the expenses in addition to charged paid by NHI
• Equipment and technical charges: charges differ according to types of services provided and equipment used

Travel expenses (Taxi fares) will also be charged.