12 | What Actually Happens During a Home Visit with a Lactation Consultant?

Leah: Let's dive in. Hey, Annie, how are you?

Annie: I'm good. How are you?

Leah: Doing well, doing well.

Annie: Well, I'm excited because this episode is sponsored by Spruce, and I have to say that Leah and I are like, Yay! Spruce is sponsoring our episode because not only is it fun to have a sponsor, it's exciting for us that it's a company that has done so much for my private practice. So Spruce, I use it for my business line. I use it for secure messaging with my clients and I use it for a bunch of other things, one of which I'm going to tell you later on in the episode as the tech tip. And I think Leah will agree with me that Spruce gives amazing customer service. They're super responsive.

Leah: Their customer service is amazing. They respond so fast and are so very helpful. A couple of times we just had questions about different features, and they responded so fast that blew my expectations away. So that was really awesome.

Annie: Yeah, anytime I've had any little glitch, because any tech software solution is going to have glitches from time to time, they have been on top of it right away. They've been very communicative about it, and they fixed it.

Leah: Yeah. And my clients love it when I tell them we can't text over normal text lines, but we do have this option. They're usually like, Oh my gosh, that's awesome, and before I even leave my visit will be downloading it and getting it all set up. So I really, really have liked using it a lot.

Annie: Well, Spruce really wants you to try them out. So if you're listening to this podcast you can go to the show notes and you'll find in there a promo code that you can use to get a free month of Spruce. So you can try it, see if you like it. If you do like it, they can port your old number over. it's super-fast and that way you're not going to have any interruption in service from whatever service you've been using before, and if it's free Google Voice you're doing it wrong I'm sorry so Spruce is not the only game out there but it's the one that Leah and I really love.

Leah: yeah and don't be afraid of putting your number over. it was so simple. it happens right when they said it would, and it was super, super easy and that was the one of the things that I was scariest about, like are my lines going to be down for days on end? Am I not going to have communication? it was seamless. It was perfect. So yeah.

Annie: Well, cool!

Leah: Today we're talking about home visits and how you run your home visit because this is something I'm always curious about. I know we've talked about it so many times like, because lactation private practice is oftentimes so isolating, you don't know what is everybody else out there doing? I think I'm doing what everybody else is doing. So today we're going to delve in and what are Annie and Leah doing? And we're going to tell you all the juicy things that we do.

Annie: I hope this episode is helpful to those of you who maybe didn't come up through Pathway 3, where you were getting supervised clinical hours actually in a lactation setting. I hope if you are in Pathway 3, you're seeking out private practice lactation consultants and not getting all of your hours in the hospital or in a clinic setting because home visits as we'll talk about later in the episode, they're so different, but if you're coming up as a volunteer breastfeeding worker and getting your hours that way, you might be super strong in the group setting and in the one-on-one by phone, but you may never have had a chance to actually watch a lactation consultant in person. So we're going to give you a little virtual peek. It's not a substitute for in-person shadowing. even if you're already an IBCLC, go find somebody to shadow. I love having new IBCLCs come along with me and because they don't have to actually do hands-on stuff with me, they can just watch and I really enjoy that. So before we actually talk about home visits and what they are and what Leah and I do, Leah has a marketing moment.

Leah: Yeah, so today I'm going to encourage all of you to take the brave initiative to ask for testimonials or reviews from your clients. This can be really great content to add on your social media, so if you get a great testimonial from someone who used your services that you can put on a pretty little Canva background and be another thing that you can share to keep building your content on social media. It's also a great thing to have the reviews on Facebook, if you do Google or Yelp, just the more reviews you can get, the better, but these moms who are sleepless and dealing with all the stuff that they're dealing with right away might not be up to filling out a review. But it's something that I've gone back like maybe I've seen a mom early on and then she'll have me come back for a return to work visit. And obviously she had me come back because she liked me and she thought that we had good work together, so that's the time that I will really maybe ask for a testimonial. we send a generic 'hey, did you like our services? Here's the link to give us a review' on all of our follow up emails. But this is more direct. sometimes I'll have that opportunity in these return to work visits or maybe a follow up visit if things are getting better to say, 'hey, reviews and testimonials really help us reach more mothers. and if you had a minute, it would be great'. And every single one that I've asked has been more than happy to jump on and do that for us, especially if I give them the direct link, they'll give me a review really quickly. Or if I just asked, 'hey, could you give us a testimonial that we could share on our website anonymously'. But anyway, I think it's really powerful way to add to your business.

Annie: Yeah. And I like your reminder that check with the people that are having you come back, or if they email you three or four months down the road and say I have a quick pumping question. I'm back to work and want to make sure I'm doing or whatever it is. Can I ask you about solid foods? We're still breastfeeding. You're like, oh, you're still breastfeeding at five months, and you're asking me about solid foods. This is somebody who likely was happy with my services, and that's a great moment to say, 'hey, would you mind, if you were happy, could you do this for me?' Because at the end of after you answer her question, or whatever it is, that's a great moment, because they're already happy that you're in their life and seeing you as someone who still has value to them, and that puts people in a place where they want to be generous in return.

Leah: Yeah, and I think I like to word it because I don't want to be like, do this for me. I like to word it as by having reviews and testimonials, I'm able to reach more mothers.

Annie: That's great.

Leah: So it's not necessarily about me. this is going to help me help more mothers and reach more mothers, so you're helping the whole world, and oftentimes, they're really responsive. So that's my marketing tip for today.

Annie: I love that. Thank you. So let's talk about home visits. So there's multiple different types of visits you could do. You could do an office visit, you could do a clinic visit, some of you are doing video consults. Some of you love phone consults, and you're doing those. But we're going to talk specifically about the home visit because that's a place where it's just so different, and different enough from not only other kinds of lactation visits, but different from any other kind of health care.

Leah: I know. We are really unique.

Annie: I often think of a home visit as more like relationship counseling than any therapy and in someone's sacred space and they have invited you in and here you are. Leah, I know you do both home and office visits. What for you makes home visits different from office visits?

Leah: Yes. I work in a pediatric clinic, and so we're seeing the families oftentimes on the same day they're seeing the doctor's visit. And I would say the biggest thing that I see as the difference is kind of the vibe of the visit because they're in doctor office mode, so things move really quickly. There's not as much. We certainly do plenty of connection and getting to know the family, but because one the timeline is different because we're in this pediatric office, we can't sit there for two hours with each family. The timelines are different. Things move faster. And although I feel like I connect with the moms, oh my gosh, the amount of connection that I can create in a home visit versus office visit is just vastly different, mostly because of time and then you're coming into their intimate setting versus the office visit. They're coming to me and it's very purposeful. You're here to help me with the .... Whereas the home visits a lot of discovery and what's going on and looking at their environment and taking in so many more factors, which require all that extra time. I don't know the living situation with my office visit clients. I might ask a little bit or they might give me a little bit but it's certainly not like sitting in their home and seeing what is this environment like. What are they dealing with the people who are in their home? What are they dealing with the different aspects of their living arrangements? It's just so much more that you get in home business. I love my clinic visits because I can see so many more moms. I feel like I'm having a bigger impact in some ways, but home visits are my heart. I love it. I love being in the mom's environment. I love just seeing them. They're just in a different space, so I can totally tell the difference.

Annie: I don't do office visits at all so I don't have anything to compare to, but I love the information I can pick up about the family just based on what I see when I walk in the door. I can pick up on cultural things like do they have a mezuzah on the door, which I see a lot here in Queens. It's just fun. It's like okay, now I know a little something about you. I know that you've got this aspect of you that's important to you. And it's just nice, those kinds of little things. I always look at the books that people have and ...

Leah: Yes, oh my gosh. I do that too.

Annie: And if we can connect over books, I totally go there, so I love that and I love seeing what personal items you've got. I love seeing their wedding photos. A lot of times you get these really young families and they maybe just got married, and I got married a long time ago. So it's so sweet and I'm like, you're sitting here with your new baby but you're still reflecting and loving that time when it was just you and I don't know. There's a lot about that stuff that I just love. I love getting really those personal things that they're not going to be asked about an intake form. It's not going to be anything you would ever ask have any clinical relevance but it just gives me this picture of these people. I love it and I also like the little clinical cues that I can get. So I could walk in and I always want to wash my hands in the kitchen, not the bathroom. They always try to send me to the bathroom but I want the kitchen, not only because I want to dry my hands with paper towels because I really don't like towels.

Leah: I agree.

Annie: So that's a thing. I know I'm not alone in that but also because I can see are there bottles in the drying rack? Are there pump parts in the drying rack?

Leah:
Yes, I always look out for parts

Annie: Is there a giant can of powdered formula on the counter? You know, whatever is going on, I can quickly get a sense of what's happening with this family, especially if they haven't been really detailed in the intake in the beginning and I don't know if they're pumping or supplementing and I just know my nipples hurt and that's I've gotten so I can start to put things together. I can what parenting books are on their table. So I can see if they have one of the really awful sleep training guides on there so I can know if they were being influenced in that way. And I can see what breast pump she has sometimes, and just like what you said about when there's other family around, I can get a sense of what her support is like, how she's being helped or not helped.

Leah: Yeah, I think all those factors are so, so valuable and I really feel like I get this deeper connection with the home visit moms, for sure for the most part. Sometimes in the office, but definitely at home visit. Yeah, I feel like I have so many places I can connect with them.

Annie: I also just like seeing people's homes, by the way, and I know I'm not alone on this. I'm like, how do you live? what kind of decor do you have? I get some families that have some really great design skills that I do not have. Oh, you can put a couch there?

Leah: I love that design. And I'll try to like, Okay, I need to remember that when I go home because I can put these things together and put things together that I would never have thought of putting together. Oh my gosh, that's so cute. I need to do that at my house. Yeah, totally fun. It's fun to have that little insight too, to get to see different things. Okay, so Amy, let's go through just a normal home visit for you, start to finish. We're going to do a quick rundown of what happens in Annie's home visits. I know, because we've talked about it multiple times, you have crazy drives or weird parking situations? But your clients have intake before the visit, right? So they have forms they fill out?

Annie: Yes.

Leah: Do you have 100% compliance with that?

Annie: I will not go to someone's home without a consent for care signed. I just won't do it. That's my own personal boundary. It's in my policies and procedures so I have 100% compliance in getting the consent signed because the platform I use which is CHARM makes that very easy. Other platforms also make it easy. So that's just the one I use. I don't have 100% compliance in getting information like what's your baby's last name? That is a big one that I don't often get, and I don't know what to put on the claim form, or what their birth weight was. I can live with that but as long as I have their consent signed, I feel like you're a legit person. You told me at least you did this for me. And so where we are, I sometimes actually do go to private homes where I'm parking right in front and ringing a doorbell and somebody lives there because there are places out in eastern Queens where people live like that like the suburbs, and sometimes I have gone out to Long Island and worked with people in private homes, but typically I'm going to apartment buildings.

So there's a couple of layers that I have to go through. I'm always parking, I'm walking, I'm buzzing downstairs, I'm getting buzzed up. I'm taking an elevator up and so I have this whole pregame thing that I do in the elevator, which mostly involves me looking at my phone and checking Facebook really quick, but I also like sometimes picture myself just revving myself up. Okay, get your game face on. get your game face on. I don't know if you've ever seen the great old movie All That Jazz with Roy Scheider, he has this ritual he does. My ritual is not like his. it doesn't involve pill popping or anything, but he always ends it by doing jazz hands and going 'it's showtime', and so that's how I feel in the elevator - it's showtime. So I ring their bell and they've all got the little peepholes and so I am always arranging my face so that I'm presenting a friendly face the moment they open the door so I'm not looking at my phone when I ring the bell. I'm looking at them. I ring the bell. I've got my nice little neutral, slightly smiling face on. I walk in and I say hi. I don't offer to shake hands; I will shake a hand that's offered to me but I don't extend my hand to shake it. I walk in, I've got all my bags, they say hi. If they say can I get you anything? If there are other people there, I will say I would love a glass of water. If it's only the parent and the baby, I will say no, thank you. I'm good. I have a water bottle in the car. So I only say yes if there's another human being beside the person I'm there to see

Leah: Yeah, that's very thoughtful of you.

Annie: And I say to them, okay, I'm just going to set my stuff down. I'm going to wash my hands and then we can get started. So if they offer to take my coat and again, if it's somebody who is not the parent I'm there to see, I will let them take my coat but if not, I just pile on my coat on the floor. I always take my shoes off. That is a cultural thing here in New York City. It's also a preference. Even if they are not a “shoes off” family, I will take my shoes off because I think shoes are disgusting. Nothing I could possibly be walking on a New York City sidewalk is to go to anyone's home.

Leah: Interesting that you say it's a cultural thing. Most people take their shoes off?

Annie: Well yeah, I go to a lot of places where they're like we are a “shoes off” house and I always try to get my shoes off before they say that so they know I'm a “shoes off” person.

Leah: I know already.

Annie: I know about the shoes. it's just disgusting, things I'm bringing in. I don't want to have my shoes on. I also can't think with shoes on either. I hate shoes. I'm anti-shoe, but I know there are some places where if you took your shoes off in someone's home, that's not cool or not done. So you got to do you but this is this is what I do. I take my shoes off. I wash my hands like I said. I try to wash them in the kitchen but if they send me to the bathroom, or if I have to use the bathroom, I am not afraid to say I just need to use your bathroom for a moment. sometimes I'm in the car for an hour before I actually see them or longer sometimes so if I have to use the bathroom, I'm going to ask to use the bathroom and I wash my hands. I take a long time. I dry my hands, or come out of the bathroom and then go to the kitchen and use their paper towels to dry my hands. And then I do all of those things. If I walk in and the baby's crying, I will hold going to the bathroom as long as I possibly can until a better moment. The baby's not crying. I'll go to the bathroom. That's if I have to go the bathroom so that we're getting really, really very close and personal.

Leah: This is good. Good. I like it. I like it.

Annie: So then I'll say I'm just going to take a moment and pull up my chart. This is if the baby is not crying, I'll say just need to take a moment to pull up the chart. I open up my iPad, which I have connected to a Bluetooth keyboard. I connect to my hotspot on my phone. I bring up their chart on CHARM. I get everything settled and as I'm doing the final pieces of that, I'll say I know you told me some things when you booked the visit, but I would love to hear just in your own words what's going on? So that's the first question I ask. So then they start talking and while they're talking, I'm recording things that are important to record. I'm charting, I'm asking follow up questions. whenever that client is telling me something momentous, or important or personal, so they're telling their birth story, or they're talking about their fertility struggles, getting pregnant or explaining to me how much it hurts, I tip my iPad, so the screen is facing down into my lap so I am looking straight at them. When they're telling me things like how many times did you breastfeed in the last 24 hours? how many bottles did the baby get, I will go back and forth between making eye contact and looking at my screen to record those things. So that's the distinction I make. personal means you get my full face. data means we're doing it like this, and I just kind of read the vibe of what's happening, and that really shows like I think hopefully they can tell that I'm actually listening. If there are things like data points that they tell me during their birth story, I will record those quickly later at a different time of the visit. So the next thing that I'll do is I'll say, Okay, I'll make sure I get all the information I want. And then I'll say Okay, the first thing we're going to do with your baby is we are going to weigh your baby with just a dry diaper on. So go ahead and undress your baby, I'm going to set up my scale. So while they're changing the baby's diaper, and I'm getting the baby, just in a dry diaper, I'll set up my scale. I ask them to give me a swaddle blanket. One of those muslin ones are my preference. I fold it for them, because this is another little sneaky home visit thing. They hand me the muslin blanket, and if it's folded like a triangle, I know they're swaddling because that's how they teach them how to do it. And if they hand it to me all in a lump, I don't know anything about them. But that's one little thing when it's in a triangle. I'm like, Okay, I know. I know something they're doing. So I fold it, I put it on there. I clear my scale with the blanket and then we weigh the baby. And then I tell her, okay, why don't we start by having you show me what you've been doing and we'll go from there.

So I start by having her just get her baby into the position and get her baby latched on. This is if they're latching. if the baby's not latching, we'll do some different stuff first. I'll get them skin to skin and laid back and start from there. If she's having nipple pain and if she's got severe nipple damage, usually I start by having you show me what you've been doing, but we already know that what you're doing is painful. So can we start with something different, or can you describe for me what you're you've been doing? And we'll see if we can start in a different place. Are you open for starting in a different place? Now this is not even specific to home or office, but speaking of nipple pain, I have a clinical policy, something I really try very hard to do is if a mom is having pain on latch, I try very hard not to be touching either her or her baby at the moment of the latch. So because I don't want her to have any perception that I'm pushing her into pain, that my physical touch is part of the pain she's feeling. So I feel very aware that I want to do all the coaching and get everything in there. But at the moment, once we're all in that place and the baby's about to go for it, I just take my hands off, so I try to get her everywhere and I'll use my hands to get her arm into position. But sometimes I'll even use some little gentle pressure on her arm to try to say lift your arm up, raise your arm up, scooch the baby up, but I don't do any of those adjustments at the moment of the latch when the mom's been having pain. I don't want to make it worse.

Leah: That's really interesting.

Annie: Yeah, that's just some little random weird thing that I do. So if the baby is starving hungry when I get in and needs to eat, I will do the 'wash my hands' thing, and then I will weigh the baby and I will take a picture of the weight on the scale, or actually, if I were, I will put it right away into the converter app on my phone because my scale does metric. And so then at least when I finally do have her information pulled up, I can go back to converter app and see what the weight was and the pre feed weight, and then I will get the baby's needs met. And then I'll say, Okay, I'm just going to take a minute and bring up your chart and you can tell me what's going on. But I will say let's just take care of this baby first. Yeah, that's a weird little home visit thing that also happens. I would imagine in the office there's some readiness when people walk in, and in a home visit, you never know what you're walking into so you just got to be flexible to roll with it.

Leah: Most of the time that's the case, although I can't tell you how many times I am working with somebody in the clinic and our waiting room is this separate little room, but it's pretty close, and I could hear the baby over there crying, but I'm trying to finish up the consult and I'm like, they need to eat. They need to eat.

Annie: Oh my God.

Leah: That is so hard mentally, because you're trying not to focus on the fact that this other little one is ready to eat and the mom is trying to hold them off so that they will eat when they're with me, so sometimes I've even been known to get another one in a room and bounce back and forth, because I cannot stand the thought of this little one waiting.

Annie: Oh my gosh

Leah: Oh, I know. It drives me crazy. I know. I feel so bad.

Annie: You do not have to actually be a parent to have so much empathy for that.

Leah: I know. I know. It's so hard. that is one of the hard things because in a home visit, you don't know. you're driving so you don't know what's going on.

Annie: I am never right on time when I say I'm going to be there. So I tell people I'll be there approximately this time, but it could be 10 minutes, just depending on parking because that's a variable I can't control.

Leah: I have a question. I'll interview you about this home visit. Do you tell your families something specific leading up to the visit? Do you tell them please have your baby ready to eat? Do you tell them have them down to a diaper? Do you tell them anything, like prep for your visit at all?

Annie: Yeah, I tell them that it's good if your baby's ready to eat about 30 minutes after I am scheduled to arrive, and they do what they can. I think the worst thing is when they're messaging me while I'm driving to them, my baby's hungry. Should I feed my baby? I am driving like and I can’t... and so that I find that very stressful. And I don't know that I handle it well, and sometimes honestly, I just ignore it and I say they are just going to have to figure it out because it's dangerous to text and drive. it's not a good idea. So...

Leah: Yeah, my assistant is really good. She'll be like, give them a little tiny snack, and then try to hold them off.

Annie: Yeah, if I can, if I'm at a very long light, then I can throw something like that in there. Just hang tight, I'll be right there.

Leah: I know, it’s so hard.

Annie: So then during the visit, I find the feeding is a really good time to chart and just kind of get caught up because especially if the baby is actually feeding, you could have 15 to 20 minutes where you're just kind of sitting there. I'll use that as a time to record things that I'm seeing in the visit. Just start checking some of the boxes on my charting template, ask more questions. A lot of times I'll wait till then to ask the birth story, just because she kind of wants something to do. we're all just waiting for the baby to be done eating. So there's a lot that I can do on my charting there, and then I always feed the baby on one side, then we'll do a post-feed weight. I'll see how that's going and then that's when I do the oral exam on the baby. I do it after one feeding because I don't want to have preconceptions about what's happening in that baby's mouth before seeing them feed. So I want to just see them feed, see what's happening in their mouth and in their body. If the baby didn't feed well and is still hungry after time on the breast, I will say let's give about half an ounce to an ounce of expressed milk before we try again.

So it just kind of gauging is this baby really hungry, especially if the baby isn't transferring well. I don't want to do an oral exam on a baby who is hungry. I want to make sure that baby is content or not stressed, because it's super important to me to keep the baby relaxed. If the baby is not handling things well, I might not do a full oral exam, I might not do everything that I would want to do because keeping that baby relaxed is more important than any data I could collect in that moment. So then we usually do the other side, talk more. while they're doing the second side, that's when I'll start to give my assessment of what's happening, and I'll say, here's what I think might be going on. Let's talk about it, answer their questions. I'll tell them what I think is going on. I'll give my explanation, then I'll say something like, I've just thrown a lot at you. What questions do you have about what I've just said? And they'll ask me their questions.

I will weigh the baby a second time. I'll say okay, so just to recap, here's what we were talking about today. What other questions do you have for me while I'm still here? sometimes if I'm a little behind in my charting, I'll say, I'm just going to take a few minutes to write up some of the things that I saw so I don't forget them. While I'm doing that, think about any questions you have for me while I'm still here.

Leah: I like that.

Annie: And then we wrap up the session. I'll say, would you like to schedule a follow up visit with me now? I could come back this day or at this time, I'll offer them a follow up time. And then I'll tell them, okay, you're going to get an email where you're going to get your care plan. I am sending a report to the pediatrician with CHARM. It will be able to do that as soon as I'm done charting, I click sign and the client gets it immediately and the pediatrician report I use the CHARM's integrated faxing and so I can get the pediatrician report out to them with one click also. So then that's done.

So my goal is always to be completely done with the charting and reporting component before I leave their house or I will finish it very quickly using my hotspot in my car before I go to my next console, so I really try not to carry things over into bringing them home, because I do have some billing things I have to do separately, I wait till I get home and I batch those and do them once a week. So that's kind of a tedious task actually. I have an admin who does that for me now so that's basically my flow for a home visit. there are little variables here and there. They don't always go exactly like that, but most of them follow that basic template.

Leah: Yeah. Well, that's awesome because I feel like we do a lot of things very, very similar.

Annie: Yeah. So tell me what you do.

Leah: So very similar to you, we send out ahead of time intake forms and the consent and everything, but one thing I always try to do is before I go in, either in the morning when I'm prepping for my day, or if it doesn't look like they filled it out, then I'll download when I'm at my home. I'll download everything and I'll try my best to. On MLC, half the time, they don't go through to the consent part because it's like a second step. you finished the first thing and then you sign that and then you finish. You have to go to this next step, and a lot of times they don't. So I want to know ahead of time where do I need to be doing that? Right off the bat, or is it already done? Because that will kind of dictate a little bit of how I change my approach. I try to get that all downloaded

Annie: Just for people listening, MLC stands for Mobile Lactation Consultant, and it is an app-based charting platform. I use CHARM, which is a browser-based charting platform. CHARM, you have to be online to chart most effectively; Mobile Lactation Consultant can be used offline, but you have to be online to download everybody's info the first time they are in your system. I wanted to give that clarification.

Leah: Yes, I forgot.

Annie: Keep going

Leah: I use an iPad for my charting and then I have a little keyboard with it. And so anyway, when I get there, I do very similar to you. I usually greet them hello, and I usually ask them where would you like to set up for the visit, because sometimes they want to be in the living room, sometimes they want to be in nursery, and in Houston, everybody has these three story townhomes, and if they're like, oh, we're going to be in the room on the third story. Here goes the hike with all my gear. I try to figure out where they're going to want to set up because I've had it happen where I don't ask that and we will be in one place, and they're like, well, no, I'd really rather feed this other place. So then I'm picking all my stuff up and then trying to get off to another room. I'll set my scale up right away, and then I'll say, Okay, I just want to review the intake with you, and if they didn't sign the consent, I just have a few things for you to sign so I'll go through. If the baby's not hungry... I set it up right away in whatever room we're going to be nursing, and I wipe it down. I use alcohol disinfecting wipes, and I know they don't kill all the things, but I feel like at least I'm doing something and then I have stronger things at home that I'll wipe down at the end of the day kind of thing. But I don't want it to be wet with some crazy chemical and then that get on the baby

Annie: You could also get wipes for your screens too, especially if the parents are going to be signing on with their finger on your screen.

Leah: I use alcohol wipes for my phone and my iPad keyboard and my screen on my iPad, and I use a little Apple pen to get their signatures so I clean that too. Yes, good point because I like to keep everything nice and clean. I'll wipe that down and while it's drying, then we'll start just talking about the intake and kind of what's going on. And I usually start by telling them, if they didn't fill out the intake form, I just need to get just some general demographic information and health information first. I have a pretty quick flow that I can get all their intake. And really, we're not even talking about what's going on with breastfeeding or the baby, cause now I've got to find the time in this visit to get through all their intake if they didn't fill out the forms ahead of time, which is so time consuming. I have a pretty fast flow that I picked up from the clinical visits, because in the clinic visits, they don't ever have anything in there ahead of time. So not only are my clinic visits only an hour, but I also have to get all their history and identify the problem and take care of it.

So those move so fast that I've been able to pick up a little bit on that. I'll try to go through that. And then as we're talking and I get to the last page where I'm getting the baby stuff, I'll be okay, so now let's delve into what's exactly going on. So then I'll let the parent tell me a little bit about the actual breastfeeding issues that are going on, and this seems to work really well to keep the conversation at a nice pace and flow so that I know I'm going to have enough time to... I want to get all that intake and first stuff done in 20, 30 minutes so that I have a whole hour and a half of just dedicated time to what's going on. So we'll go through that. And even if they filled it out ahead of time, I still go through my quick version of like, Oh, I see you put this down. Let's talk about that. I'd like to hear because sometimes people will put down things because they didn't understand the question or something, they'll put something weird and I like to go over all the things that they put in with them so that I can clarify what did you mean by this testing or you said you had infertility, but that's not really what they meant. They just meant it took them three months to get pregnant instead of one month. You know what I mean?

So I'll go through that, and then we do the same as you. I don't wash my hands until right before I start in on the visit because I know I'm going to be touching my scale bag and my computer and all my things. So right before we start in on helping with feeding is when I go wash my hands, right before I go to touch. I'm a bit of a germaphobe so I try to get all my touching of other things like my keyboard and all that with my hands the way they are, and then I wash right before I put on gloves to help with the latching and mouth examination and everything like that. And so we'll go through the latching, I do things a little... so interesting to hear how you do things and you're so thoughtful about just your point about the pain thing and everything. So neat to hear different people's perspective. I have a lot of moms who are practically like I don't want to do it. I'm like no, this is not going to help if I can get the baby on. it's not going to help if I can latch your baby because I'm not going to be able to stay here the rest of the day, so let's keep your hands there. let's do it and I might have a hand over theirs and guide them in, but I do really try with the self-efficacy. you can do and have them practicing multiple times. I know we've got a really good latch that time, but let's just build your confidence on this. let's have you take the baby off, put them back on a few times if latch is really the main concern.

And then similar to you, I always do my mouth assessment halfway through the feedings. I feel like the baby's not milk drunk where they won't even open their mouths anymore, but they're not frantic and going to do weird uncoordinated suck stuff because it was so frantic. They're like, where's the food? So I usually do it then and talk parents through what I'm seeing. I usually do lots of talking about everything that I'm seeing, and one reason is I'm not like you where I can chart every single thing in the visit. So it helps me to say it all out loud, because I can remember it totally then. when I go home, I can remember if I'm charting either in my car after, or if that's my last one. I'm home when I'm charting the rest of everything, I put in my details of my impression all that usually later. So when I'm talking it through with them, everything I see in the mouth, all of that I always just talk it out loud, and for some reason that always solidifies with me for later on. And I've been implementing some of the things we've talked about in the past, like doing a recording when I get in the car. I love that. that's such a great idea. And then also I've been trying to write down the assessment before you leave the visit. So at least you kind of know your impression even if it's not in perfect text, I'll just kind of write this is what I think is happening because I use some of the features of MLC. they have the zzz template fills so I'll fill out my templates kind of like you do while they're giving me that early talk. I'll be filling out some of those things and having my chart all prepped, and then so I do all my things that I'm going to be touching and helping them, and I have my gloves on to do the mouth work and everything and then when I take my gloves off, I'll go back to my computer then and I'll type, but I try to be completely done with my touching because remember, I washed my hands and now when I go back to be touching my computer again, which I use all over the place so I know it is not clean. And then if I need to touch again, I always wash my hands again.

Annie: Oh, and to that point, firstly, you can't wash your hands too many times during a home visit. But the second is whenever doing... I didn't even mention this and I know you do the same thing when I'm doing oral exams or handling the baby, I wear gloves. I don't wear gloves during the I'm helping you with breastfeeding part or breast assessments unless there's nipple damage. I sometimes might wear gloves but I don't usually touch that close. It's usually just in breast tissue. I can find what I need to find far enough back away from any nipple damage but I always wear gloves with the baby. I always make a show of saying I'm going to put my gloves on so they see me take a fresh pair of gloves out of my bag.

Leah: So I try to have like this block of time where I'm not going to touch anything else. I'm going to have gloves on my hands. I wear them just that whole block of time. So I am wearing them when I'm helping with latch. I am wearing them when I do my breast assessment and when I do my oral assessment, but I'm not touching anything else. I don't touch my computer. I don't even touch the scale with that. I use my wrist to touch the scale.

Annie: Once I have the gloves on, I don't touch anything else except for the baby and then I take them off, and if I have to do anything, I'll put a fresh pair of gloves on.

Leah: Yeah, Yeah, me too.

Annie: And I'll do the pinky. If I have to push my scale button, I'll use the pinky finger of my non-dominant hand. That's not going to touch anything. That one could be dirty.

Leah: Yeah, that's funny. I do try to be really aware of just making sure that I'm taking good precautions on not transferring germs or anything like that. So then at the end, I'll go through like you do. Okay, this is what I think is going on. This is our plan going forward, just making sure they understand the plan, and then I don't always send my plan right then but I do tell them you'll be getting a typed up plan of this because I want to give you lots of links and additional information that'd be helpful for you. And so that might go out at the end of the visit but more likely when I do my daily wrap up so the end of the day. I get home a little bit before end of day when I need to start dinner and all of that, and I usually am doing my wrap up then, any charting that I didn't get done, any care plans that CD still need to go out. So it's usually just a few hours after the visit. And then I usually confirm I sent them through my Spruce app. I'll send them a little message hey, I sent over your care plan. Will you please confirm that you got it? I have email. oh my gosh. I don't know, lately moms keep putting in their email addresses wrong and it will bounce back. It just drives me crazy.

I'm making sure that they received it and everything and then usually at the close, I just make sure like you do. I want to make sure before I have to go, are there any questions that you have? anything else that I can give you information on or you're not sure about, and kind of close up that way. And then I do try to let them know my expectations. I think that this will probably be something that's going to take us a few visits or I really think it would be beneficial if we did a weight check in three days, and really make sure that they know what I'm thinking. that I'm not thinking this is going to be fixed in one second, and that they are also aware that is the expectation for this. And that really helps me with people scheduling follow ups number one, but just having that continuance of care, and their expectations and we're all kind of on the same page. I think that's really, really helpful. So, anyway, that's kind of how I run my home visit. It's been fun to hear these little tidbits.

Annie: Well, just knowing we do some things the same and some a little different, and just for those of you especially who are first starting out, it's going to take you a little time to find your flow. But we hope that this has been helpful. sharing what we do to help you decide how you want to do your home visits.

Leah: Yes, yes and to know there's so many different approaches. So just because Annie and I do it this way doesn't mean that this is the end-all, be-all way, or that you couldn't create your own way of doing it just by practice and looking at what works for you, what doesn't work for you. I think I've changed my flow multiple times throughout my journey.

Annie: Well, if you've got a tip about a way that you make your home visits awesome, feel free to leave them in the comments so we can learn from you and maybe Leah and I will we'll find new things that we can do.

Leah: Yes, yes, please, because we're only just two of the many out here that are doing private practice home visits. I would love to hear how other people are approaching them as well. So, Annie before we wrap up for the day, I know you have a wonderful tech tip for us.

Annie: I do, and so our tech tip is related to this episode's sponsor Spruce. So in addition to being able to use Spruce to communicate with clients like Leah was talking about, checking in with them and sharing the note that says you got a care plan ready for you, Spruce has this feature called saved messages, which is their quick text feature. I learned that because of the security levels of Spruce, the fact that it really is creating this environment that makes it really hard for you to really be too "unprivate" with things, the regular auto quick text on my phone does not work. So if I have all these quick texts set up in my phone, they don't come into Spruce, and I think that's good because Spruce is not pulling things from other places on your phone. It's really keeping this private area. I set it up in saved messages and what I have in my saved messages, I have the names and phone numbers of the people that I refer to.

So here in New York City, we have a WhatsApp group where you call one of us. If you need a lactation visit, we're not available, we'll go on our WhatsApp group and say just the general neighborhood - Park Slope - and somebody will say I'm available Tuesday. I have in saved messages about all those people, and I will say, I'm not available, but try and then I hit dot and the first three letters of that person's name and Spruce pops in their name and their phone number and I can hit send. So that's great because there's no end to the way that you can use that and it saves me a ton of time and prevents me from doing copying and pasting or saying just go to her website, just google her. I used to do that before. I would be like this one's not available, but just google her. Don't drive. I do not text and drive. I have been known to take advantage of long traffic lights. We have some very long ones here, but more often I'm pulling over and double parking in front of a hydrant with my flashers on to send messages. So that's how I do it here in New York City. But especially if you're on the highway, never text when you're on the highway.

Leah: Don't do it, don't do it.

Annie: But this is a great way that Spruce gives you to keep things that you say frequently, or you could say yes, I'm available. Please check my website and schedule online. I know. Anybody that's ever used any kind of quick text will love it, and so that's how Spruce gives that to you in a way that isn't compromising the security of the secure messaging feature.

Leah: I love it. I love it. And it's so great that they thought about this aspect of having this open texting is like okay, but we also need to make sure our time is used wisely and that we're not having to type the same things over and over. So I think that's great. Annie, I have a question about that. Did you set that up through...? You have to set that up through the online, right? You can't do that through your phone, or can you? [Overlapping crosstalk]

Annie: You have to log in through your browser, and that's where you can access some of these power user features like saved messages or the autoresponder, and I actually prefer doing stuff like that on my computer anyway.

Leah: It's easier to type.

Annie: Yeah, it's an easier keyboard and I can copy and paste a lot more easily. So definitely, if you've never logged into Spruce through a browser, see what that looks like. You're going to see some new things that you maybe haven't seen before, and if you have not used Spruce but are intrigued by the idea, check the show notes for a code to get one month free, thanks to our episode sponsors Spruce. So Leah, it was great talking to you as always. have a wonderful week.

Leah: Thanks. you too. Bye.

Annie: Bye.