Chapter 037 Home Health Nursing

Chapter 37 Home Health Nursing

Home health nursing services enable individuals of all ages to remain in the comfort and security of their homes while receiving health care. Family support, familiar surroundings, and participation in the care process contribute to feelings of worth and dignity. Services may include skilled nursing, physical therapy, speech language therapy, occupation therapy, social services, intravenous therapy, nutritional support, home health aide, respiratory therapy, acquisition of medical supplies and equipment, and homemaker and companion care.

Educating the patient in the home setting. (From Potter, P.A., Perry, P.G. [1997]. Fundamentals of nursing: concepts, process, and practice. [4 th ed.]. St. Louis: Mosby.)

Four Different Perspectives Official Services are provided to individuals and their families in their place of residence for the purpose of promoting, maintaining, or restoring health or of minimizing the effects of illness and disability. Patient Skilled and compassionate care is provided on a one-to-one basis in the comforting and familiar surroundings of the home.

In the home, the nurse encourages the patient to use imagery to relax and relieve pain. (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6 th ed.]. St. Louis: Mosby.)

Four Different Perspectives (continued) Family It is a means to keep the family together as a functioning, integrated unit. Provider All disciplines involved are challenged to provide excellent care in often less-than-excellent conditions and surroundings.

Home care was formerly defined as simply providing physical care to the sick in their homes, but the scope and complexity of the concept and practice have grown. Roots of the concept can be traced to the New Testament of the Bible, which describes visiting the sick as a form of charity. The first home health care program in the United States was organized in 1796 as the Boston Dispensary. The first visiting nurse service in the United States was formed in Philadelphia in 1886.

Lillian Wald and Mary Brewster developed a visiting nurse service for the poor in New York City in 1893 at the Nurses’ Settlement House on Henry Street. In the 1800s and early 1900s, visiting nurse associations were formalized, and public health departments became widespread. The Social Security Act of 1935 first provided government rather than local charitable funding for selected services such as maternal health, communicable disease, and the training of public health professionals.

When Medicare became effective in 1966, it revolutionized home care by Changing it to a medical rather than nursing model of practice Defining and limiting services for which it would reimburse Changing the payment source and even changing the reason home care was provided

Diagnosis-Related Groups (DRGs) Congress enacted this prospective payment system in 1983 as a part of the Tax Equity and Fiscal Responsibility Act for hospitals receiving Medicare reimbursement. Based on major diagnostic categories, a set rate is paid for the hospitalized patient's care rather than the “cost” or charges traditionally billed by institutions.

Diagnosis-Related Groups (DRGs) (continued) The net effect of the change was a major shift of patients out of the hospital into their homes, extended-care facilities, or skilled nursing facilities. This created a challenge in terms of volumes of patients seen, necessity of more skilled nursing care over intensive times, and the evolution of highly technical procedures in the home.

Agencies may have to comply with federal, state, and local laws and regulations via the following Licensure by the state Certification by the state certifying body designated by the federal government Certificate of need granted by some state according to rules and formulas devised by state regulators Accreditation by an outside agency that evaluates how well the agency meets certain standards set by the accrediting organization

Agencies Classified According to Tax status: for profit or not for profit Location: freestanding or institution-based Governance: private or public

Seven Types of Home Care Agencies Voluntary Official Combination Hospital Proprietary Private not-for-profit Other

JCAHO is looking for agencies to establish ethics committees to handle issues that arise in the home. Psychiatric nurse clinicians are being reimbursed by Medicare for home visits. Social workers are taking a more active role in home health care. More home health agencies are employing nurse pain specialists to assess and manage pain control in the home .

Most agencies are obtaining a separate Medicare certification to provide hospice care. Pet care programs are emerging to reduce stress for the home health patient who is too ill to care for his or her pet. Electronic home visits may be evolving. One of the most rapidly growing segments in home health is home infusion therapy.

Skilled Nursing This is provided and directed by currently licensed registered nurses. Basic nursing services may be provided by the LPN/LVN under the supervision of the RN. Service goals Restorative, improvement, maintenance, promotion Nurses practicing in the home setting must be technically proficient, self-motivated, innovative, and independent decision makers.

Role of the LPN/LVN Skilled service has become a growing field of practice for the LPN/LVN as agencies cope with increased staffing needs, nursing shortages, and recognition of the contributions the LPN/LVN can make to home care. Independent practice is not allowed, but self-direction, motivation, creativity, clinical proficiency, flexibility, compassion, empathy, and patience are all essential attributes.

Physical Therapy Services must be provided by a qualified and licensed physical therapist. A physical therapist’s assistant may deliver limited services under the supervision of the licensed therapist. The goals of treatment must be restorative for Medicare reimbursement but may be maintenance or preventive for other payer sources.

Speech-Language Therapy Speech services must be provided by a master’s-prepared clinician who has been certified by the American Speech and Hearing Association. Therapy goals include minimizing communication disorders and their physical, emotional, and social impact. Independent functioning and maximum rehabilitation of speech and language abilities are primary treatment goals.

Occupation Therapy Services deal with life’s practical tasks. The therapist will choose and teach therapeutic activities designed to restore functional levels. Services include Techniques to increase independence Design, fabrication, and fitting of orthotic or self-help devices Assessment for vocational training

Medical Social Services Services are provided by social workers prepared at the master’s level. Focus is on the emotional and social aspects of illness. The care plan includes education, counseling, payment source identification, and referrals.

Homemaker-Home Health Aide The aide provides the basic support services that can enable an elderly individual, disabled adult, or dependent child to remain at home. Most aid services fall into one of three categories Personal care Physical assistance Household chores

Referral Entry point into the home health care system Can come from the patient, family, social service agency, hospital, physician, or another agency

Admission The initial evaluation and admission visits are made by an RN within 24 to 48 hours of the referral. The evaluation and admission process generally includes at least the following. Complete patient evaluation Environmental assessment Identification of primary functional impairments Assessment of the family or significant other support system Determination of knowledge and adherence to treatments and medications

Admission (continued) Evaluation and admission process (continued) Determination of desire for care and services Involvement of the patient and family in the development of the plan of care and goals Notification to the patient of rights as a patient, along with costs, payment sources, and billing practices Explanation of the patient’s right to self-determination Provision of initial nursing interventions

Care Plan The physician must be contacted for specific orders before delivery of care. A treatment plan is drafted cooperatively with the physician. The plan describes the current physical status of he patient, medications, treatments, the disciplines needed to provide care, the frequency and duration of services, the goals/outcomes, and the time frame for implementation. It must be signed by the physician and serves as the traditional physical orders.

Visits Visits for interventions by ordered disciplines are made to meet the patient-centered goals and progress toward identified outcomes. Patients may be visited as infrequently as once a month to several times a day; several visits per week are typical.

Documentation Concise and complete documentation is essential. It may be hand-written, dictated, or entered into a computer. Many agencies are beginning to use various problem classification schemes linked with nursing diagnoses, specific interventions, and defined patient outcomes. It provides an accurate picture of the type and quality of care and reflects the effectiveness of the plan of care and progress toward goals and outcomes or the reason for lack of progress.

Discharge Planning Planning begins with admission. When patient goals or other specific criteria are met, the discharge occurs. The purpose of discharge planning is to promote continuity of care in the patient’s home.

This provides documentation for outside organizations and for internal measures of improvements and refinements of policies and procedures. Three major elements Structural criteria Process criteria Outcome criteria Quality assessment plans reflect standards, objectives, and measurable outcomes and include plans for remediation or improvement as an integral part of the process.

Medicare This federal program requires agencies to be certified as meeting the federal conditions of participation, which set forth specific requirements for organization, staffing, training, types of services covered, and agency evaluation. Beneficiaries of services must be 65 or older, disabled, or have end-stage renal disease. Must be under the care of a licensed physician, homebound, and in need of skilled nursing therapy services

Medicaid This pays for home care services to indigent and low-income people of all ages. It is administered by the state but is both state and federally subsidized. Services vary from state to state, but most include the basic services covered by Medicare plus expansion of aide and personal care services.

Third Party Limited home care services are paid for. Coverage, requirements, and payment rates vary. Reimbursement is often tied to post hospitalization recoveries. A case manager will determine and arrange for a mix of home care, therapy services, counseling, supplies, and equipment for a patient.

Private Pay Individuals may also pay directly for home health services. Charges may be the standard full charge or may be scaled down based on ability of the patient to pay. Other Sources Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) have negotiated contracts with home health agencies to provide services to their patients. Both are prepaid health plans operated independently or through employer groups.

Nurses encounter great diversity in a variety of cultural interactions. Culture is present in the lives of patients, families, and health care providers and is especially apparent in the home environment. Nurses need to anticipate potential cultural problems and identify their own and other’s values. Cultural health practices may be incorporated into traditional medical care in the home environment, provided it does not conflict with the prescribed treatment.

Nursing Diagnoses Interrupted family process Impaired parenting Anxiety Caregiver role strain Impaired physical mobility Imbalanced nutrition, less than body requirements Disturbed thought processes Ineffective airway clearance Risk for impaired skin integrity

Nursing Diagnoses (continued) Family coping, compromised Family coping, disabled Coping, ineffective Ineffective management of therapeutic regimen Knowledge, deficient Risk for caregiver role strain Risk for injury

Current trends support the growth of home care as an economical, humane, preferred health delivery system for many types of care. Home care provides needed assessment and evaluation of chronic illnesses to prevent acute episodes. Aides and homemakers can provide necessary support in activities of daily living to enable the patient to remain in the home. Skilled nursing and therapy offer rehabilitation and prevention of deterioration, as well as methods to cope with physical changes.

Home health care allows individuals to maintain personal control and to participate in the direction of their personal care. Families are an important part of the success of home care services as home care workers provide care, supervision, assistance, and support in attaining the care plan goals. Home health care is not a new concept; however, legislative, regulatory, and current health care trends have changed the way it is provided.

A number of different professional and paraprofessionals disciplines provide home care services based on coordinated plan of care of approved by a physician. Teamwork is an essential component of the concept. Home health agencies are organized groups that employ or contract with professionals and paraprofessionals to provide services. Different types of agencies may be subject to varying federal, state, and local laws and regulations.

Skilled nursing care is the most frequently provided services. RNs and LPNs/LVNs under the supervision of the RNs provide direct care of different levels of complexity. Providers of care in the home must possess special qualities to effectively practice in this nontraditional environment. Home health care agencies strive to provide the highest quality of services economically. Success is evaluated through quality assurance plans.

Home health services are reimbursed by federal, state, local, group, and private sources. Although some aspects of nursing interventions in the home are the same as those practiced in other health care setting, home health care nurses pay particular attention to interaction and cooperation among family members, the patient, and other members of the health care team.

The acuity levels of patients requiring care in their homes continues to rise, and the technological equipment, including use of mechanical equipment and invasive procedures such as intravenous therapies, are increasing in home care. These factors, when combined with shorter hospital stays, require extensive discharge planning to prepare patients and family for home health care.

Edited by B. Holmes MSN/Ed, RN Assistant Professor

Chapter 037 Home Health Nursing

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Chapter 037 Home Health Nursing