8. Home Care Learning Outcomes After Completing This Chapter, You

8. Home Care LEARNING OUTCOMES After completing this chapter, you will be able to: 1. Define home health care. 2. Compare the characteristics of home health nursing to those of institutional nursing care. 3. Describe the types of home health agencies, including reimbursement and referral sources. 4. Describe the roles of the home health nurse. 5. Identify the essential aspects of the home visit. 6. Discuss the safety and infection control dimensions applicable to the home care setting. 7. Identify ways the nurse can recognize and minimize caregiver role strain. KEY TERMS caregiver role strain, 137 durable medical equipment (DME) company, 134 home care, 132 home health care nursing, 132 hospice nursing, 132 registry, 133 visiting nursing, 132 INTRODUCTION Historically, home care consisted primarily of nurses providing private duty care in clients' homes and care of the ill by their own family members. However, the delivery of professional nursing services in home settings has increased in frequency, scope, and complexity in the past two decades. Home care today involves a wide range of health care professionals providing services in the home setting to people recovering from an acute illness or injury, or who are disabled, or who have a chronic condition. A number of factors have contributed to this trend, among them rising health care costs, an aging population, and a growing emphasis on managing chronic illness and stress, preventing illness, and enhancing the quality of life. In the not-too-distant past, home health care occurred at the end of the client care continuumthat is, after discharge from an acute care facility. Today the trend is changing to use of home health care services to avoid hospitalization. Because home health nurses must function independently in a variety of home settings and situations, employers generally prefer that the nurse be prepared at the baccalaureate level or above. The American Nurses Credentialing Center (ANCC) provides certification for home health nursing at both the generalist and advanced practice levels. Advanced practice certification requires a master's degree in nursing and recognizes the need for home health clinical specialists who can provide direct care, manage client care, and engage in consulting, education, administration, and research activities. HOME HEALTH NURSING The delivery of nursing services in the home has been called a variety of terms, including home health care nursing and visiting nursing. For an example of how the terms are used interchangeably, see the website for the Visiting Nurses Associations of America and note that their description of what a visiting nurse does is listed under the section entitled Home Health. Home health care nursing or visiting nursing includes the nursing services and products provided to clients in their homes that are needed to maintain, restore, or promote their physical, psychologic, and social wellbeing. The focus of home health care nursing is individuals and their families. This differs somewhat

from the focus of community health nursing, which focuses on individuals, families, and aggregate groups (see Chapter 7). Hospice nursing, support and care of the dying person and family, is often considered a subspecialty of home health nursing because hospice services are frequently delivered to terminally ill clients in their residence. See Chapter 43

for further information about hospice care.

Home nursing care is one of the growing sectors of the health care system. Expenditures for home health are significantly influenced by increasing or decreasing Medicare payment policies, but they increase approximately 10% each year. Medicare payments for hospice services provided by home care agencies doubled between 2000 and 2003 (Smith, Cowan, Sensing, & Catlin, 2005). Factors that have contributed to the growth of home health care include (1) the increase in the older population, who are frequent recipients of home care; (2) third-party payers who favor home care to control costs; (3) the ability of agencies and institutions to successfully deliver high-technology services in the home; and (4) consumers who prefer to receive care in the home rather than in an institution. A common misperception by the general public is that home health nursing is only custodial in its scope of practice. However, health promotion is one of the intentions for the home health nurse in order to promote client self-care. Home care nurses are actively engaged in providing support and education for family caregivers as well as clients. Unique Aspects of Home Health Nursing Home care nurses must function independently in a variety of unfamiliar home settings and situations. Because the home is the family's territory, power and control issues in delivering nursing care differ from those in the hospital. For example, entry into a home is granted, not assumed; the nurse must therefore establish trust and rapport with the client and family. Due to the limited time for visits and the possibly lengthy interval between visits, this process does not always occur as quickly as it might when nursing within an acute care facility. Health care that is provided in the home is often given with other family members present. Families may feel freer to question advice, to ignore directions, to do things differently, and to set their own priorities and schedules. Home care nurses implement every step of the nursing process, using critical-thinking skills in designing, implementing, and evaluating the plan of care. Home health nurses have identified significant advantages in caring for individuals and families in the home. The home setting is intimate; this intimacy fosters familiarity, sharing, connections, and caring between clients, families, and their nurse. Behaviors are more natural, cultural beliefs and practices are more visible, and multigenerational interactions tend to be displayed. Nurses often get to know the client and family well as they may care for clients over weeks or months. Home health nurses have also identified issues that negatively affect care in the home. More than any other care providers, these nurses have firsthand knowledge and experience about the burden of caregiving and the role of family dynamics in health care practices. In the interest of cutting health care costs, policy makers, third-party payers, and medical providers are placing increasingly complex responsibilities on clients' families and significant other(s). Family caregiving demands may go on for months or years, placing the caregivers themselves (many of whom are elders) at risk for physiological and psychosocial problems. Additionally, nurses enter homes where the living conditions and support systems may be inadequate. Nurses caring for clients in rural home settings have challenges different from those in urban or suburban environments. These include the need for flexibility since clients may live far distances from the nurse and require care in the evening or at night, creativity and the ability to practice independently since fewer resources (including other nurses) are available, and the ability to work in

an environment over which there is little nurse control (Boucher, 2005). Thus, those nurses who require a high degree of certainty, structure, and consistency are less likely to be successful in rural home health locations. Practice of Home Health Nursing The home health nurse will practice a variety of roles when caring for clients. Direct hands-on care for complex health conditions occurring in clients from birth to death is becoming common in home settings. Home health nurses routinely perform physical assessments, change wound dressings, insert and maintain intravenous access for various therapies, establish and monitor indwelling urinary catheters, monitor exercise or nutritional therapies, and in short do many nursing functions formerly thought of as being confined to acute care facilities. Home health nurses serve as health educators to the client, caregivers, and families. They clarify misconceptions about the course of the illness, the treatment plan, and medications and potential interactions with over-the-counter drugs. They also educate the client and family on how to access the health care system appropriately. Indirect care is provided by the home health nurse to the client each time the nurse consults with other health care providers about ways to improve nursing care for the client. This consultation about client care issues often manifests itself in multidisciplinary care conferences where the role of the home health nurse is as client advocate. THE HOME HEALTH CARE SYSTEM The need for home health care may be identified by any person involved with the client. Clients are referred to a home health agency or private duty nursing agency. Individuals with extremely complex needs, beyond those that direct nursing care alone can provide, may benefit from the services of an agency with direct connections to a medical equipment company. Payment for home health is accomplished through private pay, third-party reimbursement, or a combination of sources. Referral Process Clients may be referred to home health care providers by a physician, nurse, social worker, therapist (e.g., physical therapist), discharge planner, or family member. Families often initiate the process by approaching one of these referral sources or by directly contacting the home health agency to make inquiries. Home care cannot begin, however, without a physician's order and a physician-approved treatment plan. This is a legal and reimbursement requirement. After an initial set of physician's orders is obtained, a nursing evaluation visit is scheduled to enroll the client and identify the client's needs. The initial visit, often referred to as "opening the case," should include the client and the immediate family involved with the client's care. At this visit, the nurse develops a plan of care, which must be reviewed, approved, authorized, and signed by the attending physician before home health agency providers can continue with services. Home Health Agencies Home health agencies offer coordinated professional, skilled, and paraprofessional services. Because clients often require the services of several professionals, case coordination (case management) is essential. This responsibility generally rests with the registered nurse. Depending on the agency, additional providers may include nurse practitioners, practical nurses, nursing assistants, home health care aides, physical therapists, occupational therapists, respiratory therapists, speech therapists, social workers, dietitians, and a pastoral care minister or chaplain. In addition, it is not unusual for home health agencies to offer the services of specialized nurses such as wound-ostomy-continence nurses or diabetes educators. The care plan implemented by the home health agency may require services once or twice a day, up to 7 days a week. The minimum time of each period of care, or visit, is usually 1 hour.

There are several different types of home health agencies which include the following: • Official or public agencies are operated by state or local governments and financed primarily by tax funds. • Voluntary or private not-for-profit agencies are supported by donations, endowments, charities such as the United Way, and third-party reimbursement. • Private, proprietary agencies are for-profit organizations and are governed by either individual owners or national corporations. Some of these agencies participate in third-party reimbursement; others rely on "private-pay" sources. • Institution-based agencies operate under a parent organization, such as a hospital, funded by the same sources as the parent. Regardless of the type of agency, all home health agencies must meet specific standards for licensing, certification, and accreditation. Private Duty Agencies This type of agency may be referred to as a registry which contracts with individual practitioners (e.g., nurses, home health aides) to care for the client in the home. The client may require care coverage from the agency for 4 to 24 hours a day. However, the agency is not focused uniquely on providing personnel for home care assignments but also supplies staff to hospitals, clinics, and other care settings. Thus, it does not afford the coordinated focus of a home care agency. Private duty care is expensive. Commercial insurance generally provides limited reimbursement. Otherwise, the client must pay privately. Durable Medical Equipment Companies A durable medical equipment (DME) company provides health care equipment for the client at home. The types of equipment can range from hospital beds and bedside commodes to ventilators and apnea monitors. Because of the cost associated with medical equipment, the nurse needs to ensure that clients have either Medicare/Medicaid or a DME benefit within their commercial insurance, or that they are able to pay privately. Before billing Medicare for any DME, it is wise to consult the list of equipment for which Medicare will reimburse the client. Most DME companies today seek accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to ensure compliance with quality standards for equipment and services. Reimbursement Health care agencies in the United States receive reimbursement for services they provide from various sources: Medicare and Medicaid, private insurance companies, and private pay. The Medicare and Medicaid programs have strict guidelines governing reimbursement for home health care (Centers for Medicare & Medicaid Services, 2004). For example, the client must (a) need reasonable and necessary home care including skilled care; (b) be homebound, that is, confined to the home except for occasional outings for medical treatment, for a trip to the barber, or for a drive; and require the use of supportive devices, special transportation, or the escort of another person; (c) have a plan of care that includes all of Medicare's criteria; and (d) need nursing care on an intermittent basis (Caruso, Scala-Foley, Archer, & Reinhard, 2004). The agency too must meet specific conditions. Payers other than Medicare or Medicaid, such as Blue Cross, Blue Shield, and HealthNet, typically negotiate reimbursement rates for home health care services. Not-for-profit agencies, like the Visiting Nurses Associations (VNAs), are reimbursed by public and private insurance plus charitable donations to the agency.

All health care agencies need to adhere to established guidelines and provide care within the predetermined reimbursement levels. Treatment plans (developed by the home health agency providers and authorized by the physician) are used by the reimbursement source. Only interventions identified on the treatment plan are paid for. Periodically the reimbursement source may request the home health provider's notes to substantiate what is being done in the home. This is a major reason why accurate documentation is critical. ROLES OF THE HOME HEALTH NURSE Historically, nurses who provided direct services in the home were strong generalists who focused on long-term preventive, educational, and rehabilitative outcomes. Today many home health nurses possess high-technology skills that were formerly used only in acute care settings. For example, nurses provide a variety of intravenous therapies in the home setting and monitor clients who are dependent on technologically complex medical equipment, such as ventilators and central intravenous lines. These nurses collaborate with physicians and other health care professionals in providing care. They play a key role in facilitating an effective plan of care as clients move among hospitals, home, school, work, and other care settings such as clinics or long-term care. Major roles of the home health nurse are those of advocate, caregiver (provider of direct care), educator, and case manager or coordinator. Advocate Advocacy begins on the first visit. The nurse explores and supports the client's choices in health care; all viable options are considered. Advocacy includes having discussions about the client's rights, advance medical directives, living wills, and durable power of attorney for health care. It also usually involves assistance to access community resources, to make informed decisions, to recognize and cope with necessary changes in lifestyle, to negotiate medical insurance, and to understand ways to effectively use the complex medical system. Advocacy can be a particular challenge when family members' or other caregivers' views differ from those of the client. In the event of conflict, the nurse, being the client's primary advocate, ensures that the client's rights and desires are upheld. Caregiver The home health nurse's major role as caregiver is to assess and diagnose the client's actual and potential health problems, plan care, and evaluate the client's outcomes. Direct personal care activities such as bathing, changing linens, feeding, and light housekeeping activities to maintain a clean and safe home environment are usually provided by a family member or a home health aide arranged by the nurse. The home health nurse, however, will provide direct care for specific procedures and treatments such as ostomy care, wound care, intravenous therapy, and so on according to agency policies and practices (see Figure 8-1). Much of the home health nurse's time is spent teaching others to provide required care. Educator The educator role of the home health nurse focuses on teaching illness care, the prevention of problems, and the promotion of optimal wellness or well-being to the client, the family, and other related persons. A common example is that of guiding the health and development of newborns. Some clients of all ages have acute illnesses that will resolve, while others have chronic conditions that will last the lifetime. The nurse's teaching and learning methods will vary based on the need of these clients. The nurse may also be involved in teaching others with whom the client interacts such as the schoolteachers of special-needs children. Education is ongoing and can be considered the crux of home care practice; its goal is to help clients learn to manage as independently as possible. All home

health nurses need to be skilled in teaching and learning principles and strategies that facilitate learning. (See Chapter 27

for detailed information.)

Case Manager or Coordinator The home health nurse coordinates the activities of all other home health team members involved in the client's treatment plan. Coordination can occur individually, in person or by telephone, with a specific team member such as the dietitian or respiratory therapist, or during a team conference where each team member provides information about the client's health status. The nurse is the main contact to report any changes in the client's condition and to bring about a revision in the plan of care as needed. Documentation of care coordination is a legal and reimbursement requirement and must be recorded on the client's medical record. Figure 8-1. Home care nurses perform skilled direct care such as changing dressings. PERSPECTIVES OF HOME CARE CLIENTS Home care clients include a diverse population that encompasses all ages, a variety of health problems, and families of different structures and cultural backgrounds. Home care clients have a wide range of health problems that include disabilities, perinatal problems, mental illnesses, and acute and chronic illnesses. The nurse should not assume that the client understands the various personnel and their roles in providing home health care. In one study, older women receiving home care were unclear regarding what they could expect of the nurse and how best to use home care services (Porter & Ganong, 2005). Although the person receiving care is considered the primary client in home care, the client's family can be considered secondary clients because often they are associated with caregiving and have a major impact on the client's wellness status. The home health nurse will encounter many different family structures ranging from single families to extended families and dwellings that house multiple families. In the home setting, family members may include not only persons related by birth and marriage, but also friends, other significant individuals, and animals. Various cultural influences also affect the client's health care beliefs and practices. The home health nurse needs to be culturally sensitive; that is, to become aware of the client's culture and form a nursing care plan with the client that incorporates his or her culture. See Chapter 18 for detailed information about making cultural assessments and providing culturally competent care. SELECTED DIMENSIONS OF HOME HEALTH NURSING Selected dimensions of home health care include assessing the home for safety features, infection control, and caregiver support. Client Safety Hazards in the home are major causes of falls, fire, poisoning, and other accidents, such as those caused by improper use of household equipment (e.g., tools and cooking utensils). The appraisal of such hazards and suggestions for remedies is an essential nursing function. See the Home Care Assessment box for a home hazard appraisal and Chapter 32 and preventive actions for individuals of all ages.

for a discussion of potential hazards

HOME CARE ASSESSMENT Home Hazard Appraisal for Adults CLIENT AND ENVIRONMENT • Walkways and stairways (inside and outside): Note uneven sidewalks or paths, broken or loose steps, absence of handrails or placement on only one side of stairways, insecure handrails, congested hallways or other traffic areas, and adequacy of lighting at night. • Floors: Note uneven and highly polished or slippery floors and any unanchored rugs or mats. • Furniture: Note hazardous placement of furniture with sharp corners. Note chairs or stools that are too low to get into and out of or that provide inadequate support. • Bathroom(s): Note presence of grab bars around tubs and toilets, nonslip surfaces in tubs and shower stalls, handheld showerhead, adequacy of night lighting, need for raised toilet seat or bath chair in tub or shower, ease of access to shelves, and water temperature regulated at a maximum of 49°C (120°F). • Kitchen: Note pilot lights (gas stove) in need of repair, inaccessible storage areas, and hazardous furniture. • Bedrooms: Note adequacy of lighting, in particular the availability of night-lights and accessibility of light switches; ease of access to commode, urinal, or bedpan; and need for hospital bed or bed rails. • Electrical: Note unanchored or frayed electrical cords and outlets that are overloaded or near water. • Fire protection: Note presence or absence of smoke detectors, fire extinguisher, and fire escape plan, and improper storage of combustibles (e.g., gasoline) or corrosives (e.g., rust remover). • Toxic substances: Note improperly labeled cleaning solutions. • Communication devices: Note presence of method to call for help, such as a telephone or intercom in the bedroom and elsewhere (e.g., kitchen), and access to emergency telephone numbers. • Medications: Note medications kept beyond date of expiration, adequacy of lighting for medication cabinet or storage, and method of disposal of sharp objects such as needles used for injections.

Obviously home health nurses cannot expect to change a family's living space and lifestyle. However, they can express their concern and react appropriately when a situation suggests that an injury is imminent. Nurses must document information they provide and the family's response to instruction, and make ongoing assessments about the family's use of safety precautions. Other aspects of client safety relate to emergency situations. The home health nurse can assist the client and caregivers as follows: • Post a list of all emergency telephone numbers (ambulance, fire, police, primary care provider) at each telephone. • Post a list of all the client's medications and potential side effects in a central location, such as on the refrigerator.

• Help the client and family apply for a medical alert system such as a bracelet or necklace (see Figure 8-2). Information on the MedicAlert System can be obtained by contacting MedicAlert Foundation International. • Enroll the client in a program that places all the client's vital medical information in one place for emergency personnel to have in the event of a life-threatening situation. The program can be obtained through a pharmacy, a primary care provider's office, the VNA, or other community support groups. The kit contains a plastic vial, a medical information form, a decal, and an instruction sheet. The information form is filled out, rolled, and placed in the vial. The vial is placed in the refrigerator, and emergency personnel are trained to routinely check there. The decal is placed on the refrigerator as a signal that the vial is inside. • Recommend the client enroll in an emergency response system. These systems provide a small device with a help button that attaches to a wrist or neck chain. The home base station can require the client to send a signal daily that indicates that he or she is OK. If the signal is not sent or if the portable device is activated, the system automatically calls the client and then dials a previously established list of emergency contacts. This system is particularly useful for clients who are alone because if they should fall, for instance, and be unable to reach a telephone, they might be left helpless for extended periods of time. Nurse Safety Some less desirable living locations pose additional personal safety concerns for the nurse. Many home health agencies have contracts with security firms to escort nurses needing to see clients in potentially unsafe neighborhoods. The nurse should avoid taking any personal belongings during these visits and have a preestablished mechanism to signal for help. Home health agencies provide training for nurses in ways to decrease personal risk. Little has been published on this important subject. See the accompanying Research Note for one example. Infection Control The goal of infection control in the home is to protect clients, caregivers, and the general community from the transmission of disease. This is particularly important for clients who are immunocompromised, who have infectious or communicable diseases, or who have draining wounds, drainage tubes, or other invasive access devices. The nurse's major role in infection control is health teaching. Clients and caregivers need to learn about effective hand washing, use of gloves, handling of linens, disposal of wastes and soiled dressings, and the practice of infection control (standard precautions). Infection control can present a challenge to the home health nurse, especially if the home care facilities are not conducive to basic aseptic requirements such as running water for hand washing.

RESEARCH NOTE Do Nurses Making Home Visits Worry About Their Own Safety? The researchers in this study surveyed 83 rehabilitation nurses who performed home visits. A common theme in the responses was concern for personal safety. These concerns were broken down by community and home-based issues. Community issues related to poor communication systems, delayed notification of dangerous situations, weather conditions predisposing to automobile hazards, and difficulty in locating clients' homes due to unfamiliar and possibly dangerous neighborhoods. Home issues included poor sanitation, inadequate housing (e.g., heat, water), uncontrolled pets, and lifestyle (e.g., substance abuse, violence).

Based on these findings, the authors proposed specific guidelines for the nurses, consisting of actions to take to prevent or cope with issues that might arise. Examples were ensuring that cell phones functioned properly; having cars properly serviced, especially for hot or freezing weather; contacting family members for driving directions or meeting the nurse at a central location and guiding the nurse to the home; carrying a signal device such as a whistle or alarm; carrying cleaning supplies such as gloves, drapes, water, and paper towels; advising the family regarding cancellation of visits; and reporting to agencies if violence or abuse is detected. IMPLICATIONS Although safety issues for any nurse visiting the client's home will vary somewhat based on the location and client characteristics, nurses must be prepared with strategies to prevent and cope with issues if they arise. All home care nurses should be thoroughly trained by the agency and know both public and private resources for assistance. The nurse also has a role in educating and assisting clients to avoid and correct unsafe situations. From "Safety Concerns for Rehabilitation Nurses in Home Care," by B. Brillhart, B. Kruse, and L. Heard, 2004, Rehabilitation Nursing, 29, pp. 227-229.

An important aspect of infection control involves handling the home health nurse's equipment and supplies. Supplies may include materials for hand cleansing; assessment equipment such as stethoscope, blood pressure cuff and monitor, thermometer, and tape measure; infection control items such as gowns, goggles, masks, gloves, and blood spill kit; and antimicrobial cleaning agents. The same organizations that accredit hospitals evaluate home health nurses' practice. Deficiencies in the use of appropriate infection control practices are common findings during these evaluations (Sturkey, Linker, Keith, & Comeau, 2005). Although some modifications in technique may be indicated in the home setting, such as the use of clean rather than sterile technique in caring for chronic wounds, all the basic principles still apply. Nurses need to follow agency protocol about aseptic practice in the home. Caregiver Support Caregiving may be directed to individuals of any age and varies from short term to long term according to the physical or mental disabilities of the care receivers. For example, some children who have permanent disabilities and adults who experience progressive deterioration such as those with Alzheimer's disease or multiple sclerosis require care on a permanent basis. Others who are recovering from a surgical procedure require care only on a temporary basis. Most caregivers have close relationships with the care receiver, that is, a spouse/partner, parent, child, friend, or other significant relationship. Many caregiving relationships, therefore, represent changes from the caring and caregiving intrinsic to all close relationships to an extraordinary and unequal burden for the caregiver. Caregivers may experience caregiver role strain when they have physical, emotional, social, and financial burdens that can seriously jeopardize their own health and well-being. The home health nurse needs to recognize signs of caregiver role strain and suggest ways to minimize or alleviate this problem. Signs of caregiver overload include the following: • Difficulty performing routine tasks for the client • Reports of declining physical energy and insufficient time for caregiving • Concern that caregiving responsibilities interfere with other roles such as those of parent, spouse, worker, friend

• Anxiety about ability to meet future care needs of client • Feelings of anger and depression • Dramatic change in the home environment's appearance The nurse needs to encourage caregivers to express their feelings and at the same time convey understanding about the difficulties associated with caregiving and acknowledge the caregivers' competence. The nurse can obtain a realistic appraisal of the situation by asking a caregiver to describe a typical day and daily or weekly leisure and social activities. It is also helpful to identify activities for which assistance is desired. These activities may include client care needs such as hygiene, mobility, feeding, or treatments; house cleaning; laundry; shopping; house repairs; yard work; transportation; doctor's or hairdresser's appointments; or respite. Activities that are commonly done by nurses and aides, such as changing an occupied bed and transferring a client from bed to chair, may be overwhelming to a caregiver who has not performed them before. Demonstrating them in the home and allowing caregivers to perform them with the nurse's supervision increases their confidence and increases the likelihood of them asking for assistance in other situations. When activities for which assistance is required are identified, the nurse and caregiver need to identify possible sources of help. Both volunteer and agency sources need to be explored. Volunteer sources of help may include family members (cousins, siblings), neighbors, friends, church associates, or caregiver support groups in the community. Other sources include, for example, a home health aide for light housekeeping and grocery shopping, Meals on Wheels, day care, transportation, and counseling and social services. Families with a chronically ill member may benefit from a weekend respitea program some hospitals provide in which the client is admitted to a skilled unit for observation and care, enabling the caregiver a break from ongoing health care needs. Caregivers need to be reminded of the importance of caring for themselves by getting adequate rest, eating nutritious meals, asking for help, delegating household chores, and making time for leisure activities or simply some time alone. Family members other than the caregiver also may need help to learn ways to support the caregiver. The nurse may discuss the importance to the caregiver of regular phone calls, cards, letters, and visits; offer encouragement to take day trips or a vacation; listen without giving advice; acknowledge the burden of caregiving and the need to feel appreciated; and so on. A particular challenge exists when the nurse is in a position to be a caregiver to a family member. Although the nurse's clinical expertise and familiarity with the client and setting can be especially useful, negotiating the professional distancing that is sometimes needed when providing care to clients can be difficult with family. The nurse may feel obligated to provide care, even when this is over and above regular employment responsibilities. The nurse must have the opportunity to step back and experience the role and emotions of being a family membernot only those of being a nurse. Figure 8-2. MedicAlert emblems. (Reproduced with permission: 2003. All rights reserved.  MedicAlert is a Federally Registered Trademark and Service Mark.) THE PRACTICE OF NURSING IN THE HOME The home health nurse assesses the health care demands of the client and family and the home and community environment. This process actually begins when the nurse contacts the client for the initial home visit and reviews documents received from the referral agency. The goal of the initial visit is to obtain a comprehensive clinical picture of the client's needs.

Most agencies have a packet that includes forms for consent to treatment; physical, psychosocial, and spiritual assessment; medications; pain assessment; family data; financial assessment including insurance verification; client's bill of rights; care plan; and daily visit notes. During the initial home visit, the home health nurse obtains a health history from the client (see Figure 8-3), examines the client, observes the relationship of the client and caregiver, and assesses the home and community environment. Parameters of assessment of the home environment include client and caregiver mobility, client ability to perform self-care, the cleanliness of the environment, the availability of caregiver support, safety, food preparation, financial supports, and the emotional status of the client and caregiver. Following this initial client examination, the nurse determines whether further consults and support personnel are needed. For example, would the client benefit from a dietary consult or Meals on Wheels? Is a home health aide needed to assist with activities of daily living and homemaker tasks? Is a social worker needed to help with financial resources or future care needs such as placement in a nursing home? What additional supplies does the client need? Before completing the initial interview, the nurse also discusses what the client and family can expect from home care, what other health care providers may be needed to help the client achieve independence, and the frequency of home visits. Establishing Health Issues As in other care environments, the nurse identifies both actual and potential client problems. One of the most common examples of health issues that nurses address with clients in home care settings is lack of knowledge related to health conditions and self-care. Because client education is considered a skill reimbursed by Medicare and other commercial insurance carriers, it is important for the nurse to include knowledge deficits within the plan of care.

BOX 8-1

Medicare's Required Data for the Nursing Plan of Care

1. All pertinent diagnoses 2. A notation of the beneficiary's mental status 3. Types of services, supplies, and equipment ordered 4. Frequency of visits to be made 5. Client's prognosis 6. Client's rehabilitation potential 7. Client's functional limitations 8. Activities permitted 9. Client's nutritional requirements 10. Client's medications and treatments 11. Safety measures to protect against injuries 12. Discharge plans 13. Any other items the home health agency or physician wishes to include

Note: From Medicare Home Health Agency Manual (HCFA Publication 11 PB 98-955200), by Centers for Medicare & Medicaid Services 2001. Retrieved June 12, 2006, from http://new.cms.hhs.gov/manuals/downloads/pub_11.zip

Planning and Delivering Care The nurse needs to encourage and permit clients to make their own health management decisions. Alternatives may need to be suggested for some decisions if the nurse identifies potential harm from a chosen course of action. Strategies to meet goals generally include teaching the client and family techniques of care and identifying appropriate resources to assist the client and family in maintaining self-sufficiency. Box 81 lists Medicare's required data for the nursing plan of care. To implement the plan, the home health nurse performs nursing interventions, including teaching; coordinates and uses referrals and resources; provides and monitors all levels of technical care; collaborates with other disciplines and providers; identifies clinical problems and solutions from research and other health literature; supervises ancillary personnel; and advocates for the client's right to self-determination. Technical skills commonly performed by home health nurses include blood pressure measurement; body fluid collection (blood, urine, stool, sputum); wound care; respiratory care; and all types of intravenous therapy, enteral nutrition, urinary catheterization, enterostomal care, and renal dialysis (see Figure 8-4). A large part of the nurse's role involves teaching the client and caregiver the necessary skills for selfcarefor example, administering insulin injections, measuring blood glucose, and administering medications. Medication instruction about dosage, frequency of administration, and possible side effects is of particular concern for many clients. (See Chapter 35 for more information.) Clients who are receiving high-technology interventions are often anxious about their ability to manage such sophisticated equipment. The home health nurse is challenged to alleviate the client's fears and to provide thorough instruction, demonstration, and periodic evaluation of the client and family's performance of such skills. Members of the home care team specially trained in the skill, such as intravenous nurses and respiratory therapists, generally make periodic visits to service the equipment and to monitor the client's skills. Even though the client and family may become independent in self-care skills, the home health nurse still has the ultimate responsibility to ensure the client is receiving the prescribed therapy at the appropriate timed intervals. Ongoing communication with the primary care provider about the client's progress is critical, and the nurse must make ongoing assessments to ensure that all aspects of the care are being followed. On subsequent home visits, the nurse observes the same parameters assessed on the initial home visit and relates findings to the expected outcomes or goals (see Figure 8-5). The nurse can also teach caregivers parameters of evaluation so that they can obtain professional intervention if needed. Documentation of care given and the client's progress toward goal achievement at each visit is essential. Notes must also reflect plans for subsequent visits and when the client may be sufficiently prepared for self-care and discharge from the agency. Figure 8-3. Interviewing the home care client. Figure 8-4. The nurse monitors the client's response to treatments and therapy. Figure 8-5. Determining the success of the care plan includes comparing assessment findings to

previous values. Weighing this tube-fed baby provides critical data about her progress. THE FUTURE OF HOME HEALTH CARE What is the future for home health care? More studies are needed to determine the practicality, safety, effectiveness, cost, and satisfaction with home careespecially new models of "hospital-at-home" care. Trends in the home health care industry include: 1. Ethics committees to handle ethical issues that arise in the home. These committees may be necessary for agencies to receive accreditation. 2. Third-party reimbursement for community clinical nurse specialists and psychiatric nurse specialists. These advanced practice nurses can provide education, support, counseling, and therapy for clients and their families. 3. Third-party reimbursement for social workers. Social workers can assist clients and their families in the home with financial and household problems, freeing the nurse to focus on nursing care. 4. Nurse pain specialists to assess and manage pain in the home, thus avoiding costly hospitalizations and procedures. 5. Pet care for clients who may become too ill to care for them. Clients can make arrangements for the care of a pet if they are hospitalized or die. 6. Electronic home visits. A computerized system can obtain information, such as blood pressure readings, allowing case managers to review a client's progress from off-site.

LIFESPAN CONSIDERATIONS

Home Care

CHILDREN One goal of Healthy People 2010 is to reduce the number of children with disabilities living in care facilities from over 24,000 in 1997 to 0 by 2010 (U.S. Department of Health and Human Services, 2000). Ideally, all children with disabilities would live in a secure, "permanent" family environment. Such an environment is one that supports family strengths, connects families to their community, and fosters ongoing, secure relationships. At times, children with disabilities may need to be placed in adoptive or medical foster homes. Home health nurses can strengthen family functioning by: • Providing information, advice, and instruction on care of the child. • Identifying natural support systems (e.g., extended family, neighbors, friends). • Helping families find community resources to meet their needs (e.g., respite care, technical and equipment services). • Assisting families with alternative placement options as needed (e.g., medical foster care). • Advocating for families with other health care providers and policy makers. ELDERS

Clients who have been hospitalized are often discharged after short stays and may still be acutely ill. This becomes a challenge for home health nurses in planning and implementing care. Special areas of concern for elders in this situation include the following: • Healing time is slower due to changes that normally occur in aging, such as impaired circulation and alteration in immune response. • Changes in medications or lingering traces of anesthesia may alter cognitive status, even though it is usually temporary. • Weakness and fatigue create safety issues, such as risk for falling. • Chronic diseases already present may have been complicated by other conditions acquired while hospitalized. • Assessment should be initiated while the client is in the hospital to determine the need for assistive devices or environmental changes when the client returns home. Some examples of these devices are walkers, raised toilet seats, safety bars in the bathroom, and better lighting. Good planning eases the transition to home care for the client and caregiver. In the future, although the number of elders will increase, fewer family caregivers may be available. However, elders appreciate receiving care from family members (Crist, 2005), and nurses should facilitate this when possible.

Critical Thinking Checkpoint Mr. Madden is a 67-year-old African American male with a 20-year history of hypertension and diabetes mellitus. He has recently undergone amputation of three toes due to poor circulation. Because he is progressing well and his diabetes is under control, he is being discharged from the acute care setting to go home. He has been referred to the hospital-based home health agency, which will assign a nurse to change his foot dressings, administer IV antibiotics, and monitor his blood glucose levels. 1. When delivering care in the home environment, how will the nurse's role be similar to and different from that of the nurse's role in the acute care environment? 2. What rights does the client have when being cared for at home that may not be afforded him while institutionalized? 3. What factors could negatively affect the care of Mr. Madden in his own home? 4. Speculate about personal and financial savings derived by clients being cared for at home rather than in a hospital or other institution. See Critical Thinking Possibilities in Appendix A.

CHAPTER 8 REVIEW CHAPTER HIGHLIGHTS • Home health care is an alternative to acute and subacute health care facilities. The trend has changed from using home health care after hospitalization to using it to avoid hospitalization.

• Hospice nursing, often considered a subspecialty of home nursing, supports terminally ill clients and their families during the last stages of life and bereavement. • Home health agencies offer skilled professional and paraprofessional services. Because clients often require the services of several professionals simultaneously, case coordination is essential. • There are several types of home health agencies: official or public agencies, voluntary or private not-for-profit agencies, private proprietary agencies, and institution-based agencies. All home health agencies must meet specific standards for licensing, certification, and accreditation. • Private duty agencies provide professional nursing and home health aide care for 4 to 24 hours per day. • Health care agencies in the United States receive reimbursement for services they provide from various sources: Medicare and Medicaid, private insurance companies, and private pay. The Medicare and Medicaid programs have strict guidelines. • Referrals for home health services may be made by the client's physician, a nurse, a social worker, a therapist, a discharge planner, or a family member. Home care requires, however, a physician's order and an approved treatment plan. • Major roles of the home health nurse are those of advocate, caregiver, educator, and case manager. • The home health nurse assesses the care needs of clients in their home; plans, implements, and supervises that care; teaches clients and their families self-care; and mobilizes the resources of hospitals, primary care providers, and community agencies in meeting the needs of the clients and their families. • Home care clients include a diverse population that encompasses all ages, a variety of health problems, and families of different structures and cultural backgrounds. The home health nurse needs to be culturally sensitive, that is, become aware of the client's culture, and form a nursing care plan with the client that incorporates the client's culture. • Important dimensions of home health nursing include the home visit in which the nurse assesses the client and they make plans for care; client and nurse safety; infection control; and caregiver support. TEST YOUR KNOWLEDGE 1. Care in the home is an alternative to hospital placement. Which of the following is one major difference associated with in-home care? 1. Does not focus on curative and lifesaving approaches 2. Is less able to manage complex symptoms 3. Facilitates extensive involvement of significant others/family 4. Permits use of pain medication regimens not allowed in the hospital 2. If a primary care provider prescribed the following, which could be delegated to the home health aide? 1. Feeding and bathing the client 2. Teaching the client about medications 3. Assessing wound healing progress 4. Adjusting oxygen flow

3. After the nurse instructed a client about the rationale for sitting with feet elevated to enhance venous return, the client refuses to perform the activity. Which statement by the nurse would be most useful? 1. "If you won't cooperate, I can't help you." 2. "Tell me the reasons you won't put your feet up." 3. "It is essential that you do this." 4. "I'll notify your doctor that you are unable to keep your feet up." 4. A home health nurse is providing care for a client who has paralysis on one side and whose spouse provides most of the care. Which of the following may be a sign of caregiver role strain? 1. The caregiver loses weight and has insomnia. 2. The caregiver asks other family and friends for help. 3. The caregiver asks the nurse what other ways he or she can help the client. 4. The caregiver seems sad whenever the client's prognosis is discussed. 5. A client is scheduled to be discharged from the hospital. The discharge planner at the hospital should acquire which of the following first before home nursing care can be initiated? 1. Insurance coverage 2. An in-home caregiver 3. A curable health problem 4. A physician's authorization See Answers to Test Your Knowledge in Appendix A. EXPLORE MEDIALINK WWW.PRENHALL.COM/BERMAN COMPANION WEBSITE • Additional NCLEX Review • Case Study: Home Care Nursing • Application Activities: Hospice Nursing Duties of the Home Health Assistant Home Care of a Diabetic Client • Links to Resources READINGS AND REFERENCES SUGGESTED READINGS Bedard, M., Koivuranta, A., & Stuckey, A. (2004). Health impact on caregivers of providing informal care to a cognitively impaired older adult: Rural versus urban settings. Canadian Journal of Rural Medicine, 9(1), 15-34. This article reports a study of informal caregiving for cognitively impaired Canadian elders in urban versus rural settings. The authors concluded that rural caregivers overall

had more specialized needs in the promotion of healthy behaviors and care management of cognitively impaired elders. Ervin, N., Scrivener, K., & Simmons, T. (2004). Using the linkage model for integrating evidence into home care nursing practice. Home Health Care Nurse, 22, 606-611. The heart failure patient population of a home care agency shows improved outcomes following implementation of an evidence-based practice model by the agency. RELATED RESEARCH Castleman, J., & Gailor, N. (2004). Informal caregiving burden: An overlooked aspect of the lives and health of women transitioning from welfare to employment? Public Health Nursing, 21, 24-31. Grant, J. S., Glandon, G. L., Elliott, T. R., Giger, J. N., & Weaver, M. (2004). Caregiving problems and feelings experienced by family caregivers of stroke survivors the first month after discharge. International Journal of Rehabilitation Research, 27, 105-111. Langa, K., Valenstein, M., Fendrick, A., Kabeto, M., & Vijan, S. (2004). Extent and cost of informal caregiving for older Americans with symptoms of depression. American Journal of Psychiatry, 161, 857-863. Taft, S. H., Pierce, C. A., & Gallo, C. L. (2005). From hospital to home and back again: A study in hospital admissions and deaths for home care patients. Home Health Care Management and Practice, 17, 467-480. REFERENCES Boucher, M. A. (2005). Making it: Qualities needed for rural home care nursing. Home Healthcare Nurse, 23, 103-108. Brillhart, B., Kruse, B., & Heard, L. (2004). Safety concerns for rehabilitation nurses in home care. Rehabilitation Nursing, 29, 227-229. Caruso, J. T., Scala-Foley, M. A., Archer, D., & Reinhard, S. C. (2004). Making sense of Medicare: A Medicare house call. American Journal of Nursing, 104(7), 71-72. Centers for Medicare & Medicaid Services. (2001). Medicare home health agency manual (HCFA Publication No. 11, PB 98-955200). Retrieved June 12, 2006, from http://www.cms.hhs.gov/manuals/downloads/pub_11.zip Centers for Medicare & Medicaid Services. (2004). Medicare and home health care (CMS Publication 10969). Baltimore: U.S. Department of Health & Human Services. Crist, J. D. (2005). The meaning for elders of receiving family care. Journal of Advanced Nursing, 49, 485-493. Porter, E. J., & Ganong, L. H. (2005). Older widows' speculations and expectancies concerning professional home-care providers. Nursing Ethics, 12, 507-521. Smith, C., Cowan, C., Sensing, A., & Catlin, A. (2005). Health spending growth slows in 2003. Health Affairs, 24, 185-194. Sturkey, E. N., Linker, S., Keith, D. D., & Comeau, E. (2005). Improving wound care outcomes in the home setting. Journal of Nursing Care Quality, 20, 349-355.

U.S. Department of Health and Human Services. (2000). Healthy people 2010: Understanding and improving health (2nd ed.). Washington, DC: U.S. Government Printing Office. SELECTED BIBLIOGRAPHY American Nurses Association. (1999). Scope and standards of home health nursing practice. Washington, DC: American Nurses Publishing. Bradley, P. J. (2003). Family caregiver assessment: Essential for effective home health care. Journal of Gerontological Nursing, 29(2), 29-36. Byrne, M. (2003). Culture-derived strategies of a pediatric home-care nursing specialty team. International Nursing Review, 50(1), 34-43. Hartung, S. Q. (2005). Choosing home health as a specialty and successfully transitioning into practice. Home Health Care Management and Practice, 17, 70-87. Hogue, E. (2003). Five crucial legal issues for home care providers. Remington Report, 11(1), 22-24. Joint Commission on Accreditation of Healthcare Organizations. (2004). 2004-2005 Comprehensive accreditation manual for home care. Oakbrook Terrace, IL: Author. Keller, S., Hunter, D., & Shortt, S. (2004). The impact of hospital restructuring on home care nursing. Canadian Journal of Nursing Leadership, 17(2), 82-89. Reinhart, E. (2005). Infection control in home care. Boston: Jones & Bartlett. Schumacher, K., & Marren, J. (2004). Home care nursing for older adults: State of the science. Nursing Clinics of North America, 39, 443-471.