Home Care Home Care of Patients with Chronically of Patients with Chronically Ill in the World and TurkeyIll in the World and Turkey

Prof. Dr. Güler CimeteProf. Dr. Güler Cimete

Marmara University,School of NursingMarmara University,School of Nursing

President of Home Care AssociationPresident of Home Care Association

Home careHome care HC is provision of protective, therapeutic, HC is provision of protective, therapeutic,

rehabilitative services in the place of rehabilitative services in the place of

residence of individuals and families who residence of individuals and families who

have needs resulting from acute illness, have needs resulting from acute illness,

long-term health conditions, long-term health conditions, permanent disability or terminal illness.permanent disability or terminal illness.

home care services are based on holistic home care services are based on holistic

and multidisciplinary health team approachand multidisciplinary health team approach

Development of home care servicesDevelopment of home care services

Home care began in the US around the 1800s. Care Home care began in the US around the 1800s. Care was given to sick person by sisters/ladyswas given to sick person by sisters/ladys

First home care organization is Boston Dyspensary, First home care organization is Boston Dyspensary,

(1796) (1796)

Visitor nurses began to care giving for patients at Visitor nurses began to care giving for patients at their home, at 1880s. their home, at 1880s.

In 1898, home care services began to payed by In 1898, home care services began to payed by national budget. national budget.

In 1909, the Metropolitan life insurance company In 1909, the Metropolitan life insurance company began offering home nursing services to policy began offering home nursing services to policy holders.holders.

In 1966, Medicare and Medicaid began to In 1966, Medicare and Medicaid began to reimbursement of home care services reimbursement of home care services

In 1990s, home care continues to be a diverse and In 1990s, home care continues to be a diverse and rapidly growing service industry.rapidly growing service industry.

Development of home care services in many Development of home care services in many European countaries is similar with US. European countaries is similar with US.

Home care team: Home care team:

physician, physician, nurse, nurse, physical therapist, physical therapist, social worker, social worker, home care aid, home care aid, occupational therapist, occupational therapist, language therapist, language therapist, dietitian, dietitian, patient, patient, family members, ect ……family members, ect ……

Who need home careWho need home care

People who have;People who have; Acute illnessAcute illness NewbornsNewborns Chronic illness/ disability Chronic illness/ disability

pysical, mental, physicologicalpysical, mental, physicological

Terminal stage illnessTerminal stage illness

Olders Olders

Conditions requiring home health care most Conditions requiring home health care most frequently include frequently include

diabetes, heart failure, diabetes, heart failure,

chronic ulcer of the skin, chronic ulcer of the skin,

osteoarthritis, hypertension.osteoarthritis, hypertension.

In our country;In our country;

cancer, SVO, cancer, SVO,

heart failure, trauma heart failure, trauma

Providers and users of home care Providers and users of home care services in USAservices in USA

20 000 providers deliver home care to 7.6 20 000 providers deliver home care to 7.6 million individualsmillion individuals

Almost two-thirds (62.3 percent) of home Almost two-thirds (62.3 percent) of home health care recipients are women.health care recipients are women.

More than two-thirds (68.6 percent) of home More than two-thirds (68.6 percent) of home

health care recipients are over age 65. health care recipients are over age 65.

health care trend from institualized care to.health care trend from institualized care to. home carehome care Causes of thatCauses of that

1- Demographic changes. Contuniusly increase 1- Demographic changes. Contuniusly increase the life expectancy at birt, older population the life expectancy at birt, older population and chronic illnessand chronic illness

2- Medical knowledge and technology continue 2- Medical knowledge and technology continue to advance in home careto advance in home care

Ventilators are manufactured solely for Ventilators are manufactured solely for home use.home use.

3- Home care is cost effective*3- Home care is cost effective*

4- Other adventages. Most patients and 4- Other adventages. Most patients and families prefer to home care,** families prefer to home care,**

*Nicholson et.al. (2001), Aust. Health Review, 24(4): 181-87*Nicholson et.al. (2001), Aust. Health Review, 24(4): 181-87

*Tuggey,Plant,Elliot. (2003) Thorax, 58(10); 867-71.*Tuggey,Plant,Elliot. (2003) Thorax, 58(10); 867-71.

** Elgen, Zander (1990) ** Elgen, Zander (1990) www.www.thracicthracic.org/.org/adobeadobe//statementstatement/home1-2/home1-2 pdf pdf

1- Demographic changes1- Demographic changes

Globally, at the begining of the 21st century, 1 in every 10 Globally, at the begining of the 21st century, 1 in every 10 persons was 60 years or overpersons was 60 years or over

by 2020 the figure will be about 1 of every 8. by 2020 the figure will be about 1 of every 8.

by 2050 %20 of the population will be 60 years age and olderby 2050 %20 of the population will be 60 years age and older

More than 80% of individuals older than 65 have at least one More than 80% of individuals older than 65 have at least one chronically illness. chronically illness.

2- 2- Thecnologic developmentsThecnologic developments

Home care therapiesHome care therapies

oxygen therapy, inhalation (nebulizer) therapy, oxygen therapy, inhalation (nebulizer) therapy, tracheostomy care, tracheostomy care, home apnea monitoring, home apnea monitoring, intravenous medications, intravenous medications, mechanical ventilation. mechanical ventilation. Woun careWoun care Tube feeding, TPNTube feeding, TPN IV infusionIV infusion Others………………Others………………

Ventilator Ventilator

Tecnology allows, encourages and supports chronic Tecnology allows, encourages and supports chronic ventilator users to live at home.ventilator users to live at home.

Ventilator market growed to more than 40% in 2006.Ventilator market growed to more than 40% in 2006. (USA)(USA)

*The number of ventilator-dependent patients doubled *The number of ventilator-dependent patients doubled from 1980 to 1990, -with about 20% of the estimated from 1980 to 1990, -with about 20% of the estimated 11,419 patients being cared for at home-11,419 patients being cared for at home-

*…….Chest 1998. 113, 289-344*…….Chest 1998. 113, 289-344

20032003

*6% of patients with cystic fibrosis *6% of patients with cystic fibrosis received home oxygen therapy, received home oxygen therapy,

8.9% used supplemental tube feedings 8.9% used supplemental tube feedings at homeat home

*Cystic Fibroses Foundation, Annual Report. *Cystic Fibroses Foundation, Annual Report. http://www.cff.org/uploadedFiles/publications/files/2003%20patienthttp://www.cff.org/uploadedFiles/publications/files/2003%20patient%20registryreport.pdf%20registryreport.pdf

3- Payment system and Cost-Effectiveness3- Payment system and Cost-Effectiveness

Home care services can be paid by Home care services can be paid by

the patient/ family the patient/ family

public and private sources.public and private sources.

Public payors Public payors (USA):(USA):

Medicare, Medicaid, Medicare, Medicaid,

the Older Americans Act, the Veterans Administration, and the Older Americans Act, the Veterans Administration, and

Social Services block grant programs. Social Services block grant programs.

In the USA, the federal government reimburses home In the USA, the federal government reimburses home health care through the Medicare program (usually 60 health care through the Medicare program (usually 60 days)days)

65 years and older people are included by Medicare65 years and older people are included by Medicare

Respiratory care equipment and home oxygen Respiratory care equipment and home oxygen therapy may be reimbursed under Medicare, therapy may be reimbursed under Medicare, Medicaid, or private insurance. Medicaid, or private insurance.

Medicare does not reimburse for the in-home Medicare does not reimburse for the in-home services of respiratory therapists (RTs), services of respiratory therapists (RTs),

HOME CARE EXPENDİTURE (USA)HOME CARE EXPENDİTURE (USA)

In 2003In 2003

Total expenditure for health care ; $ 1.673.6 Total expenditure for health care ; $ 1.673.6 billion billion

Home care expenditure; $ 38.3 billionHome care expenditure; $ 38.3 billion

Sources of payment for home health care, Sources of payment for home health care, (USA, 2003)(USA, 2003)

Sources of paymentSources of payment 38.3 billion $ 38.3 billion $ Percent of totalPercent of total

MedicareMedicare 12.212.2 31.931.9

MedicaidMedicaid 5.15.1 13.313.3

State and lokal State and lokal governmentsgovernments

6.06.0 15.715.7

Private insurancePrivate insurance 6.96.9 18.018.0

Out of packetOut of packet 6.96.9 18.018.0

OtherOther 1.11.1 2.92.9

Medicare home health utilization by principal Medicare home health utilization by principal diagnosis, 1999.diagnosis, 1999.

Total all diagnosis %100Total all diagnosis %100

Diseases of the respratory 11.6Diseases of the respratory 11.6

systemsystem

Pneumonia 3.7Pneumonia 3.7

Sullivan et.al. noted that nearly 50% of Medicare Sullivan et.al. noted that nearly 50% of Medicare costs are incurred by about 10% of patients with COPD costs are incurred by about 10% of patients with COPD ((not only home care, hospital and emergency expenditure more…. .not only home care, hospital and emergency expenditure more…. . ) )

Sullivan. Et.al. Sullivan. Et.al. ChestChest 2000;117(Suppl 2):5-9 2000;117(Suppl 2):5-9

Cost of inpatient care compared to homeCost of inpatient care compared to home

ConditionsConditions Per patient,Per patient,

per monthper month

Hospital costHospital cost

Per patient,Per patient,

per monthper month

Home care costHome care cost

Per patient,Per patient,

per monthper month

$ savings$ savings

*Ventilator *Ventilator dependent adultsdependent adults

21.570 $21.570 $ 7050 $7050 $ 14.520 $14.520 $

**Oxygen depen-**Oxygen depen-dent childrendent children

12.090 $12.090 $ 5220 $5220 $ 6840 $6840 $

***Congestive ***Congestive heart failure among heart failure among the elderlythe elderly

1750 $1750 $ 1605 $1605 $ 153 $153 $

****IV antibiotic ****IV antibiotic therapy for sellü-therapy for sellü-litis, osteomyelitlitis, osteomyelit

*Bach, et.al. (1992) *Bach, et.al. (1992) Pediatrics, 92(1); 128-134Pediatrics, 92(1); 128-134

12 510 $12 510 $

** Field. Et.al (1991) ** Field. Et.al (1991) American J of Diseases American J of Diseases Children. 145,; 729-33Children. 145,; 729-33

4650 $4650 $

******Rich. Et.al. (1995) The Rich. Et.al. (1995) The New England J of Med. New England J of Med. 333(18);1190-95.333(18);1190-95.

7860 $7860 $

****William. Et.al. (1993) ****William. Et.al. (1993) Clinical Therapy, 15; 169-79.Clinical Therapy, 15; 169-79.

Home care is less costly than hospital careHome care is less costly than hospital care

for patients with chronic respiratory for patients with chronic respiratory

conditions, especially for home care of conditions, especially for home care of

patients receiving long-term intravenouspatients receiving long-term intravenous

therapy or chronic ventilator care therapy or chronic ventilator care (1, 2, 3).(1, 2, 3).

1-Williams DN. 1-Williams DN. Am J MedAm J Med 1994;97:50–55 1994;97:50–55 2-Fields AI.et.al. 2-Fields AI.et.al. Am J Dis ChildAm J Dis Child 1991;145:729–733. 1991;145:729–733.

3- Pond MN.et.al. 3- Pond MN.et.al. Eur Respir JEur Respir J 1994;7:1640–1644. 1994;7:1640–1644.

Bergner, et.alBergner, et.al. . attempted cost comparisons of specialize attempted cost comparisons of specialize respiratory home care with standard home care. respiratory home care with standard home care.

It was found that both interventions were expensive, It was found that both interventions were expensive, and that home health care delivered by specially and that home health care delivered by specially trained respiratory nurses was more expensive than trained respiratory nurses was more expensive than standard home health care while producing similar standard home health care while producing similar health-related quality of life outcomes. health-related quality of life outcomes.

Bergner, et.al. Bergner, et.al. Med Care.Med Care. 1988;26:566–579 1988;26:566–579

4- Other adventages4- Other adventages

Home care services; Home care services;

increase the functioning and health-related quality of increase the functioning and health-related quality of life of patients life of patients (5b)(5b)

increase the satisfaction of patient and caregiver from increase the satisfaction of patient and caregiver from home carehome care

reduce emergency room use reduce emergency room use (1, 2, 3),(1, 2, 3), not reduce not reduce (4,5a)(4,5a)

1-Farrero. et.al.1-Farrero. et.al.ChestChest 2001;119:364–369, 2-Bourbeau. et.al. 2001;119:364–369, 2-Bourbeau. et.al. Arch Intern MedArch Intern Med 2003;163:585–591. 2003;163:585–591.

3- Haggerty. et.al. 3- Haggerty. et.al. ChestChest 1991;100:607–612 1991;100:607–612

4-Smith. et.al. 4-Smith. et.al. Aust N Z J MedAust N Z J Med 1999;29:718–725. 5a-Dranove. 1999;29:718–725. 5a-Dranove. InqInq 1985;22:59–66 1985;22:59–66.. 5b-Winkler MF. Et.al. Nutr Clin Prac. 2006 Dec. 21(6);544-565b-Winkler MF. Et.al. Nutr Clin Prac. 2006 Dec. 21(6);544-56

Home care services;Home care services;

reduce clinic visits reduce clinic visits (6, 7),(6, 7), no make difference no make difference (8,9)(8,9)

reduce the number of hospitalization reduce the number of hospitalization (10),(10), not reduce not reduce (11, 12, 13, 14, 15)(11, 12, 13, 14, 15)

reduce unsheduled physician visits reduce unsheduled physician visits (16)(16)

6-Dranove D. 6-Dranove D. InqInq 1985;22:59–66. 7- Neff DF. et.al. 1985;22:59–66. 7- Neff DF. et.al. Home Health NurseHome Health Nurse 2003;21:543–549. 2003;21:543–549.

8- Littlejohns P, et.al. 8- Littlejohns P, et.al. ThoraxThorax 1991;46:559–564. 9- Smith BJ. et.al. 1991;46:559–564. 9- Smith BJ. et.al. Aust N Z J MedAust N Z J Med 1999;29:718–725. 1999;29:718–725. 10-Barnett M. 10-Barnett M. Prof NurseProf Nurse 2003;19:93–96, 11- Davies L.et.al. 2003;19:93–96, 11- Davies L.et.al. BMJBMJ 2000;321:1265–1268 2000;321:1265–1268 12- Sala E.et.al12- Sala E.et.alEur Respir JEur Respir J 2001;17:1138–1142 2001;17:1138–1142. . 13-Shepperd S.et.al13-Shepperd S.et.alBMJBMJ 1998;316:1786–1791 1998;316:1786–1791 14- Hernandez C.et.al. 14- Hernandez C.et.al. Eur Respir JEur Respir J 2003;21:58–67 15- Cotton MM. et.al 2003;21:58–67 15- Cotton MM. et.alThoraxThorax 2000;55:902–906. 2000;55:902–906. 16- Bourbeau J.et.al. 16- Bourbeau J.et.al. Arch Intern MedArch Intern Med 2003;163:585–591 2003;163:585–591

There is no difference in mortality between There is no difference in mortality between patients treated for acute COPD exacerbation patients treated for acute COPD exacerbation in hospital and those treated at home in hospital and those treated at home (17, 18).(17, 18).

17-Davies L. et.al. 17-Davies L. et.al. BMJBMJ 2000;321:1265–1268 2000;321:1265–1268 18-Hernandez C.et.al. 18-Hernandez C.et.al. Eur Respir JEur Respir J 2003;21:58–67 2003;21:58–67

Future home care goals may include Future home care goals may include

patient and family satisfaction, patient and family satisfaction,

reduction of complications resulting from reduction of complications resulting from hospitalization, hospitalization,

maintaining an acceptable quality of life, maintaining an acceptable quality of life,

enabling a comfortable and dignified death. enabling a comfortable and dignified death.

Cost reduction could become a collateral benefit, Cost reduction could become a collateral benefit, instead of a primary goal, for home health care. instead of a primary goal, for home health care.

Respite CareRespite Care

Formal respite care allows family care givers Formal respite care allows family care givers time away from caregiving activitiestime away from caregiving activities

HOME CARE HOME CARE SERVİCES in TURKEYSERVİCES in TURKEY

Needs Needs and problems related to home and problems related to home care in Turkeycare in Turkey

All factors which increased to needs for home care at another All factors which increased to needs for home care at another countries are true for Turkey, too. countries are true for Turkey, too.

Older population is increasingOlder population is increasing There is a growing the number of chronically-ill patient There is a growing the number of chronically-ill patient Caregivers from family members are decreasingCaregivers from family members are decreasing Discharge services are not sufficientDischarge services are not sufficient

additionallyadditionally

Home care law is not contain all aspects of home Home care law is not contain all aspects of home care services.care services.

There is not public home care systemThere is not public home care system

Public insurance system is not including to home care Public insurance system is not including to home care services, services,

Private home care services are reimbursed by private Private home care services are reimbursed by private insurange agencies or by pocket of the patients or insurange agencies or by pocket of the patients or families families

Providers of home care servicesProviders of home care services

Private home care agenciesPrivate home care agencies

Private hospitalsPrivate hospitals

Some public hospitals Some public hospitals (generally voluntary and limited (generally voluntary and limited service)service)

Municipalities Municipalities

Home care team in private agencies Home care team in private agencies

Generally, composed fromGenerally, composed from

NurseNurse

Home care aideHome care aide

Physician Physician

Services of private home care agenciesServices of private home care agencies

Patient care; Patient care; wound care, respratory therapy, oxygen therapy, phsicalwound care, respratory therapy, oxygen therapy, phsical

therapy, IV infusion, enteral feedings, TPN, healththerapy, IV infusion, enteral feedings, TPN, health

education, ventilation support, etc. ...education, ventilation support, etc. ...

Dignostic studies; x-ray, lab….Dignostic studies; x-ray, lab….

Supplies of medical equipment for patientsSupplies of medical equipment for patients

Transportation of patientsTransportation of patients

Diagnosis of patientsDiagnosis of patients End stage cancer/terminal patientsEnd stage cancer/terminal patients

Heart disease with COPD or without any lung diseaseHeart disease with COPD or without any lung disease

SVO SVO

Post operative period for serious illnessPost operative period for serious illness

OthersOthers

Home care services of Municipalities Home care services of Municipalities

Home care for older, poor, chronic patientsHome care for older, poor, chronic patients

Services are not paid but limitedServices are not paid but limited

Home Care AssociationHome Care Association

It was establised in 2005It was establised in 2005

Aim of the Association; prepare a home care Aim of the Association; prepare a home care law which is include all aspects of home care law which is include all aspects of home care services and work together with Ministry of services and work together with Ministry of Health for legislated it.Health for legislated it.

Thank YouThank You