Home Health Care

By Rita Daniels, RN

Home Health Care

Hello and welcome to my nursing presentation, Home Health Care by Rita Daniels.1

The baby boomer generation, approximately 7 million people, is currently entering the ranks of the young old (60-74 years of age) and beginning to become eligible for Social Security benefits in 2011, with the older generations (90 years older and up) being the fastest growing segment of the age population (Touhy & Jett, 2011, p. 4).

By 2030, up to 72 million people will be 65 years old or older (Touhy & Jett, p. 4).

2ObjectivesDefine Home Health Care

Learn about Medicare basics: what is covered and what is not covered

Learn about Private Duty Nursing in Michigan

Discuss the recruitment and retention of new nurse graduates into home health care

Home health care is a wide range of health services provided in the clients homeskilled nursing care

non-medical services

Private duty care

Definition of Home Health Care

Skilled care: wound care, pressure sores care, physical, speech and occupational therapy, patient and caregiver education, IV or nutrition therapy, injections or monitoring of serious illness or unstable health status.

Non-medical services: home health aide services such as help with activities of daily living (ADLs), light housekeeping, errands, shopping for the client (www.medicare.gov).

4Home care is the patient-preferred setting.

The patient is more comfortable at home, the care is provided less expensively at home, and it achieves optimal health outcomes for many patients. There are less patient incidents and safety issues in the home setting. It has to do with the patient being in control. (www.jointcommission.org).

Why Home Health

Care?

Our care is very high tech and very skilled and we know how to provide these services in a less controlled environment than what you have in any other health care setting (www.jointcommission.org).

5Medicare Basics under the Home Health Benefit (beneficiaries not covered under any other program)

Services covered under the Medicare home health benefit include, but are not limited to, skilled nursing care, physical therapy, occupation therapy, speech therapy, medical social services, and medical supplies.

Clients require a physician certification of need

Home health services are intended for beneficiaries who are unable to access services in an outpatient setting,

Receive a fact to face encounter with the physician or designated personnel

clients who are homebound, or require intermittent services,

need reasonable and necessary care;

have had a recent hospitalization, a change in health status, or a new onset or exacerbation of health condition (www.michigan.gov).

Skilled care is designed for short term, to help people get back on their feet, and then to discontinue.

7Services not covered under the Medicare Home Health Benefit

Benefits under Medicare do not cover people requiring 24 hour-a-day care at home;

meals delivered to the home

homemaker services or personal care given by home health aides

Medicare Basics under the Private Duty Nursing Benefit

Private Duty Nursing is defined as nursing services for beneficiaries who require more individual and continuous care, in contrast to part-time or intermittent care, than is available under the home health benefit. People who have chronic illnesses such as multiple sclerosis or ventilator-dependent patients may qualify for this benefit (www.michigan.gov).

The medical criteria required includes the beneficiary is dependent daily on technology-based medical equipment to sustain life; has frequent episodes of medical instability within the past 3 to 6 months; and the beneficiary requires continuous skilled nursing care on a daily basis

Private Duty Nursing (non-Medicare)

Private Duty Nursing can be defined as care provided by private funds, insurance companies, trust funds.

Private duty nurses are professional practitioners who give direct, comprehensive care on an hourly or live-in basis. As a private duty nurse, an RN can work for an agency or as a private contractor (Hagerty, J.D., n.d.).

In Michigan, a Medicaid enrolled Nurse (RN/LPN) must be registered in the State of Michigan, and cooperate with MDCH in quality monitoring activities, beneficiary complaint resolution, and post-payment audit reviews (www.michigan.gov).

In Michigan, Private Duty Nursing Agencies must be accredited by Community Health Program (CHAP) or the Accreditation Commission for Health Care (ACHC) as a PDN agency (www.michigan.gov). A Medicaid enrolled nurse may work independently or through an agency.

10A private duty nurse may also work independently or through an agency. Care provided by a private duty nurse may involve a wide variety of nursing duties from wound care for pressure sores, coordinating physical, speech and occupational therapy, patient and caregiver education, IV or nutrition therapy, injections or monitoring of serious illness or unstable health status) and supervision or performance of non-medical services (i.e., home health aide services such as help with activities of daily living (ADLs), light housekeeping, errands, shopping for the client). Characteristics of a Home HealthCare Nurse

Personal Factors: Do I have what it takes?

Systemic Factors: Its not what I expected

Relational Factors:

Its the relationships that count

(Patterson et al, 2013, Figure 1)

Analysis of participants stories suggests the meaning of being a new graduate nurse in home care can be understood through the interplay of personal, systemic, and relational factors affecting their decision to remain in home care following orientation, preceptorship and transition to independent practice (Patterson et al, 2013, p. 3)

Personal factors encompasses graduate nurses stating i can do this, I dont have enough experience, I was just so out of my comfort zone, and I love the independence.

Systemic factors include comments like its not what I expected, taking the care out of caring work, the work is not steady enough, and its an expensive job.

Relational factors included comments like: both feeling supported in the learning processes and feeling the absence of supportive relationships, fostering independence, being there for each other, and building relationships with clients.

11Nursing TheoryThe Neal Theory (1997 and 1998) addresses home health care nurses and proposed a model on Home Health Nursing Practice which posits that home health care nurses transition through three stages to achieve autonomy in the logistical and clinical aspects of home health care (Foley, 2013, p. 132). Dependence, moderate dependence and autonomy characterize Neals Theory about how nurses define their practice and build a research-based theory of home health nursing practice (Neal, 2000, p. 25).

(Neal, 1999, figure 1)The length of time of each stage varies depending on the individuals, their clinical experience, their adaptability, their motivation, their confidence and the quality and length of orientation. (Neal, 2000, p. 20).

The Neal Theory (1999) states home health nursing is autonomous in that typically the nurse works alone and makes many independent clinical decisions. The nurse must be adaptable, creative and open-minded to become truly autonomous (p. 13). 12Neal Theory componentsHome care nurses not only practice holistic health care, they also care for the patient entity (everything that affects the patient)Home care nurse often start over when they admit a patient to service. Patients may not be taught what they need to know in the in-patient settings, they may not remember it or know how to apply the information in the homeHome care nurses reach beyond book learning by using intuition. They are open-minded, creative, innovative and flexible.Home care nurses link patients with care givers, health care professionals, community and other resources, and sometimes with family members. (Neal, 1997, p. 1)

Home healthcare is provided in an unstructured setting. Assistance may be obtained over the phone if the appropriate party is available. Supplies may be scarce or inadequate to fill the need. The number of allowable visit to complete instruction and to assist the patient and caregiver to manage care is limited (Neal, 1999, p. 1).

Mensik (2007) reports that Cushman et al (2001) found that in 2000, 82% of home health care agencies reported difficulties in attracting registered nurses and 63% reported difficulty in keeping them. The need of HHC nurses between 2000 and 2010 will grow at a rate of 36% (Mensik, 2007).13Business Theory

Home health care can be for profit or non-profit, depending on agency policy. Capitalism is the economic system behind for profit home health care agencies. Altruism or community benefit can be the motivating factor for the non-profit home health agencies, often governed by hospitals or other care agencies. According to the Alliance for Advancing Nonprofit Health Care (2013), about 17 percent of home health care agencies are estimated to be non-profit (www.nonprofithealthcare.org).

Home health care has become an industry employing thousands of people as well as affecting thousands of clients. As it affects so many people and involves so much money, it is imperative it becomes regulated to provide excellent care to those who need it and to identify and eliminate those agencies that provide inferior service. The Home Care Association of America represents more than 1,300 member organizations and over 300,000 employees throughout the United States providing private pay in-home care services for the elderly and disabled (www.homecareaoa.org).

14Home health care is one of the most profitable franchises (Kennedy, 2012).

The economy doesnt affect the industry,

The number of seniors needing care continues to grow,

Increasing numbers of sicker patients are being discharged from hospitals,

Tele-monitoring is a growing component of the home health care industry,

and an increasing number of employed adults have no one to stay home with the parent or parents.

Business Theory: capitalism expanded

The federal government oversees Centers for Medicare and Medicaid Services to have and maintain a licenseAssessment of the Home Care Environment

Nursing systems theory stipulates that nursing systems emerge as a nurse designs and provides nursing related to the patients self-care needs (www.ehow.com)

Orems Nursing System theory recognizes three models of nursing systems that may emerge. In the Wholly Compensatory system, the nurse provides care for the patient. In the Partially Compensatory System, the nurse and the patient share the responsibility for self-care. In the Supportive-Educative System, the patient is entirely responsible for self-care, but the nurse provides consultation and support (www.ehow.com)

As it applies to Home Health Care nursing, all three models may be used, depending on the condition of the patient. 16*ResourcesThe Centers for Medicare and Medicaid Services, the Home Care Association of America (formerly the National Private Duty Association) (HCAOA), professional journals such as Home Health Care Management and Practice and Home Healthcare Nurse, and accrediting agencies like ACHC and CHAP provide resources for home health care agencies (www.homecareaoa.org).

.

Founded in 2002, the Home Care Association of America is the nation's first association for providers of private duty home care, which includes non-medical home care services. The HCAOA is the recognized resource for information and definition of private duty home care practice, supported by a strong national membership of providers. HCAOA leads the industry that cares for people at home through education and advocacy Founded in 2002, the Home Care Association of America is the nation's first association for providers of private duty home care, which includes non-medical home care services. The HCAOA is the recognized resource for information and definition of private duty home care practice, supported by a strong national membership of providers. HCAOA leads the industry that cares for people at home through education and advocacy (www.homecareaoa.org).

17Quality and SafetyThe Home Health Quality Improvement National Campaign, the Centers for Medicare and Medicaid Services, and the National Association for Home Care and Hospice (NAHC) are at the forefront of the industry for quality and safety

The National Association for Home Care and Hospice is the nation's largest trade association representing the interests and concerns of home care agencies, hospices, and home care aide organizations (www.homecareaoa.org).

The Home Health Quality Improvement (HHQI) National Campaign has been dedicated to improving the quality of care provided to Americas home health patients. A free resource, the campaign offers evidenced based resources and best practice educational tools, including best practice intervention packages (BPIPs) for medication management, fall prevention, and reducing avoidable re-hospitalizations (www.homehealthyquality.org). 18What is the logical interpretation of the data about this issue?

Home health care will continue to grow as an industry and as a business. Additional nurses will be needed to staff home health agencies and more schools will have to address the needs of the home care industry in their curriculum. Home health care has to recruit graduate nurses.

What are the likely outcomes of the various positions on this issue?

To minimize surprises stemming from the structure of the home care system, employers need to ensure new graduates are informed of the realities of home care nursing work including the potential for extended workdays, fluctuating work hours, additional work at home following the completion of client visits and possible expenses associated with using ones own car and cell phone along with processes for reimbursement of these expenses (Patterson et al, 2013, p. 7).Inferences/Implications/Consequences:

According to Patterson et al (2013), notwithstanding the impact of systemic factors on new graduate nurses experiences in home care, the finding of this study clearly support the continuation of extended orientation and preceptorship programs for new graduate nurses beginning their careers in home care (p. 7).

19Strategies that could improve quality and safety related to Home Health CareANA StandardsAssessmentCollects comprehensive, pertinent data Involves all family and healthcare providersUses EBP, analytical tools, and critical thinking

QSEN CompetencyEvidence-Based Practice: integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care

The ANA Home Health Nursing Scope and Standards of Practice, published in 2007, defines home health nursing as: the provision of nursing care to acutely ill, chronically ill, terminally ill, and well patients of all ages in their residence. Home health nursing focuses on health promotion and care of the sick while integrating environmental, psych-social, economic, cultural and personal health factors affecting an individual's and family's health status (ANA, 2007, p. 4).

Meets these standards with the implementation of an initial nursing assessment by an RN required by Medicare, Medicaid, and agency standards upon admission. Medicare requires an initial nursing assessment within 48 hours of the acceptance of a case. Agency standards differ, but usually require an RN to perform the assessment and develop the Plan of Care for and with the family and client.

20ANA StandardsANA Quality of PracticeSystematically enhances the quality of nursing practice Participates in quality improvement activities Incorporates evidence based knowledge

QSEN CompetencyQuality improvement: use data to monitor the outcome of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems of practice

Strategies that could improve quality and safety related to Home Health Care

ANA Standards of Practice and QSEN Competencies are virtually identical21ANA StandardsCollaboration

Collaborates with patient, family, and others in the conduct of nursing practice Partners with others to effect change Provides for continuity of care

QSEN CompetencyTeamwork and Collaboration:

Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care. Strategies that could improve quality and safety related to Home Health CareAgain, the ANA Standards for Home Health Nursing and the QSEN Competency matches each other.

22The personal characteristics for success in private duty nursing include adaptability, a sense of humor, excellent manners, and the ability to establish a warm, yet professional relationship with the patient and family. Other traits for success include creativity, self-direction, and independence. (Hagerty, J.D. n.d.)

What does It Take to Be a Home Health Care Nurse?

In recruitment and retention of the new nurse graduate, after reviewing the systemic factors, the relational factors and the personal factors presented by Patterson et al (2013, figure 1), a new graduate nurse, or any nurse for that matter, has to decide if home health care is right for him/her.

23Why Choose Home Health Care?Pros

Fastest growing segment of nursing todaySets own scheduleWorks independentlyVariety of patientsEncourages flexibility, creativity, and adaptability

Cons

Driving long distancesUse of own vehicle + cell phoneLess compensationNo back-up on siteLess formal structure

While factors such as confidence, supportive relationships, and the ability to find meaning in nurse-clientinteractions pulled the participants into homecare nursing, other factors pushed them away. These factors included being inexperienced, a lack of support from preceptors, peers, and managers, and unexpected realities of home care nursing work that were in conflict with what they had expected the job to be (Patterson, 2013, p. 94).

24Alliance for Advancing Nonprofit Health Care. (2013). Value of Nonprofit Health Care. Retrieved from: www.nonprofithealthcare.org

American Nurses Association, (2007). Home health nursing scope and standards of practice. Silver Spring, MA: Nursesbook

American Association of Colleges of Nursing. (2012). QSEN education consortium: Graduate-level QSEN competencies knowledge, skills and attitudes. Retrieved from: http://www.aacn.nche.edu/faculty/qsen/competencies.pdf

References

25Hagerty-Davis, J. (n.d). Career management: Managing your career. Nursing Spectrum. Retrieved from: nsweb.nursingspectrum.com/Arne-Nuzzo, P. 1996. Orientation to home care nursing. United States: Aspen Publishers Inc.Home Care Association of America website (2013). Retrieved from: http://www.homecareaoa.org/Home Healthy Quality Improvement National Campaign. (2013). Retrieved from: http://www.homehealthyquality.org

References26Kennedy, K. (2012). Home health care is one of the most profitable franchise. USA Today. Retrieved from: http://usatoday30.usatoday.com/money/industries/health/story/2012-05-03/home-health-care-a-profitable-franchise/54813562/1Home Care Association of America website (2013). Retrieved from: http://www.homecareaoa.org/Home Healthy Quality Improvement National Campaign. (2013). Retrieved from: http://www.homehealthyquality.org

ReferencesReferencesMeadows, C. (2006). Building bridges: Strategies to support new registered nurses in home health. (Doctoral thesis, Royal Roads University, Canada). Retrieved from http://proquest.umi.com.ezproxy.lib.ryerson.ca/pqdweb?RQT=403&TS=1302054316&clientId=10120

Mensik, J. (2007). Impact of organizational attributes on nurse satisfaction in home health. Home Health Care Management Practrice 19(6), p. 456-569. Retrieved from: http://hhc.sagepub.com/content/19/6/456. Doi: 10.1177/1084822307304254

Michigan Department of Community Health. (2013). Medicaid Provider Manual. Home Health. Retrieved from: http://www.michigan.gov/mdch/0,1607,7-132--87572--,00.html National Association for Home Care and Hospice website (2013). Retrieved from: http://www.nahc.org/

Neal, L.J. (2000). Validating and refining the Neal theory of home health nursing practice. Home Healthcare management and Practice 12(16), p. 16-25.

Neal, L.J. (1999). Preparing students to practice in the home. Nurse Educator, 24(4), pp 13-15.

ReferencesNeal, L.J. (2000). Validating and refining the Neal Theory of Home Health Nursing Practice. Home Health Care Management Practice 12(16). Doi 10.1177/108482230001200205Patterson, E., Hart, C., Bishop, S.E., Purdy, N. (2013). Deciding if home care is right for me: The experience of the new graduate nurse. Home Health Care Management & Practice XX(X), 1 -8. Doi: 10.1177/1084822312473828Private Duty today website. Guides to Home Care Licensing in Your State. Retrieved from: http://www.privatedutytoday.com/guides/licensing/index.htm#MIThe Joint Commission. (2011). Home the best place for health care: A position statement from The Joint Commission on the state of the home care industry. Retrieved from: http://www.thejointcommission.orgTouhy, T. W. & Jett, K. (2011). Ebersole & Hess Toward healthy aging: Human needs & nursing response. (8th ed). St Louis, MO: Elsevier.Yoder-Wise, P.S. (2011). Leading and managing in nursing (5th ed). St. Louis, MO: Elsevier-Mosby.

References