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Update on home health care: How it’s changing

Jeffrey Jones, age 82, recently was discharged from the hospital with cellulitis of the right lower leg, diabetes, and hypertension. He’d gone to the emergency department (ED) after checking his blood pressure at a supermarket pharmacy; a nurse happened to walk by, saw his dangerously reading, and drove him to the ED.

At discharge, the nurse refers Mr. Jones to a local home health agency for follow-up with a nurse and communicates the physician’s orders for Mr. Jones to the agency. Home care is directed not just to the patient but also to family members—in this case, Mr. Jones’s wife, who will be his caregiver. The home care nurse will teach them both about his medications and care regimen and instruct them to watch for signs and symptoms related to cellulitis, such as fever, warmth, and redness of the leg.

Over the last decade or so, home care has grown more complex. This article explores the role of the home care nurse and updates acute-care hospital nurses on today’s home health care scene. This is especially important because with home care expanding, acute-care nurses need to work together more closely and effectively with home care nurses.

What is home care?

Many definitions of home care exist, and home care can “look like” many different things. You might think of it as a service in which visiting nurses make home visits to provide wound care or other skilled or hands-on care, or may visit at-risk teenage mothers and their infants. Some home care nurses visit aides or companions who are staying with frail elders and provide meals, light housekeeping, and assistance with activities of daily living. All of these activities may fall under the umbrella of home care.

However, as government reimbursement decreases and pay-for-performance and other outcome- and quality-driven initiatives take effect, the definition of home care must incorporate prevention and community. To that end, the U.S. Public Health Service defines home care as services “provided to individuals and families in their places of residence for the purpose of promoting, maintaining, or restoring health or for maximizing the level of independence while minimizing the effects of disability and illness, including terminal illness.”

In this article, home care refers to any health care given in the patient’s home. Such care may be provided by Medicare-certified or Medicaid-certified home health agencies, visiting nurse associations, hospice nurses who make home visits, community health nurses who provide well-child care to at-risk mothers, and many other types of home care. Also, some organizations provide what’s generally termed nonmedical home care provided by aides or companions to help frail elders remain safely in their homes. These services might include personal care (such as assistance with hair washing), light housekeeping, shopping, meal preparation and clean up, and other types of care that can help patients stay in the home.


Role of Medicare

The largest payer of home care services is Medicare, the federal health insurance program for people ages 65 and older, as well as for certain younger people with disabilities and those with end-stage renal disease. Just as there are hospital covered days or services, Medicare has strict rules and coverage criteria for home care services. The rules are complex and are undergoing significant change. President Obama’s proposed 2015 budget includes provisions for home health copayments and additional cuts to Medicare for home care. If enacted, these changes (along with previous significant cuts and changes) could have devastating effects on patients and their families.

Assuming the patient is homebound, meets eligibility criteria, and needs skilled care, Medicare might cover nursing services; physical, occupational, or speech therapy; home health aides; and medical social workers. Each of these services has a defined scope and specific types of care that professionals may provide. (See the box below.)

Home healthcare team members

The home healthcare team may consist of:

  • medical director
  • registered nurses
  • licensed practical nurse
  • licensed vocational nurse
  • occupational therapist
  • physical therapist
  • physical therapy assistant
  • speech therapist
  • speech-language pathologist
  • dietitian or nutritionist
  • medical social worker
  • pharmacist
  • wound, ostomy, and continence nurse.

In some cases, certain home care services must be provided under the supervision of a licensed provider.

For specific information about covered services, see www.medicare.gov/Pubs/pdf/10050.pdf.

First home care visit

The nurse’s initial evaluation and assessment/admission visit is lengthy—2 hours or even longer. Usually, she starts by collecting insurance verification and other basic information. Then she obtains an in-depth history and performs a comprehensive assessment using the OASIS-C tool. OASIS is an acronym for Outcome and ASessment Information Set, which must be used for all assessments of Medicare and Medicaid patients.

Next, the nurse reviews various forms with the patient and asks the patient to sign them. They typically include consent forms, patients’ rights and responsibilities form, Health Insurance Portability and Accountability Act form, insurance and related release forms, and an advance directive. The nurse tells the patient and family members how to contact the HHA and the nurse, as well as how to access a 24-hour on-call nurse. (See the box below.)

Being all things to the patient

Imagine knocking on a stranger’s door and introducing yourself to a patient you’ve never met in a setting that’s personal and private. You are a stranger—a guest in the patient’s home. The home setting imparts a certain intimacy that makes the visit seem very personal: All parties must establish a comfort level with one another. As the visitor, you must acknowledge that you’re in the patient’s and family’s space and convey respect for that space.

What’s more, you will become all things to the patient, playing multiple roles beyond the nurse clinician. In effect, you’ll serve as the admitting nurse, the clinical decision maker, the person who knows and operationalizes the rules regarding home care, the provider of hands-on care, and the instructor who teaches the patient and family—all while working to meet the plan-of-care goals, coordinating other services the patient needs, and collaborating with the physician.

On the initial home care visit, the nurse measures Mr. Jones’s blood pressure, examines and assesses his cellulitis and the surrounding skin, and follows the physician’s orders for the dressing, care, and management of the leg and cellulitis wound. She teaches the family what warning signs to watch for and explains Mr. Jones’s pain management regimen, hypertension medications, and new antibiotics for his cellulitis.

Mr. Jones tells the nurse that although previously he was very active, he now spends most days in a wheelchair because of the leg swelling and pain. The nurse develops a plan of care (with input from the physician and patient) that involves a physical therapy assessment to develop a home exercise plan. She also counsels Mrs. Jones on a low-sodium diet and provides teaching sheets about diet and medications, warning signs and symptoms, and what to do if these occur. Her next visit is scheduled for 3 days later.

Patient populations served

Although elderly adults frequently are cared for at home, other patient populations also may receive home care by nurses, therapists, aides, and social workers. Some home health agencies specialize in pediatric care, helping children with congenital problems or chronic illnesses who are on ventilators or rely on other types of technology. These children and their families require a great deal of support and possibly around-the-clock care. Other home care patient populations include patients with head trauma and end-of-life patients of all ages who need palliative and hospice care. (See the box below.)

Examples of patients who may need home care

  • An older adult new to diabetes or insulin treatment
  • A child going home with a tracheostomy and learning problems
  • A patient discharged with a urinary catheter for long-term use who will be homebound
  • A patient with a wound who needs further assessment, care, and management
  • A patient who needs skilled care and education or training after discharge
  • A patient with a complex chronic illness who needs ongoing management, such as medication management and assessment for changes in the plan of care

Nurse’s role in home care

No matter what the setting or patient specialty area, you can help patients function safely at home. In fact, in many cases, the home is the optimal care setting because:

  • it doesn’t put the patient at risk for hospital-acquired infections
  • it keeps the patient safer in some ways because the nurse has only one patient to care for, meaning fewer opportunities for wrong-patient errors; also, patients know their homes inside-out
  • there are no time limits or age restrictions for visitors
  • patients’ make their own cultural and food choices
  • patients can wear their own clothes and maintain their dignity and individuality.

As the population ages, home care is expected to grow and home nursing opportunities are likely to expand. Nurses play a key role in helping patients get back to where they want to be. So think of home care the next time you have a patient who’s ready to return to the home—the healthcare setting of the future.

For resources on home care, see the box below.

Home care resources

Home health care: What it is and what to expect: www.medicare.gov/what-medicare-covers/home-healthcare/home-health-care-what-is-it-what-to-expect.html

Home health services: www.medicare.gov/coverage/home-health-services.html

International Home Care Nurses Organization: http://ihcno.org/

Marrelli TM. Handbook of Home Health Standards—revised Reprint: Quality, Documentation and Reimbursement. 5th ed. Philadelphia, PA: Mosby; 2012.

Visiting Nurse Associations of America: http://www.vnaa.org/

Tina M. Marrelli is president of Marrelli and Associates, a healthcare consulting and publishing firm in Venice, Florida. She can be reached at
news@marrelli.com.

Selected references

Centers for Disease Control and Prevention. Home Health Definition of Terms; 2012. www.cdc.gov/nchs/nhhcs/nhhcs_home_highlights.htm. Accessed April 21, 2014.

What is Medicare? www.medicare.gov/sign-up-change-plans/decide-how-to-get-medicare/whats-medicare/what-is-medicare.html. Accessed April 21, 2014.

Wilkerson KB. No Place Like Home: A History of Nursing and Home Care in the United States. Baltimore, MD: Johns Hopkins University Press; 2003.

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2 thoughts on “Update on home health care: How it’s changing”

  1. Brian says:

    I sorry but “Home Health” and “Home Care” are two completely different things, and your article tends to promote the confusion most people have about the two. Home Health agencies that provide a SKILLED need as defined by CMS often provide completely different services than that of HomE Care agencies which are sometimes covered by Medicaid but not always if not the will cost the person money. As a Home Health Case Manager I all to often have to educate and inform people about what type of services they may or may not qualify for and what type of services our agency provides. They are often times misinformed and think they are going to have people come in and provide non skilled services or services on a daily basis which are not covered by Medicare or MRP’s. I see a lot of people get upset, dismayed and sometimes even angry because they believe they are going to be provided with in Home Care services. Medicare or CMS guidelines only cover in Home Health which is deemed skilled and intermittent. Anything else provided and billed for under Medicare would be fraud.

  2. Yvonne Knauff says:

    Back to good old public health nursing and the Visiting Nurses! What goes around, comes around!

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