Home Health Care

1. Home Health Care By Rita Daniels, RN

2. 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).

3. Objectives Define 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

4. Definition of Home Health Care Home health care is a wide range of health services provided in the clients’ home skilled nursing care non-medical services Private duty care

5. Why Home Health Care? Home 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).

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

7. 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).

8. Services 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

9. 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

10. Private Duty Nursing (non-Medicare) Private Duty Nursing can be defined as care provided by private funds, insurance companies, trust funds.

11. A 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 Health Care Nurse Personal Factors: Do I have what it takes? Systemic Factors: It’s not what I expected Relational Factors: It’s the relationships that count (Patterson et al, 2013, Figure 1)

12. Nursing Theory The 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 Neal’s Theory about how nurses define their practice and build a research-based theory of home health nursing practice (Neal, 2000, p. 25). 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). (Neal, 1999, figure 1)

13. Neal Theory components Home 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 home Home 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)

14. Business 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).

15. Business Theory: capitalism expanded • Home health care is one of the most profitable franchises (Kennedy, 2012).  • The economy doesn’t 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.

16. Assessment of the Home Care Environment The federal government oversees Centers for Medicare and Medicaid Services to have and maintain a license

17. *Resources . The 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).

18. Quality and Safety The 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

19. Inferences/Implications/Consequences: What 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 one’s own car and cell phone along with processes for reimbursement of these expenses (Patterson et al, 2013, p. 7).

20. ANA Standards QSEN Competency Evidence-Based Practice: integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care Assessment • Collects comprehensive, pertinent data • Involves all family and healthcare providers • Uses EBP, analytical tools, and critical thinking Strategies that could improve quality and safety related to Home Health Care

21. ANA Standards QSEN Competency Quality 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 ANA Quality of Practice • Systematically enhances the quality of nursing practice • Participates in quality improvement activities • Incorporates evidence based knowledge Strategies that could improve quality and safety related to Home Health Care

22. ANA Standards QSEN Competency Teamwork and Collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care. Collaboration • Collaborates with patient, family, and others in the conduct of nursing practice • Partners with others to effect change • Provides for continuity of care Strategies that could improve quality and safety related to Home Health Care

23. What does It Take to Be a Home Health Care Nurse? The 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.)

24. Pros • Fastest growing segment of nursing today • Sets own schedule • Works independently • Variety of patients • Encourages flexibility, creativity, and adaptability • Cons • Driving long distances • Use of own vehicle + cell phone • Less compensation • No back-up on site • Less formal structure Why Choose Home Health Care?

25. References Alliance for Advancing Nonprofit Health Care. (2013). Value of Nonprofit Health Care. Retrieved from: www.nonprofithealthcare.org American Nurses Association, (2007). Home healthnursing 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

26. References Hagerty-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

27. References Kennedy, 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/54813562/1 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

28. References Meadows, 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.

29. References Neal, L.J. (2000). Validating and refining the Neal Theory of Home Health Nursing Practice. Home Health Care Management Practice 12(16). Doi 10.1177/108482230001200205 Patterson, 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: 10.1177/1084822312473828 Private Duty today website. Guides to Home Care Licensing in Your State. Retrieved from: http://www.privatedutytoday.com/guides/licensing/index.htm#MI The 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.org

30. References Touhy, T. W. & Jett, K. (2011). Ebersole & Hess’ Toward healthy aging: Human needs & nursing response. (8thed). St Louis, MO: Elsevier. Yoder-Wise, P.S. (2011). Leading and managing in nursing (5thed). St. Louis, MO: Elsevier-Mosby.