Evolution of Home Health Care: History, Politics, and Challenges

1. Chapter 32Clients Receiving Home Health and Hospice Care

2. History and Politics of Home Health • Care in the home by family members throughout history • Latter half of 20th century, hospitals making referrals for home care for nonacute patients • Medicare home health benefit: brief visits, temporary care; no reimbursement for health promotion or long-term care • Balanced Budget Act and Medicare prospective payment system: payment rates based on client characteristics and need for service  closure of many Medicare-certified agencies • Cost and number of visits declined; rates of wound healing incontinence and psychosocial problems increased • Decreased patient contact; increased documentation

3. Home Health Agencies • Voluntary nonprofit: charitable; exempt from paying taxes; financed with nontax funds; VNAs • Hospital-based: part of hospital as a separate department; nonprofit or generate revenue • For-profit proprietary agencies: individual owners, often part of large regional or national chain administered through corporate headquarters; pay taxes on profits • Government and city agencies • Noncertified agencies: private; funding from direct payment by client or insurers; governed by individual owners or corporations

4. Clients and Families • Client as the individual and family (and significant others) • Most common diagnoses: essential hypertension, heart failure, diabetes, chronic skin ulcers, osteoarthritis • Most clients admitted after hospitalization • Family members as informal caregivers: personal care to sophisticated skilled care • Primary caregiver: daily tasks of care • Secondary caregiver: intermittent responsibilities • Caregivers assume enormous burdens: physical, psychological, economic

5. Home Health Care Personnel • Nurses: RNs, LPNs • Home care aides • Physical therapy • Occupational therapy • Social work • Administrative personnel

6. Question Is the following statement true or false? • The Medicare home health benefit led to the closure of many home health agencies.

7. Answer • False • The Medicare prospective payment system led to the closure of many agencies due to the changes in payment.

8. Reimbursement for Home Health Care • Corporate • Insurance companies, HMOs, PPOs, case management programs • Governmental third-party payers • Medicare, Medicaid, military health system, Veterans Administration • Individual clients and families

9. Medicare Criteria & Reimbursement • Criteria • Service type and frequency reasonable & necessary • Client homebound • Plan of care on Medicare forms • Client in need of skilled service (observation, assessment, teaching, performing selected procedures) • Service intermittent and part-time • Episode of care: 60 days • Admission: assessment using OASIS • Medicare documentation: OASIS, Medicare Plan of Care

11. Nursing Practice During Home Visits • Locating and getting through the door (making the connection) • Promoting self-management • Detecting • Collaborating, mobilizing, strengthening, teaching, solving problems

12. Question Which of the following would classify a client as homebound? a. Client uses a walker to go to the grocery store with a friend every other week b. Client goes to a medical adult day care program every Tuesday morning c. Client goes to the local hairdresser with her daughter once a month d. Client uses a cane when going to church services with the family every Sunday

13. Answer b. Client goes to an adult day care program every Tuesday morning • Homebound status is defined as the ability to leave home with difficulty in mobility and only for medical appointments or adult day care related to the client’s medical care. Going to the grocery store, hairdresser, or church services, even with assistive devices such as a walker or cane, would not qualify the client as homebound.

14. Home Health Nursing Case Management • Case manager for each client • Responsible for coordinating other professionals and paraprofessionals involved in client’s care • Case conferencing with team members (Medicare mandate, every 60 days) • Supervising paraprofessionals • Knowledge of reimbursement for services

15. Selected Nursing Challenges in the Home • Infection control • Clients • Home health care team • Medication safety • Risk for falls (see Display 32.3) • Technology at home • Nurse safety (see Display 32.3)

16. Future of Care in the Home • Community-based long-term care to address needs of the frail elderly or severely disabled for more prolonged care • New lines of business to meet changing needs and payment issues • Possible development of a national community-based long-term care benefit

17. Overview of Hospice Care • Hospice movement to humanize end-of-life experience and provide palliative care (relief of suffering without curing underlying disease) • Four major changes in end-of-life care: • Care should attend to body, mind, and spirit. • Death must not be a taboo topic. • Medical technology should be used with discretion. • Clients have a right to truthful discussion and involvement in treatment decisions.

18. Evolution of Hospice Care • Originated in England with St. Christopher’s Hospice (1967) • First hospice in U.S. established in 1974 by Florence Wald, Dean of the Yale School of Nursing • Establishment of Medicare hospice benefit in 1982 • Change in characteristics: now variety of end-stage diseases, not just cancer • Movement of hospice from charity to business

19. Question Is the following statement true or false? • Currently, most clients receiving hospice care are diagnosed with cancer.

20. Answer • False • Today, hospice care involves a variety of diagnoses involving end-stage diseases, not just cancer.

21. Hospice Services & Reimbursement • Medicare hospice benefit: prognosis of 6 months or less, sign up for comfort-focused hospice benefit, waive regular hospice benefit; acknowledgement of terminal prognosis; choosing comfort care instead of life-extending care • Hospice coordinating care in all settings • Four payment levels • Routine home care with intermittent visits • Continuous home care when the patient’s condition is acute and death is near • Inpatient hospital care for symptom relief • Respite care in a nursing home to relieve family members

22. Hospice Nursing Practice • RN as central to hospice interdisciplinary team • Case manager; frequent visits • Collaboration with physicians • Rotation through 24/7 on-call to ensure continuous availability by telephone and visits for emergent problems • Competencies similar to home health nurses, with addition of expertise in relieving physical and emotional suffering of terminally ill people and families (see Fig. 32.2)

23. Hospice Nursing Practice (cont.) • Sustaining oneself • Connecting, speaking truth, and encouraging choice • Collaborating • Strengthening the family • Comforting (palliative care, pain management; see Displays 32.6, 32.7) • Spiritual practice and “letting go”

24. Ethical Challenges • Ethical implications of interventions • Respect or disregard for client autonomy • Relief or disregard for client suffering • Avoidance of killing at the very end of life • Hospice nurse: advocate for client and family

25. Future of Home Health and Hospice • Transformation into a community-based long-term care system; cost containment • Change in the model for service provision to address those living with disabling and terminal illness • Extinction of Medicare definitions for homebound, medical necessity, and skilled nursing • Change in focus for hospice to be based on client choice and reality of terminal diagnosis • Need for ongoing case management • Increased education and supportive networks for clients and family caregivers • Telehealth and home monitoring

26. Question Is the following statement true or false? • In the future, hospice care will continue to use the definitions established by Medicare.

27. Answer • False. • Future hospice will entail the extinction of Medicare definitions for homebound, medical necessity, and skilled nursing.

28. Internet Resources • Family Caregiver Alliance: http://www.caregiver.org • Home Healthcare Nurses Association: http://www.hhna.org • Hospice and Palliative Nurses Association: http://www.hpna.org • National Association for Home Care and Hospice: http://www.nahc.org • National Hospice and Palliative Care Organization: http://www.nhpco.org