Chapter 34: Home Health and Hospice

Question 1

Home visits integral part of nursing for over a century
Includes a wide range of health care services provided to people in their homes to help them through an illness or injury
Typically more affordable than and just as effective as health care that people receive in a hospital or skilled nursing facility
Examples of diff types of home care: wound care, education, IV therapy, nutrition therapy, follow-up after hospital discharge, monitoring of an unstable or chronic illness
Goal: to help people get better in their own homes to regain as much independence as possible

Answer 1

Home health care

Question 2

Focuses on caring for people facing a terminal illness when the goal is no longer curing the disease
Most care occurs in the home with support given to clients and their families
Goal: each person will die pain free and with dignity
Ongoing support is provided to the family after the patient dies

Answer 2

Hospice care

Question 3

Primary purpose is to provide nursing health care to individuals and their families in their home - full functioning or best while in their home; usually more affordable; seem like it better because want be at home in own environment and with loved ones
Specific Services nurses offer vary according to the type of agency providing services and the population served
Focus of all home health visits on indiv who referral received; assess indiv-fam interaction and provides edu and intervention for fam and client; nurse identifies needs for referrals to community services and performs referrals as necessary
Reimbursement – home health agencies receive fixed amount of money based on reasonable cost given the client’s diagnosis and plan of care; currently most reimbursement based on pat need for skilled nursing
Home health care cont Focuses on care of sick patients and is expanding to include health promotion and disease prevention interventions, including client and family education
Each visit Nurses must document that the care provided and is of a skilled nature that a requires the knowledge and assessment skills of a nurse and must verify that the patient or a family member could not provide the same level of care by themselves
Services coordinated in the home may also include physical, occupational, and speech therapists; social workers; and home health aides; physician order if home health; intermittent/part-time basis; not full time; spot check on planned care; IV therapy, post-hospital visits - all usually covered
Diff from hospice - no plan of care reviewed and not be under review of physician - review is that this indiv and expected 6 months or less to live
Telephone support services are becoming an increasingly important aspect of home health care
One to one care - need someone in home assisting 24-hrs/day not covered by insurance companies, Medicare, Medicaid; considered private pay; income if low enough can qualify for home community support services - good option for them

Answer 3

Purpose of home health services

Question 4

Differ in financial structure, organizational structure, governing board, pop served
Official (i.e., public); organized, operated, and funded by local or state governments; funded by taxpayers but also receive reimbursement from third-party payers
Nonprofit – not required to pay federal taxes because of their exempt status; profits reinvested into the agency; may include independent home health agencies and hospital-based agencies
Proprietary – classified as for-profit and pay federal taxes on the profits generated; 62% home health agencies
Hospital-based agencies - 12% certified home health agencies

Answer 4

Types of home health agencies

Question 5

Meet federal standards
Able to Receive Medicare payments for services provided to eligible individuals

Answer 5

Certified home health agencies

Question 6

Not all home health agencies certified
Operate outside the Medicare system
Some Provide non–Medicare-covered services
Do not provide nursing care and not eligible to receive medicare reimbursement

Answer 6

Noncertified home care agencies

Question 7

Many home health agencies offer special, high-technology home care services
Examples of high-tech services:
Key to success: pats, fams, caregivers ability to learn care necessary for successful home program and motivation of indivs to provide care; if support not available then other arrangements necessary

Answer 7

Social home health programs

Question 8

Offering technological services at home is:
Beneficial to the patient’s health
Less costly than hospitalization

Answer 8

Many home health agencies offer special, high-technology home care services

Question 9

Daily infusions of TPN or antibiotic therapy
Pediatric services for children with chronic health problems
Follow-up for premature infants at risk for complications
Ventilator therapy
Home dialysis programs

Answer 9

Examples of high-tech services:

Question 10

Advhome health: Keep pat at home, decreased cost, payer support
Some younger do through private insurance
May be eligible for home care through a Medicare-certified home health agency
Private health insurance/Medicare adv

Answer 10

Reimbursement for home care

Question 11

Individual 65 or older - eligible for Medicare
Homebound and under the care of a physician - BOTH
Requires medically necessary skilled nursing care or therapy services - something only we can provide and takes a professional
Services must be intermittent or part-time and require physician authorization and periodic review of the plan of care - cannot be to be covered; other pieces can be covered by other exceptions
Home care RN determines the schedule and number of visits without calling Medicare to get pre-approval
Medicare pays for visits based on 60 day episodes and may predetermined amount based on pats conditions; if 4/fewer visits used standarized per visit amount may be paid instead
Only exception is hospice care - own thing; terminally ill with life expectancy <6 months; eligible receive medicare hospice benefits which no requirement for indiv be homebound or need for skilled nursing care

Answer 11

May be eligible for home care through a Medicare-certified home health agency

Question 12

Not Medicare eligible; could not take care self and leave home; require home care services but require private insurance companies
Used for home care Requires preapproval of services and referrals from primary care providers - sent to physician office; RN case manager at insurance company determines number visits covered
RN at the insurance company determines the number of visits that the insurance company will cover - physician signs it and snet over to insurance company and they look at answers and determine how many visits need and based on stat standards of care for diagnosis and how long recover with certain interventions

Answer 12

Private health insurance/Medicare adv

Question 13

Data set that determines Medicare pay rate and measures outcomes for adult home care patients to monitor outcome-based quality improvement
OASIS data set includes sociodemographic, environmental, support system, health status, and functional status attributes of an adult patient as well as information about service utilization
These items are used to monitor outcomes, plan patient care, provide reports on patient characteristics for each agency, and evaluate and improve clinical performance
Nurses must use OASIS for all patients receiving skilled care that is reimbursed by Medicare and Medicaid

Answer 13

OASIS (Outcome and assessment information set)

Question 14

Based on/according to ANA standards (2008)

Answer 14

Nursing standards and educational prep of home health nurses

Question 15

Generalist Home Health Nurse
Advanced Practice Home Health Nurse

Answer 15

Based on/according to ANA standards (2008)

Question 16

Should be educated as the baccalaureate level because of the autonomy and critical thinking skills necessary in home care
Care based on ANA standards and QSEN competencies

Answer 16

Generalist Home Health Nurse

Question 17

Master’s or doctoral degree in nursing

Answer 17

Advanced Practice Home Health Nurse

Question 18

Expectations at generalist level: - Skills that home health nurse must possess
In home care The nurse has a primary function of managing an interdisciplinary team (PT, OT, social workers, nurse assistants, chaplains, etc.)
Performing holistic, periodic assessments of client and family/caregiver resources
Participating in performance improvement activities
Collecting and using research findings to evaluate the plan of care
Educating clients/families on health promotion/self-care activities
Being a client advocate
Promoting continuity of care
Uses the Scope and Standards of Home Health Nursing Practice to guide clinical practice
Identifies ethical issues and explores options with the necessary individuals and staff members to achieve resolution

Answer 18

Generalist home health nurse

Question 19

Community health assessment skills
Provide client and caregiver education
Perform nursing actions following the client’s plan of care
Manage resources to facilitate the best possible outcomes
Provide and monitor care
Collaborate with other disciplines and providers to coordinate client care
Supervise ancillary staff and caregivers

Answer 19

Expectations at generalist level: - Skills that home health nurse must possess

Question 20

Visit preparation
Visits - 30-90 min depending on need of client but most about 60 min
The referral
Initial telephone contact
Environment
Improving Communication
Building trust
Doc key component during and after home visit so everyone knows what done for pat and for reimbursement

Answer 20

Conducting a home visit

Question 21

Imp prepare for home visit by Review the referral form: obtain name, age, diagnosis, address, telephone number, insurance coverage, reason for referral, meds, diet, phys orders, care plan goals, and other disciplines involved
The first home visit gives the nurse the opportunity to establish a trust relationship with the client and family

Answer 21

Visit preparation

Question 22

Formal request for a home visit – may come from a variety of sources: hospital, clinics, PCP, fam, client
Contains name, age, diagnosis or health status, address, telephone number, insurance coverage, and reason for referral
Includes current medications, diet, physician’s orders, care plan goals, and other disciplines involved

Answer 22

The referral

Question 23

Nurse can contact the client and Inform client about the service referral and exchange essential information - during call pat will establish a rapport
Obtain permission to visit
Set mutually acceptable time for visit
Nurse is a guest in the client’s home, so it is important that the client agrees to the visit
Verify address

Answer 23

Initial telephone contact

Question 24

Begins when leaves agency and travels to pats home; while driving Observe the area surrounding the client’s home and the condition of the client’s home (single, multi family, two story)
Accessibility of the home - sidewalks, steps
Safety concerns - live alone, high crime, tripping hazards (broken concrete, loose rugs)
Conditions inside the home - running water, adequate ventilation, hot and cold running water, food in home
Caregiver/support system - caregiver lives in home or if pat has adequate support sys

Answer 24

Environment

Question 25

Assess the client’s needs and create a comfortable atmosphere for communication

Answer 25

Improving Communication

Question 26

The nurse must and has build a trust relationship early in the visit or the client will not allow additional visits

Answer 26

Building trust

Question 27

Assessment – first step; gather subjective data and complete a client assessment; info used as data help form diagnosis and plan of care
Diagnosis and planning
Intervention
Evaluation

Answer 27

Application of the nursing process

Question 28

Next step
Identify/develops nursing diagnosis and develop a nursing care plan for the client and family
Nurse should Develop a plan that identifies short-term and long-term goals and measurable outcomes for the client
Nurse should Involve the client and family in the planning process and about/with the availability of and with access to community resources

Answer 28

Diagnosis and planning

Question 29

Differences between nursing care plan and treatment care plan
Nursing care plan addresses specific nursing interventions designed to treat the patient’s actual or potential problems and includes identified goals with measurable outcomes
Plan of treatment – includes the type of home health services rendered, the projected frequency of visits by each discipline, and the necessary interventions

Answer 29

Identify/develops nursing diagnosis and develop a nursing care plan for the client and family

Question 30

Next step
Involves Developing plans and goals for the next visit
Make appropriate and necessary referrals

Answer 30

Intervention

Question 31

Evaluate progress, modifying plans, discontinue care when goals are achieved

Answer 31

Evaluation

Question 32

2 kinds
Formal
Informal

Answer 32

Caregivers

Question 33

Professionals and paraprofessionals who provide in-home health care and personal services
Compensated for the services they provide

Answer 33

Formal

Question 34

Include Family members who are caring for the client
presence/absence of involved fam member can make difference between pat completing plan of care successfully and staying at home or having to go to a facility
When family member/caregiver involved nurse spends a lot of time assessing skills and comfort level of caregiver
Education provided by home health nurse
Skills and comfort level of the caregiver also assessed by home health nurse
Volunteers, adult day health centers, or senior service centers

Answer 34

Informal

Question 35

Admitted into hospice care life expectance <6months; from curative to comfort care
Improves end-of-life care for the terminally ill - not to kill pat; not curing disease or making better but make them comfy; diagnosed with something where not live for 6 months; certified by a physician
Relieves suffering throughout the illness
Supports the patient and family/caregiver through the dying process - work with fam members - more involved than dealing with pat because help pat and is exhausting - day-to-day lives and amount care putting into it is a lot - need resources to help them
Provides grief support to the family after the patient has died - referrals to support groups
Hospice care is a team approach – each patient has a physician, nurse, social worker, nursing assistant, and spiritual counselor to provide a multidisciplinary, holistic approach to caring for that patient and his or her family - not have be homebound - need diagnosis from physician; steadily might need more help
Some pats might want cont curative treatments and not want enter hospice care; pats >6months or want pursue curative treatments enter - palliative care: focuses on symptom management while also receiving treatments for diseases
Provided in a variety of settings

Answer 35

Hospice home care

Question 36

Dying pat is focus of skilled nursing care, home health nurse knows that Careful assessment of the caregiver’s mental and physical health is very important
Although pat’s wishes imp, All decisions regarding care are made considering the health of the caregivers
Caregivers are at increased risk for developing mental and physical health problems, so nursing interventions must be directed toward preventing a decline in the caregiver’s health
Caregivers need reassurance for the care they provide and reminders that they can’t do anything “wrong” if it is done for the patient’s comfort

Answer 36

Caring for the caregiver

Question 37

Sometimes caregiver May need the nurse’s time and attention as much as, if not more than, the patient

Answer 37

Dying pat is focus of skilled nursing care, home health nurse knows that Careful assessment of the caregiver’s mental and physical health is very important

Question 38

Pain control is an important goal for hospice nurses and their patients
Medications are given in doses sufficient to keep the patient free of pain and is administered on a regular schedule to prevent pain from recurring before the next dose
Hospice nurses help in managing other symptoms and items (nausea and vomiting, constipation, diarrhea, fatigue, decreased appetite) through medications and/or strategies to help cope with the symptoms
Nurse along with other members of hospice team Provides emotional support to patient and/or family as they adjust to patient’s impending death

Answer 38

Pain control and symptom management

Question 39

Increasing fluids – to prevent constipation
Frequent rest periods – to minimize fatigue
Eating small amounts – to cope with the decrease in appetite

Answer 39

Hospice nurses help in managing other symptoms and items (nausea and vomiting, constipation, diarrhea, fatigue, decreased appetite) through medications and/or strategies to help cope with the symptoms