TERM 3- MY NOTES FOUNDATIONS OF NURSING CH.37 "Home Health Nursing " Flashcards
Home health care services enable individuals of all ages to remain in the comfort and security of their homes while receiving health care. Family support, familiar surroundings, and participation in the care process contribute to feelings of worth and dignity. Possible services include skilled nursing, physical therapy, psychiatric therapy, pain education and management, speech language therapy, occupational therapy, social services, intravenous therapy, nutritional support, respiratory therapy, acquisition of medical supplies and equipment, and home health aide, homemaker, pet-care assistance, and companion care.
A)true
B)false
A
Patients most often receive referrals for home health services upon discharge from the hospital; however, it is also possible for the patient, the family, or the health care provider to request home health care at other times.
A)true
B)false
A
To qualify for coverage by Medicare, a health maintenance organization (HMO), or various types of insurance, it is necessary for the patient to be “homebound,” meaning unable to leave the home or requiring a great deal of effort to travel for appointments to see the health care provider. The patient also has to be in need of intermittent skilled nursing care.
A)true
B)false
A
Patients older than 65 years account for half of all home health patients. Patients of all ages with various diagnoses account for the other half.
A)true
B)false
A
Hospitals are most likely to discharge those patients to home health care with a stroke, chronic obstructive pulmonary disease, fractured hips needing surgical interventions, and joint replacement procedures.
A)true
B)false
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Home health care includes services ranging from wound care to ostomy assistance, setting up oral medications, prefilling insulin syringes or administering injections of vitamin B12, assisting patients postoperatively after undergoing total hip and total knee replacements, and monitoring patients with heart failure, diabetes, and hypertension.
A)true
B)false
A
The visits occur sometimes as often as twice daily and as seldom as monthly.
A)true
B)false
A
Home health care is needed because Americans are living longer and thus have more disease conditions that require care. Also, hospital stays are, on the average, much shorter than in the past, so many patients still require nursing interventions on discharge from the hospital.
A)true
B)false
A
Home health care is also essential because an increasing number of women work outside the home. Women who traditionally provided health care for their families are no longer available to provide this service. There is an increased mobility in our society and an increase in single-parent families with female heads of households.
A)true
B)false
A
HOME HEALTH CARE DEFINED
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Home health care preserves individual independence and integrity and keeps families together.
A)true
B)false
A
The following are definitions of home health care as viewed from four different perspectives:
- Official: A component of comprehensive health care in which individuals and their families receive services in their place of residence for the purpose of promoting, maintaining, or restoring health, or of minimizing the effects of illness and disability.
- Patient: Skilled and compassionate care provided on a one-to-one basis in the comforting and familiar surroundings of the home. Providers base care on individual needs and personalized schedules and do so over a given period to enable adjustment, change, and learning to take place effectively.
- Family: A means to keep the family together as a functioning, integrated unit. The goals are learning to adapt to change, preventing dysfunctional patterns from setting in, and attaining family wellness within the scope of an individual member’s illness or disability. It provides needed emotional support and linkage with the larger community support systems.
• Provider: Challenges all disciplines involved to provide excellent care in often less-than-excellent conditions and surroundings. Independence, creativity, communication, and excellent clinical skills are integral aspects of daily practice. It is an opportunity for nurses to demonstrate the best of their profession and themselves in cooperation with the health care team to patients and families with physical and psychological needs.
A)true
B)false
A
HISTORICAL OVERVIEW
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The former definition of home care was simply providing physical care to the sick in their homes, but the scope and the complexity of the concept and practice have grown.
A)true
B)false
A
Roots of the concept go back to the New Testament of the Bible, which describes visiting the sick as a form of charity.
A)home care
B)false
A
Sixth-century monks practiced home care as an important aspect of their work in the community.
A)true
B)false
A
One of the earliest organized systems for home care was developed in 1617 by St. Vincent de Paul, who organized the Sisterhood of the Dames de Charite to meet social welfare and visiting nursing needs.
A)true
B)false
A
In the 1700s, families were the primary caregivers.
A)true
B)false
A
The poor were hospitalized, whereas those with financial means were cared for in their homes by visiting physicians
A)true
B)false
A
The first home care program in the United States came into being in 1796 as the Boston Dispensary
A)true
B)false
A
In 1859, William Rathbone of Liverpool, England, established the Metropolitan Nursing Association, the first organized district nursing service, because of the outstanding home care his dying wife received. He believed that many people with long-term illnesses had a better chance to receive the kind of care they desired in their own homes than in a hospital-a belief central to home care today
A)true
B)false
A
The Metropolitan Life Insurance Company had a major effect on the growth and nature of home serrvices when, in 1909, it began offering nursing services to its millions of industrial policy holders. This initiiated third-party payment for services. Payment until then had been primarily a matter of charity or the responsibility of the patient.
A)true
B)false
A
The Social Security Act of 1935 first provided governmental rather than local charitable funding for selected services such as maternal health, treatment for communicable diseases, and the training of public health professionals. The Act subsidized assistance for the poor and aged. Amendments to the Act in 1950 further defined services and opened the door to direct payment for providers
A)true
B)false
A
A revolution, however, occurred in 1965 with the enactment of Title XVIII (known as Medicare) and Title XIX (known as Medicaid) amendments to the Social Security Act.
A)true
B)false
A
Medicare provided direct federal monies for the health care of all citizens 65 and older (or disabled), regardless of socioeconomic status.
A)true
B)false
A
The companion Medicaid bill covered the care needs of the poor and indigent of all ages.
A)true
B)false
A
When Medicare became effective in 1966, it revolutionized home care by:
(1) changing it to a medical rather than nursing model of practice,
(2) defining and limiting the services it reimbursed,
(3) changing the payment source and even changing the reason for providing home care
True
The next major influence on home care came in 1983. Congress enacted the prospective payment system (PPS) as a part of the Tax Equity and Fiscal Responsibility Act for hospitals receiving Medicare reimbursement. This system, based on major diagnostic categories and diagnosis-related groups (DRGs), pays a set rate (according to diagnosis) for the hospitalized patient’s care rather than the “cost,” or charges an institution traditionally bills according to its own schedule of fees. The net effect of the change was a major shift of patients out of hospitals and into their homes, extended-care facilities, or skilled nursing facilities.
A)true
B)false
A
Discharge for such patients occurred earlier in their convalescence, and thus the patient required more nursing care. This created a challenge to home care in terms of volume of patients seen, of the need to provide more skilled nursing care over more intensive periods, and the evolution of highly technical procedures in the home.
A)true
B)false
A
In an effort to control home health expenditures, Congress imposed new limits on home health payments through a provision of the Balanced Budget Act of 1997 (BBA) called the Interim Payment System (IPS). Until BBA, there were no limits on payment for covered home health services provided to qualifying patients as long as visit costs were within “reasonable
A)true
B)false
A
To reduce the growth in home health, the IPS imposed lower per-visit limits and imposed a new agency-specific, aggregate per-beneficiary limit based on agencies’ federal fiscal year spending in 1994.
A)true
B)false
A
BBA also provided the authority for development of a PPS for home health. Thus Medicare pays providers of home health services at fixed predetermined rates
for services and supplies to cover an episode of care during a specific period.
A)true
B)false
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The goal of PPS is to produce new incentives for the home health provider to be more efficient in the delivery of home health services
and still remain financially solvent.
A)true
B)false
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Home care visits and Medicare expenditures for home care quadrupled between 1980 and 1991. This was directly attributed to shorter hospitalizations, more seriously ill patients being discharged to home, and increased acceptance of the delivery of higher technology care in the home.
A)true
B)false
A
Life Span Considerations
Older Adults
Home Care Services
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- The growing number of older adults has resulted in increased need for home health care services.
- Early-discharge policies have resulted in very ill older adults leaving the hospital. This increases the importance of patient teaching, early discharge planning, and appropriate referral to home health agencies by hospital staff nurses.
- Many older adults do not require total care but do require a limited amount of assistance. Home care reduces disruption of lifestyle and is more cost effective than institutional placement.
- Transfer to a hospital or nursing home even on a temporary basis increases the stress level of older people. Stress is decreased if they receive care in a familiar environment.
- It is crucial for caregivers to learn the importance of preserving the older adult’s autonomy, and to make any modifications to the home environment with consideration of the older adult’s physical strengths and remaining functional abilities, not just the patient’s disabilities.
- A number of service agencies exist that are in a position to assist older adults in their communities. These include Meals-on-Wheels, home health aides, homemakers, and home-based physical therapy services. As a nurse, make sure you are familiar with home health services in your area, and help older people make arrangements for the appropriate services
True
TYPES OF HOME CARE AGENCIES
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The agency typically has to comply with federal, state, and local laws and regulations via the following:
- Licensure by the state. This gives legal permission to operate within that state only. Regulations vary widely. Not all states have such laws.
- Certification by the state certifying body that the federal government designates. The federal government set the rules governing certification (a process in which the government evaluates and recognizes an individual, institution, or educational program as meeting certain predetermined standards). Only certified agencies are permitted to receive Medicare payment. Many states piggyback Medicaid reimbursement to certification, as do some insurers.
- Certificate of need: Some states grant this according to rules and formulas that state regulators devise. Cost of starting and running the agency, availability of personnel, and need for their services are generally considered in this process.
- Accreditation by an outside agency that evaluates and judges how well the agency meets certain standards that the accrediting organization sets. An agency will sometimes obtain this accreditation (a process whereby a professional association or nongovernmental agency grants recognition to a school or institution for demonstrated ability in a special area of practice or training) from the National League for Nursing Community Health Accreditation Program, The Joint Commission, or the National Homecaring Council. Other groups sometimes grant accreditation to special programs or specialized agencies. Some of these national accrediting agencies are seeking “deemed status” from federal regulators, which will allow their accreditation to also serve as the required certification. This will eliminate the need for separate surveys for some agencies
True
Now agencies are classified according to
(1) tax status, for profit or not for profit;
(2) location, freestanding or institution based;
(3) governance, private or public.
True
CHANGES IN HOME HEALTH CARE
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Changes are occurring in home health care. The Joint Commission (TJC) is looking for agencies to establish ethics committees to handle ethical issues that arise in the home.
A)true
B)false
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Medicare is reimbursing psychiatric nurse clinicians for home visits. Psychiatric patients are required to be under the care of a psychiatrist and have a psychiatric diagnosis.
A)true
B)false
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The psychiatric nurse clinician provides therapy and education, as well as counsels family members
A)true
B)false
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Patients with acquired immunodeficiency syndrome (AIDS) represent a growing home health care population
A)true
B)false
A
Social workers provide assistance with a patient’s emotional, financial, and household problems, thus allowing the nurse more time to perform nursing interventions
A)true
B)false
A
Most agencies are obtaining a separate Medjcare certification to provide hospice care. Medicare-certified hospices receive per diem payments rather than a fee for visit. This method of payment is more economkal for insurers and taxpayers.
A)true
B)false
A
Pet-care programs are emerging to reduce stress for home health patients who are too iJI to care for their pets. A “durable power of attorney for pet care” allows a patient to make arrangements for pet care if he or she becomes hospitalized or dies. Some home health agencies provide special pet services, such as transporting pets to veterinarian appointments.
A)true
B)false
A
Electronic home visits have evolved. A computerized system now has the capacity to call a patient on the telephone at home and ask recorded questions such as, “What is your blood pressure?” The patient is able to respond by using the phone’s keypad. In this way the nurse is able to efficiently review the patient’s progress without making a home visit.
A)true
B)false
A
One of the most rapidly growing segments in home health is home infusion therapy; an increasing number of home health agencies are offering home infusion services in an effort to compete for patient referrals. Health care facilities are eager to have home health agencies provide this service, since home intravenous (IV) therapy fits right in with their cost-cutting strategies. A 30-day IV antibiotic regimen of one common cephalosporin, for example, costs about $5000 when the patient receives it in the hospital but just $1600 when the patient is at home.
A)true
B)false
A
Antibiotics, hydration, and total parenteral nutrition (TPN) are three of the most common forms of home IV therapy, and the practitioner often orders them for patients at home without any prior hospital admission. Other less frequently used therapies include IV analgesic medications, chemotherapy, and dobutamine (Dobuhex); dobutarnine, whose administration once occurred only in the intensive care unit (ICU), now serves as palliative therapy for home care patients with severe refractory CHF and for those awaiting heart transplants.
A)true
B)false
A
SERVICE COMPONENTS
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Primary services include the following: • Skilled nursing • Physical therapy • Speech-language therapy • Occupational therapy • Medical social services • Homemaker- home health aide
True
Other therapy services (e.g., respiratory) or professional services (e.g., nutritional counseling, pharmacy, podiatry, dentistry, and psychiatric or mental health) are sometimes among an agency’s offerings.
A)true
B)false
A
Medicare requires a plan of treatment signed by the physician, outlining all disciplines, treatment, frequency, and duration. These orders are necessary to recertify every 60 days
A)true
B)false
A
Health Promotion
Home Care
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- The most common diagnoses for home care patients are diabetes mellitus, hypertension, heart failure, osteoarthritis, stroke, acute and chronic wounds, chronic obstructive pulmonary disease, heart disease, cancer, and psychiatric disorders.
- Commonly performed treatments in the home include administration of infusion therapy (i.e., antibiotic administration), patient-controlled analgesia for pain management, enteral feedings, parenteral nutrition, chemotherapy, hydration therapy, and psychiatric counseling and education.
• The nurse and a rehabilitation team member will at times also provide medical equipment in the home to facilitate medical treatment and safety, such as electrical beds, wheelchairs,
commodes, walkers, and other assistive devices.
True
SKILLED NURSING
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Service Goals
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Skilled nursing services revolve around four major goals:
- Restorative: The return to a previous level of functioning as appropriate and realistic
- lmprovernent: Achieving better health and a higher level of functioning than at admission
- Maintenance: Preserving functional capacities and independence by maintaining current level of health
- Promotion: Teaching healthy lifestyles that keep the effect of illness or disability to a minimum and prevent the recurrence of illness
True
Provider Attributes
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Nurses practicing in the home setting are caregivers, teachers, counselors, case managers, and advocates.
A)true
B)false
A
To be a home health nurse, you need to be technically proficient and self-motivated, have expert organizational skills, be innovative, be an independent decision maker, and respond to problems promptly. Common sense, flexibility, compassion, empathy, patience, honesty, and dependability are essential.
A)true
B)false
A
You will generally provide services in the patient’s home; hence you will need to feel comfortable with the unknown, as well as accept differences in etluuc cultures and value systems.
A)true
B)false .
A
Nurses who depend on the security of the institutional setting, immediate medical direction, and frequent peer support find the independence of home care practice difficult.
A)true
B)false
A
lf you are a home health nurse, it is necessary that you keep in mind the dominant role the patient and the family play. Unlike the hospital situation, home health nursing requires that nurses and other providers adapt to the patient, family, and home environment. You will be a visitor in the patient’s home.
The patient’s and family’s cultural values and beliefs are very important for you to acknowledge and respect.
You will often encounter the use of home remedies and complementary and alternative therapies and have the responsibility to carefully guide the patient and family in their safe and effective use
True
Strong communication skills are essential for teaching, counseling, interviewing, and listening. A high energy level, cheerfulness, and a positive attitude are valuable attributes, because you will often be called on to work with patients and families who are under stress.
A)true
B)false
A
Respect for the patient’s dignity, privacy, and need of autonomy is an integral part of providing efffective nursing services. Commitment to professional standards of practice, ongoing continuing education, and skills updates are important.
A)true
B)false
A
ROLE OF THE LPN/LVN
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An RN has to supervise LPNs/LVNs. Although . LPNs/LVNs are not empowered to make detailed patient assessments or clinical judgments, their observations, reporting, documentation, teaclting, and technical care capabilities are important to home care.
A)true
B)false
A
Provider Attributes
,
Personal and professional attributes described for RNs also apply to the LPN /LVN.:
Independent practice is not allowed, but self direction, motivation, creativity, clinical proficiency, flexibility, compassion, empathy, and patience are all essential attributes. Good commu. nkation skills-both written and spoken-are necessary. The ability to work alone, follow directions, recognize important changes in condition, and assist in patient teaching is needed. Evaluation of care interrventions and recommendations for alteration of the plan of care constitute a part of the role.
A)true
B)false
A
Functions
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Depending on the agency, agency policies, and state practice acts, the LPN / LVN will sometimes provide the following services in the home as directed and supervised by the RN:
- Catheter care and teaching
- Ostomy care and teaching
- Wound care and sterile dressing changes
- Obtaining specimens for cultures
- Injection administration
- Prefilling insulin syringes
- Fingersticks for blood glucose readings
- Monitoring physical status (such as lung sounds, bowel sounds, pulses, edema, and weight)
- Teaching, monitoring, or setting up medications, including IV medications
- Nutrition; assessment of nutrition and hydration status; teaching about prescribed diet; administration of nasogastric, gastrostomy, and jejunostomy tube feedings, and teaching families about tube feedings
- Specimen collection
- Therapeutic diet teaching or reinforcement
- Respiratory care, management of oxygen therapy, mechanical ventilation, and physiotherapy
- Tracheostomy care, including suctioning
- Enemas for special conditions
- Insertion of urinary catheter, irrigation, and observation for infections
- Bowel and bladder training
- Pain management
- Emotional support
- Preventive health measures
- Patient and family teaching
- Vi tal signs
True
Safety Alert!
Home Oxygen Use
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MASK OR CANNULA
• Ensure that the straps are not too tight
• Remove straps two or three times/day to wash, dry, and stimulate skin
• Pad any pressure points
• Observe tops of ears for skin impairment from pressure points
ORAL AND NASAL MUCOUS MEMBRANES
• Assess oral and nasal mucous membranes two or three times/day
• Use water-based gel on lips and nasal mucosa
• Provide frequent oral hygiene
• Provide humidification via humidifier or nebulizing device
DECREASING RISK FOR INFECTION
• Remove mask or collar and cleanse with water two or three times/day
• Cleanse skin carefully at this time and observe for cuts, scratches, and ecchymosis
• Change disposable equipment frequently
• Remove secretions that are expectorated
DECREASING RISK OF FIRE INJURIES
• Post “No Smoking” warning signs in home where they are clearly visible
• Do not allow open flames, wool blankets, or mineral oils in the area where oxygen is in use
• Do not allow smoking in the home
True
PHYSICAL THERAPY
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The goals of treatment have to be restorative for Medicare reimbursement but will in some cases be for maintenance or prevention for other payer sources.
A)true
B)false
A
The therapist completes a detailed assessment of the patient and then determines treatment, education, and assistive devices needed for rehabilitation. These are included as a part of the physician approved plan of treatment. Treatments range from muscle strengthening to transcutaneous nerve stimulation and ultrasound treatments.
A)true
B)false
A
Patients who have orthopedic conditions, such as repair of a fractured hip, a total hip or total knee replacement, and those with neuromuscular diseases such as stroke, multiple sclerosis, or amyotrophk lateral sclerosis receive referral to a physical therapist
A)TURE
B)false
A
The therapist actively teaches the patient and the family the rehabilitaation plan to promote self-care and independence. Communication with the physician and the RN promotes continuity of care.
A)true
B)false
A
SPEECH-LANGUAGE THERAPY
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Independent functioning and maximum rehabilitation of speech and language abilities are primary treatment goals. Often the provision of services occurs after stroke or surgery.
A)true
B)false
A
Possible therapies range from language relearning to working with eating or swallowing disorders or teaching lipreading to those with hearing disorders.
A)speech therapy
B)false
Aa
Pathologists work closely with the patient and family for rehabilitation or adjushnent to a new disability.
A)true
B)false
A
OCCUPATIONAL THERAPY
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Based on a complete evaluation of functional level, the therapist will choose and teach therapeutic activities designed to restore functional levels. Services include the following:
- Techniques to increase independence
- Analysis of activities as they relate to patients’ skin, their environment, their families, and their routines
- Expanding the disease management approach into a lifestyle management approach
- Design, fabrication, and fitting of orthotic or self help devices
- Assessment for vocational training
True
Occupational therapists assist patients to improve in their performance of activities of daily living (ADLs), as well as their sensory-motor, cognitive, and neuromuscular functioning .
A)true
B)false
A
MEDICAL SOCIAL SERVICES
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Their focus is on the emotional and social aspects of illness. The patient, the family, or other support systems undergo evaluation for social, emotional, and environmental factors. The care plan includes education, counseLing, payment source identifica tion, and referrals.
A)MEDICAL SOCIAL SERVICES
b)false
A
Coping with stress and crisis intervention are also part of social worker services. Social services in home health are generally short term.
A)true
B)false
A
HOMEMAKER-HOME HEALTH AIDE
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These workers are an integral part of the home health care team. They provide the basic support services that sometimes enable an elderly individual, disabled adult, or dependent child to remain at home.
A)HOMEMAKER-HOME HEALTH AIDE
B)social service
A
Most home aide services fall into one of three categories:
(1) personal care, or assistance with bathing, oral hygiene, eating, dressing, and toileting
(2) physical assistance with transfers, medications, and ambulation
(3) household chores, or cookking, light housekeeping, shopping, and laundry . Medicare will not cover visits made solely for the third reason.
True
Medicare and Medicaid require on-site supervision -of the aide every 2 weeks, principally by an RN. Supervision by a licensed physical therapist is acceptable if skilled nursing is not involved. Private payers, however, often do not have such requirements. Aide services are sometimes provided in blocks of time ranging from 1 to 2 hours for Medicare to 8 to 24 hours for private or other payment sources.
A)true
B)false
A
Coordinated Care
Delegation
PATIENT BATHING
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Skills of bathing are often acceptable to delegate to assistive personnel (AP); however, skin and range-of-motion (ROM) assessment require the critical thinking and knowledge application unique to the nurse. As a nurse, do the following:
- Instruct the care provider what type of bath (complete, partial assist, tub, shower) is appropriate to the patient’s diagnosis, needs, and ability.
- Remind the care provider to notify you of any skin integrity problems so you will make sure to inspect areas of impairment or potential impairment.
- Remind the care provider to use an organized approach and reassuring tone of voice so the patient feels safe and comfortable during bathing.
- Instruct the care provider to encourage the patient to report any concerns or discomfort during the bath.
- Instruct the care provider to encourage as much independence in the patient’s self-care skills as appropriate and to provide positive feedback.
True
