♦ Home care is a component of comprehensive health care in which services are provided to patients of all ages and their families in their homes to restore, maintain, or promote health and to minimize the effects of illness and disability.
♦ Based on the patient’s needs, the appropriate care is planned, coordinated, and supplied by a home care agency.
♦ Home care nursing requires a nurse to have a broad-based knowledge of all facets of health care.
♦ With the speedy discharge of patients from hospitals, the increasing number of older patients, and the availability of safe, easily operated health care equipment, home care has an increasing role in heathcare.
♦ Dramatic changes in home care regulations have occurred since the Balanced Budget Act of 1997.
– These legislative changes included prospective pay and the implementation of a standardized assessment tool (OASIS) when providing home care.
– In addition, the Health Care Financing Administration (HCFA) investigated billing practices and how care was being provided, which resulted in the closing of more than 20% of home care agencies since 1996.
♦ The home care industry may conceivably become one of the primary suppliers of health care in the United States. Currently, long-term care is the primary supplier of health care.
♦ Because skilled nursing service lies at the heart of any successful home care program, it’s important for you to understand home care principles and practices.
Certification and accreditation
♦ Home care agencies serving Medicare patients, except for some hospices and home health aide (HHA) agencies, are regulated by the Medicare Conditions of Participation.
– These standards are accepted for use by many other private insurance companies and the Medicaid system as well.
– Hospices are certified as Medicare providers under a separate federal standard.
♦ Federal agencies ensure compliance with standards by providing audits by health surveyors employed and licensed by state department agencies.
– These health surveyors have moved from annual inspections to more frequent visits, commonly related to service complaints.
– The inspectors determine if an agency can be “certified” under HCFA regulations for Medicare. For more information, see “Managing and improving care,” page 513.
♦ In addition to Medicare certification, agencies may opt for accreditation by The Joint Commission or the National League for Nursing’s Community Health Accreditation Program (CHAP).
– Although The Joint Commission and CHAP accreditation isn’t required, many managed care and private insurance companies mandate this accreditation for their contracted agencies.
– Home care agencies not Medicarecertified or The Joint Commission- or CHAP-accredited can still serve the needs of privately paying clients and those who need only the services of a certified nurse’s aide or a homemaker.
– However, they may be required to meet standards of the Area Agency of Aging to serve clients supported by those programs.
♦ An agency applying for accreditation must show compliance with established standards.
♦ Every 3 years, the accrediting body reviews the agency’s operations, policies, and procedures; interviews staff; and evaluates home visits and compliance with clinical practice standards.
Determining the patient’s eligibility
♦ The provider must recognize the patient as being homebound (able to leave the home infrequently, primarily for medical care) and requiring intermittent skilled care services (nursing, physical therapy, and speech therapy) for him to be eligible for home care covered by Medicare, Medicaid, and many private insurance companies.
♦ Nursing services are broken down into:
– services provided only by an RN, such as completing the OASIS tool
– services that can be delegated to an LPN or certified HHA under the supervision of an RN every 14 days.
♦ HHA services, occupational therapy, and medical social services are ancillary services that can only be provided when a skilled care service provider is already in the home.
♦ Other services may be offered at home, such as nutrition and respiratory services, but these aren’t considered skilled care. (See Understanding skilled and ancillary home care services.)
♦ Patients are referred for home care services mainly by facility discharge planners. They may also be referred by physicians, their families, community agencies, skilled nursing facilities, or insurance case managers.
♦ The home care agency must obtain a physician’s order before starting service, and the physician must review a progress report and recertify the need for continued skilled service every 2 months (not more than 62 days).
Continuing developments
Several major trends are emerging as the home care industry continues to evolve:
♦ Accountability pressures—Today, home care services are reimbursed by Medicare, Medicaid, and managed care private insurers. More and more private insurers are requiring that home care services be preauthorized. This cost-conscious environment confronts the nurse with challenges ranging from loss of control over patient care to ethical dilemmas and quality improvement issues.
♦ Emphasis on outcomes—Diseasespecific management programs—such as those now in place for diabetes and heart failure—will require home care agencies to develop critical pathways that incorporate patient outcome analysis. In the future, an agency’s quality will be measured by outcome data.
♦ Computerizing care—Increasingly, home care nurses are coping with an expanding paperwork load by using laptop computers. These are equipped with software that speeds clinical documentation to develop the care plan, formulate goals, monitor patient progress, update drugs, and generate visit notes. This technology expedites the exchange of current clinical data and other information among physicians, other care providers, and reimbursers.
♦ Financial stability—As reimbursement moves from cost-based to prospective pay, greater emphasis will be placed on streamlining care, triaging admissions, and improving efficiency.
♦ Client satisfaction—Home care agencies have always focused on client satisfaction. However, given the potential that a single complaint can turn into a full agency survey, many home care agencies are extending their response to service complaints.
Understanding skilled and ancillary home care services
This table shows examples of skilled and ancillary services used in home health care and how they may be reimbursed.
SERVICES
INDICATIONS AND EXAMPLES
CONSIDERATIONS
Physical therapy (skilled service)
Indicated for functional limitations and deficits in safety, mobility, strength, and range of motion; examples: gait training, strengthening exercises
Some states allow trained physical therapists to perform wound debridement. A physical therapist (PT) may be the sole professional on a home care case and may complete all OASIS tools. A certified physical therapy assistant may be used by the PT for some visits but must be supervised by the PT every 15 visits or 30 days, whichever comes first.
Speech therapy (skilled service)
Indicated for dysphasia and dysphagia; examples: assessment and evaluation, diagnostic testing, teaching and training, aural rehabilitation, maintenance therapy
Medicare won’t reimburse for repetition and reinforcement, work-related therapy, or a nondiagnostic or nontherapeutic routine. Speech therapists may also complete OASIS data and be the sole provider in the home.
Occupational therapy (ancillary service)
Indicated for functional limitation of activities of daily living that relates to the primary or secondary diagnosis; examples: therapeutic activities, energy-conservation methods, task simplification
Skilled nursing, physical therapy, or speech therapy must be ordered and provided for occupational therapy services to be reimbursed. The occupational therapist (OT) can complete the discharge OASIS tool and be the sole provider left in a home on recertifications. A certified occupational therapy assistant may be used by the OT if supervised according to regulations.
Medical social service (ancillary service)
Indicated for social or emotional difficulties of the patient or caregiver that affect treatment or rate of recovery; examples: referrals, counseling, long-term care planning
Skilled nursing, physical therapy, or speech therapy must be ordered and provided for medical social service to be reimbursed. OASIS forms may not be completed by medical social service representatives.
Home health aide (HHA) care (ancillary service)
Determined by the home care nurse, usually at the initial visit; HHA assistance with personal hygiene, patient transfers, light meal preparation, light housekeeping and, possibly, drugs (for drugs, check state laws)
Skilled nursing, physical therapy, or speech therapy must be ordered and provided for HHA care services to be reimbursed.
Ethical and legal aspects of home care
♦ The Code for Nurses of the American Nurses Association (ANA) includes standards of ethical conduct and practice that are relevant to home care.
♦ As in any other health care setting, you’re expected to provide services while respecting the patient’s human dignity and uniqueness without regard to his socioeconomic status, personal attributes, or nature of the health problem.
♦ Specific ethical principles include autonomy, beneficence, veracity, fidelity, justice, and respect for others. Each of these principles helps to define the quality and adequacy of health care delivered in the home setting. (See Applying ethical principles in home health nursing.)
♦ Many factors can complicate ethical decisions, such as the legal right of a competent adult to refuse care, increasing patient sophistication, living wills, confidentiality issues, and limited financial resources.
♦ Ethical concerns are strongly emphasized in the home care field. In its accreditation process, The Joint Commission directs agencies to establish committees that handle ethical issues that arise in the home.
♦ Ethical guidelines are supported by a network of federal and state laws relating to home nursing care.
– For example, you won’t lose your nursing license if you fail to abide by the ANA’s Code for Nurses — a voluntary guide document.
– However, you may lose your license if you violate your state’s nurse practice act, which sets legal practice standards in your state.
♦ Federal and state laws relevant to home care are briefly reviewed here.
Federal legislation
♦ Federal legislation sets requirements for all home health care nurses.
♦ The Omnibus Budget Reconciliation Act (OBRA) of 1993 substantially changed the law relating to participating Medicare agencies. The law requires that:
– patients be screened for eligibility
– they be informed of their legal rights before signing the home care contract
– they be fully informed in advance about the agency’s care plan and about changes in care or treatment that may affect their well-being, as well as any costs they may incur in addition to what their insurance pays.
Applying ethical principles in home health nursing
PRINCIPLE
MEANING
EXAMPLE OF NURSING APPLICATION
Autonomy
Personal freedom
Allowing the patient to decide when to implement care or to refuse treatment
Beneficence
Duty to promote good
Allowing the patient to die without lifesustaining treatment if that’s what he desires
Veracity
Being truthful
Providing the patient with enough information to allow him to make informed choices about care
Fidelity
Keeping one’s promise
Not promising the patient that you or another health care worker will be at the bedside when death comes (a promise you may not be able to keep)
Justice
Treating others fairly
Ensuring that you’ll provide the care that the patient needs even if there are other, more seriously ill patients that you need to see
Respect for others
Right of individuals to be treated equally
Treating all patients with the same level of empathy and competent care, even when they’re noncompliant or of another culture or race
♦ The law gives the patient a voice in planning his care and treatment and addresses confidentiality and grievance issues.
♦ The specific scope of practice for an LPN in home health care is mandated by the individual agency, within the guidelines of state and federal regulations.
♦ A separate OBRA provision sets strict criteria for HHAs, who typically provide a large share of hands-on patient care.
♦ An agency may not use any individual who isn’t a licensed health care professional unless that person has successfully completed a training program that meets minimum federal standards and is deemed competent to provide assigned services. For more information, see “Working with home health aides,” page 511.
♦ The Older Americans Act was amended in 1987 to strengthen home care consumer protections such as the rights of developmentally disabled persons.
♦ The Patient Self-Determination Act of 1991 requires federally funded home care agencies to abide by the terms of a patient’s living will or other special directive such as a durable power of attorney. If a patient lacks such an instrument but wants to obtain it, the agency must instruct the patient how to do so.
♦ Since 1999, home care agencies have been required to collect specific information on each patient who is older than age 18 and not receiving services related to childbirth.
– An Outcome and Assessment Information Set (OASIS), made up of 79 data elements, helps this process by allowing the agency to submit completed information electronically to the HCFA.
– In addition to the initial OASIS assessment, a repeat assessment is done if the patient is admitted to a health care facility, has a significant change in his condition, is recertified for ongoing care, or is discharged.
– OASIS helps home care agencies determine patient needs, plan care, assess care over the course of treatment, and learn how to improve the quality of that care.
– It incorporates all information regarding the patient’s health, functional status, health service use, living conditions, and social supports.
– It allows quality to be monitored and is essential for accurate payment under the new home health prospective payment system (PPS) instituted on October 1, 2000.
– Timely and accurate completion of the OASIS is essential so that the employer can review the guidelines and identify the specifications of the OASIS.
♦ The PPS sets an amount of money per patient and care is reviewed per episode rather than per number of visits.
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