Scope of Practice of Home Health Nursing



Scope of Practice of Home Health Nursing







Evolution of Home Health Nursing

Community-based care, including home health nursing, has been provided for centuries. Florence Nightingale, William Rathbone, and their colleagues, formalized home health practice in England during the 1800s, selecting the titles of district nurses (home health) and health visitors (public health), which are still in use in the United Kingdom. Both Notes on Nursing (Nightingale, 1859) and A Guide to District Nurses and Home Visiting (Craven, 1889) shaped American nurses’ goals to formalize home visiting programs in the United States.

Nurse home visiting was conducted by both lay and trained nurses beginning in the early 19th century in many cities and towns in the United States. After mid-century, Roman Catholic and Protestant sisters and deaconesses across the country were joined by dedicated women providing home nursing services through local churches or settlement houses. These services continued even as secular trained nurses were increasingly employed by new voluntary organizations growing out of the charity organizing movement, beginning in the mid-1880s in New York City, Buffalo, Philadelphia, and Boston (Dieckmann, 2012). Known as visiting nurse associations or services, these local agencies were generally led by boards of prominent, wealthy women concerned about their community’s health and social services.

Early nurse leaders, including Lillian Wald, Lavinia Dock, Margaret Sanger, and Mary Breckinridge, refined and publicized diverse models of health promotion and disease prevention. In the late 1800s Visiting Nurse Associations (VNAs) and the nursing divisions of governmental health agencies, such as city and county health departments, provided the majority of services. Community health nurses, as generalists, gave nursing care to the sick, as well as health promotion services to individuals, families, and communities. Public health principles and practice, and components of family and community care, were integrated into home-based nursing services.


Several key events drove the steady but slow growth of home care in the early 1900s. In 1909 the Metropolitan Life Insurance Company created an innovative program that paid for nurses to care for its policyholders in the home, prompting other life insurance companies to provide this critical service as well. During World War II, as physicians made fewer home visits and focused instead on providing care in offices and hospitals, the home care movement grew, with nurses providing most of the health and illness care services in the home. In 1946, Montefiore Hospital in New York City developed a post-hospital acute care program and initiated convalescent home care (Buhler-Wilkerson, 2003, 2012).

In 1952, the American Nurses Association (ANA) and the National League for Nursing (NLN) became the primary national nursing organizations, following the merger and restructuring of other organizations. The NLN became the primary membership organization for nurses practicing in the community for the next 30 years.

At mid-20th century, improvements in care and treatment of acute illness had revealed the need to address the burden of chronic illness on Americans through disease-specific prevention, screening, medical management, and rehabilitation (Commission on Chronic Illness, 1956-1959). Both visiting nurse and official agencies expanded home visiting to include rehabilitation, with new emphasis on a multidisciplinary team that included physical, occupational, and speech therapies; social services; and nursing assistants (later called home health aides).

The 1965 Social Security Amendments that introduced Medicare (Title XVIII) included a home health benefit, increased the reach and visibility of home health care, and led to significant growth in this field. Because of the new reimbursement benefits, physicians and hospitals began to discharge patients earlier. In 1976, after 10 years of Medicare services, home health remained at just 1% of total annual reimbursements. The potential for creative expansion of home health services was constrained by congressional amendments and administrative controls that decreased Medicare’s focus on post-hospital services.

When the Centers for Medicare & Medicaid Services (CMS) phased in the diagnosis-related groups (DRGs) hospital reimbursement model during the early 1980s, shorter hospital stays became the norm and the need for home care services expanded. Home health nurses were thus faced with providing highly complex clinical care for patients in the patients’ homes. New treatments and technology enabled more patients to be treated at home, resulting in increased
referrals to existing agencies and the establishment of many new agencies, some affiliated with hospitals and some independent, proprietary enterprises. Home health nursing practice emphasized acute care in the home, and some agencies began to offer services 24 hours a day, 7 days a week.

With the growth in home health care, CMS attempted to rein in costs through changes in the reimbursement method by establishing the prospective payment system (PPS) and through additional regulations and oversight of home health agency practices. These measures prompted organizational mergers, new reimbursement and quality specialists, and new models for delivering care. The Visiting Nurse Associations of America (VNAA) and the National Association for Home Care and Hospice (NAHC) were formed to help home health agencies address these challenges. These two organizations became the primary specialty advocacy organizations for home health agencies, and continue to provide strong national leadership.

Responding to the expansion of nursing services provided in the home and the need to formalize this specialty practice, ANA published the first version of its practice standards, Standards of Home Health Nursing Practice, in 1986. Scope of Practice for Home Health Nursing was published in 1992, followed by the combined and expanded Scope and Standards of Home Health Nursing Practice in 1999 and another revision in 2008.

Looking forward to 2020, home health nurses will be caring for a more diverse patient population with:



  • More families and communities in need of health promotion and disease prevention services


  • More infants, children, and adults surviving with deficits from severe illnesses and/or injuries


  • More patients who will request palliative and hospice nursing services


  • More older adults with multiple chronic diseases, illnesses, and more complex needs


  • Increased numbers of people who have joined the ranks of the “very old”


  • More patients of differing cultures and languages


  • More patients, families, and communities wanting greater choices and care personalized to their needs

Reimbursement for home health care services and models of care will continue to shift and change as the provisions of the 2010 Patient Protection and
Affordable Care Act (ACA) and the vision of the 2010 Institute of Medicine (IOM) report, The Future of Nursing, are implemented. Home health nurses will expand their services related to patient engagement, patient-centered care, best evidence-based practices, and care coordination, including across healthcare settings. In addition, home health nurses will assume an even more integral part in making health care less costly, more efficient, and more effective through enhanced use of advanced practice registered nurses, transition-ofcare models, and new ways of engaging patients with motivational interviewing and coaching techniques.

The impact of the changing world—globalization, emerging infections, pandemics, natural and manmade disasters, communication and technological advances, economic changes—will have implications for home health nurses and the care they provide. Transitioning patients along the care continuum to the setting that most efficiently, effectively, comfortably, and cost-effectively meets their needs (which is frequently the patient’s home) will be a paramount concern.

The home and community are increasing in importance as the recommended point of care delivery. With the speed of technologic advances in medical procedures and efforts directed at satisfying a well-informed public, the home health industry needs to push forward to exceed expectations for care delivery in the community. This involves efforts to define the future goals of home health care. Home health nurses are strategically poised to lead in accountable care, transitioning care from acute settings, and collaborating with other care providers, the patient, and the patient’s family. These nurses develop individually suited home- and community-based care plans and instruct, guide, coach, and support the patient and family in achieving the best possible outcomes while remaining in the communities they value.


Home Health Nursing’s Scope of Practice

According to the Bureau of Labor Statistics (2010), about 140,000 nurses work in home health nursing, a practice setting predicted to outpace the growth of other settings in the coming decades. These professional nurses should incorporate the updated content of this home health nursing document into practice. The goal of home health nursing is to improve the health, well-being, and quality of life of all home health patients, their families, and other caregivers, and to help people to remain in their homes. This can best be accomplished through the significant and visible contributions of registered nurses using standards and evidence-based practice.





Definition of Home Health Nursing

Home health nursing is a specialty area of nursing practice that promotes optimal health and well-being for patients, their families, and caregivers within their homes and communities. Home health nurses use a holistic approach aimed at empowering patients, families, and caregivers to achieve their highest levels of physical, functional, spiritual, and psychosocial health. Home health nurses provide nursing services to patients of all ages and cultures and at all stages of health and illness, including end of life.

This new home health nursing definition reflects the workgroup’s thoughtful discussion and consensus decision-making about the importance of describing home health nursing today and for the future. Public comment during the development and review process affirmed the new definition.

Home health nursing is nursing practice applied to patients of all ages in the patients’ residences, which may include private homes, assisted living, or personal care facilities. Although there are multiple terms to identify the recipient of home health nursing services—patient, client, customer, healthcare consumer—this document uses the term patient. Patients and their families and other caregivers are the focus of home health nursing practice.

The goal of care is to maintain or improve the quality of life for patients, their families, and other caregivers, or to support patients in their transition to end of life. These goals are accomplished by building relationships and engaging the patient, family, and other caregivers through the provision of direct patient care and the promotion of independence, accountability, and self-care. Additionally, the home health nurse, through interprofessional collaboration, initiates, coordinates, manages, and evaluates the resources needed to enhance and promote the patient’s optimal level of well-being, capabilities, and independence. Nursing activities necessary to achieve these goals use evidence-based practices and may include preventive, maintenance, restorative, and rehabilitative interventions to prevent potential problems, manage existing health problems, improve clinical outcomes, and prevent hospital and other inpatient admissions and readmissions.

Although the term home care is used by many national associations and publications, the professional title of home health nurse is defined and recognized by the nursing profession, other healthcare professionals, and the public. The workgroup members involved in this scope and standards revision considered the terms home care nurse and home health care nurse and concluded that the title and tradition of home health nurse should be continued.





Distinguishing Characteristics of Home Health Nursing

Home health nursing is a specialized area of nursing practice that focuses on individuals in need of care in their homes, their families, and their caregivers. Home health nurses provide care to patients across the lifespan, from the prenatal through the postdeath periods. Home health nursing practice embraces primary, secondary, and tertiary prevention; assistance to families with coordination of community resources and health insurance benefits; and delivery of healthcare services in a patient’s home, including nonconventional residences. Home health nursing stresses the holistic management of personal health practices for the treatment of diseases or disability.

Home health nursing reflects more than a change in location or acute care services delivered in the home. Home health requires a change in the definition and structures of care to reflect a broad array of coordinated services, benefits, and caregivers available to patients experiencing complex problems. Home health nurses who care for these patients practice independently and require highly developed skills in assessment and care coordination. Although home health nurses practice in collaboration with other healthcare professionals, they frequently are the only professionals in the home actually providing care to the patient. As such, they must be expert in assessment, clinical decisionmaking, and clinical practice. These skills form the foundation for definition of outcomes, planning, nursing care interventions, evaluation, communication with other interprofessional healthcare team members, and referral to other healthcare settings when appropriate.

Home health patients may require nursing care resources 24 hours a day, 7 days a week. The frequency and duration of these services is dependent upon the home care delivery model and holistic needs of the unit comprised of the patient, family, and other caregivers. Home health nurses may provide services ranging from intermittent visits to full-time extended daily care. Home health nurses also provide important assistance and guidance for patients and families in decision-making about how best to meet identified needs.

Another distinguishing characteristic of home health nursing is its emphasis on patient and caregiver teaching. The goal of home health nursing is to enable patients and their caregivers achieve independent self-management of the patient’s illness, disease, or disability. Thus, the home health nurse provides education and counseling so the patient and caregiver have the knowledge, skills, and abilities to achieve this independence. Home health nurses assess learning needs, learning styles, and health literacy. They teach about health promotion,
disease prevention and management, medications, safety, and resource access. Home health nurses provide counseling and coaching to help patients and their caregivers adapt and cope with the lifestyle changes necessitated by chronic illnesses and disabilities. They use the principles of adult learning and evaluate learning using teach-back and return-demonstration techniques.

Home health nursing differs from other nursing specialties in the degree of responsibility nurses assume in managing the financial cost of care. Home health nurses work directly with public and private payors and with consumerdirected payment programs. Home health nurses must have advanced knowledge of reimbursement systems to help patients obtain the care they need while containing the cost of care.




The Nursing Process in Home Health Nursing

Home health nurses use the nursing process, the essential methodology by which patient goals are identified and achieved. The nursing process, comprised of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation, is used throughout clinical care, administration, education, research, quality improvement, and other home health practice areas. (The nursing process is also the basis for the Standards of Practice for Home Health Nursing, which are set out in the next section.)


Assessment

Home health nurses assess the physical, psychosocial, and environmental factors that affect a patient’s health. In addition, they perform in-depth functional assessments and medication assessment.

Physical assessment includes interviewing patients and their caregivers about the patient’s health history and diagnoses, and includes performing a complete physical assessment of all the patient’s body systems and capabilities, along with a review of nutritional needs.

Psychosocial assessment includes assessing the patient’s cognitive, developmental, behavioral, and coping status and includes screening for anxiety, depression, and abuse or neglect. This assessment also addresses social support systems and spiritual needs. Furthermore, a psychosocial assessment discovers the patient’s language preference, health literacy, learning style, and cultural needs and preferences. Special attention is paid to the multiple impacts the patient’s illness and disease have on the family, the caregiver, and the patient’s/family’s finances.


Environmental assessment focuses on risks within the home and community to the patient’s and home health clinician’s personal health and safety. A home environmental assessment includes attention to obstacles within the home that may increase the risk for falls (e.g., throw rugs, clutter), presence of needed safety features (e.g., grab bars in the bathroom, rubber bathmats), presence of smoke alarms, and safety practices that are required for home treatments, such as oxygen safety. Sanitation issues that may affect the risk of infection are also assessed. Some examples of clinician safety issues to be addressed include presence of latex in the home for those with allergies, pet issues, and presence of firearms in the home (National Institute for Healthcare Safety and Health [NIHSH], 2010).

Home health nurses perform comprehensive medication assessments, which include reconciling medications in the home to the prescriber’s list and the patient’s diagnoses; monitoring the medications for effectiveness, side effects or adverse effects, and interactions; assessing the ability of the patient and the caregiver(s) to safely and consistently administer the medications; and identifying any barriers or issues related to medication adherence.

Home health nurses also perform comprehensive functional assessments to determine the patient’s risk for falls and ability to safely perform activities of daily living (ADLs) and independent activities of daily living (IADLs), including the ability of the patient and caregiver(s) to safely manage all medical/assistive devices and equipment.



Diagnosis

Home health nurses derive their diagnoses and identify problems from the assessment data. Diagnoses can be focused on the physical, psychosocial, cultural, spiritual, environmental, economic, and interpersonal aspects of care. Home health nurses, in collaboration with the patient, the family, other caregivers, and interprofessional team members, identify actual problems as well as situations that might become problems if unattended.


Outcomes Identification

The home health nurse partners with the patient, family, and other caregivers to identify specific, measureable, attainable, relevant, and time-defined (SMART) goals for the patient based on the patient’s identified problems and diagnoses (Doran, 1981). In home health, these goals are the expected patient outcomes: the results of the care by the home health nurse and the
interprofessional team. Ideally, the ultimate goal of the plan of care is to return the patient to the highest possible level of self-care within the community. This involves preparing the patient and caregivers to be independent in selfmanagement of disease and other identified problems. However, sometimes the goal is comfortable end-of-life care.


Planning

Home health nurses develop a plan of care in collaboration with the patient, family and other caregivers, and other healthcare providers. This plan is based upon the comprehensive assessment; identified diagnoses, problems, or issues; and expected outcomes or goals. Drawing upon evidence-based strategies and best practices to develop the plan of care, the home health nurse adapts the plan to incorporate and meet the unique needs, preferences, and goals of the patient and caregiver(s).

When the need for other services and supplies is identified, the home health nurse collaborates with the interprofessional home health team to further develop the most effective and economical plan. When the goal of discharging the patient back to the community and self-care cannot be achieved, ongoing home health care may be provided and revisions to the plan of care are made. In addition, home health nurses are engaged in education, administration, and research activities, which also require planning.



Implementation

Home health nurses implement the plan and provide skilled nursing interventions to patients, as well as patients’ families and caregivers, including direct care, teaching, counseling, coaching, care management, and resource coordination. In collaboration with the patient, family, and other caregivers, home health nurses determine the most appropriate care strategies, which may include complementary therapies and culturally sensitive approaches, to meet identified patient needs and support achievement of expected outcomes. Teaching and coaching of the patient, family, and caregiver(s) are integral to the implementation component of the nursing process for home health nurses. Teaching supports the achievement of patient outcomes and the movement of the patient and the family toward engagement and independence. As patient educators, home health nurses use a variety of media and strategies to develop and reinforce enhanced self-care skills. Home health nurses provide information about community health resources to patients, patients’ families,
and other caregivers. Through this information exchange and advocacy, including effective teach-back and return-demonstration techniques, home health nurses engage patients, families, and other caregivers in planning for and seeking additional services as their needs dictate.

The home health nurse assesses the implementation of the care plan and care provided by the licensed practical nurse/licensed vocational nurse (LPN/LVN) and home health aide. Although the LPN/LVN and home health aide may be team members in the home health setting, the registered nurse provides ongoing assessment and supervision to help ensure positive outcomes. When the patient receives services from multiple practitioners, including nonprofessionals, home health nurses often assume the role of case or care manager and coordinate efforts of all the involved stakeholders, including the patient’s primary care provider and other caregivers, to optimize patient outcomes.


Evaluation

The evaluation of patient outcomes provides critical data from which to determine the effectiveness of the plan. Evaluation is an ongoing and dynamic process. The home health nurse evaluates progress toward expected outcomes and thus determines the effectiveness of the plan of care. As the patient’s status changes and new data are collected, modifications of the plan of care may be required.


Educational Preparation of Home Health Nurses

Home health nursing, because of its level of independence in practice, requires registered nurses to have a strong foundation of knowledge and expertise. Completion of the baccalaureate nursing degree is the appropriate and preferred educational preparation for home health nurses because of the curricular emphasis on public/community health principles and practice, case management, patient teaching, and leadership. Neal-Boyan (2001), with a consortium of Home Healthcare Nurses Association members (Harris, 2001), developed a core curriculum addressing program management, concepts and models, disease management, and trends, issues, and research, followed by a later publication in 2011 describing “paradigm” home care clinical case studies.

Every nurse entering the specialty must complete an extensive orientation program to master the numerous competencies of the home health nurse. Structured preceptor programs, support from colleagues, clinical experiences, and lifelong learning through academic and continuing education
programs promote this professional growth and enhance the ability of both new and experienced home health nurses to assume evolving home health nursing roles and meet the expanding demands of this specialty practice. Associate-degree and diploma nurses who work in home health nursing are strongly encouraged to seek additional education to meet qualifications at the baccalaureate level.




Certification in Home Health Nursing

Because home health nursing is characterized by specialized knowledge, skills, and competencies that are needed to care for patients in the unique setting of patients’ homes, achievement of home health nursing or other specialty certification demonstrates such competence to employers and patients. However, at the time of publication, the previously offered American Nurses Credentialing Center (ANCC) home health nurse and home health clinical nurse specialist certifications are no longer available. Certified home health nurses may continue to retain this certification by meeting the continuing education recertification process requisites. Exploratory discussions about an alternative home health nursing certification mechanism are under way. However, home health nurses can also affirm their competence, knowledge, and skills through other nursing certifications, such as in oncology, infusion, wound care, diabetes, pediatrics, hospice and palliative care, psychiatric-mental health, and gerontological nursing.


Practice Roles and Responsibilities

The diverse roles, responsibilities, and functional areas detailed in this section identify some of the clinical and leadership positions in home health nursing. These roles may overlap and complement each other depending on the size of the home health organization, number of staff, and services provided.


Home Health Nurse

Home health nurses provide nursing care in accordance with Nursing: Scope and Standards of Practice, Second Edition (ANA, 2010a), as well as the more detailed and specific home health nursing standards. Competent home health nursing practice requires flexibility, creativity, and innovative approaches to problem-solving in the context of individual and environmental differences and resource availability.


Effective home health nursing practice includes identification of and attention to environmental, economic, familial, and cultural characteristics. In addition, a fundamental understanding of psychosocial and safety issues affecting patients, families, and other caregivers is critical for the effective delivery of home health nursing. Because patients residing in their homes may receive healthcare services from an array of providers, home health nurses often assume the role of case or care manager and coordinator. Therefore, the preferred minimum qualifications for a registered nurse practicing in home health nursing are:



  • A baccalaureate degree in nursing


  • A desire and ability to motivate patients, families, and caregivers in health promotion and disease management by applying change theory, learning principles, and teaching skills


  • An ability to apply critical thinking to physical, psychosocial, environmental, cultural, family, and safety issues


  • An ability to utilize clinical decision-making in applying the nursing process to care of patients in their homes


  • An ability to practice as an effective member of an interprofessional team


  • An ability to apply case/care management, communication, and collaboration principles and skills to provide care in the home health setting


  • An ability to work within different organizations’ payment models while advocating for optimal outcomes for patients

Home health nursing is an autonomous practice requiring additional knowledge and skills beyond those acquired in basic baccalaureate nursing educational programs. The requisite knowledge base and skills for home health nursing can be further developed through individualized formal orientation programs, structured preceptor programs, guided clinical experience based on the specific learning needs of the nurse, and graduate education. Each home health nurse must build and maintain the professional knowledge, skills, and abilities that support evidence-based practice, clinical decision-making, and effective teaching that empower the patient to attain self-management and achieve the best outcomes possible. The employing agency also has an obligation to establish an environment conducive to such professional development.



Graduate-Level Prepared Home Health Nurse

A home health nurse may have completed master’s or doctoral level education to accrue advanced knowledge, skills, abilities, and judgment associated within one or more nursing or other specialties. Home health nurses function at an advanced level, as designated by elements of their position in such practice areas as administration, education, research, informatics, and quality improvement. For instance, those who have completed a course of study for a master’s of business administration (MBA), master’s of health administration (MHA), or other graduate management degree are well prepared for policy, executive, and organizational leadership positions.


Advanced Practice Registered Nurse

Advanced practice registered nurses (APRNs) hold a master’s or doctoral degree in nursing, are expert clinicians and consultants, and advance nursing and home health practice by contributing to home healthcare research and by educating and mentoring undergraduate and graduate clinicians. As the Institute of Medicine Future of Nursing report (IOM, 2010) indicates, APRNs are needed to augment healthcare services, including in home health. The need and opportunities for APRNs in home health care—especially clinical nurse specialists and nurse practitioners—are immense (IOM, 2010; McClelland, McCoy, & Burson, 2013; Auer & Nirenberg, 2008). APRNs specializing in the needs of home health patients and special populations (e.g., pediatrics, geriatrics) and disease management specialties (e.g., cardiac, diabetes, psychiatric-mental health, and wounds) can improve and enhance the outcomes of home health patients.

Advances have been made in the collaborative role of APRNs working with home health registered nurses and prescribing clinicians. Evolving practice permits the clinical nurse specialist or nurse practitioner who is not directly practicing in home health to collaborate with the certifying physician in accordance with state law and perform the initial home health certification by documenting the required face-to-face encounter with the patient. With the need to develop new care delivery services as the healthcare system evolves, APRNs will find autonomous, creative, and innovative ways to meet the continuity-ofcare, transitional, and palliative care needs of patients seeking home-based care.


Clinical Nurse Specialist

The clinical nurse specialist (CNS) is an expert in evidence-based nursing practice, treating and managing the health concerns of patients, families, groups,
communities, and populations. In home health care, CNS practice is targeted toward achieving quality, cost-effective outcomes in three spheres of influence (National Association of Clinical Nurse Specialists [NACNS], 2010):

Patient care. CNSs provide comprehensive assessments, expert care, care planning, and care management, including pharmacologic and nonpharmacologic treatments, for home health patients, families, and groups with specific or complex needs. They provide care using evidence-based clinical interventions.

Nurses and nursing practice. CNSs meet the educational needs of nurses and interprofessional colleagues through formal and informal teaching methods. They promote evidence-based practice and consult with staff and administration to improve clinical outcomes.

Organization or system. CNSs act as change agents, initiating innovative programs and quality improvement strategies to enhance the programs and processes of home health agencies and the healthcare systems of which they are a part. They develop and implement evidence-based, best-practice models, and pioneer programs to achieve the safest, most efficient, effective, and economical care for the organization’s patient population.


Nurse Practitioner

Nurse practitioners (NPs) are prepared to diagnose and treat patients with undifferentiated symptoms, as well as those with established diagnoses. Initial, ongoing, and comprehensive care includes:



  • Taking comprehensive histories, and providing physical examinations and other health assessment and screening activities


  • Diagnosing, treating, and managing patients with acute and chronic illnesses and diseases


  • Prescribing pharmacologic and nonpharmacologic therapies, including durable medical equipment


  • Making appropriate referrals for patients and families

Opportunities for nurse practitioners in home health practice are expected to increase substantially because of healthcare reform and other initiatives. Their ability to practice to the full scope of their education, abilities, and licensure will become even more important and valued in the home care setting.



Clinical Roles


CARE OR CASE MANAGER

The care or case manager role involves not only the delivery of direct care to the patient, but also coordination of and with the care provided by other disciplines. When a patient is admitted to service, the nurse care manager uses the nursing process to assess the patient’s unique situation, and develops a plan of care (POC) in consultation with the patient, family, caregivers, team members, and the physician. The home health nurse implements the POC, continually evaluating the patient’s progress toward goal achievement, and making planof-care adjustments to enable the patient to achieve the highest possible level of health, well-being, and function. Specific activities in this process include:

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Jun 21, 2016 | Posted by in NURSING | Comments Off on Scope of Practice of Home Health Nursing

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