A group of researchers conducted studies involving clients who had psychiatric illnesses and lived in various community settings. During one interprofessional study, psychiatric nurses made home visits to elders who lived in public housing, had psychiatric symptoms, and were referred by building personnel (Rabins et al, 2000). The nurses conducted comprehensive psychiatric assessments; provided counseling, coaching, medication monitoring, and referrals; and coordinated care with social workers and physicians. Clients’ psychiatric symptoms were reduced. The findings of another study indicated that clients who had dementia benefited when hospice care was provided, as did their family caregivers (Bekelman et al, 2005).

In Australia, a nurse and a pharmacist made home visits to older adults with diagnoses of atrial fibrillation and heart failure (Inglis et al, 2004). They conducted comprehensive health and medication assessments, provided health education, and made follow-up referrals. The nurse maintained telephone contact with clients for 6 months and provided care coordination. Clients in the experimental home visiting group had fewer hospital readmissions and shorter hospitalizations than those in a control group.

In Taiwan, public health and home health nurses participated in an extensive, interprofessional community-oriented program of research using home and clinic visits and telephone calls. Huang et al (2004) reported on the effectiveness of a 6-week home nursing program with elderly Chinese diabetic clients who lived alone. After weekly visits including structured education and monitoring, elders improved their levels of fasting blood glucose, post-meal blood glucose, and hemoglobin A1c. The researchers (Huang, 2005; Hsueh et al, 2010) also demonstrated successful outcomes when nurses have provided smoking cessation education and encouragement to long-term smokers. The Nurse-Family Partnership was initiated in 1977 by a researcher, David Olds, and a nurse, Harriet Kitzman; it is probably the best known and well-funded nurse home visit program in the United States (Olds et al, 1997; Kitzman et al, 2000). The Partnership involves nurses who provide structured education and case management during regularly scheduled home visits to pregnant women; visits continue until the children’s second birthday. Recipients of care have been ethnically diverse, low-income, first-time mothers and their families who lived in New York, Tennessee, and Colorado. Longitudinal, randomized controlled trials documented numerous lifelong improvements in health outcomes that were statistically significant and economically sound. Mothers had fewer children, were more likely to become employed, and were less likely to enter the criminal justice system; children were less likely to be abused; and both mothers and children demonstrated improved health and development. The researchers estimate that nurses visit more than 30,000 families in nearly 40 states; federal and private funding continues to increase as the program maintains successful outcomes and grows (Olds et al, 1997; Kitzman et al, 2000; Donelan-McCall et al, 2009).

The Program of All-Inclusive Care for the Elderly (PACE) began in 1972, and is a managed care model of integrated health and personal care services for non-institutionalized individuals aged 55 and older who meet frailty criteria (Dobell and Newcomer, 2008). Interprofessional care is provided in adult day-care centers with home-based assessments and supportive services also provided as needed. Home health care and hospice can be services offered through this model. Because of the model’s success, it is now included in Medicare and Medicaid capitation plans. As of 2009, 72 PACE programs operated in 30 states (National PACE Association, 2010).

As a result of a fragmented health care system, increasing complexity of client care, and rising costs, transitional care has gained much needed attention. Transitional care is defined as “a set of actions designed to ensure the coordination and continuity of health care as clients transfer between different locations and different levels of care in the same location” (Coleman and Berenson, 2004, p 1). Challenges to quality care originate from a lack of depth, accuracy, and timeliness of information received from the referring site; the need for complex medication reconciliation; and difficulties with communication and coordination among community-based providers.

Transitional care programs that involve home health have emerged as low- and high-intensity interventions that include, but vary from, traditional home care interventions. Low-intensity interventions include coaching, telephone follow-up, and specific disease management programs (Boling, 2009). For example, a program by Coleman and colleagues (2006) proposes an intervention that emphasizes medication self management, use of a client-centered health record, arranged physician follow-up, and client education about warning signs, symptoms, and how to respond to them. The intervention includes a home visit and at least three telephone calls made by a nurse or trained provider after a transition.

High-intensity transitional care programs are designed for populations who have complex or high-risk health problems. An example is the Transitional Care Model where advanced practice nurses perform transitional care from hospital to home providing in-hospital visits and discharge planning followed with home visits, primary care office visits, and telephone follow-up for 1 to 3 months after discharge (Brooten et al, 2001; Naylor, 2004; Naylor and Van Cleave, 2010). Examples of high-risk groups for whom the Transitional Care Model has been tested in numerous studies include women with high-risk pregnancies, adults with cognitive impairments, older adults with common medical and surgical conditions, and older adults with heart failure (Brooten et al, 2001; Naylor, 2004; Naylor and Van Cleave, 2010). The research model is currently implemented in practice settings in collaboration with major insurance companies and home care agencies (Naylor and Van Cleave, 2010).

Outcomes achieved with the Transitional Care Model consistently show cost savings and improvements in clinical and quality outcomes for clients receiving the intervention compared with usual care. The most common outcome across all populations is a consistent reduction in readmissions to a hospital. The Transitional Care Model strategies emphasize screening in acute care for high-risk clients; engaging the elder/caregiver in designing personalized goals and the plan of care; managing symptoms; educating and promoting self-management; and collaborating with the multidisciplinary team members to assure continuity and collaboration.

The Veterans Affairs Administration Hospital-Based Home Care Program targets individuals who have complex chronic disabling diseases with the goal of maximizing the independence of the client and reducing preventable emergency room visits and hospitalizations (Beales and Edes, 2009). An interprofessional team provides comprehensive longitudinal primary care that incorporates telehealth and electronic health records (EHRs). Nurses serve as case managers, continually evaluate clients’ needs, and deliver care. Approximately three fourths of Veterans Affairs facilities offer the home care program. The program has produced positive outcomes (Mader et al, 2008; Beales and Edes, 2009; Chang et al, 2009).

In 1967, the American Academy of Pediatrics originated the concept of medical home in an attempt to establish centralized, accessible health care records for medically complex, chronically ill children (Friedberg et al, 2009; Homer et al, 2008). Although there are distinct variations of medical home, the models typically include superb access to care; client engagement in care; EHRs that may be client controlled; care coordination; integrated, comprehensive care; ongoing, routine client feedback; and publicly available information about practices (Davis and Stremikis, 2010; Ferrante et al, 2010). More recently, the Centers for Medicare and Medicaid Services (CMS) and politicians supported medical home as a model to decrease costs and incorporated the concept into health care reform. Nurse practitioners are especially interested in policy implications and participating as leaders in this movement (Graham, 2010).

Staff members of home health agencies provide care at home and help clients and their families achieve improved health and independence in a safe environment. According to CMS (2008) and NAHC (2008), approximately 7.6 million clients received Medicare-certified home health services in 2007. Persons who were 65 years and older accounted for more than 85% of all home health clients. Recipients of home health services had diverse needs, but circulatory disease was the most common diagnosis, followed by neoplasms and endocrine diseases, especially diabetes. It was estimated that 9284 Medicare-certified home health agencies employed up to 17,000 staff members. The size of individual agencies varied from those that employ a few nurses to the Visiting Nurse Service of New York with its 2500 nurses and more than 12,000 staff members (VNSNY, 2010). Annual national expenditures for home health care in 2007 and 2008 were approximately $57 to $64 billion. As the largest payer, Medicare accounted for 37% of total home health reimbursement. Home health payments represented 3.3% of the total Medicare reimbursement while hospitals represented approximately 35%. In addition to Medicare, state and local governments accounted for 19.9% of home health reimbursement, Medicaid for 19%, private insurance for 12%, out-of-pocket or private pay 10%, and other sources 3% (CMS, 2008; NAHC, 2008).

Home health agencies can be divided into five general categories with a description of each to follow:

Although the size, administrative, organizational, and board structures of Medicare-certified agencies differ, they must meet ever-changing licensure, certification, and accreditation regulations established by national and state groups (Buhler-Wilkerson, 2007; NAHC, 2008; Fazzi et al, 2010). The primary source of those regulations is CMS (2009). Because the conditions are lengthy and complex, many agencies employ a nurse to become an expert and ensure that the agency is in compliance. To be Medicare-certified, key criteria identified in the Conditions of Participation are: (a) the client must be home-bound, (b) services must be intermittent and include a skilled service provided by a nurse, physical therapist, or speech and language pathologist, (c) a plan of care must be initiated and followed, and (d) Medicare forms, physician orders, and client records must be completed on a timely basis. Skilled nursing services is the Medicare term that describes the duties of the registered nurse, and refers to the requirement of nursing judgment. Those services involve assessment, teaching, and selected procedures; using Omaha System terms, they may also be categorized as Teaching, Guidance, and Counseling; Treatments and Procedures; Case Management; and Surveillance (Martin, 2005).

Slightly more than 1 million clients received Medicare-certified hospice services in 2007 with an average stay of 71 days. The average length of stay is rising as home health nurses and others provide information about end-of-life hospice care to clients and families, and hospice becomes more widely accepted by the public. Initially, cancer was the primary diagnosis of most clients; currently, cancer is the diagnosis of about one third of hospice clients and various neurological, cardiac, and other end-stage diseases comprise two thirds of the diagnoses (Zerwekh, 2006; NAHC, 2008; HAA, 2009; Perry and Parente, 2010).

Medicare, Medicaid, managed care, private insurance, and private donations fund most hospice services. The number of Medicare-certified hospices grew from 31 in 1984 to more than 3000 in 2009. Hospice services account for approximately 2.5% of the total Medicare budget, just less than home health services. Services are provided based on Medicare criteria. After the client acknowledges a terminal prognosis and selects comforting care rather than life-extending care, hospice organizations coordinate services in partnership with the client and family and provide financial case management. The four types of care and the percentage documented in 2005 were: (1) routine home care with intermittent visits, 96.5%, (2) continuous home care when condition is acute and death is near, 1.1%, (3) general inpatient/hospital care for symptom relief, 2.2%, and (4) respite care in a nursing home of no more than 5 days at a time to relieve family members: 0.2% (NAHC, 2008; HAA, 2009).

Medicare-certified hospice providers can be divided into the following four general categories:

Hospice programs are usually operated and staffed as independent entities or corporations even when they are part of a larger organization because of the specialized nature of the practice and complex regulations. The focus of hospice care is comfort, peace, and a sense of dignity at a very difficult time. Comprehensive services emphasize continuity of care. According to Zerwekh (2006), hospice addresses four foci: (1) attention to the body, mind, and spirit, (2) death is not a taboo topic, (3) health care technology should be used with discretion, and (4) clients have a right to truthful discussion and participation in treatment decisions.

The client’s family and friends are essential hospice team members who are involved in symptom and medication management, personal care, and the use of supplies. Death produces intense emotions even when family members have prepared for it. Bereavement services involve attending the funeral or other services for the deceased client, and contact at anniversaries of death, holidays, and the client’s birthday for 13 months after the client’s death. Hospice organizations usually offer support group opportunities for families or refer them to support groups in the area (Altilio et al, 2008; Baker et al, 2008; Malloy et al, 2008).

The interprofessional hospice team includes nurses, physicians, social workers, therapists, chaplains, counselors, aides, pharmacists, and volunteers. In 2008, there were approximately 95,000 employees and 50,000 volunteers; nurses, aides, and social workers were the largest groups of employees (NAHC, 2008). There were more than 10,000 hospice-credentialed nurses and 271 certified advanced practice nurses in palliative care; the latter group included clinical specialists and nurse practitioners (HPNA/ANA, 2007). Working with clients who are dying involves unique emotional stress; hospice programs address the team’s well-being as well as that of the clients and families (Hinds et al, 2005; Zerwekh, 2006; HPNA/ANA, 2007; Baker et al, 2008; HAA, 2009; Viola et al, 2009).

As early as 1970, the nurses, other staff, and administrators of the Visiting Nurse Association (VNA) of Omaha, Nebraska, began addressing nursing practice, documentation, and information management concerns. At that time, practitioners were not using computers, and there was no systematic nomenclature or classification of client problems and concerns, interventions, or client outcomes to quantify clinical data and integrate with a problem-oriented record system. These realities provided the incentive for initiating research and involving community test sites throughout the country. Between 1975 and 1993, the VNA of Omaha staff conducted four extensive, federally funded development and refinement research studies that established reliability, validity, and usability of the Omaha System. Avedis Donabedian, the developer of the structure, process, and outcome approach to evaluation, was a valuable consultant (Donabedian, 1966; Martin, 2005). The result of the research was the Problem Classification Scheme, the Intervention Scheme, and the Problem Rating Scale for Outcomes. These three components of the Omaha System were designed to be used together, be comprehensive, relatively simple, hierarchical, multi-dimensional, and computer compatible. The Omaha System has existed in the public domain since the initial research in 1975, and therefore is not held under copyright (Martin, 2005; Omaha System, 2010; Martin et al, 2011).

As depicted in Figure 41-3, the Omaha System conceptual model is based on the dynamic, interactive nature of the nursing or problem-solving process, the practitioner–client relationship, and concepts of diagnostic reasoning, clinical judgment, and quality improvement. The client as an individual, a family, or a community appears at the center of the model; this location suggests the many ways the Omaha System can be used and the essential partnership between clients and practitioners.

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