Advanced Practice RN's in the Home Health Care Arena
Identification of the phenomenon.
There is an urgent need for APRN services in the home health care environment. That is the pivotal position this paper proposes to pursue. In a general sense, it is clearly evident that there is an urgent need for quality home care that exceeds the minimum expectations of patients and their families; this need exists because excellence and integrity in the delivery of home health care can help erase (and overshadow) the negative publicity perpetuated by incidents of malpractice, of gross incompetence, and of scandalous acts of patient abuse at the home care level. There can be no equivocation on the issue of the existing demand by consumers for the highest quality of service available when it comes to home health care; the cost of health care has been going up and up, and hence, the quality of service should be rising too - even faster than the cost.
II. Review of Literature
A. Relevant Literature reviewed as appropriate for the qualitative study planned.
The Basics of Home Health Care Services. The trend towards home health care (HHC) has been gaining widespread acceptance and momentum over the past few years. The reasons for the growth of HHC are numerous; families would certainly rather have their elderly members in the comfort of their own home (rather then in a nursing care facility), where love and familiarity are plentiful, and where grandma's rocking chair still has those same hand-crocheted doilies on the arms that were there when grandpa was alive. HHC is also the preferred choice when a younger family member is injured or ill, and the doctor has offered the patient a chance to heal at home rather in the stale atmosphere of a hospital. Costs are a consideration as well: it's certainly more economical for a family on a budget (as most families are) to have their loved member at home.
An explanation for the literature reviewed in this paper: there is a dearth of data relating to the specific training and planning for, and results of, placing advanced practice nursing talent in home health care situations; therefore some of the literature in this paper is being reviewed to demonstrate the increasing need for advanced practice nurses in home care environments, and to illustrate the gaps in quality medical care now being offered by some home care agencies.
Meanwhile, as an introduction to the issue at hand, it may be useful to take a condensed look at HHC and some of its particulars. There are two main categories of HHC - intermittent and continuous. Intermittent care is "a periodic home visit where nurses concentrate their time on assessment, intervention, and patient/family teaching" (Madigan, 1997).
A typical example of intermittent care would be, say, a child may be in traction at home following a skateboard accident, having already spent a week in a hospital. At least one mature member of his family is in the home at all times (dispensing appropriate/prescribed medications, toileting, changing bed clothing), and the visiting nurse comes to the home perhaps twice a week, to check on the boy and the care being given to him. A typical continuous care situation involves "nursing care where the nurse provides the bulk of the care to the child," Madigan writes, in the Journal of the Society of Pediatric Nurses. The child, in the continuous care instance, might be ventilator- dependent, and thus requires the continuous care. The nurse's shift in this kind of situation is usually 8 to 12 hours in length, and family members fill in the gaps when the nurse is not present (albeit HHC agencies nearly always provide 24-hour on-call services, if there is a problem while the nurse is not present).
And there are more considerations, such as: A) what if the child lives in a rural area outside the community where he was hospitalized, and that particular area is not serviced by the hospital's home health care agency? In that case, there should be a home health care trade association in the state which can provide a list of agencies to choose from. B) And, key questions have to be asked prior to the family accepting the services of an agency, such as: does the agency have nurses with pediatric nursing experience? Do they have on-call services 24 hours a day, 7 days a week? Do they provide care on weekends? Are they accredited by either JCAHO or CHAP? Ms. Madigan's article goes on to suggest these additional questions: what services are available, from the HHC provider and outside providers contracting with the HHC agency? What is their experience with high technology cases? What are their administrative and staff credentials? What is the process for staff supervision (lines of authority)? Does the agency care for Medicaid patients, how are payments determined prior to delivery of service, what precisely is the billing process - and exactly what are the costs of services?
Nurses providing HHC spend a good deal of their time teaching children and their families about the illness or condition of the home-bound patient, and about treatment regimens and of course medications. The goal of HHC is to "discharge the child from home health care with sufficient patient/family knowledge for the early detection of problems" (Madigan, 1997). There are five "general categories of patients and families" for which HHC is necessary, Madigan writes. The first category is the technology-dependent patient (on ventilators, for example). Category #2 (still in the pediatrics genre) is the patient "whose condition makes leaving the home burdensome"; for example, a child in a skeletal traction at home, or a child with a cast that makes sitting in an automobile difficult, or those with multiple burns making movement very painful. In the 3rd category are those whose family members' ability to learn care-giving is in serious doubt, for physical, emotional, intellectual - or other numerous reasons. The 4th category of a child who benefits from HHC is in the event the family cannot, or will not, follow-up on nursing instructions for proper care. And in this group, there also may be a question of "abuse or neglect" on the part of the family - or, they may simply state flatly they do not wish to provide follow-up care. And number five on this list is for children who live in outlying areas where the doctor is 25 or more miles away.
Integrating Advanced Practices Nurses into Home Care Environments
There is a growing and indeed in some cases an "overwhelming" preference for home care (vs. institutionalizing) among the elderly, especially for those with chronic illnesses and those who are physically dependent, according to an article in Nursing and Health Care Perspectives (Mitty & Mezy, 1998). And the federal government's Medicare and Medicaid financing is available for many older people, to promote their "independent living" and hence to match the demand for home care. But according to the journal article, there is a dearth of linkages between home care delivery agencies and academic nursing programs, and the article urges changes in health care to "support the expanded role of NPs as primary care providers."
After all, NPs have a "proven efficacy in health promotion, early identification and prevention of complications," as well as patient compliance and education - so, it is a logical argument to bring advanced practice nurses into the home care environment, and in order to plan for the future, more specifically targeted nursing teaching programs are proposed as a solid strategy for integrating primary care by NPs into the home care genre. The growth of home care services was tremendous between 1988 and 1995, as the number of Medicare home health visits jumped from 37 million to 252 million. Money spend through Medicare home health care visits also leaped during that period - from $2.1 billion to about $16 billion, which is the fastest-growing budget item in Medicare.
To the authors of the article, this data indicates that skilled care nursing - which entails "nursing judgment" beyond merely "hands-on" service - is being expanded into home care environments. The authors also note that the "quality and cost" of home health care services have "come under heavy attack from policymakers and regulators" (albeit authors don't say why this is true). And while studies to date have not shown any "significant savings" for home care, other studies report "significant functional improvement and/or institutional cost savings" within sixty days of admission to home health for those with "chronic illness, for recipients at high risk for hospitalization, and for elderly persons receiving comprehensive geriatric assessment."
The point of the article under review is to promote the fact that advanced practice nursing care is needed in the home environment more than ever, and yet there is not a big push within the nursing education community to provide curricula specifically tailored towards training NPs for home care work. And in addition, the article points out that…