Home Health Services, Which Is Key Area Of Concern?

Background

Domicile wellness care is a arrangement of care provided by skilled practitioners to patients in their homes under the management of a doc. Home wellness care services include nursing intendance; physical, occupational, and speech-language therapy; and medical social services.¹ The goals of home health intendance services are to help individuals to ameliorate role and live with greater independence; to promote the client's optimal level of well-beingness; and to assist the patient to remain at home, avoiding hospitalization or admission to long-term care institutions.^2–4 Physicians may refer patients for abode health care services, or the services may exist requested by family members or patients.

The Centers for Medicare and Medicaid Services (CMS) estimates that 8,090 home health care agencies in the United states of america provide intendance for more than 2.iv million elderly and disabled people annually.⁵ To be eligible for Medicare reimbursement, dwelling house health care services must be accounted medically necessary past a physician and provided to a home-bound patient. In add-on, the care must be provided on an intermittent and noncontinuous footing.⁵ Medicare beneficiaries who are in poor health, accept low incomes, and are 85 years of age or older have relatively high rates of domicile health intendance use.⁶ Mutual diagnoses among habitation health intendance patients include circulatory affliction (31 pct of patients), heart illness (xvi percentage), injury and poisoning (15.9 pct), musculoskeletal and connective tissue disease (xiv.ane percent), and respiratory disease (xi.six percent).⁷

Delivering Health Intendance in the Abode

The home health care environment differs from hospitals and other institutional environments where nurses piece of work. For example, home health intendance nurses piece of work alone in the field with support resources available from a central office. The nurse-physician work relationship involves less straight physician contact, and the physician relies to a greater degree on the nurse to make assessments and communicate findings. Home health care nurses spend more time on paperwork than infirmary nurses and more time dealing with reimbursement issues.^{8 , 9} Certain distinctive characteristics of the home health care surround influence patient safe and quality of outcomes: the high caste of patient autonomy in the home setting, limited oversight of breezy caregivers by professional clinicians, and situational variables unique to each dwelling.

Respect for patient autonomy is valued in hospital-based care. Even so, many decisions are fabricated by clinicians on behalf of hospitalized patients. In home health care, clinicians recognize that the care setting—the home—is the inviolable domain of the patient. Therefore, compared to the hospitalized patient, the domicile health care patient oft has a greater part in determining how and even if certain interventions will exist implemented. For case, in a hospital, nurses, physicians, and pharmacists may all play a role in ensuring that the patient receives antibiotics at therapeutically advisable intervals. At home, notwithstanding, the patient may choose to take the medication at irregular times, despite advice almost the importance of a regular medication schedule. Thus, interventions to promote patient safety and quality intendance must account for the fact that patients volition sometimes cull to act in ways that are inconsistent with the relevant evidence, and the clinician's best efforts may not upshot in desired outcomes.

In add-on to deliberate choices fabricated by informed and capable patients regarding their intendance, individual patient variables may also influence home-based outcomes in ways that are different from those patients who are hospitalized. Ellenbecker and colleagues^{10 , 11} reported that reading skill, cognitive ability, and financial resource all affect the power of abode health care patients to safely manage their medication regimens. Yet, none of these variables may play a meaningful role in the prophylactic administration of medications to hospitalized patients.

In improver to cocky-care, some domicile-jump patients receive assistance from family members or other breezy caregivers. Professional clinicians accept no dominance over these caregivers. Further, the home environment and the intermittent nature of professional home health care services may limit the clinician's ability to observe the quality of care that informal caregivers deliver—unlike in the hospital, where care given by back up staff may more easily be observed and evaluated. For example, because of limited access to transportation, a husband may determine not to purchase diabetic supplies for his dependent wife. This beliefs may not come to the clinician's attention until an adverse event has occurred. Prove-based interventions are predicated on careful assessment. Withal, express opportunity to directly find the patient and breezy caregivers may hinder efforts to rapidly determine the etiology of an adverse event. If a home health care patient is found with bruises that the patient tin can't explain, is the cause a fall, physical abuse, or a claret dyscrasia? In both self-care past patients and intendance by informal caregivers, safety and quality standards may non exist understood or accomplished.

Another distinctive characteristic of domicile health intendance is that clinicians provide intendance to each patient in a unique setting. In that location may be situational variables that present risks to patients that may be difficult or impossible for the clinician to eliminate. Hospitals may have ecology safety departments to monitor air quality and designers/engineers to ensure that the summit of stair risers is prophylactic. Dwelling wellness care clinicians are not likely to have the training or resources to appraise and ameliorate such risks to patient rubber in the patient'due south habitation.

Finally, given the large number of elderly persons who receive intendance from Medicare-certified home health care agencies, it is reasonable to conceptualize that some patients volition exist in a trajectory of decline. Due to both normal aging and pathological processes that occur more than frequently with advancing historic period, some elderly persons will experience decreasing ability to deport out activities of daily living (ADLs), fifty-fifty when loftier-quality dwelling health care is provided. Thus, an implicit goal of home health care is to facilitate a supported decline. That is, patients who do non show clinical signs of improvement may nonetheless receive quality care that results in a decelerated decline or increased quality of life. This is consistent with the American Nurses Clan's assertion that promoting the patient's optimal level of well-being is a legitimate goal of abode health care.³

Assessing Quality of Intendance in the Home

The goals and multidisciplinary nature of habitation health care services nowadays challenges to quality measurement that differ from those constitute in a more traditional hospital setting. The CMS mandates reporting of home wellness care issue measures. The Consequence-Based Quality Monitoring (OBQM) program monitors, reports, and benchmarks agin events such as emergent care for injury acquired by fall or blow, increased number of pressure ulcers, and substantial decline in three or more ADLs.⁵

Pay for functioning, a mechanism that ties a portion of an agency's reimbursement to the commitment of intendance, is another CMS quality initiative anticipated in the near future.¹² In preparation, quality-improvement organizations and providers are working to identify and develop a gear up of functioning measures proven constructive in home intendance. A 2006 Medicare Payment Advisory Committee report to Congress identified patient rubber as an of import component of quality and the need to expand quality measures to include process and structural measures. An expanded approach to quality measurement should attain the post-obit goals: broaden the patient population being evaluated, aggrandize the types of quality measures, capture aspects of intendance directly under providers' command, reduce variations in practice, and improve information technology.¹³

In January 2007, the dwelling house health customs, wellness care leaders, and quality-improvement organizations launched the Dwelling house Health Quality Improvement National Campaign 2007. The campaign focuses on improving the quality of patient care in the home health care setting by providing agencies with monthly all-time exercise intervention tools. The goal is to preclude avoidable hospitalizations for abode health intendance patients. The Home Wellness Quality Improvement National Campaign uses a multidisciplinary approach to quality improvement that includes key abode health, hospital, and physician stakeholders.¹⁴

Research Evidence

In many respects, home health intendance clinicians and clinicians working in other settings have like concerns well-nigh patient safety and care quality. For example, patient falls occur both in homes and in hospitals, and some measures aimed at preventing falls are every bit applicable to both settings. However, the significant differences between dwelling health care and other types of health care oft require interventions tailored to the abode health intendance setting.

This chapter includes an analysis of the evidence on promoting patient prophylactic and health care quality in relation to problems frequently seen in home health care. The following six areas were selected for review:

• Medication management

• Fall prevention

• Unplanned hospital admissions

• Nurse work environment

• Functional outcomes and quality of life

• Wound and pressure level ulcer management

Adverse events in these areas could jeopardize achievement of one or more than home health care goals.

Medication Management

Nearly one-third of older dwelling health intendance patients take a potential medication trouble or are taking a drug considered inappropriate for older people.¹⁵ Elderly home health care patients are peculiarly vulnerable to adverse events from medication errors; they often take multiple medications for a multifariousness of comorbidities that have been prescribed past more than than ane provider. The majority of older habitation health intendance patients routinely accept more than five prescription drugs, and many patients deviate from their prescribed medication government.¹¹ The potential of medication errors among the home wellness intendance population is greater than in other wellness care settings because of the unstructured environment and unique advice challenges in the home health intendance system.^eleven

A search of the literature identified just three studies testing interventions to amend medication direction and adherence in dwelling health care patients.^16–18 The studies are summarized in Table 1. All 3 studies used a controlled experimental blueprint, with random assignment of patients to ane or 2 treatment groups and a control group of usual care. The populations studied were elderly Medicare patients receiving home wellness care, ranging from 41 to 259 patients.

Table 1

Summary of Testify Related to Medication Management

The interventions tested were patient education delivered past telephone or videophone with nurse followup, educational activity tailored to individual patients, and medication review and collaboration amongst providers (e.m., nurse, pharmacist, doc) and patient. Specific outcomes included identifying unnecessary and duplicate medication, improving the employ of specific categories of medication such as cardiovascular or psychotropic drugs, and identifying the extent of use of nonsteroidal anti-inflammatory drugs (NSAIDs). The effectiveness of the interventions was measured by improved medication management and adherence to drug protocols. Adherence was estimated considerately from medication refill history and medication outcome monitoring, and subjectively from patient self-study scores on pre- and postintervention questionnaires testing cognition, understanding of disease, and adherence.

Testify from these studies suggests that all of the interventions tested were at least somewhat effective. Medication use improved for patients receiving the intervention, while command groups had a pregnant decline in adherence to drug protocols. The educational interventions were nigh successful when individually tailored to patients' learning abilities. The interventions were most effective in preventing therapeutic duplication and improving the apply of cardiovascular medications, less constructive for patients taking psychotropic medication or NSAIDs. Generally, as cognition scores improved, adherence improved. When more than 1 intervention was tested, there was generally no deviation between the ii intervention groups.

Bear witness-Based Practice Implications

Nurses must be vigilant for the possibility of medication errors in the habitation health care setting, recognizing the associated run a risk factors. Engineering science provides many opportunities to improve communication with patients, to provide patients with accurate information, to educate them nearly their medications, and to monitor medication regimes. Paying shut attending to at-run a risk patients is most effective; therefore, accurate documentation and review of medications during each patient encounter is of import. The evidence suggests that frequent medication reviews and collaboration with other members of the health intendance team, especially pharmacists, will assistance to prevent adverse events associated with poor medication management.

Enquiry Implications

More effective methods are needed to improve medication use in the home health care population. Research should continue to expand the noesis of factors that contribute to medication errors in abode health care and decide what interventions are the nigh constructive in improving medication management in the dwelling.

Fall Prevention

Emergent care for injury caused past falls or accidents at abode is ane of the most frequently occurring adverse events reported for patients receiving skilled home health intendance services.^nineteen Xxx percent of people historic period 65 and older living in the customs fall each year. One in five of these autumn incidents requires medical attention.^xx Falls are the leading cause of injury-related expiry for this population.²¹ Among the elderly, Stevens²² reported direct medical costs in 2000 totaled $179 meg for fatal fall-related injuries and $19 billion for nonfatal injuries due to falls.

Although there is strong testify of effective fall-prevention interventions for the general over-65 population,^{20 , 23 , 24} knowledge of fall prevention in habitation health intendance is limited. For the general older population living in the community, evidence suggests that individualized home programs of muscle strengthening and balance retraining; circuitous multidisciplinary, multifactorial, wellness/environmental gamble factor screening and intervention; dwelling take a chance assessment and modification; and medication review and adjustment can all reduce the incidence of falls.²⁰ However, patients in dwelling house health intendance are often older, sicker, and frailer than the average community-residing older adult, and it is not known if knowledge from other settings is transferable to home health intendance.

Research studies specific to home health intendance are predominantly retrospective, descriptive, correlational designs in single agencies, using matched control or randomized control groups to explore patient characteristics and other factors contributing to patient falls.^25–27 Findings suggest that factors related to falls for domicile health intendance patients are previous falls, primary diagnosis of low or anhedonia, apply of antipsychotic phenothiazines and tricyclic antidepressants, secondary diagnoses of neurological or cardiovascular disorders, balance bug, frailty, and absence of handrails.^25–27

A literature review located only 3 studies testing interventions to forestall falls.^28–30 The studies are summarized in Tabular array 2. All three interventions were quality-comeback programs in single agencies. The findings suggest that adventure factor screening and intervention using a valid and reliable instrument and physical therapy aimed at comeback in gait and remainder may reduce injury and emergent intendance for falls. Unfortunately, at that place is no prove that the number of falls incurred by the home health intendance population can be reduced. Information technology may exist that improved provider assessments increased the number of falls reported and documented.

Table 2

Summary of Evidence Related to Fall Prevention

Testify-Based Practice Implications

Home health care providers need to know the adventure factors for falls and demonstrate constructive cess and interventions for fall and injury prevention. Falls are by and large the upshot of a circuitous set of intrinsic patient and extrinsic ecology factors. Use of a fall-prevention program, standardized tools, and an interdisciplinary approach may be constructive for reducing fall-related injuries.

Inquiry Implications

In that location are several limitations in the current testify on falls in home health intendance. Most of the inquiry is descriptive, and there are no randomized controlled studies. Findings from small-scale, unmarried-bureau quality-improvement projects cannot be generalized. It is non known if predictors for falls in domicile health care patients are the aforementioned equally those for other community dwellers over historic period 65. Research is needed to expand the knowledge of factors that contribute to falls in this population and to develop constructive interventions. Research is besides needed to explore factors to foreclose injury from falls, equally information technology is likely that the incidence of falls in this population cannot be completely eliminated.

Unplanned Infirmary Admissions

A primary goal of dwelling health care is to discharge the patient to self or family care and avoid subsequent hospitalizations. Unplanned access to the hospital is an undesirable effect of home wellness care that causes problems for patients, caregivers, providers, and payers. Unplanned hospital admissions are associated with complications, morbidity, patient and family stress, and increased costs.³¹ An estimated 1,034,034 abode wellness care patients were hospitalized in 2004. The national rate of unplanned hospital admissions for home health care patients has gradually increased from 27 percent in 2000 to 28 percent in 2006,³² and it is the just publicly reported abode health care patient effect that has never improved at the national level.³³

Several researchers have explored the characteristics of abode health care patients and other factors associated with hospitalization.^{31 , 34–39} The studies take been predominantly retrospective, descriptive, and correlation designs examining habitation intendance populations from unmarried or multiple agencies.^{31 , 35–38} I study is a prospective study of a random sample of agencies.³⁹ Evidence suggests that unplanned infirmary admissions are due mostly to an acute exacerbation of chronic affliction—exacerbations that could exist prevented through knowledge of risk factors, provider communication, and careful monitoring.³⁹ Adventure factors associated with unplanned hospital admissions are polypharmacy,^{31 , 35} length of home health care episode,^{34 , 36} development of a new trouble or worsening primary or secondary diagnosis,³⁶ wound deterioration and falling accidents,³¹ and age.^{31 , 37} Based on this prove most experts^{31 , 37} conclude that 20 to 25 percent of unplanned hospital admissions are preventable. For example, Shaughnessey and colleagues² establish that agencies actively involved in Outcomes-Based Quality Improvement (OBQI) monitoring reduced their rate of patient hospitalizations when compared to non-OBQI agencies.

The Briggs National Quality Improvement and Hospitalization Reduction Study³³ convened a console of experts to identity best practice strategies that agencies should implement to prevent unplanned hospitalizations. Recommended best practices included implementing a fall prevention programme, forepart loading visits, management support, 24-hr on-call nursing coverage, medication management, case management, patient/caregiver educational activity, special support services, affliction management, positive dr. and hospital relationships, information-driven services, safety and adventure assessment, and telehealth. These recommendations were non empirically tested, however.

Merely eight studies have tested the effectiveness of interventions to foreclose unplanned hospital admissions for home health care patients. Five of these studies employed a randomized controlled trial design, and three used a nonrandomized control or comparison group pattern. The tested interventions consisted primarily of increasing the intensity of care provided through a disease management plan, a team management home-based principal care program, a multidisciplinary specialty squad intervention, advanced exercise nurse (APN) transitional intendance, telehealth services, and intensive rehabilitative care prior to hospital discharge.^40–43 Virtually of these interventions were effective or somewhat constructive in preventing or delaying hospitalization. Additionally, four of the studies reported lower mean costs or charges for the intervention groups related to lower hospital costs,^{twoscore , 42–44} and one study⁴⁵ reported college costs for the intervention group based on the costs of the squad-managed primary care intervention.

In these studies, patients with congestive heart failure (CHF) had fewer unplanned infirmary admissions and longer survival times prior to first admission^39–42 if they received APNtransitional care, team-managed abode-based primary care, or a multidisciplinary specialty squad intervention.^xl–43 Patients with CHF who received telecare and telephone interventions also had significantly fewer emergency room visits, just no change in infirmary admissions.⁴² Squad-managed abode-based main care has been found to be nigh effective for people who are severely disabled.⁴⁵ Daly and colleagues ⁴⁴ reported that long-term mechanically ventilated patients who received a illness direction program intervention involving APN services and interdisciplinary coordination had significantly fewer mean days of hospitalization.

Results from one nonrandomized controlled study suggest that patients with chronic obstructive pulmonary disease (COPD) who received APN transitional care as well experienced fewer unplanned hospital admissions.⁴⁶ Intrator and Berg⁴⁷ reported that patients hospitalized with hip fractures had fewer unplanned hospital admissions when they received abode wellness care services following inpatient rehabilitation compared with those patients who received inpatient services just. Findings are summarized in Tabular array 3.

Table 3

Summary of Bear witness Related to Unplanned Hospital Admission

Bear witness-Based Do Implications

Evidence suggests that specialized, coordinated, interdisciplinary care has a positive impact on unplanned infirmary admissions in select home health care populations. Agencies tin identify patient characteristics associated with hospitalization unique to their patient population. High-take chances patients may require specialized interventions across the traditional telescopic of home health care services. Targeted interventions using process-of-care analysis and information available from the Issue and Assessment Information Gear up (OASIS), within the framework of OBQI, may result in fewer unplanned hospital admissions for dwelling health care patients.

Research Implications

The bachelor evidence suggests that in addition to the use of APNs for care of complex cases, traditional home health care professionals, individually or through interdisciplinary practice, may be effective in preventing unplanned hospital admissions with targeted interventions. Although numerous strategies have been recommended by researchers and other domicile care experts, most interventions have not been empirically tested. Costs and benefits of the various interventions also need further exploration. The measurement of intervention costs and cost savings from prevented hospitalizations are not well understood. Some patient populations, due to the nature and complexity of advanced affliction process, may crave more intense and specialized home health intendance services that volition non result in price savings. On the other mitt, utilize of seemingly more expensive transitional resources, such as APNs, accept been proven cost effective, although adoption of such inquiry-based all-time practices may exist impeded by lack of reimbursement and incentives.⁴⁸ Research is needed to understand the affect of shifting care and toll to home wellness intendance on patient outcomes and dwelling health care manufacture fiscal status.

Nurse Work Environs

Evidence from the acute care setting suggests a human relationship betwixt nurses' work surround, patient safety, and quality of patient intendance.^49–51 A positive work environment is 1 that supports nurse autonomy and control over the work environment, including shared governance or decisionmaking.^52–55 It is an environment with strong and visible nursing leadership, organizational support, peer support, and positive dr. collaboration.^53–55

Enquiry exploring the relationship of the piece of work environment, patient safety, and quality in home health intendance is in early stages of development. At that place have been no randomized controlled studies to date. Feldman and colleagues⁵⁶ examined the relationship of patient adverse events with characteristics of the nurses' work environment at one very big urban domicile wellness care agency. Characteristics of 86 abode health intendance teams inside the agency were examined. Researchers reported that adverse events were lower for teams with higher patient volume and visits, fewer weekend admissions, more equitably distributed incentives, and more teamwork. Rates were higher when teams perceived supervisor back up for adverse effect reporting. This is the showtime rigorous study to identify organizational factors associated with potential agin events, and at that place were limitations. It was a descriptive, correlational study, and the agency involved in the report is non typical of near agencies in the United States as it serves a disproportionately diverse urban population. Several of the findings approached significance only at a probability level (alpha) of 0.10.

Kroposki and Alexander⁵⁷ explored the relationships among patient satisfaction, nurse perception of patient outcomes, and organizational structure in a descriptive study. They reported that college patient satisfaction scores were more likely in home health intendance agencies where nurses and supervisors had adept working relationships, opportunity for shared decisionmaking was present, and formalization of organizational and professional guidelines existed. Limitations of this study included its descriptive, nonrandomized design of multiple agencies from ane State and the lack of a reliable and validated tool to measure nurse perception of patient outcomes. Findings are summarized in Table 4.

Table iv

Summary of Bear witness Related to Nurse Work Environment

Evidence-Based Practice Implications

Agencies should consider how characteristics of the work environs may exist influencing patient prophylactic and quality outcomes. It is necessary to explore the context of the environs when examining clinicians' practices in an effort to place necessary organisation changes.

Research Implications

It is not known what characteristics of the home health care nursing work environment are related to patient condom and quality. Home health care research is needed to investigate the relationship of work environment characteristics, nurse satisfaction, and patient outcomes.

Functional Outcomes and Quality of Life

The goal of care provided in the home is to restore or maintain patient physical and mental performance and quality of life, or to dull the rate of decline to allow the patient to remain at home and avoid institutionalization. Nearly patients and family members prefer the dwelling environment, when information technology is feasible. A patient's and family unit'southward ability to function independently and safely in the domicile increases the possibility of the patient remaining there.

Improving patient condom and quality of care by educating and assisting caregivers (families and providers) is an approach tested in several randomized controlled trials. The findings are summarized in Tabular array 5. Archbold and colleagues⁵⁸ pilot tested preparedness, enrichment, and predictability (PREP), a formal nursing intervention designed to prepare family caregivers to provide care. While the study had many limitations, preliminary evidence on the effectiveness of the intervention suggests that families benefit from existence informed and prepared.

Table 5

Summary of Show Related to Functional Outcomes and Quality of Life

Other researchers have tested interventions to improve nurse providers' knowledge and sensation.^59–61 Intervention studies to brainwash and inform nurse providers accept been conducted in small and large urban and rural home health intendance settings, with nurses randomly assigned to an intervention group or a control group. The interventions by and large provided nurses with additional teaching, extra resources for patients, and specialized patient information. In i frequently reported study, evidence-based intendance with specific illness-related data was sent to nurses past "just-in-time" email reminders.^{59 , 60}

In all cases the interventions improved nurses' performance, which resulted in meliorate patient outcomes. Patients of nurses in these studies showed significant comeback in pain management, quality of life, satisfaction with care, and other variables associated with improved quality of care, including meliorate communication with providers, better medication management, and improved illness symptoms. Nurses' improved performance included increased documentation of critical patient assessments. In the instance of "merely-in-time" e-mail reminders, the intervention group that had additional clinical and patient resources had improve patient outcomes, suggesting that the multifaceted arroyo or stronger dose of the intervention was more effective.

A number of randomized controlled trials have tested the effectiveness of specific interventions to improve patient safety and quality in disease management,^{62 , 63} urinary incontinence,^{64 , 65} level of ADL performance,^{44 , 46 , 66–68} quality of life, full general wellness outcomes, and patient satisfaction.^{44 , 46 , 59 , 62 , 66–70} Corbett⁶³ demonstrated that individualized patient education in foot care for diabetics was effective in improving patients' cocky-care. Scott and colleagues⁶² demonstrated an improvement in quality of life in patients with CHF though a program of patient education and mutual goal setting. Dougherty and colleagues⁶⁴ and McDowell and colleagues⁶⁵ tested behavioral direction interventions to treat urinary incontinence in the elderly and reported positive results based on behavior management interventions of self-monitoring and bladder training. Mann and colleagues⁶⁷ tested the introduction of assistive technology (canes, walkers, and bath benches) and changes made to the abode surroundings (calculation ramps, lowering cabinets, and removing throw rugs) with populations of frail elderly. These interventions were successful in slowing functional reject in the study patients.

Some of the research prove suggests more efficient mechanisms for providing intendance. In exploring the amount of care that is effective, Weaver and colleagues⁷¹ decreased (compared with usual care) the number of post-hospitalization visits past patients with knee and hip replacements and added one preoperative dwelling visit. No differences in functional power, quality of life, or level of satisfaction between those patients receiving usual care (more visits) and those receiving the intervention (fewer postoperative visits and ane preoperative visit) were found. Several studies have examined the use of technology in patient functioning and independence. Johnston and colleagues⁶⁹ tested real-fourth dimension video nursing visits and institute no difference in patient outcomes or level of satisfaction with usual care or care enhanced by video engineering science.

A number of randomized controlled trials accept tested the outcomes of interventions based on the specialty of the provider combined with different models of intendance direction, or interventions based solely on different models of care direction.^{44 , 46 , 65 , seventy , 71} Inquiry examining the effect of APN providers on the quality of patient care suggests they have a positive effect. In two studies testing the transitional care model, APN-directed teams delivered intendance to patients with COPD⁴⁶ and CHF⁷⁰ and institute improvements in the group in the transitional care model. Patients experienced fewer depressive symptoms and an increase in functional abilities when compared with patients receiving usual care.^{46 , 70} Patients in these studies also needed fewer nursing visits, had fewer unplanned hospital admissions, and had fewer astute care visits. A nurse practitioner's urinary incontinence behavioral therapy was effective in decreasing the number of patients' urinary incontinence accidents.⁶⁵ The Veterans Affairs Squad-Managed Domicile-Based Primary Care was an add-on to care routinely provided in the Veterans Affairs Domicile-Based Master Intendance program.⁴⁴ The added component emphasized continuity of care and team management with a principal care director, 24-hour on-telephone call nursing availability for patients, prior blessing of hospital admissions, and squad participation in discharge planning. The investigators plant significant improvements in quality of life, functioning, pain direction, and full general wellness outcomes for terminally sick patients in this report, and an increase in satisfaction for nonterminally ill patients and family unit caregivers.

Withal, mixed results take been obtained from the research to date on the effectiveness of models of intendance management.^{66 , 68} Some intervention models have been less effective than others. The interventions are usually an add together-on to routine intendance, and their effectiveness has been determined by a comparison to a control grouping of usual or routine home wellness intendance. An intervention model that does not announced to be effective is the Health Outcomes Management and Evaluation model tested by Feldman and colleagues⁶⁶ This model adds a consumer-oriented patient self-care guide and training to improve nurses' teaching and support skills. Study results showed no difference in patient quality of life or satisfaction. Tinetti and colleagues⁶⁸ compared the outcomes of a systematic, multicomponent rehabilitation programme, including therapies for physical and functional impairments, to the outcomes from usual home-based rehabilitation care. No differences were found betwixt the two groups.

Evidence-Based Practice Implications

The preceding discussion suggests that working closely with and supporting family unit caregivers is, and will continue to be, an important aspect of helping patients to remain in their homes. Information technology as well suggests that nurses' effectiveness in working with patients tin be enhanced if nurses are supported in their work. Back up tin can be provided by electronic communication, reminders of protocols, disease-specific educational materials for patients, and working with APN colleagues to serve as clinical experts for staff. Home wellness care nurses are relatively isolated in the field, and any mechanism to improve communication with supervisors in the role and with other providers volition assist nurses in their practice. Incorporating the use of remote engineering science to substitute for some in-person visits can improve access to domicile wellness care staff for patients and caregivers.⁶⁹

Specific patient interventions can be helpful in improving patient wellness and quality of life. Interventions of individualized education and disease-specific programs, such as a behavioral direction program for urinary incontinence or educational programs for pes care, should be incorporated into practice. The rate of a patient'south functional refuse can be slowed and costs reduced through a systematic approach to providing assistive engineering and environmental interventions to frail elderly patients in their homes. A patient's demand for these interventions can exist determined with a comprehensive assessment and continued monitoring.

Research Implications

Bear witness of the outcomes of health care provided in the home is limited; there are very few controlled experiments on which providers tin can base their practice. Research is limited in the areas of composition, duration, and amount of home health care services needed to ensure patient safety and quality. Inquiry is needed to make up one's mind effective interventions to improve, maintain, or slow the pass up of functioning in the domicile health intendance population. More inquiry is likewise needed to determine mechanisms to keep nurses informed and supported. Providing communication and support is a challenge when providers are geographically dispersed and spend most of their time in the field. Remote technology has the potential to reduce costs: information technology tin can substitute for some in-person visits, and it tin improve admission to home health care staff for patients and caregivers.

Wound and Pressure Ulcer Management

Agin wound events are monitored under the OBQM program. Emergent intendance for wound infections, deteriorating wound status, and increment in the number of pressure level ulcers are monitored and reported as agin events.^seventy The data are used to reflect a alter in a patient's health status at ii or more times, usually between abode health care admission and transfer to a infirmary or other wellness intendance setting. Data for these outcomes are collected using Oasis-designated intervals. Patient upshot measures related to surgical wounds that are monitored under the OBQI include improvement in the number of surgical wounds and improvement in the status of surgical wounds.¹⁸

Wound Management

Over a third of dwelling health care patients require treatment for wounds, and nearly 42 percent of those with wounds have multiple wounds. Over lx percent of wounds seen in home wellness care are surgical, while just under one-quarter are vascular leg ulcers and some other one-quarter are pressure ulcers.⁷¹ Most home health intendance nurses tin can accurately identify wound bed and periwound characteristics; the majority (88 percent) of wound treatments accept been found to be appropriate.⁷² The ceremoniousness of wound treatments in habitation health care is significantly related to wound healing. Patients with healing wounds had shorter home health care visits and shorter home health care lengths of stay.⁷¹

A literature review identified vii studies that tested interventions to improve wound care management in domicile wellness care.^73–79 Findings are summarized in Table six. 3 compared effectiveness of diverse wound treatments. Capasso and Munro⁷⁴ found no significant difference in wound closure between amorphous hydrogel dressings and wet-to-dry saline dressings, but costs were found to be significantly higher for the saline dressings due to the need for more than nursing visits. Kerstein and Gahtan⁷⁶ found the percentage of venous leg ulcers healed using hydrocolloidal dressings was half-dozen times higher than with saline gauze dressings and nearly 4 times greater using an Unna boot; the hydrocolloidal dressings were about price-effective. Use of negative force per unit area wound therapy resulted in successful closure of 43 percent of wounds that failed to respond to previous treatment.⁷⁸

Table 6

Summary of Show Related to Wound Management

Iv studies reported positive outcomes from interventions to improve and back up habitation health intendance nurse practice.^{73 , 75 , 77 , 79} Use of telemedicine to provide consultation with wound management experts resulted in improved healing rates, decreased healing time, and decreased home visits and hospitalizations related to wounds.^{73 , 77} Fellows and Crestodina⁷⁵ studied the rate of bacterial contamination of normal saline solutions prepared from distilled h2o and table common salt, a practice common for wound intendance in the abode, and found refrigerated solutions substantially growth-free at 4 weeks. A quality improvement project reported a reduction in adverse events through structured nurse education, introduction of protocols, and competency review.⁷⁹

Pressure Ulcer Management

Rodriques and Megie⁸⁰ found that 37 percentage of wounds in home wellness care patients were force per unit area ulcers, with a mean wound duration of nearly 27 months. Nearly 1 in 10 patients admitted to home wellness care had pressure ulcers and approximately i-3rd were at risk of developing new ulcers; yet according to i study, only 27 percent of patients with existing ulcers and 14 percentage of those at take chances were receiving advisable pressure-reducing treatment.⁸¹ Incontinence, limitations in ADLs, mobility impairment, peel drainage, contempo fractures, anemia, employ of oxygen, and recent institutional belch were associated with pressure ulcer development.^{81 , 82} Guidelines from the Wound, Ostomy and Continence Nurses Guild⁸³ call for an initial risk cess for pressure ulcers of all patients on admission to abode wellness care, and reassessment every visit thereafter, using a validated risk cess tool. However, i written report found that only 21 per centum of agencies used a validated tool such as the Braden Scale⁸⁴ to identify patients at run a risk, nearly 8 per centum performed no assessments on admission, and only 33 percent used risk prediction or pressure ulcer prevention protocols.⁸⁵ Just over one-half of agencies reported routine pare inspections past nurses of at-adventure patients.

A literature review resulted in identification of v studies relating to force per unit area ulcer management in home health care. The findings are summarized in Tabular array 7. Three studies were randomized controlled trials testing interventions to improve pressure ulcer healing.^86–88 One intervention tested the use of air-fluidized bed therapy with services of a nurse specialist;⁸⁷ a second intervention used noncontact normothermic wound therapy.⁸⁸ Both resulted in significant improvement in wound healing compared to conventional moist dressings. Overall healing rates were similar for polymer hydrogel and hydrocolloidal dressings, although debridement performance of the hydrogel dressing resulted in more favorable clinical evaluation.⁸⁶

Tabular array 7

Summary of Evidence Related to Pressure Ulcer Direction

The remaining 2 studies evaluated the use of the Braden Scale for prediction of pressure ulcer risk in domicile wellness care patients, with mixed results. Ramundo⁸⁹ reported that the Braden Scale had validity in identifying at-chance patients, just limited predictive ability, while Bergquist⁸² institute that the summative score of the scale was significantly associated with pressure ulcer development. All subscale scores except diet were significantly and negatively associated with force per unit area ulcer evolution.

Prove-Based Practice Implications

When compared with moisture-to-dry or moist saline dressings, nearly wound treatments tested showed greater effectiveness or lower cost. Habitation wellness care nurses should be knowledgeable in the use of the full range of existing and emerging wound products, practices, and treatments and demonstrate skill in authentic wound assessment and staging. Provision of structured resource, expert consultation, and competency testing for abode health intendance nurses can improve home health intendance wound direction. Nurses must be knowledgeable in risk factors for pressure ulcer evolution and relevant preventive measures; they must appraise every patient using a valid and reliable instrument, such as the Braden Calibration, on admission to home health care and regularly thereafter.

Research Implications

Relatively little is known near the most effective practices for wound care in the home health care setting. Although studies have compared different treatments for wounds, the virtually efficacious treatments for different wounds are unknown in the presence of various risk factors institute in the home wellness care setting. Randomized controlled clinical trials exist comparing unlike force per unit area ulcer treatments in the home, with the exception of care of other types of wounds. Promising findings from studies with small sample sizes should exist replicated with larger samples and diverse populations.

Determination

Habitation health intendance clinicians seek to provide high quality, safe care in ways that honor patient autonomy and accommodate the individual characteristics of each patient's home and family unit. Falls, failing functional abilities, pressure ulcers and nonhealing wounds, and adverse events related to medication administration all have the potential to result in unplanned infirmary admissions. Such hospitalizations undermine the accomplishment of important home health care goals: keeping patients at home and promoting optimal well-being. Withal, the unique characteristics of home health care may arrive difficult to utilize—or necessary to modify—interventions that have been shown to be effective in other settings. Therefore, research on effective practices, conducted in home health intendance settings, is necessary to support excellent and evidence-based care.

In reviewing the extant studies, the authors of this affiliate found useful prove in all selected areas. All the same, the number of studies was few and many questions remain. Replications of investigations originally conducted in health intendance settings other than the home, and studies considering dwelling health care-specific issues are needed to support evidence-based clinical decisions. The available evidence suggests that the work environment in which home health care nurses practice may indirectly influence patient outcomes in many areas, and that technology can be used to back up positive patient outcomes. Thus, studies that link nurse-related variables to improved intendance prophylactic and quality are needed, every bit well as studies that focus directly on patients. The demographics of an aging society will sustain the trend toward dwelling house-based care. Home health care practices grounded in conscientious research will sustain the patients and the clinicians who serve them. Given the focused review of evidence-based studies comprising this chapter, many informative sources of use to the practicing home wellness intendance nurse are omitted. Table 8 lists additional primal resources.

Search Strategy

The literature review for this chapter focused on identifying show-based practices that supported the goals of dwelling health care: to promote independent functioning; to remain at home, avoiding infirmary or nursing home admission; and to achieve optimal well-being. The search was conducted using multiple variations of key terms informed by the characteristics of home health care described at the outset of this chapter, adverse events used in the OBQM,⁵ goals of the Habitation Wellness Quality Improvement National Campaign 2007,¹⁴ and the nurse-sensitive quality indicators developed by the American Nurses Association.¹⁵ The Cumulative Alphabetize to Nursing & Centrolineal Health, Cochrane Library, Medline, and ProQuest Nursing & Allied Health databases were searched, as well every bit the grey literature and government Web sites, including the CMS and Bureau for Healthcare Inquiry and Quality. Manus searches were conducted of the reference lists of retrieved articles. Search limitations were English language linguistic communication, U.s.a. or Canada, peer-reviewed journals or scholarly literature, published between 1990 and the starting time quarter of 2007. Studies cited in the evidence table were accepted for review using the following inclusion criteria:

• The study was published betwixt 1990 and the first quarter of 2007, inclusive.

• The inquiry was conducted in the United States or Canada.

• The study included an intervention that directly or indirectly influenced a patient result.

• The intervention took place nether the auspices of a abode health intendance agency.

• Subjects in the study had to be home health care patients (not customs-residing or outpatient ambulatory) and 18 years of historic period or greater.

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Source: https://www.ncbi.nlm.nih.gov/books/NBK2631/

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