HOME HEALTH CARE

Home Health Care andGeriatric NursingBy SARAH B. KEATING

T his article marks a first for a section in this JOURNAL

relating to home health care and geriatric nursing.This initial article will outline major issues and trends inhome health care affecting the needs of the elderly and inresponse to the changes proposed by health care reform.Subsequent articles will explore each of these issues byexperts in the field who will share their perspectives withour readers.

Financing of Home Health Care

Of major concern to health care providers and their cli­ents is the financial bases of home health care services.Presently, home health care is financed by fees for service(private pay), private health insurance, health mainte­nance organization (HMO) plans, Medicare and Medic­aid reimbursement for services, general funds for thoseofficial agencies supported by local governments, andcharity cases. A few agencies across the nation are par­ticipating in prospective payment programs funded byMedicare.

Capita ted, or "bundling of services," financial plansare also available to those agencies with contracts to serveas managed care providers. These plans consist of targethome health care populations with the agency bidding fortheir care. Calculating the actual cost of nursing care forthese programs avoids financial risks to agencies since thepre-agreed upon , fixed amount of money may not meetunanticipated costs. Nursing care can be cos ted outthrough various formulae. They include numbers of visitsper client, numbers of hours required for care, travel, sal­aries, and ancillary services.

Home Health Care and Health Care Reform

As health care reform begins to take shape, the role ofhome health care becomes paramount. Several of the ba­sic premises in reform are access, universal coverage, anda standard package of benefits for all. At this point, the

SARAH B. KEATING, RN. EdD, is chair of and a professor in the De­partment of Nursing at San Francisco State University.GERli\TR NURs 1994;15:47-9.Copyright @ 1994 by Mosby-Year Book. Inc.a197-4572/94/$3.00 + 0 34/1/51633

Keat ing

role of home care is unclear, although most experts agreethat home health care provides a cost-effective and qual­ity-of-life alternative for people needing acute care ser­vices or long-term care. Home health care and hospiceservices must be included in the basic benefits package inany reform plan (National Association for Home Care,December 1992). At the same time, there appears to bean emphasis on primary health care, defined as first con­tact with the health care system, health promotion, andprevention of disease . These services are as important tothe cIder population as the y are to younger groups. Mosthome health care clients are referred by other healthagencies and providers; however, home health care is anideal setting for case finding and health-promoting activ­ities . Leaders in home health care need to examine thesepossibilities and be ready to provide primary health care.

As health care reform begins to

take shape, the role of home

health care becomes paramount.

Another central concept in health care reform is man­aged competition . Home health care agencies and theirpartners, if they are part of a larger health care corpo­ration , can develop managed care plans for relevant pop­ulation groups and bid for provision of services to thesegroups. Small stand-alone agencies will be at risk in thecompetitive market and need to consider collaboratingwith other agencies for multiple, competitive services andcooperative, marketable managed care plans.

Total Quality Management and Accreditation

Health care reform proposals call for standards of careand total quality management. Included in the two exist­ing accrediting agencies for home care, the Joint Com­mission on Accreditation of Healthcare Organizationsand the Community Health Accreditation Program, arequality-of-care standards and education, training, and su­pervision requirements. The National HomeCaringCouncil also provides standards. Managed care plans

GERIATRIC NURSING Volume 15, Number I 47

have a heavy emphasis on measurable outcomes of carewith built-in strategies for periodic checks. These casemanagement systems use the experience of home healthcare providers who incorporate quality-assessment skillsinto practice and meet predetermined standards of carebased on Medicare and Medicaid or other payor require­ments. With newer managed care strategies, accountabil­ity of the provider agency to the payor and the client willincrease. Joint assessment activities by the provider andthe payor will promote quality of care.

Information Systems and High Technology

Information and high-tech communication systemssupport cost-effective and total quality management inhome health care. There are ethical and practical issuesrelated to these newer technologies that must be con­fronted by home care providers. Financial support forservices rendered requires documentation in addition toensuring quality care. The current system requires hoursof provider time to record home visits. Providers are re­luctant to devote the time required for documentationwhen time spent with the patient and family holds ahigher priority.

With newer managed care

strategies, accountability of the

provider agency to the payor and

the client will increase.

Computer technologies such as laptops offer time­saving and cost-efficient support for home visit recording.In addition, they may be integrated into a mainframe ac­counting system so that financial documentation, man­agement activities, quality of care, agency statistics, fore­casting of trends, and research data become available.Initiating these systems requires technologists to developthe systems according to the unique requirements of theagencies. Hardware is an expensive item, and its futureutility must be forecast so that it will not become out­dated. Staff training and support in implementing thesystem are costly. Therefore long-range benefits must becalculated against short-term costs. Client confidentialityand staff members' fear of computers are of concern andmust also be taken into account.

High-tech communication systems are a boon to thehome health industry. On-call telecommunications serveto place the appropriate care provider in the right place atthe right time. Agencies save on costs when records aresent by fax, as it is cheaper than when they are mailed ordelivered personally. Electronic mail and voicemail pro­vide systems that allow providers' access to one another,other information systems, and to breaking news andchanges in clinical practice. Clinical support technologiesexpand the realm of care in the home and challengehealth care providers to keep abreast of changes.

48 GERIATRIC NURSING January/February 1994

Ethical and Legal Issues in Horne Health Care

Ethical and legal issues in home health care and hos­pice settings abound. Even with health care reform, theseissues will continue and new issues will arise. Physician­assisted suicide, access to care, benefit packages, andother societal pressures may lead to legislative changesthat will affect home care. Premature discharge fromcare, no matter what the setting, places stress on healthcare providers as they balance the need for care versuscost. Religious and personal values continue to cause dis­sension among providers, clients, and society. Durablepower of attorney and quality-of-life issues are part of thehealth care rights of clients that sometimes vary fromhealth care providers' values and beliefs. Family and cli­ents' rights tug at one another, with the health care pro­vider frequently in the role of arbitrator.

Affordable respite care for the at-home provider is achallenge for health care providers. Home visits to neigh­borhoods racked with poverty and violence place bothcare providers and their elderly clients at risk. Agencylegal requirements for ensuring staff safety becomean issue. Yet, legal requirements prohibit agencies fromdenying care to clients whose value and belief systemsare at variance with the health care providers'. The effectof health care reform will affect home care agen­cies positively and adversely. These effects are majorissues for home care providers and senior citizen clientsto address and to act proactively in the social policyarena.

Ethnic and Multicultural Diversity Issues

The nation's population of elders is ethnically and mul­ticulturally diverse. Particular attention must go to thoseelderly with English as a second language. Frequently, el­ders of varying ethnic and cultural backgrounds are ste­reotyped by providers into certain role behaviors and ex­pectations. Assigning elders to certain behaviors based onhealth conditions and age category is also erroneous. Pro­viders must be sensitive and responsive to the various eth­nic and cultural differences of their clients. Providers whoare bilingual or multilingual are required to meet theneeds of clients.

The increasing life expectancy in the United Statescreates several generations of elders from the young,newly retired group to the frail elderly. Each group hasits own health care needs and generational values. Add­ing to the large population of elders are the baby boomersof the '40s and '50s, who will bring additional demands tohome health care.

Home health care providers can offer well elder andprevention services, as well as health maintenance for cli­ents with diagnosed chronic disease, acute care for ill­nesses necessitating more intense care, and hospice ser­vices for those with terminal diseases. Home health careworkers must have the educational preparation, experi­ence, and genuine concern for their clients to meet thesechallenges in home health care for the multiculturally di­verse elder population.

Keating

Differentiation of Practice and Nursing EducationDemands

The home health care setting mandates interdiscipli­nary collaboration. The various disciplines represented inhome care include counseling, medicine, nursing, nutri­tion, occupational therapy, physical therapy, social work,speech therapy, and so forth. Nursing practice in homecare is multilevel, with home health aides and homemak­ers on the first level and clinical specialists, nurse prac­titioners, supervisors, case managers, administrators, andresearchers at the top levels. Scope of practice and dif­ferentiated practice based on education and experiencebecome factors in determining responsibilities and sala­ries. To describe some of the issues and trends relating tonursing scope of practice and education, an upcoming is­sue of GERIATRIC NURSING will present a concept paperwritten and edited by a coalition of nurse educators andpractitioners in community health, home health care, and

hospice nursing. The concept paper responds to these is­sues as they affect nursing practice in California. It raisessome of the shared concerns facing nursing practice andeducation and presents ideas for meeting the needs of cli­ents in community settings.

Summary

Future articles on home health care will discuss indepth many of the issues raised in this first section. Afterthe proposals for health care reform are presented in de­tail to the nation, analyses of their effect on home healthcare and geriatric nursing will be reviewed by leaders inthe field. Clinical practice changes and issues in homehealth care nursing will also be discussed as innovations,regulations, consumer demands, and funding sources takeeffect. Readers are encouraged to submit issues and ideasof interest to the JOURNAL for experts to discuss in futurearticles. -

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Keating GERIATRIC NURSING Volume [5, Number I 49