Home Care Nurse is Not With Patient but Continues to Chart Care

Background

Home health care is a system of care provided by skilled practitioners to patients in their homes under the direction of a physician. Home health care services include nursing care; physical, occupational, and speech-language therapy; and medical social services.¹ The goals of home health care services are to help individuals to improve function and live with greater independence; to promote the client's optimal level of well-being; 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 home health care services, or the services may be 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 provide care for more than 2.4 million elderly and disabled people annually.⁵ To be eligible for Medicare reimbursement, home health care services must be deemed medically necessary by a physician and provided to a home-bound patient. In addition, the care must be provided on an intermittent and noncontinuous basis.⁵ Medicare beneficiaries who are in poor health, have low incomes, and are 85 years of age or older have relatively high rates of home health care use.⁶ Common diagnoses among home health care patients include circulatory disease (31 percent of patients), heart disease (16 percent), injury and poisoning (15.9 percent), musculoskeletal and connective tissue disease (14.1 percent), and respiratory disease (11.6 percent).⁷

Delivering Health Care in the Home

The home health care environment differs from hospitals and other institutional environments where nurses work. For example, home health care nurses work alone in the field with support resources available from a central office. The nurse-physician work relationship involves less direct 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 hospital nurses and more time dealing with reimbursement issues.^{8 , 9} Certain distinctive characteristics of the home health care environment influence patient safety and quality of outcomes: the high degree of patient autonomy in the home setting, limited oversight of informal caregivers by professional clinicians, and situational variables unique to each home.

Respect for patient autonomy is valued in hospital-based care. Nonetheless, many decisions are made 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 home health care patient often has a greater role in determining how and even if certain interventions will be implemented. For example, in a hospital, nurses, physicians, and pharmacists may all play a role in ensuring that the patient receives antibiotics at therapeutically appropriate intervals. At home, however, the patient may choose to take the medication at irregular times, despite advice about the importance of a regular medication schedule. Thus, interventions to promote patient safety and quality care must account for the fact that patients will sometimes choose to act in ways that are inconsistent with the relevant evidence, and the clinician's best efforts may not result in desired outcomes.

In addition to deliberate choices made by informed and capable patients regarding their care, 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 resources all affect the ability of home health care patients to safely manage their medication regimens. Yet, none of these variables may play a meaningful role in the safe administration of medications to hospitalized patients.

In addition to self-care, some home-bound patients receive assistance from family members or other informal caregivers. Professional clinicians have no authority 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 support staff may more easily be observed and evaluated. For example, because of limited access to transportation, a husband may decide not to purchase diabetic supplies for his dependent wife. This behavior may not come to the clinician's attention until an adverse event has occurred. Evidence-based interventions are predicated on careful assessment. However, limited opportunity to directly observe the patient and informal caregivers may hinder efforts to quickly determine the etiology of an adverse event. If a home health care patient is found with bruises that the patient can't explain, is the cause a fall, physical abuse, or a blood dyscrasia? In both self-care by patients and care by informal caregivers, safety and quality standards may not be understood or achieved.

Another distinctive characteristic of home health care is that clinicians provide care to each patient in a unique setting. There may be situational variables that present risks to patients that may be difficult or impossible for the clinician to eliminate. Hospitals may have environmental safety departments to monitor air quality and designers/engineers to ensure that the height of stair risers is safe. Home health care clinicians are not likely to have the training or resources to assess and ameliorate such risks to patient safety in the patient's home.

Finally, given the large number of elderly persons who receive care from Medicare-certified home health care agencies, it is reasonable to anticipate that some patients will be in a trajectory of decline. Due to both normal aging and pathological processes that occur more frequently with advancing age, some elderly persons will experience decreasing ability to carry out activities of daily living (ADLs), even when high-quality home health care is provided. Thus, an implicit goal of home health care is to facilitate a supported decline. That is, patients who do not 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 Association's assertion that promoting the patient's optimal level of well-being is a legitimate goal of home health care.³

Assessing Quality of Care in the Home

The goals and multidisciplinary nature of home health care services present challenges to quality measurement that differ from those found in a more traditional hospital setting. The CMS mandates reporting of home health care outcome measures. The Outcome-Based Quality Monitoring (OBQM) program monitors, reports, and benchmarks adverse events such as emergent care for injury caused by fall or accident, increased number of pressure ulcers, and substantial decline in three or more ADLs.⁵

Pay for performance, a mechanism that ties a portion of an agency's reimbursement to the delivery of care, 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 set of performance measures proven effective in home care. A 2006 Medicare Payment Advisory Commission report to Congress identified patient safety as an important component of quality and the need to expand quality measures to include process and structural measures. An expanded approach to quality measurement should accomplish the following goals: broaden the patient population being evaluated, expand the types of quality measures, capture aspects of care directly under providers' control, reduce variations in practice, and improve information technology.¹³

In January 2007, the home health community, health care leaders, and quality-improvement organizations launched the Home 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 best practice intervention tools. The goal is to prevent avoidable hospitalizations for home health care patients. The Home Health Quality Improvement National Campaign uses a multidisciplinary approach to quality improvement that includes key home health, hospital, and physician stakeholders.¹⁴

Research Evidence

In many respects, home health care clinicians and clinicians working in other settings have similar concerns about patient safety and care quality. For example, patient falls occur both in homes and in hospitals, and some measures aimed at preventing falls are equally applicable to both settings. However, the significant differences between home health care and other types of health care often require interventions tailored to the home health care setting.

This chapter includes an analysis of the evidence on promoting patient safety 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 ulcer management

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

Medication Management

Nearly one-third of older home health care patients have a potential medication problem or are taking a drug considered inappropriate for older people.¹⁵ Elderly home health care patients are especially vulnerable to adverse events from medication errors; they often take multiple medications for a variety of comorbidities that have been prescribed by more than one provider. The majority of older home health care patients routinely take more than five prescription drugs, and many patients deviate from their prescribed medication regime.¹¹ The potential of medication errors among the home health care population is greater than in other health care settings because of the unstructured environment and unique communication challenges in the home health care system.¹¹

A search of the literature identified only three studies testing interventions to improve medication management and adherence in home health care patients.^16–18 The studies are summarized in Table 1. All three studies used a controlled experimental design, with random assignment of patients to one or two treatment groups and a control group of usual care. The populations studied were elderly Medicare patients receiving home health care, ranging from 41 to 259 patients.

Table 1

Summary of Evidence Related to Medication Management

The interventions tested were patient education delivered by telephone or videophone with nurse followup, education tailored to individual patients, and medication review and collaboration among providers (e.g., nurse, pharmacist, physician) and patient. Specific outcomes included identifying unnecessary and duplicate medication, improving the use 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 objectively from medication refill history and medication event monitoring, and subjectively from patient self-report scores on pre- and postintervention questionnaires testing knowledge, understanding of disease, and adherence.

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

Evidence-Based Practice Implications

Nurses must be vigilant for the possibility of medication errors in the home health care setting, recognizing the associated risk factors. Technology provides many opportunities to improve communication with patients, to provide patients with accurate information, to educate them about their medications, and to monitor medication regimes. Paying close attention to at-risk patients is most effective; therefore, accurate documentation and review of medications during each patient encounter is important. The evidence suggests that frequent medication reviews and collaboration with other members of the health care team, especially pharmacists, will help to prevent adverse events associated with poor medication management.

Research Implications

More effective methods are needed to improve medication use in the home health care population. Research should continue to expand the knowledge of factors that contribute to medication errors in home health care and determine what interventions are the most effective in improving medication management in the home.

Fall Prevention

Emergent care for injury caused by falls or accidents at home is one of the most frequently occurring adverse events reported for patients receiving skilled home health care services.¹⁹ Thirty percent of people age 65 and older living in the community fall each year. One in five of these fall incidents requires medical attention.²⁰ Falls are the leading cause of injury-related death for this population.²¹ Among the elderly, Stevens²² reported direct medical costs in 2000 totaled $179 million for fatal fall-related injuries and $19 billion for nonfatal injuries due to falls.

Although there is strong evidence of effective fall-prevention interventions for the general over-65 population,^{20 , 23 , 24} knowledge of fall prevention in home health care is limited. For the general older population living in the community, evidence suggests that individualized home programs of muscle strengthening and balance retraining; complex multidisciplinary, multifactorial, health/environmental risk factor screening and intervention; home hazard assessment and modification; and medication review and adjustment can all reduce the incidence of falls.²⁰ However, patients in home health care 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 care.

Research studies specific to home health care 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 home health care patients are previous falls, primary diagnosis of depression or anhedonia, use of antipsychotic phenothiazines and tricyclic antidepressants, secondary diagnoses of neurological or cardiovascular disorders, balance problems, frailty, and absence of handrails.^25–27

A literature review located only three studies testing interventions to prevent falls.^28–30 The studies are summarized in Table 2. All three interventions were quality-improvement programs in single agencies. The findings suggest that risk factor screening and intervention using a valid and reliable instrument and physical therapy aimed at improvement in gait and balance may reduce injury and emergent care for falls. Unfortunately, there is no evidence that the number of falls incurred by the home health care population can be reduced. It may be that improved provider assessments increased the number of falls reported and documented.

Table 2

Summary of Evidence Related to Fall Prevention

Evidence-Based Practice Implications

Home health care providers need to know the risk factors for falls and demonstrate effective assessment and interventions for fall and injury prevention. Falls are generally the result of a complex set of intrinsic patient and extrinsic environmental factors. Use of a fall-prevention program, standardized tools, and an interdisciplinary approach may be effective for reducing fall-related injuries.

Research Implications

There are several limitations in the current evidence on falls in home health care. Most of the research is descriptive, and there are no randomized controlled studies. Findings from small, single-agency quality-improvement projects cannot be generalized. It is not known if predictors for falls in home health care patients are the same as those for other community dwellers over age 65. Research is needed to expand the knowledge of factors that contribute to falls in this population and to develop effective interventions. Research is also needed to explore factors to prevent injury from falls, as it is likely that the incidence of falls in this population cannot be completely eliminated.

Unplanned Hospital Admissions

A primary goal of home health care is to discharge the patient to self or family care and avoid subsequent hospitalizations. Unplanned admission to the hospital is an undesirable outcome of home health 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 home health 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 only publicly reported home health care patient outcome that has never improved at the national level.³³

Several researchers have explored the characteristics of home health care patients and other factors associated with hospitalization.^{31 , 34–39} The studies have been predominantly retrospective, descriptive, and correlation designs examining home care populations from single or multiple agencies.^{31 , 35–38} One study is a prospective study of a random sample of agencies.³⁹ Evidence suggests that unplanned hospital admissions are due mostly to an acute exacerbation of chronic disease—exacerbations that could be prevented through knowledge of risk factors, provider communication, and careful monitoring.³⁹ Risk factors associated with unplanned hospital admissions are polypharmacy,^{31 , 35} length of home health care episode,^{34 , 36} development of a new problem or worsening primary or secondary diagnosis,³⁶ wound deterioration and falling accidents,³¹ and age.^{31 , 37} Based on this evidence most experts^{31 , 37} conclude that 20 to 25 percent of unplanned hospital admissions are preventable. For example, Shaughnessey and colleagues² found 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 panel of experts to identity best practice strategies that agencies should implement to prevent unplanned hospitalizations. Recommended best practices included implementing a fall prevention program, front loading visits, management support, 24-hour on-call nursing coverage, medication management, case management, patient/caregiver education, special support services, disease management, positive physician and hospital relationships, data-driven services, safety and risk assessment, and telehealth. These recommendations were not empirically tested, however.

Only eight studies have tested the effectiveness of interventions to prevent 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 design. The tested interventions consisted primarily of increasing the intensity of care provided through a disease management program, a team management home-based primary care program, a multidisciplinary specialty team intervention, advanced practice nurse (APN) transitional care, telehealth services, and intensive rehabilitative care prior to hospital discharge.^40–43 Most of these interventions were effective or somewhat effective 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,^{40 , 42–44} and one study⁴⁵ reported higher costs for the intervention group based on the costs of the team-managed primary care intervention.

In these studies, patients with congestive heart failure (CHF) had fewer unplanned hospital admissions and longer survival times prior to first admission^39–42 if they received APNtransitional care, team-managed home-based primary care, or a multidisciplinary specialty team intervention.^40–43 Patients with CHF who received telecare and telephone interventions also had significantly fewer emergency room visits, but no change in hospital admissions.⁴² Team-managed home-based primary care has been found to be most effective for people who are severely disabled.⁴⁵ Daly and colleagues ⁴⁴ reported that long-term mechanically ventilated patients who received a disease management 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 also experienced fewer unplanned hospital admissions.⁴⁶ Intrator and Berg⁴⁷ reported that patients hospitalized with hip fractures had fewer unplanned hospital admissions when they received home health care services following inpatient rehabilitation compared with those patients who received inpatient services only. Findings are summarized in Table 3.

Table 3

Summary of Evidence Related to Unplanned Hospital Admission

Evidence-Based Practice Implications

Evidence suggests that specialized, coordinated, interdisciplinary care has a positive impact on unplanned hospital admissions in select home health care populations. Agencies can identify patient characteristics associated with hospitalization unique to their patient population. High-risk patients may require specialized interventions beyond the traditional scope of home health care services. Targeted interventions using process-of-care analysis and data available from the Outcome and Assessment Information Set (OASIS), within the framework of OBQI, may result in fewer unplanned hospital admissions for home health care patients.

Research Implications

The available 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 home 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 disease process, may require more intense and specialized home health care services that will not result in cost savings. On the other hand, use of seemingly more expensive transitional resources, such as APNs, have been proven cost effective, although adoption of such research-based best practices may be impeded by lack of reimbursement and incentives.⁴⁸ Research is needed to understand the impact of shifting care and cost to home health care on patient outcomes and home health care industry fiscal status.

Nurse Work Environment

Evidence from the acute care setting suggests a relationship between nurses' work environment, patient safety, and quality of patient care.^49–51 A positive work environment is one 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 physician collaboration.^53–55

Research exploring the relationship of the work environment, patient safety, and quality in home health care is in early stages of development. There 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 large urban home health care agency. Characteristics of 86 home health care teams within 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 support for adverse event reporting. This is the first rigorous study to identify organizational factors associated with potential adverse events, and there were limitations. It was a descriptive, correlational study, and the agency involved in the study is not typical of most 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 higher patient satisfaction scores were more likely in home health care agencies where nurses and supervisors had good 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 one State and the lack of a reliable and validated tool to measure nurse perception of patient outcomes. Findings are summarized in Table 4.

Table 4

Summary of Evidence Related to Nurse Work Environment

Evidence-Based Practice Implications

Agencies should consider how characteristics of the work environment may be influencing patient safety and quality outcomes. It is necessary to explore the context of the environment when examining clinicians' practices in an effort to identify necessary system changes.

Research Implications

It is not known what characteristics of the home health care nursing work environment are related to patient safety 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 functioning and quality of life, or to slow the rate of decline to allow the patient to remain at home and avoid institutionalization. Most patients and family members prefer the home environment, when it is feasible. A patient's and family's ability to function independently and safely in the home increases the possibility of the patient remaining there.

Improving patient safety 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 Table 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 being informed and prepared.

Table 5

Summary of Evidence Related to Functional Outcomes and Quality of Life

Other researchers have tested interventions to improve nurse providers' knowledge and awareness.^59–61 Intervention studies to educate and inform nurse providers have been conducted in small and large urban and rural home health care settings, with nurses randomly assigned to an intervention group or a control group. The interventions generally provided nurses with additional education, extra resources for patients, and specialized patient information. In one frequently reported study, evidence-based care with specific disease-related information was sent to nurses by "just-in-time" e-mail reminders.^{59 , 60}

In all cases the interventions improved nurses' performance, which resulted in better patient outcomes. Patients of nurses in these studies showed significant improvement in pain management, quality of life, satisfaction with care, and other variables associated with improved quality of care, including better communication with providers, better medication management, and improved disease symptoms. Nurses' improved performance included increased documentation of critical patient assessments. In the case of "just-in-time" e-mail reminders, the intervention group that had additional clinical and patient resources had better patient outcomes, suggesting that the multifaceted approach 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 functioning,^{44 , 46 , 66–68} quality of life, general health 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' self-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 management 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 home environment (adding ramps, lowering cabinets, and removing throw rugs) with populations of frail elderly. These interventions were successful in slowing functional decline in the study patients.

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

A number of randomized controlled trials have tested the outcomes of interventions based on the specialty of the provider combined with different models of care management, or interventions based solely on different models of care management.^{44 , 46 , 65 , 70 , 71} Research 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 care to patients with COPD⁴⁶ and CHF⁷⁰ and found 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 acute 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 Team-Managed Home-Based Primary Care was an add-on to care routinely provided in the Veterans Affairs Home-Based Primary Care program.⁴⁴ The added component emphasized continuity of care and team management with a primary care manager, 24-hour on-call nursing availability for patients, prior approval of hospital admissions, and team participation in discharge planning. The investigators found significant improvements in quality of life, functioning, pain management, and general health outcomes for terminally ill patients in this study, and an increase in satisfaction for nonterminally ill patients and family caregivers.

However, mixed results have been obtained from the research to date on the effectiveness of models of care management.^{66 , 68} Some intervention models have been less effective than others. The interventions are usually an add-on to routine care, and their effectiveness has been determined by a comparison to a control group of usual or routine home health care. An intervention model that does not appear 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 program, including therapies for physical and functional impairments, to the outcomes from usual home-based rehabilitation care. No differences were found between the two groups.

Evidence-Based Practice Implications

The preceding discussion suggests that working closely with and supporting family caregivers is, and will continue to be, an important aspect of helping patients to remain in their homes. It also suggests that nurses' effectiveness in working with patients can be enhanced if nurses are supported in their work. Support 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 health care nurses are relatively isolated in the field, and any mechanism to improve communication with supervisors in the office and with other providers will assist nurses in their practice. Incorporating the use of remote technology to substitute for some in-person visits can improve access to home health care staff for patients and caregivers.⁶⁹

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

Research Implications

Evidence of the outcomes of health care provided in the home is limited; there are very few controlled experiments on which providers 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. Research is needed to determine effective interventions to improve, maintain, or slow the decline of functioning in the home health care population. More research is also 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: it can substitute for some in-person visits, and it can improve access to home health care staff for patients and caregivers.

Wound and Pressure Ulcer Management

Adverse wound events are monitored under the OBQM program. Emergent care for wound infections, deteriorating wound status, and increase in the number of pressure ulcers are monitored and reported as adverse events.⁷⁰ The data are used to reflect a change in a patient's health status at two or more times, usually between home health care admission and transfer to a hospital or other health care setting. Data for these outcomes are collected using OASIS-designated intervals. Patient outcome 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 home health care patients require treatment for wounds, and nearly 42 percent of those with wounds have multiple wounds. Over 60 percent of wounds seen in home health care are surgical, while just under one-quarter are vascular leg ulcers and another one-quarter are pressure ulcers.⁷¹ Most home health care nurses can accurately identify wound bed and periwound characteristics; the majority (88 percent) of wound treatments have been found to be appropriate.⁷² The appropriateness of wound treatments in home 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 seven studies that tested interventions to improve wound care management in home health care.^73–79 Findings are summarized in Table 6. Three compared effectiveness of various 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 nursing visits. Kerstein and Gahtan⁷⁶ found the percentage of venous leg ulcers healed using hydrocolloidal dressings was six times higher than with saline gauze dressings and nearly four times greater using an Unna boot; the hydrocolloidal dressings were most cost-effective. Use of negative pressure wound therapy resulted in successful closure of 43 percent of wounds that failed to respond to previous treatment.⁷⁸

Table 6

Summary of Evidence Related to Wound Management

Four studies reported positive outcomes from interventions to improve and support home health care 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 water and table salt, a practice common for wound care in the home, and found refrigerated solutions essentially 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 percent of wounds in home health care patients were pressure ulcers, with a mean wound duration of nearly 27 months. Nearly 1 in 10 patients admitted to home health care had pressure ulcers and approximately one-third were at risk of developing new ulcers; yet according to one study, only 27 percent of patients with existing ulcers and 14 percent of those at risk were receiving appropriate pressure-reducing treatment.⁸¹ Incontinence, limitations in ADLs, mobility impairment, skin drainage, recent fractures, anemia, use of oxygen, and recent institutional discharge were associated with pressure ulcer development.^{81 , 82} Guidelines from the Wound, Ostomy and Continence Nurses Society⁸³ call for an initial risk assessment for pressure ulcers of all patients on admission to home health care, and reassessment every visit thereafter, using a validated risk assessment tool. However, one study found that only 21 percent of agencies used a validated tool such as the Braden Scale⁸⁴ to identify patients at risk, nearly 8 percent performed no assessments on admission, and only 33 percent used risk prediction or pressure ulcer prevention protocols.⁸⁵ Just over half of agencies reported routine skin inspections by nurses of at-risk patients.

A literature review resulted in identification of five studies relating to pressure ulcer management in home health care. The findings are summarized in Table 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

Table 7

Summary of Evidence Related to Pressure Ulcer Management

The remaining two studies evaluated the use of the Braden Scale for prediction of pressure ulcer risk in home health care patients, with mixed results. Ramundo⁸⁹ reported that the Braden Scale had validity in identifying at-risk patients, but limited predictive ability, while Bergquist⁸² found that the summative score of the scale was significantly associated with pressure ulcer development. All subscale scores except nutrition were significantly and negatively associated with pressure ulcer development.

Evidence-Based Practice Implications

When compared with wet-to-dry or moist saline dressings, most wound treatments tested showed greater effectiveness or lower cost. Home health 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 accurate wound assessment and staging. Provision of structured resources, expert consultation, and competency testing for home health care nurses can improve home health care wound management. Nurses must be knowledgeable in risk factors for pressure ulcer development and relevant preventive measures; they must assess every patient using a valid and reliable instrument, such as the Braden Scale, on admission to home health care and regularly thereafter.

Research Implications

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

Conclusion

Home health care 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. Falls, declining functional abilities, pressure ulcers and nonhealing wounds, and adverse events related to medication administration all have the potential to result in unplanned hospital admissions. Such hospitalizations undermine the achievement of important home health care goals: keeping patients at home and promoting optimal well-being. Nevertheless, the unique characteristics of home health care may make it difficult to use—or necessary to alter—interventions that have been shown to be effective in other settings. Therefore, research on effective practices, conducted in home health care settings, is necessary to support excellent and evidence-based care.

In reviewing the extant studies, the authors of this chapter found useful evidence in all selected areas. However, the number of studies was few and many questions remain. Replications of investigations originally conducted in health care settings other than the home, and studies considering home 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 support positive patient outcomes. Thus, studies that link nurse-related variables to improved care safety and quality are needed, as well as studies that focus directly on patients. The demographics of an aging society will sustain the trend toward home-based care. Home health care practices grounded in careful 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 health care nurse are omitted. Table 8 lists additional key resources.

Search Strategy

The literature review for this chapter focused on identifying evidence-based practices that supported the goals of home health care: to promote independent functioning; to remain at home, avoiding hospital 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 beginning of this chapter, adverse events used in the OBQM,⁵ goals of the Home Health Quality Improvement National Campaign 2007,¹⁴ and the nurse-sensitive quality indicators developed by the American Nurses Association.¹⁵ The Cumulative Index to Nursing & Allied Health, Cochrane Library, Medline, and ProQuest Nursing & Allied Health databases were searched, as well as the grey literature and government Web sites, including the CMS and Agency for Healthcare Research and Quality. Hand searches were conducted of the reference lists of retrieved articles. Search limitations were English language, United States or Canada, peer-reviewed journals or scholarly literature, published between 1990 and the first quarter of 2007. Studies cited in the evidence table were accepted for review using the following inclusion criteria:

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

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

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

• The intervention took place under the auspices of a home health care agency.

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

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

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