Home care is a form of health care service provided wherever a patient lives. Patients can receive home care services whether they live in their own homes with family members or in an assisted living facility. The purpose of home care is to promote, maintain, or restore a patient's health and reduce the effects of diseases or disabilities.
The goal of home care is the provision of whatever a patient needs in order to remain living in his or her home, regardless of age or disability. The services provided may range from such homemaking services as cooking or cleaning to skilled medical care for patients on ventilators or dialysis machines or those receiving infusion therapies. Some patients require home-health aides or personal care attendants to help them with activities of daily living (ADL).
Medical, dental, and nursing care may all be delivered in the patient's home, which allows him or her to feel more comfortable and less anxious. Therapists from speech-language pathology, physical therapy, and respiratory therapy departments often make regular home visits, depending on the patient's specific needs. General nursing care is provided by both registered and licensed practical nurses; however, there are also nurses who are clinical specialists in psychiatry, obstetrics, and cardiology who provide care in these areas when prescribed. Home-health aides provide what is called custodial care in domestic settings; their duties are similar to those of nurses' aides in the hospital. Professionals who deliver care to patients in their homes are employed either by independent for-profit home-care agencies or by hospital agencies or departments. Personal care attendants can also be hired privately by patients; however, not only is it more difficult to evaluate an employee's specific background and credentials when he or she is not associated with a certified agency or hospital, but medical insurance may not cover the expense of an employee who does not come from an approved source.
Often, patients are more comfortable in their own homes, rather than a hospital settings. Depending on the patient's living status and relationships with others in the home, however, the home is not always the best place for caregiving. Nevertheless, home care continues to grow in popularity. Hospital stays have been shortened considerably, starting in the 1980s with the advent of the diagnosis-related group (DRG) reimbursement system as part of a continuing effort to reduce healthcare costs. But as a result, many patients come home "quicker and sicker," and in need of some form of care or help that family or friends may not be able to offer. Community-based healthcare services are expanding, giving patients more options for assistance at home.
It is helpful to have some basic information about the evolution of home care in order to understand the public's demand for quality health care, cost containment, and the benefits of advances in both medical and communication technologies. The first home care was delivered by members of Roman Catholic religious orders in Europe in the late seventeenth century. This form of care giving was later performed by registered nurses who "visited" people in their homes. Visiting Nurse Associations (VNAs) were formed toward the close of the nineteenth century. Today there are many home-care agencies and VNAs that continue to deliver a wide range of home-care services to meet the specific needs of patients throughout the United States and Canada.
Social factors have historically influenced home-care delivery and continue to do so today. Before the 1960s, home care was a community-based delivery system that provided care to patients whether they could pay for the services or not. Agencies relied on charitable contributions from private citizens or charitable organizations, as well as some limited government funding. But as the life expectancy of the United States population began to rise, advances in medical science saved patients who might have died in years past. As a result, more and more elderly or disabled people required medical care in their homes as well as in institutions. Consequently, the federal government put Medicare and Medicaid into place (1965) to help fund and regulate health-care delivery for this population.
Funding and regulation
Government involvement resulted in regulations that changed the focus of home care from a nursing-care delivery service to care delivery under the direction of a
Home-care delivery services provided by Medicare-certified agencies are tightly regulated. For example, a patient must be home-bound in order to receive Medicare-reimbursed home-care services. The homebound requirement—one of many—means that the patient who receives home-care services from a Medicare-certified agency must be physically unable to leave his or her home (other than for infrequent trips to the doctor or hospital), thereby restricting the number of persons eligible for home-care services. Private insurance companies and HMOs also have certain criteria for the number of visits that will be covered for specific conditions and services. Restrictions on the payment source, the physician's orders, and the patient's specific needs determine the length and scope of services.
Assessment and implementation
Since home-care nursing services are provided on a part-time basis, patients, family members, or other caregivers are encouraged and taught to do as much of the care as possible. This approach goes beyond payment boundaries; it extends to the amount of responsibility the patient and his or her family or caregivers are willing or able to assume in order to reach that expected outcome. Nurses who have received special training as case managers visit the patient's home and draw up a plan of care based on assessing the patient, listing the diagnoses, planning the care delivery, implementing specific interventions, and evaluating outcomes or the efficacy of the implementation phase. Planning the care delivery includes assessing the care resources within the circle of the patient's family and friends.
At the time of the initial assessment, the visiting nurse, who is working under a physician's orders, enlists professionals in other disciplines who might be involved in achieving expected outcomes, whether those outcomes include helping the patient return to a certain level of health and independence or maintaining the existing level of health and mobility. The nurse provides instruction to the patient and caregiver(s) regarding the patient's particular disease(s) or condition(s) in order to help the patient achieve an agreed-upon level of independence. Home-care nurses are committed to helping patients make good decisions about their care by providing them with reliable information about their conditions. Since
home care relies heavily on a holistic approach, care delivery includes teaching coping mechanisms and promoting a positive attitude to help motivate patients to help themselves to the extent that they are able. Unless the patient is paying for home-care services out-of-pocket and has unlimited resources or a specific private long-term care insurance policy, home-care services are scheduled to end at some point. Therefore, the goal of most home-care delivery is to move both the patient and the caregivers toward becoming as independent as possible during that time.
Home-care delivery is influenced by a number of variables. Political, social, and economic factors place significant constraints on care delivery. Differences among nurses, including their level of education, years of work experience, type of work experience, and level of cultural competence (cross-cultural sensitivity) all influence care delivery to some extent.
The following list identifies some of the professional issues confronting home-care nurses at the turn of the twenty-first century. They include:
- legal issues
- ethical concerns
- safety issues
- nursing skills and professional education
The legal considerations connected with delivering care in a patient's private residence are similar to those of care delivered in healthcare facilities, but have additional aspects. For example, what would a home care nurse do if she or he had heard the patient repeatedly express the desire not to be resuscitated in case of a heart attack or other catastrophic event, yet during a home visit, the nurse finds the patient unresponsive and cannot find the orders not to resuscitate in the patient's chart anywhere? What happens if the patient falls during home-care delivery? While processes, protocols, and standards of practice cannot be written to address every situation that may arise in a domestic setting, timely communication and strong policy are essential to keep both patients and home care staff free of legal liability.
Ethical implications are closely tied to legal implications in home care—as in the case of missing DNR (do not resuscitate) orders. For example, what measures are appropriate if a home-care nurse finds a severe diabetic and recovered alcoholic washing down a candy bar with a glass of bourbon? The patient is in his or her own residence and has the legal right to do as he or she chooses. Or what about the family member who has a bad fall while the nurse is in the home providing care? Should the nurse care for that family member as well? What is the nurse's responsibility to the patient when he or she notices that a family member is taking money from an unsuspecting patient? Complex ethical issues are not always addressed in policy statements. Ongoing communication between the home-care agency and the nurse in the field is essential to address problematic situations.
Safety issues in home care require attention and vigilance. The home-care nurse does not have security officers readily available if a family member becomes violent either toward the health-care worker or the patient. Sometimes home-care staff are required to visit patients in high-crime areas or after dark. All agencies should have some type of supervisory personnel available 24 hours a day, seven days a week, so that field staff can reach them with any concerns. Also, clear policy statements that cover issues of personal safety must be documented and communicated regularly and effectively.
With advances in technology and the increased effort to control cost, home care is beginning to involve telecare in the delivery services. Telecare uses communications technology to transmit medical information between the patient and the health care provider.
Implications for nursing education
While there is no specific degree program required for delivery of home-care services, providing nursing care in a patient's home differs significantly from hospital care. Home-care nurses provide care for patients of every age, economic class, and level of disability. Some nurses provide specialized hospice, mental health, or pediatric care. Home-care nurses, on the average, spend more time teaching patients and caregivers than in an institutional setting, since the emphasis in home care is to foster independence and to improvise with the tools at hand. And while all nurses are patient advocates, homecare nurses must respect social and cultural values as part of the impact that the family and the home environment have on the patient's overall health. Home-care nurses are case managers, since they apply the entire nursing process to each of their patients. They must implement their own quality improvement during care delivery. Home care nursing often involves more than biomedically-based care, depending on the patient's religious or spiritual background. Nurses who visit patients in their homes often spend more time with them and encounter situations and opportunities where each communicate on a higher level of understanding and sensitivity. Finally, home care delivery demands that employees exercise a high level of flexibility, creativity, and the ability to work without constant supervision.
Activities of daily living (ADLs)—The activities performed during the course of a normal day, for example, eating, bathing, dressing, toileting, etc.
Home health aide—An employee of a home-care agency who provides the same services to a patient in their home as nurses aides perform in hospitals and nursing homes. Home-care agencies differ according to state regulations and agency policy regarding the scope of duties provided by home health aides.
Medicaid—The United States' federally-funded program for state-operated programs that provide medical assistance to permanently disabled patients and to low-income people.
Medicare—The federally-funded national health insurance program in the United States for all people over the age of 65.
Personal care attendant—An employee hired either through a healthcare facility, home-care agency, or private agency to assist a patient in performing ADLs.
Psychiatric nursing—The nursing specialty concerned with the prevention and treatment of mental disorders and their consequences.
Registered nurse—A graduate nurse who has passed a state nursing board examination and been registered and licensed to practice nursing.
Respiratory therapy—The department of any healthcare facility or agency that provides treatment to patients to maintain or improve their breathing function.
Beers, Mark H., M.D., and Robert Berkow, M.D., eds. The Merck Manual, 17th ed. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
Price, June. Avoiding Attendants from Hell: A Practical Guide to Finding, Hiring & Keeping Personal Care Attendants. Chesterfield, MO: Science and Humanities Press, 1998.
Rice, Robyn, PhD. Home Care Nursing Practice: Concepts and Application, 3rd ed. St. Louis, MO: Mosby, 2001.
Sankar, Andrea. Dying at Home: A Family Guide for Caregiving, revised and updated edition. Baltimore, MD: The Johns Hopkins University Press, 1999.
Goulet, C., et al. "A Randomized Clinical Trial of Care for Women With Preterm Labor: Home Management Versus Hospital Management." CMAJ 164, no. 7 (Apr 3, 2001): 985-991.
Jenkens, R.L., and White, P. "Telehealth Advancing Nursing Practice." Nursing Outlook 49, no. 2 (March-April 2001): 100-105.
Rhinehart, E. "Infection Control in Home Care." Emerging Infectious Diseases 7, no. 2 (Mar-Apr 2001): 208-212.
Spratt, G. and Petty, T.L. "Partnering for Optimal Respiratory Home Care: Physicians Working With Respiratory Therapists to Optimally Meet Respiratory Home Care Needs." Respiratory Care 46, no. 5 (May 2001): 475-88.
Hospice Foundation of America. 2001 S Street NW, Suite 300, Washington, DC 20009. (800) 854-3402. <http://www.hospicefoundation.org>.
National Association for Home Care. 519 C Street, NE. Washington, DC 20002. (202) 547-7424.
Visiting Nurse Associations of America. 3801 East Florida Avenue, Suite 900, Denver, CO 80210. (800) 426-2547.
Senior Housing Net. <http://www.seniorhousing.net>.
Susan Joanne Cadwallader