Home care is a form of health care service provided where a patient lives. Patients can receive home care services whether they live in their own homes, with or without 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 disease or disability.
The goal of home care is to provide for the needs of the patient to allow the patient to remain living at home, regardless of age or disability. After surgery, a patient may require home care services that may range from such homemaking services as cooking or cleaning to skilled medical care. 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 patients' homes, which allows them 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 a 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 may provide care when necessary. 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, hospital agencies, or hospital 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.
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 nursing often involves more than biomedically based care, depending on a patient's religious or spiritual background.
Most patients are more comfortable in their own homes, rather than in a hospital setting. 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. Consequently, 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 health care 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. Communitybased health care 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. Members of Roman Catholic religious orders in Europe first delivered home care in the late seventeenth century. Today, there are many home care agencies and visiting nurse associations (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. Life expectancy of the United States population began to rise as 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. In response, the federal government put Medicare and Medicaid programs into place in 1965 to help fund and regulate health care delivery for this population.
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 physician. Home care delivery is paid for either by the government through Medicare and/or Medicaid; by private insurance or health maintenance organizations (HMOs); by patients themselves; or by certain non-profit community, charitable disease advocacy organizations (e.g., ACS), or faith-based organizations.
Home care delivery services provided by Medicare-certified agencies are tightly regulated. For example, a patient must be homebound in order to receive Medicarereimbursed home care services. The homebound requirement—one of many—means that the patient must be physically unable to leave 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.
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 expected outcomes. 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 caregivers.
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 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.
Some of the professional issues confronting home care nurses include:
The legal considerations connected with delivering care in a patient's private residence are similar to those of care delivered in health care 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, and during a home visit, the nurse finds the patient unresponsive and cannot find the orders not to resuscitate in the patient's chart? 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 do-not-resuscitate ( DNR ) 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 is 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 delivery services are using "telecare," which uses communications technology to transmit medical information between the patient and the health care provider. Providing care to patients without being in their immediate presence is a relatively new form of home nursing, and is not without its problems. While some uncertainty exists regarding legal responsibilities and the potential for liability, much has been done to make telecare an effective way to hold costs down for some patients. Home care nurses who are required to make telecare visits should know what regulations exist in the particular state before providing care. The chief problem lies in diagnosing and prescribing over the phone. Technological advances have enabled patients to access telecare through the Internet using personal computers or using televisions. With the most recent advances in telecare, the following services may now be offered:
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Susan Joanne Cadwallader
Crystal H. Kaczkowski, MSc