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LOSANGELESHARBORCOLLEGEAssociateDegreeRegisteredNursingProgram
NURSING339NursingProcessandPracticeinthecareof
theGerontologicClient
UNITI
HomeHealth–SelfTeachingModule
E.Moore
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TABLEOFCONTENTS
Unit1Objectives/OverviewofHomeHealthandCommunityNursing
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Pretest
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HistoryofHomeCare
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DefinitionsofHomeCare
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MedicareHomeCare
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WhoisEligibleForHomeCare
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Skills&KnowledgeNeededbytheHomeHealthNurse
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HomeHealthServicesOffered
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HospiceCare
31
SafetyinHomeCare
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TypicalHHNurseDay+MakingtheHomeVisit+Advantages/DisadvantagesofbeingaHHNurse
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StudentNurseProcedures
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TableofContents-continued
HomeHealth–PatientHandoutsv EmergencyPlan–whentocallHHAvs.911v EligibilityforHHC+Dischargecriteriav MedicalSuppliesforPatientswithMedicarev ImportantNoticeaboutMedicareHMOPlansv StatementofPatientPrivacyRights(OASIS)v NoticeAboutPrivacyv AdditionalPolicies,e.g.ConflictofInterestv YourRightstoMakeMedicalDecisionsv ThinkSafetyv ElectricalSafetyv SomeTipsforUsingMedicationsSafelyv FoodandDrugInteractionsv OxygenSafetyv PoisonSafetyv InfectionControlv FloodSafetyv FireSafetyv EmergencyPreparednessv EarthquakeSafetyv TipsfortheElderlybeforeanEarthquakev DisposalTipsforHomeHealthCarev KnowYourRights–areyoulimitedEnglish
proficient?(LEP)v FallPreventionChecklistv IsItTimeforaMedicalAlarm(e.g.LifeLine)?v SpeakUp–HelptoPreventErrorsinYourCare
Note:SomeHandoutsinSpanish
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LOSANGELESHARBORCOLLEGEAssociateDegreeRegisteredNursingProgram
NURSING339:NURSINGPROCESSANDPRACTICEINTHECAREOFTHEGERONTOLOGIC
PATIENT
UNITI-PatientCareManagementinHomeHealthandtheCommunitySettingDescription:InthisunitthestudentwillbeachievingobjectiveswhicharecenteredaroundtheclinicalperformanceinHomeHealthcareandthecommunitysetting.Thestudent,undertheguidanceofthenursepreceptor,willobserveandassistthenurseresponsibleforthepatient’scareinthehomesetting.Theywillidentifybothphysicalandpsychosocialneedsofthepatientinthehomesetting.TheconceptsoftheRoyAdaptationmodelandthenursingprocesswillbeintegratedinthestudent’sclinicalperformanceandinteractionwithpatients/families.EstimatedTimeofAchievement:2clinicdays
1. ObjectivesCourseContent LearningActivities2. Identifypatientswhoareappropriate
andeligibleforhomecareservices.3. Exploreservicesoffered,including-
Skillednursing,rehabilitationservices,socialservice,homehealthaide/homemaker,andhospice.
4. Describeskillsneededforhomecarenurses.
5. Comparereimbursementforhomehealthservicestothatofacutecare.
6. ComparehomehealthMedicareregulationstothoseinacutecare.
7. Examinetheregulatorybodiesimpactinghomehealthandcommunityservices(includinglongtermcare):♦ FederalgovernmentandCOP’s♦ Stategovernment–DepartmentofHealthServices
♦ OBRA1987♦ TheJointCommission
8. Assesstheculturalcharacteristicsrelatedtopatient’shealthcareincludinghealthbeliefs,health&dietpractices,familyrelationships,andcommunication.
9. Identifythepatient'sreactionstothestressoftheirillness.
10. Differentiatetheadaptive/maladaptivecopingmechanismsused
HomeHealthSelfTeachingModuleandCommunityClinicalGuideLecture:Overviewof:
♦ HomeHealth♦ Hospice♦ LongTermcare♦ Assistedliving♦ Adultdaycare♦ Alzheimer’sunits♦ Residentialcare
HistoryofHomecare+
♦ Eligibility♦ Definitions♦ Safetyconsiderations♦ Insurancecoverage,e.g.Medicarevs.privateinsurance♦ Hospicebenefit♦ Interdisciplinaryteam♦ Differencesbetween
homecareandhospice
Resources:Syllabus–UnitI:HomeHealthandCommunityNursingSelf-StudyGuide.Tablowski,PatriciaA.(2014).GerontologicalNursing3ndedition,Pearson–PrenticeHall:NewJersey.
InternetResources:♦ National
AssociationforHomeCarewww.nahc.org
♦ CaliforniaAssociationforHealthServicesatHomewww.cahsah.org
♦ NationalHospiceOrganizationwww.NHO.org
♦ Hospiceand
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bythepatientandtheirfamilies.11. Demonstrateaphysicalexamination.12. Compareobjectivedatafromphysical
examinationandcaregiventonormsandappropriatecriteria.
13. Identifypatientsneedingreferraltospecializedservices
14. Organizeandplanfordailyhomevisitsdeterminingpurposeforvisitandfollowupplan.
15. Identifynecessarysuppliesneededfortheindividualhomevisit.
16. Practiceappropriateinfectioncontrolinthehomesetting.
17. Assesssafetyinthefield(safetyinthehome,carsafety,personalsafety).
18. Conductahomesafetyevaluationofthepatient’shome.
19. Demonstrateunderstandingofdisposalincontaminatedmaterials.
20. Evaluateeffectivenessofinterventionsby
comparingpatientbehaviorsbeforeand
afterinterventionstooutcomecriteria.21. Compiledatafrompatientmedical
record,homehealthfile,nursingcareplan,staffreportsandpatientassessment.
22. Collaboratewithpreceptorandmultidisciplinaryteaminprovidingcaretothepatientusingpreviouslylearnedskills.
23. Reportsignificantchangesinpatient'shealthstatustophysician.
24. Practicetherapeuticcommunicationinthehomesetting.
25. Participatinginteamconferences.26. assesspatient's(and/orfamily's)
knowledgebaseanddeficitsregardinghealthmanagementanddevelopteachingplanbasedontheseneeds.
27. DocumentscaregivenutilizingAIEorDARformat.
28. Demonstratesprofessionalismby:♦ acceptingresponsibilityandaccountability
forallnursingactivitiesonassignedpatients
PalliativeNursesAssociationwww.hpna.org
Evaluation:
Thenursepreceptorwillcompleteaclinicalevaluationofthestudentattheendoftheweek.ThestudentwillcompleteallnecessarypaperworkasidentifiedunderInstructionsanddirectionsforcommunitybasedexperience,whichtotals16hrs.AttendancePolicy:Thisisaconcentrated1dayexperience.Thestudentwillberequiredtomake-upanyabsences.Thestudentmustattendtheorientationlecturecomponentofthecourse.
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♦ practicingwithinthelegalandethicalframeworkfortheprofession,agencyandcollege
♦ consultingwithpreceptorand/orinstructorwhenproblemsarisenotwithinscopeofpracticeorexperience
♦ maintainingmalpracticeinsurance,CPRcertificationandhealthstatus
♦ maintainingawell-groomedappearancewhileinagencyrequireddresscode
♦ practicingpromptnessinclinicalworkandnotifyingagency/preceptorifunabletoperformassignment
♦ maintainingconfidentialityofpatient'srecordsandpersonalinformation.
♦ researchingallaspectsofanticipatedcaretobeadministered;dressingchanges,centrallines,medications,etc.
♦ appropriatelyconferringwithpreceptorifdatabaseincompleteorlackofunderstandingtoanyaspectofcare.
♦ submittingallrequiredpaperworktoinstructorinatimelymanner.
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PRETESTDirections-ReadtheunitandcompletethePretestbeforethefirstdayofclassfor339.CompletingthistestwillinsurethatyouarepreparedfortheHomeHeathexperience.Youwillbegivenawrittentestontheinformationinthisunitonthefirstdayofclass.Youmustpassthetestwith75%accuracy.1. Agenerictermthatdescribesarangeofprofessionalandtechnicalservicesthat
maybeprovidedinthehomeis:a. HMOb. HomeHealthAgencyc. SocialSecurityd. HomeCare
2. Whatmustanagencyhavebeforeprovidingservicestoapatient?a. Proofofinsuranceb. Patient'srequestc. Physician'sorderd. Copyofthepatient'smedicalrecorde. Alloftheabove
3. Commodes,walkers,hospitalbedsareexamplesof:
a. Physicaltherapyb. Durablemedicalequipmentc. Medicalsuppliesd. ItemsnotcoveredunderMedicare
4. Ahomehealthagencyisalways:a. Accreditedb. Licensedc. Aproviderofhomecareservicesd. Cannotprovidehospiceservices
5. Themostcommonmedicaldiagnosisfortheelderlyinhomecareis:
a. AIDSb. Cancerc. Hipreplacementsd. CongestiveHeartFailuree. Alloftheabove
6. Thestateprogramforhealthcoverageforthepooris:
a. Medi-Calb. SocialSecurityc. Medicared. Section8
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7. MedicarePartB
a. Ismandatoryandfinancedbytaxesb. Pays100%ofallservicesc. Isastateprogramforeveryoneover65yearsofaged. MaybepurchasedbypeoplewhomayormaynotalreadyhavePartA
8. WhichservicesarecoveredunderMedicarePartA?
a. Skillednursingb. Medicalsocialworkerc. Physicaltherapyd. Speechtherapye. Alloftheabove
9. ThoseeligibleforMedicareinclude:
a. Peoplewhoare65yearsofageorolderb. Peopleunder65whohavebeendisabledforatleast2yearsc. Peoplewithend-stagerenaldiseased. Alloftheabove
10. TheConditionsofParticipation(COPs)
a. ArerequirementsoftheMedicarelawforHospiceandhomecareprovidersb. MustbeobservedbeforeaHomehealthagencycanbecertifiedc. IncludehavingavalidPlanofCared. Alloftheabove
11. ThemaincriteriathatmustbemetforapatienttobecoveredforMedicarehomecarebenefitsincludes:a. Patientmustdesirehomecareservicesb. Patientdoesnotwanttoperformneedednursingactionsandrequests
assistancec. Familymembersrequestnursingassistanceforelderlyrelatived. Thepatientishomebounde. Alloftheabove
12. Tobeconsideredhomebound,Medicarerequiresthatthepatient
must:a. Haveaphysiciancertifythathe/sheishomeboundb. Experienceaconsiderableandtaxingefforttoleavehomec. Haveaconditionthatrequirestheassistanceofanotherpersontoleavehomed. Haveaconditioninwhichleavinghomeiscontraindicatede. Alloftheabovearecorrect
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13. Documentationisespeciallyimportantinhomecarebecause:a. Chartsarereviewedperiodicallyb. Itinsurescontinuityofcarec. Reimbursementrestssolelyondocumentationd. Physiciansreadandrelyonnursingnotese. Alloftheabove
14. Apatientwhohasgeneralizedweakness,unstablevitalsignsandrequiresfeeding
pergastrictubesshouldbereferredto:a. OccupationalTherapyb. HomeHealthAidesc. SkilledNursingd. Nutritionist
15. Mr.Smithisa68-year-olddiabeticwhoisrecoveringfromabelowtheknee
amputationofhisleftleg.Heishavingmuchtroublegettingaroundandcaringforhimself.Hesometimesonlyeatsonceadaybecausehehaslittlemoney.Heisverydepressedaboutlosinghisleg.Heneedstobereferredto:a. MedicalSocialWorkerb. PsychiatricNursec. Wound/Ostomy/ContinenceNursed. HomeHealthAidee. PhysicalTherapist
16. Mrs.Garciaisan82-year-oldpatientwhoisrecoveringfromatotalhip
replacement.Sheneedsassistancewithpersonalhygienedoingsomelighthousework.Herhusbandis86andtooweaktotakecareofher.Sheshouldbereferredto:a. Skillednursingb. Homehealthaidec. Wouldnotreferforanycared. Medicalsocialworkere. PhysicalTherapy
17. A36year-oldblindpatientwithseverespasticcerebralpalsy,hasdeveloped
contracturesofhislowerextremities.Heshouldbereferredto:a. Skillednursingb. HomeHealthaidec. PhysicalTherapyd. Occupationaltherapye. MedicalSocialWorker
18. Ahomecarepatientwhoisdisorientedtotimeandplaceandishavingdifficulty
withhisshorttermmemory,shouldbereferredto:
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a. OccupationalTherapistb. PsychiatricNursec. SpeechandLanguagePathologistd. HomeHealthaide
19. WhichofthefollowingistrueofHospice?
a. AllterminallyillpatientsareautomaticallyenrolledinHospiceprogramsb. Patientsmusthavealifeexpectancyof3monthsorlessc. Hospicepatientsmaycontinuetoreceivechemotherapyd. Hospicepatientsareeligibletoreceivemedicaltreatmentforconditions
unrelatedtotheirterminalillness20. Therolesofthehospicenurseinclude:
a. Keepingthepatientaspain-freeaspossibleb. Providingemotionalsupportforthefamilyc. Teachingthefamilyhowtocareforthepatientinthehomed. Orderingallneededmedicalequipmentandsuppliese. Alloftheabove
21. Safetyconsiderationsinhomecareinclude:a. Neverusethepatientsownsuppliesforprocedures/treatmentsb. Placethenursingbagonthebedorcleanareaonthefloorc. Usethepatient'sbarsoapandtowelsiftheyappearcleand. Washhandsbeforeandaftervisite. Alloftheabove
22. Whatproceduresisthestudentnurseallowedtodowhileunderthesupervisionof
homehealthR.N.?
a. Flushcentrallinesb. Sign/witnesspermitsc. GiveIVpushmedicationsd. Insertafoleycathetere. Alloftheabove
23. ThelargestspecialpopulationcaredforthroughMedicareis/are:
a. Womenb. Disabledveteransc. PeoplewithAIDSd. Elderlye. Dialysispatients
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24. Whichofthefollowingnursingskillswouldbenecessaryforelderlypatients:
a. Painmanagementb. Careandmanagementofindwellingcathetersc. Spiritualcounselingforapatientandcaregiverd. Teachingfamilycaregiversaboutskincaree. Alloftheabove
25. WhichofthefollowingstatementsaretrueregardingtheHealthCareFinancing
Agency (HCFA)?
a. ItisresponsiblefortheadministrationofMedi-Calb. ItisresponsiblefortheadministrationofMedicarec. ItcontractswiththestatedepartmentsofhealthtomonitortheMedicare
certificationprocessd. Alloftheabovearetrue
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HISTORYOFHOMECARE AsfarbackastheNewTestamentintheBible,therearereferencestopeoplewhovisitedthesickintheirhomestoprovidecare.Duringtheeleventhcenturymilitarynursingordersdevelopedandeventuallybecamevisitingnurseservices.Inthe1850’sWilliamRathbonesupportedthefurtherdevelopmentofnursesandhomecareservicesinEnglandafteraprolongedexperienceofhavinganursecareforhiswifeintheirhome.Together,heandFlorenceNightengale,setupavisitingnursetrainingprogramin1859.Thegraduatesoftheschoolfocusedonhelpingthe“sickpoor.” HomecaredevelopmentintheUnitedStatesbeganintheearly1800’s.In1883LillianWaldandMaryBrewsterfoundedtheHenryStreetSettlementinNewYork.TheHenryStreetSettlementwasaplacethatprovidedservicestoall.Itisstillamodelforexistinghomecareagenciestoday.Itprovidedhealtheducation,careforthesick,andcommunicationandreferraltopatientsandphysicians.Personnelassistedwitharrangementsforhospitalizationsaswellasdailycomforts.Theyalsokeptdataandrecordsofalltheworktheyaccomplished. In1912theNationalOrganizationforPublicHealthNursingwasformedwithLillianWaldservingasthefirstpresident.Thegoalsofthisorganizationweretoprovideforstandardsofquality,collectionandanalysisofdata,advisoryservicestocolleaguesandinstitutesofhigherlearning,andadvisoryservicesfornurses. In1965theSocialSecurityActestablishedtheMedicareprogram.WiththeadventoftheMedicareprogram,homecarebecamemorewidelyavailableandusedbythosewhowereeligible.Manynon-profitandfor-profitcompanieswereestablishedtoaddressthehomecareneedsoftheaged,poorandsick.TheMedicaid/Medi-Calprogramwasenactedbythefederalgovernmentin1970toassistthepooranddisabled.Thisprogramfurtherextendedeligibilityforhomecareservicestomanymoreoftheneedy.
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DEFINITIONSOFHOMECARE1. Homecareandhomehealthcarearegenerictermsthatdescribearangeof
professionalandtechnicalservicesthatmaybeprovidedinthehome.
a. Homecareencompassesabroadrangeofdisciplinesandservicesthatmaybeprovidedinthehomesettingforafewminutesaday,afewhoursaday,orupto24hoursaday.Itisasynthesisofcommunityhealthnursingandskillsfromotherspecialtyareas.
b. Apatientmaybereferredtohomecarebyseveralways.Areferralcanbe
initiatedfromaphysician’soffice,thehospital,aHMO,andsometimes,fromthepatient.Regardlessofhowthereferralisinitiated,theagencymusthaveaphysician’sorderbeforevisitingthepatient.
c. Reimbursementforservicesorderedfromahomecareagencyarepaidby
either: • Privateinsurance• HMO’s• Self• Medicare• Medi-Cal
d. ApprovalfromHMO”sandprivateinsurancecompaniesaremandatorybefore
theagencycanprovideservices.MedicareandMedi-Calwillpayforservicesifthepatientiseligible.OverhalfofthehomecarecasesarepaidforbyMedicare
e. Dependingonthetypeofhomecareorganization,homecarestaffmay include:
• Physician/medicaldirector• Licensedvocationalnurses• Physicaltherapists• Speechtherapists• Nutritionists• Registerednurses• Medicalsocialworkers• Occupationaltherapists• Homecareaides,attendants• Companions,live-ins• Volunteers
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f. Suppliesmaybeprovidedfordressingschanges,infusiontherapy,pulmonarycare,woundcare
g. Durablemedicalequipment(DME)maybeprovidedandincludeitemssuchasbeds,commodes,wheelchairs,walkers,rails,etc.
2. HomehealthagencyisatechnicaltermthatdescribesalicensedorMedicare certifiedproviderofhomecareservices3. Patientsneedinghomecarehavevarieddiagnoses.Accordingtoonelargestudy themostcommonmedicaldiagnosesfoundintheMedicarepopulationinclude thefollowing:
• Congestiveheartfailure• Cerebralvascularaccident• Chronicobstructivepulmonarydisease• Pneumonia• Hypertension
4. Theelderlyarethelargestspecialpopulationcaredforthroughhomecare.
SafetyConsiderationsEspeciallyImportantfortheElderly
~ Infectioncontrol/universalprecautions~ Night-light;Welllightedwalkways~ Removescatterrugs~ Personalemergencyresponsesystem~ Meticulousskincareandprecautions~ Airmattress,otherprotectiveequipment~ Tubrail,grabbarsforbathroomsafety~ Wearsupportiveandnonskidshoes~ Handrailonstairs~ Fallprecautions~ Identifyandreportanyskinproblemsimmediately~ Assistwithambulation
NursingServiceSkillsfortheElderly
~ Providepatientandcaregiverwithhomesafetyinformationandinstruction~ Comprehensiveassessmentofallsystemsforpatientnewtohomecare~ Observationandassessmentofelderlypatientwithpain~ Medicationmanagementofelderlypatientonmultiplemedications~ Teachingandtrainingfamilycaregiversrelatedtoskincare,positioning,
constipation
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~ prevention,andfeedingregimen~ Providesupporttopatientandfamily-membercaregivers~ Rehabilitationmanagementrelatedtosafebedmobilityandtransfers~ Spiritualcounselingforpatientandcaregiverwhoareverbalizingthemeaningor
reasonofillnessandagingtonurseoraideteammembers~ Assesspatient’sresponsetoorderedinterventionsandreportchangesor
unfavorableresponsestothephysician~ Monitor/managebowelandbladderfunctionsofelderlypatientwithhistoryof
impaction~ Insertion,care,andmanagementofindwellingcatheter~ Teachfamilycaregiversigns,changestoreporttonurseandphysician
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TESTYOURSELF
1. Durablemedicalequipment(DME)includes:a. Dressings,bandages,woundcaresuppliesb. Intravenousequipmentc. Wheelchairs,walkers,bedsd. Medicationse. Alloftheabove
2. Whichofthefollowingmostaccuratelydefinesahomehealthagency;
a. referstoprofessionalandtechnicalservicesprovidedinthehomeb. referstoskillednursingcarec. referstoalicensedproviderofhomecareservicesd. referstoalicensedorMedicarecertifiedproviderofhomecareservicese. alloftheabove
3. Whichnursingleaderisconsideredtobethemotherofhomehealthnursingin
theUnitedStates?a. WilliamRathboneb. FlorenceNightengalec. MaryBrewsterd. LillianWald
4. Whichofthefollowingwouldyouexpecttobeonthehomecarestaff?
a. Psychiatristsb. Marriagecounselorc. Socialworkersd. Childcareproviders
5. Whichofthefollowingstatementsistrue?
a. AsmallpercentageofhomecarepatientsarereceivingMedicarebenefitsb. Theagencymusthaveaphysician’sorderbeforevisitingthepatientc. Ahomehealthcareagencywillprovideservicestoanypatientwhois
referredd. Allpatientsreceivinghomehealthcarehave24hour-a-daynursingcare
6. Whichofthefollowingnursinginterventionsaremostimportantforanelderly
patient?a. Teachingoffamilycaregiversrelatedtoskincareandpositioningb. Implementandteacharespiratorytherapyprogramc. Teachingpatienttoelevatelegswhensittingd. Teachingpatienttowearloosecomfortableshoese. Teachingoffamilycaregiverstoassessvitalsignsespeciallybloodpressure
Answers:1-c;2-d;3-d;4-c;5-b;6-a
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MEDICAREHOMECAREMedicareisanationwidehealthinsuranceprogramthatwasenactedin1965undertheSocialSecurityAct.Medicareconsistsofthreeparts-PartA,PartB,andPartD.Itisafederalprogramforpeoplewhoare65yearsofageandolder,ordisabled,orhaveend-stagerenaldisease.Medicareistheworld’slargesthealthinsuranceprovider.Therearemanycoveragerulesandexclusionstocoverageandeligibility.Medicareisresponsibleforsettingmanyofthestandardsrelatedtohomecare.OverhalfofthepeoplereceivinghomehealthcarearecoveredunderMedicarebenefits.TheHealthCareFinancingAdministration(HCFA)isthegovernmentalagencyresponsiblefortheadministrationofallMedicareandMedicaid/Medi-Cal(thestateprogramforhealthcoverageforthepoor)programs,includinghospitals,homecareandhospice.
MEDICARE–PARTAMostofthefundingforcoveredinpatienthospital,skillednursingfacility(SNF)stays,homehealthandhospiceservicesarecoveredunderpartMedicarePartA,withthepatientpayingasmalldeductible.IndividualseligibleforSocialSecurityareautomaticallyentitledMedicarewhentheyreachage65.ThosewhoareeligibleforSocialSecurityandareunderage65musthavebeendisabledforatleast2years.MedicarePartAisfinancedthroughpayrolltaxesfromworkersandemployers(FICAtax).ManyexpertsareprojectingthatMedicarePartAwillbebankruptinthenearfuture.ThehomehealthcareservicesthatcanbeprovidedandcoveredunderMedicarePartAincludeskillednursing,homehealthaide,physicaloroccupationaltherapy,speech-languagepathology,andmedicalsocialservices.ItisimportantthatthehomecarenursebeknowledgeableaboutMedicareandotherInsurerstobeabletoassistpatientswhentheyhavequestionsaboutbenefits,coverageandcare.
MEDICARE–PARTB
MedicarePartBisvoluntary,andenrollmentisopentoindividualsage65andolderorthosealreadyentitledtoPartAbenefits.ThebeneficiarypaysamonthlypremiumforPartBcoverage.PartBprovidescoverageforphysicianservices,somehomecarerelatedtohomemedicalequipmentandsupplies,homecareservicesforthosewithoutPartAinsurance,ambulanceservice,TPN,somechemotherapyandradiation,andkidneydialysisandtransplants.Italsocoversthefullcostofsomemedicalsuppliesand80%oftheapprovedamountfordurablemedicalequipmentsuchaswheelchairs,hospitalbeds,oxygensupplies,andwalkers.MostPartBbenefitshaveaco-paymentthatthepatientoranotherinsurancecompanypays.
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MEDICARE–PARTDMedicareprescriptiondrugcoverageisinsurancethatcoversbothbrand-nameandgenericprescriptiondrugsatparticipatingpharmaciesinyourarea.Medicareprescriptiondrugcoverageprovidesprotectionforpeoplewhohaveveryhighdrugcostsorfromunexpectedprescriptiondrugbillsinthefuture.MEDICARECONDITIONSOFPARTICIPATIONTheMedicareConditionsofParticipation(COPs)aretherequirementsoftheMedicarelawthathomecareandhospiceprovidersmustcontinuallymeetinordertoparticipateintheMedicareprogram(i.e.theymustbecertifiedorhaveMedicarecertification).Homecare,hospiceorotherhealthcareorganizationsapplyforMedicarecertification.TheHCFA(Doyourememberwhatthatis?)contractswiththestatedepartmentsofhealthtoperformtheactualon-sitesurveyandreviewfortheMedicarecertificationprocess.TheinitialMedicarecertificationprocessisalabor-intensiveandlengthyprocessforthehomecareorganization.NursesurveyorsreviewallthevariouscomponentsoftheCOPsincludingclinicalandadministrativepoliciesandprocedures,homevisitsandpatientinterviews.Thenursesurveyorwillreadthepatient’sPOC(planofcare)andcheckthatitisfilledoutcompletely;lookatthefrequencyofservicesandcountthevisitnotes;reviewthespecificphysician’sordersonthePOCanddetermineifthePOCisbeingfollowed;andcheckandcountthemedicationsonthe485formandverifythatthemedicationsheetmatchesexactlyandthatallallergiesareaddressedconsistently.Statesurveyorsareusuallyspecificallytrainedinhomecare;theirroleistoprotectthewelfareandsafetyofpatientswhoarereceivingMedicarebenefits.OncethehomehealthagencymeetsalloftheMedicarestandardsandreceivescertification,theycanthenbillMedicareandotherpayorsforhomecareservicesprovidedtotheirpatients.SurveysalsooccurthereaftertodeterminethatanagencycontinuestomeetthestandardsdefinedintheMedicareCOPs.Theseareusuallyunannouncedandmaybepartofaroutinesurveyingprocessorinitiatedasaresultofacomplaint.
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TESTYOURSELF
1. WhichofthefollowingistrueregardingMedicare?a. Medicareisastateprogramforthedisabledb. TheSocialSecurityAgencyadministersMedicarec. ApersonwhowasdisabledlastmonthiseligibleforMedicared. Itisafederalprogramforthose65yearsofageoroldere. Alloftheabove
2. MedicarePartA
a. isfinancedthroughpayrolltaxcontributionsb. providesservicessuchasspeechtherapy,skillednursingandhospicec. individualseligibleforSocialsecurityareautomaticallyentitledd. thepatientusuallypaysasmalldeductibleforthoseservicesprovidede. alloftheabovearetrue
3. MedicarePartBa. isvoluntarywiththebeneficiarypayingamonthlypremiumforservicesb. paysforallmedicalequipmentusedinhomecarec. requiresnoco-paymentd. pays100%forapproveddurablemedicalequipmente. alloftheabovearetrue
4. Medicarecertificationsurveysareusuallyperformed:
a. onbecominganewMedicare-participatingorganizationb. onanongoingbasisthroughthelifeofanorganizationc. whenthestatebelievesthatpatientsafetymaybecompromisedd. whentherearenumerouscomplaintsagainstanagencye. alloftheabovearetrue
Answers:1-d;2-e;3-a;4-e
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WHOISELIGIBLEFORHOMECAREThemaincriteriathatmustbemetforpatientstobeeligibleandcoveredforMedicarehomecarebenefitsgenerallyincludethefollowing:
• Medicare-certifiedagency• Homeboundpatient• EligibleMedicarebeneficiaryandappropriatepayor• Coveredservices• Coveredskillednursingservice• Physician-approvedplanofcare(POC)• Documentationsupportscarecovered
1. MEDICARECERTIFIEDAGENCY
HomecareagenciesthatarenotMedicarecertifiedwillnotbereimbursedforservicesprovidedbyMedicare.MedicarebeneficiariesmustreceivehomecareservicesfromanagencythatisMedicarecertifiediftheywantMedicaretopayforthecare.ThepatientmustbeunderanMD’scare,whomustapprovethePlanofCare(POC)–mustbere-signed/re-certifiedevery62days.
2. THEHOMEBOUNDPATIENT
ForaMedicarebeneficiarytobeeligibletoreceivecoveredhomehealthservices,thelawrequiresthatthebeneficiarybehomeboundandthataphysiciancertifythatthepatientisconfinedtohisorherhome.Thetermhomeboundissynonymouswithconfinedtohome,asformedicalreasons.Inreality,thisdoesnotmeanthatthepatienthastobe“bedriddentobeconsideredasconfinedtohome”.Theconditionofthepatientsshouldbethat“thereexistsanormalinabilitytoleavehomeandconsequently,leavingtheirhomerequiresaconsiderableandtaxingeffort.”
Ifapatientleaveshishomeinfrequentlyorforshortdurationssuchastogotothebarbershoporwalkaroundtheblock,heisconsideredhomebound.Ifthepatientleaveshishometoreceivemedicaltreatment,heisstillconsideredhomebound.Leavingthehomeformedicaltreatmentincludesattendanceatanadultdaycarecentertoreceivemedicaltreatment,outpatientkidneydialysis,andappointmentsatoutpatientfacilitiestoreceivechemotherapyorradiation.
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Generallyspeaking,apatientisconsideredhomeboundifhehasaconditionthatrestrictshisabilitytoleavehisplaceofresidenceexceptwiththeaidofcrutches,walker,canesandwheelchairs,theuseofspecialtransportation,ortheassistanceofanotherpersonorifleavinghomeismedicallycontraindicated.Someexamplesofhomeboundpatientswouldbe:
~ apatientwhoisparalyzedfromastrokeandisconfinedtoawheelchairorneedscrutchesinordertowalk.
~ apatientwhoisblindorsenileandrequirestheassistanceofanotherpersontoleavehisresidence.
~ apatientwhohaslosttheuseofhisupperextremitiesandthereforeisunableto
opendoors,usehandrails,etc.Thispersonneedstheassistanceofanothertoleavehishome.
~ apatientwhohasjustreturnedfromahospitalstayinvolvingsurgerysufferingfromresultantweaknessandpainandthereforehis/heractivitymayberestrictedbythephysician(i.e.maygetoutofbedforBRPonly;sitinchair15minuteTID)
~ apatientwithsuchsevereatheroscleroticheartdiseasethathe/shemustavoidallstressandphysicalactivity.
~ apatientwithapsychiatricproblemthatismanifestedbythepatient’srefusaltoleavehomeorifleavingunattendedwouldnotbeconsideredsafe.
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TESTYOURSELF(answeryesorno)
1. Mr.Smithisa77-year-oldmanwhohadalefthippinning.Inaddition,hehashadarecentexacerbationofchronicCHF.Herequirestheassistanceofsomeonetoambulateandbecomesdyspneicafterwalking20feet.Visitsareneededtoassesshiscondition.Mr.Smithisreceivingphysicaltherapy.Hisphysicaltherapistandhisphysicianhavedeterminedthatheneedstouseequipmentthatwouldn’tbeabletobebroughttohishome.Aneighborwilldrivehimtothehospital3timesaweek.IsMr.Smithhomebound?Whatcriteriadoeshemeet?Answer:Yesapersonisconsideredhomeboundwhenheleavesthehouseformedicalreasonsandthedocumentationsupportsthatitrequiresaconsiderableandtaxingefforttoleave.Also,thepatientisreceivingtreatmentthatcannotbeprovidedathome.
2. JimmyNewtonisa20-year-oldquadriplegic.AhomehealthcomesintwiceadayforADLsandtogethimuptohismotorizedwheelchairinthemorning,andputhimtobedintheevening.Askillednursevisitshimthreetimesaweekfordisimpaction.Jimmytravelsinahandicapvantoattenddailyclassesattheuniversity.Ishehomebound?Answer:Noheisleavinghomedailyfornon-medicalreasons.
3. Ms.Rodriguezisan80-year-oldladywhoneedsaskillednursetoadministerforteodailyfortreatmentofosteoporosis.Sheisunabletoself-injectthemedicationbecauseofseverearthritisinherarmsandhands.Herniecedriveshertoasmalldinereverynightfordinner.Isshehomebound?Answer:NOsheisleavingherhomefrequentlyfornon-medicalreasons.TheskillednursecouldarrangeforMealsonWheels.
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3. ELIGIBLEMEDICAREBENEFICIARYandAPPROPRIATEPAYOR
ThepatientmustbeaneligiblebeneficiaryandMedicareistheappropriatepayor.Inotherwords,thepatientmeetsthehomeboundrequirementsandisaMedicarebeneficiaryandMedicareistheappropriatepayorforthehomecareservices;thepatientmustneedtheskillednursingservicesandtheservicesarecovered.Anexampleofapersonnotcoveredwouldbesomeonewhois70-years-oldandstillworkingfull-time.Medicareisnothisprimaryinsurer.HewouldnotmeettherequirementsbecauseMedicareisnotthecorrectpayor.
4. COVERABLESERVICES
HomecareservicesunderMedicaremustbereasonableandnecessarybasedonthepatient’scondition.Reasonableandnecessaryconnotesthatitisstandardandacceptablemedicaltreatment.Documentationofthepatient’suniquephysicalneedsandmedicalconditionisveryimportantwhenjustifyingtheneedtoreceivehomecarebenefits.
5. COVEREDSKILLEDNURSINGSERVICES
Theorderednursingcareisacoveredskillednursingservice.Medicarewillcoverthefollowingskillednursingservicesifdocumentationsupportscoveredcareandservicesarecoveredundertheplanofcare(POC)~ Observationandassessmentofthepatientscondition(generalmed/surg)~ Managementandevaluationofapatientcareplan~ Teachinge.g.newdiabetic~ Administrationofmedications(subq.,IM,IV)~ PICCandCentrallinecare~ Tubefeedings~ Nasotrachealandtracheostomyaspiration~ Catheters~ Woundcare~ OstomyCare~ Rehabilitationnursing~ Venipuncture~ Psychiatricevaluation,therapy,andteaching~ Postpartum/wellbabyvisits~ Antepartumhighrisk
6. PHYSICIAN-APPROVEDPLANOFCARE
TheservicesprovidedmustfallunderaPOCestablishedandapprovedbyaphysician.ThePOCmustbecompletedforeveryMedicarepatientonadmissionandevery62daysthereafter.BysigningthePOC,thephysiciancertifiesthat:
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~ thehomecareserviceswereprovidedbecausethepatientwashomebound~ thepatientneedsorneededskillednursing,speechtherapy,physicaltherapyor
occupationaltherapy~ aPOChasbeenestablishedandisperiodicallyreviewedbyaphysician~ theservicesareorwerefurnishedwhileunderthecareofaphysician
7. DOCUMENTATIONSUPPORTSCARE
Theclinicaldocumentationmustvalidatethattheservicesforcoveredcareweredeliveredandnecessary.Reimbursementinhomecarerestssolelyondocumentation.ThehomecarenursehasapivotalroleincreatingdocumentationthatsupportscoverageforpatientswhomeetthecriteriaandhaveMedicarebenefits.
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TESTYOURSELF
1. Whichofthefollowingpatientswouldbeconsideredhomebound?a. A77year-oldmaleseverelyconfusedmalewithAlzheimer’sdiseaseb. Afrail69year-oldwomanwithosteoporosisc. A35year-oldparaplegicwhogetsaroundinamotorizedwheelchairand
attendsexerciseclassesdailyattheYMCAd. A78year-oldwomenwithchronicheartdiseaseanddiabetes
2. ThemaincriteriathatmustbemetforapatienttobeeligibleforMedicarehome
benefitsinclude:a. Licensedhomehealthcareagencyb. Allpatientsare65yearsorolderc. Periodicphysicianvisitsd. Documentationsupportscarecoverede. Alloftheabove
3. WhichofthefollowingisacoverableserviceforMedicarehomecarebenefits?
a. InjectionsofB12toa66year-oldmale,orderedbyaphysicianwhobelievesallelderlypatientsneedB12injectionsasaprophylacticmeasure
b. Speechtherapyfora4year-oldchildwholispsc. Physicaltherapyforanactive65year-oldafterakneereplacementd. Occupationaltherapyforaparalyzed72year-oldstrokepatiente. Alloftheabovearecoverable
4. WhichofthefollowingisNOTaskillednursingserviceprovidedunder
Medicare?a. Tubefeedingsb. AssistancewithADL’sc. Medicalgassesd. Studentnursevisitse. Noneoftheabove
5. WhichofthefollowingistrueregardingaMedicareapprovedPlanOfCare
(POC)?a. Mustbeestablishedandapprovedbyaphysicianb. Thepatientneedsskillednursingcare,PTorOTc. Thepatientishomeboundd. ThePOCisreviewedevery62dayse. Alloftheabovearetrue
Answers:1-a;2-d;3-d;4-b;5-e
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SKILLSANDKNOWLEDGENEEDEDBYTHEHOMEHEALTHNURSE
BASICRULESANDSTANDARDSThehomehealthnursemusthaveknowledgeofadministrativerulesandstandardsofhomecare.HomecareregulationsincludeMedicare;anystatelicensureforhomecare;accreditationbodies;andanyapplicablenationalorlocallawsorregulations.Knowledgeofcorrectdocumentationproceduresisalsoextremelyimportant.Reimbursementisbasedonaccuratedocumentation.Ifanagencyisnotreimbursedforservices,itmaystopprovidinghomecarevisitsandthepatientwillbedeprivedofnecessaryhealthcare.FLEXIBILITYInhomecarethepatientsareincharge.Patientneedsarethecriteriathatdrivethehomevisit.Visitsmaybescheduledaccordingtopatientconvenience.Forexample,apatientmaynotwantastudentnursetoaccompanythehomehealthnurseintohis/herhome,orthepatientmaypreferthatthenursevisitintheafternooninsteadofthemorning.Thehomecarenursemustalwaysbepreparedfortheunexpected(e.g.,arainstorm,anearthquake,detours,thesuppliersendingthewrongsizecatheters,etc.)thenurseshouldalwayscarryextrasuppliesforthosedayswheneverythinggoeswrong.ATTENTIONTODETAILSTheabilitytopayverycloseattentiontodetailsisaskillneededbothindocumentingdataandaddressingcomplexpatientneeds.Thisincludesobservationofchangesinthepatient’scondition,problemsintheenvironmentandfollowinguponverbalphysicianorders.STRONGCLINICALSKILLSAllhomecarecliniciansneedanin-depth,clinicalknowledgebaserelatedtoobservationandphysicalassessmentskills;teaching;technicalskillssuchascatheterizations,IVtherapy,medicationadministration,criticalthinkingandproblemsolving.Registerednursesworkinginhomecareshouldhaveaminimumof2yearsofacutecareexperience.COMMUNICATIONSKILLSThenurserequirestheabilitytocommunicateeffectivelywithpeoplefromdiverseculturesandeducationalbackgrounds.Thenursemustbeabletoteachhealthcarepracticestothepatientsand/ortheirfamilymembers.Relayingimportantinformationaboutthepatient’sstatustothephysicianandotherhealthteammembersisalsoafunctionofgoodcommunication.TIMEMANAGEMENTSKILLSSuccessfulmasteryoftimemanagementisessentialtosuccessfulhomecare.Cliniciansmustbeabletomanageschedulingvisits,documentation,andothersupportactivitiesrelatedtopatientcare.RELIABLECARANDGOODDRIVINGSKILLSInhomecare,theclinicianmusthaveasafe,reliablecar,safedrivingskills,theabilitytoreadamaporhaveaworkingGPS,andagoodsenseofdirection.
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HOMEHEALTHSERVICESOFFERED
1. SKILLEDNURSING:ExperiencedRegisteredNursesdoacompleteassessmentoneachpatientreferredforskillednursingservices.Informationfromthiscomprehensiveassessmentisusedtodevelopaplanofcarethatwillbecommunicatedandcoordinatedwithotherteammembersincludingthepatient’sreferringphysician.Allcareplansincludeeducationforbothpatientsandtheirfamiliesorcaregiverstoassisttheminmanagingtheircareneedsinasafeindependentway.Patientsneedingskillednursingwouldincludethoseexperiencingthefollowing:
GeneralNeeds MedicationNeedsSignificantchangeingeneralcondition UnreliablewithmedicationsUnstablevitalsigns MedicationinstructionDrainingwounds/decubitusulcers InjectionsTerminalillness AerosolmedicationsSymptomsofinfectionordestabilization OxygeninuseEdema InfusionPsychiatricsymptomsNeedforsterileprocedure EliminationNeedsParenterallinecare Indwellingcathetercare/irrigation Bowelandbladdertraining FecaldisimpactionNutritionNeeds Ostomycare/instruction Tubefeedings Specialdiet
SpecialtyNursingAreas
PsychiatricNursesThesenursesfocusonpatientswhohaveaprimaryorsecondarypsychiatricdiagnosis.Theyproviderehabilitationtoguidethepatienttoasafelevelofindependencebydeterminingthepatient’sabilitytoperformself-careactivitiesandtheirmentalstatustoremainsafelyinthehomesetting.InfusionTherapyNursesThesenursesusuallyhavespecialtytraininginantibiotic,parenteral,andenteralnutrition,continuouschemotherapy,painmanagementandhydrationtherapy.Theyprovideinterventionstomaintainandaccesscentrallinessuchas,Broviac,Hickman,GroshongcathetersandPICClines.
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Wound/Ostomy/ContinenceNurses(WOCN)
Theseclinicianshaveadvancedpracticeandtraininginenterostomaltherapy.Thesenursespecialistsarelikelytoknowthelatestskincaretechniquestocareforthenewostomy,topreventskinbreakdowninthebed-boundpatient,andtointervenewiththelatestwoundcleaningtechniquesinthepatientwithsevereskinbreakdownand/ordeepwoundcareneeds.Incontinenceofbowelandbladderisalsopartofthisspecialtyarea.MaternalChildNursesThesenurseshaveadvancedtrainingforhigh-riskmothersandinfants,aswellaspost-partumcareofearlydischargemothersandinfants.
2.CertifiedHomeHealthAide:Aidesprovidesupportservicesunderthedirectionofthenurse.Assistancewithbathing,grooming,andotheraspectsofselfcare.Apatientwouldbereferredforthisserviceforthefollowingreasons:
• Inabilitytodoownpersonalhygienecare
• Lacksable,willingcaregiver
• Needforlighthousework
• Needsassistancewithactivitiesofdailyliving
• Needsskincareforbowel/bladderincontinenceorexcessiveperspiration3.MedicalSocialWorkers(MSW):Medicalsocialworkersprovidecomplete
assessmentsofpsychosocialneeds,assistancewithresourcesandplanning,andassistthephysicianandotherteammembersinunderstandingthesignificantsocialandemotionalfactorsrelatedtothehealthproblem.Forexample,ifapatientcouldnotpayforhismedicationsthatwereorderedonthePOC,theMSWwouldassistthepatientinobtainingthem.ReasonsforreferraltoaMSWinclude:
NeedforCommunityServicesAlternate living arrangements Homemaker Referral to community services Set up community service / follow up / act as patient advocate with other agencies
CounselingNeedsChange in body image Death and dying Interpersonal problems Need for socialization Denial of illness / care needs Planning future care needs
AssistanceWithActivities
ofDailyLivingMeals / housing / self care / transportation Unsafe living conditions Evaluate ability to care for self
FinancialAssistanceAssistance with reimbursement Referrals to local, state and federal assistance programs
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4. Physicaltherapists:Registeredphysicaltherapistsprovidecompleteassessmentandtreatmentforneurologicalandorthopedicconditions,aswellasotherconditionsrequiringstrengtheningandtraininginambulationandtheuseofassistancedevices.Thephysicaltherapistisalsopivotalinassessinghomesafetyandinassistingtheentireteaminensuringasaferecoveryathome.ReasonsforreferraltoPTinclude:
• Difficultyintransfers/ambulation
• Instructioninbedmobility
• Instructionintransfers
• Muscle,joint,orbackpain
• Newlydevelopedcontractures
• Difficultywithlowerextremitybrace
• Assistivedeviceinstruction5. OccupationalTherapists:RegisteredOccupationalTherapistsprovidecarefor
patientsrequiringtrainingandstrengtheninginordertoregainindependenceinself-careactivities.ReasonsforreferraltoOTinclude:
• Difficultywithactivitiesofdailyliving• Limitedupperextremityrangeofmotion• Instructioninenergyconservation• Decreasedcoordination/lossoffinemotorcontrol• Difficultyproblemsolvingorothercognitivedisorders• Splinting/adaptiveequipmenttraining
6. SpeechandLanguagePathologists:CertifiedspeechPathologistsassessand
providecareforpatientswithcommunicationdeficitsandswallowingdisorders.Patientandfamilyeducationisanintegralpartoftreatmentbythespeechpathologist.Reasonsforreferraltoaspeechpathologistinclude:
• Difficultywithreceptiveorexpressivecommunication• Poorgagreflex/swallowingdifficulty• Disorientationtotime/place• Shortattentionspan/short-termmemorydeficit• Facialortonguemobilitydeficits
7. Nutritionists:RegisteredDieticiansprovidenutritionalassessmentandeducation
toaidthepatient’srecovery.
8. Pharmacy:Pharmacistsprovideconsultingservicestotheteamtoensuremaximumefficiencyinthecareofthepatient’smedicalcondition.
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TESTYOURSELF
1. A67-year-oldstrokepatientisdisorientedtotimeandplaceandhavingdifficultyswallowing.Thepatientshouldbereferredto:a. Medicalsocialworkerb. Skillednursingservicec. Occupationaltherapistd. Speechpathologiste. Physicaltherapist
2. A71-year-oldladywithseverearthritisishavingbackpainanddifficultygettingin
andoutofbedandambulating.Sheshouldbereferredto:a. Occupationaltherapistb. PhysicalTherapistc. SpeechTherapistd. SkilledNursinge. HomeHealthAide
3. A68-year-oldmalewithalefthipreplacementiscomplainingofbladder
incontinenceandhassevereperianalskinbreakdown.Heshouldbereferredto;a. Wound/Ostomy/Continencenurseb. Homehealthaidec. Medicalsocialworkerd. Nutritionservicese. Alloftheabove
4. A65-year-oldishavingdifficultywithADL’sespeciallydressingandfeedinghimself
afteraCVA.Heshouldbereferredto:a. Medicalsocialworkerb. Homehealthaidec. OccupationalTherapistd. PhysicalTherapiste. Skillednursing
Answers:1-d;2-b;3-a;4-c
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HOSPICECARE
WHATISHOSPICECARE?HospicecarehasenabledmillionsofAmericansandtheirfamiliestoreceivequalityend-of-lifecarethatprovidescomfort,compassion,anddignity.Hospicecareinvolvesateam-orientedapproachtoexpertmedicalcare,painmanagement,andemotionalandspiritualsupportindividuallytailoredtothepatient’sneedsandwishes.Supportisextendedtothepatient’slovedonesalso.Atthecenterofhospiceisthebeliefthateachofushastherighttodiepain-freeandwithdignity,andthatourlovedoneswillreceivethenecessarysupporttoallowustodoso.Thefocusisoncaring,notcuring.Inmostcases,careisprovidedinthepatient’shome.Hospicecareisalsoprovidedinfreestandinghospicefacilities,hospitals,andnursinghomesandotherlong-termcarefacilities.Hospiceservicesareavailabletopatientsofanyage,religion,race,genderorillness.ADMISSIONTOHOSPICETobeeligibleforMedicareHospice:1.Aphysicianmustcertifythatthepatienthasaterminalillnesswithalifeexpectancyof
lessthan6months.2.Thepatientmustbeawareofhis/herownprognosisandexpressthatnofurther
treatmentisavailableordesired.Thepatientandfamilymustalsoknowthatartificial,life-prolongingproceduresareinconsistentwiththehospicephilosophy.
3.Medicarepatientsmusthaveaphysicianandthemedicaldirectorofthehospiceprogramcertifythattheyhaveaterminalillnesswithalifeexpectancyof6monthsorless.MedicarepatientsmustreceivecareformaMedicarecertifiedHospiceagency.
Patientsonhospicecanstillreceivemedicaltreatmentforproblemsnotrelatedtotheirterminaldiagnosis.REIMBURSEMENTReimbursementforservicesrenderedbyHospicearepaidforby:
• Medicare• Medi-Cal• PrivateInsurance• HMO’s• Self
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PURPOSEThepurposeofHospiceistoreducethefearsandsufferingofterminallyillpatientsandtheirfamiliesandtocontributetothequalityoftheirlivesduringthedyingprocess.Hospicealsoaidsthefamiliesduringtheirperiodsofbereavementandtheirstepstowardreadjustment.Hospiceconsidersthepatientandthefamilyasaunitofcare.Thefamily,aswellasthepatient,isgivenemotionalsupporttocopewithimpendingdeath.OneuniquedifferencebetweenHospiceandotherhealthcarefacilitiesistheprovisionforbereavementfollow-up.Familymembersareofferedgroupcounselingsessions,contactbytelephoneandpersonalvisitsafterthepatient’sdeath.TheHospiceteamconsistsof:
• Amedicaldirector• Hospicecoordinator• Nurses• MedicalSocialWorkers• BereavementCoordinator• HomeHealthAides• Volunteers• PastoralSupport• Rehabstaffasneeded(speechtherapists,O.T.,P.T.,nutritionists,etc.)
Hospicenursesarehighlyskilledandprovideallnursingcarerequiredforthepatient.ThisIncludesfoleycatheterization,IVtherapy,medications,orderinganyequipmentneededsuchashospitalbeds,suctionapparatus,oxygen,andcommodes.Theirrolealsoincludesteachingthefamilyhowtocareforthepatientwhenpossible.Theyalsoinstructthefamilyinhowtodealwiththeclinicalsignsofimpendingdeath.AmajoremphasisinHospiceissymptommanagement,e.g.pain,nausea,andsoforth.Manyterminallyillpatients,especiallythosewithcancer,experienceseverepain.ThegoalofHospiceistokeepthepatientaspain-freeaspossible,yetstillalert.Painmedicationisgivenaroundtheclockinsteadof“asneeded”whichisthecustomaryprocedure.Preventionofuntowardsymptomsaremucheasiertoaccomplishthantreatingsymptoms.Thehospicenurseisexpertatboth.Onanotherlevel,hospicecarefocusesontheemotionalneedsofthefamilyunderstressbyprovidingprofessionalcounselingorsimplythesympatheticearofavolunteer.Underhospicecare,thefamilycaregiversareentitledto‘RespiteCare’.Respitecareallowsthefamilyaspecifiednumberofhoursperweek(numberdeterminedbyInsuranceprovider)toleavethehouseforpersonalactivities,whileahomehealthaidestayswiththepatient.Familymemberscouldusethistimetogotothemovies,gettheirhairdone,gogroceryshopping,etc.Thenursesencouragestressedoutfamilymemberstousethisservice.
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Nursesalsoassessthephysicalandspiritualneedsofthepatientandfamilyandoftentimesreferotherdisciplinesforadditionalsupport.Forexample,theymaycallapastororrabbiforapatientwhoexpressesaneedforspiritualcomfortoraphysicaltherapisttoassistfamilymemberstotransferandmovethepatient.Teamconferences,whichincludeallmembersofthehospiceteam,volunteers,physician,nurses,aides,socialworkers,areheldatregularintervals.Intheconferences,theteammembersdiscussproblemsandaskforadviceindealingwiththeirpatients.
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TESTYOURSELF
1. Allowingthefamilymembercaregiverofahospicepatienttoleavehomeforafew
hoursforpersonalactivitiesiscalled:a. Revivalcareb. Reliefcarec. Respitecared. Renewalcare
2.Onedifferencebetweenhospiceandotherhealthcarefacilitiesis:
a. Hospiceagenciesmustbecertifiedb. Hospiceagenciesprovidephysicalandemotionalsupportc. Hospiceagenciesprovideforbereavementfollow-upd. Hospiceagenciesutilizeteamconferencesforstaffsupport
3.Whoiseligibleforhospice?
a. apatientwhohasbeencertifiedbyphysiciantohaveaterminalillnessb. apatientwhohas6monthsorlesstolivec. apatientwhoexpressesthathewantsnomoretreatmentsforhisterminal
illnessd. Alloftheabove
4. Whatisthemajoremphasisinnursingcare?
a. tokeepthepatientpainfreeb. tokeepthepatienthopefulofacurec. tobeafriendtothepatientd. toeducatethepatientinallcurativetreatmentsforhisillness
Answers:1-c;2-c;3-d;4-a
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SAFETYINHOMECAREPersonalsafetyisanappropriateconcerninhomecare,asitisinanycommunityorhome.Itisparticularlyimportanttohomecarenurseswhoentergeographicalareaswithwhichtheymaynotbefamiliarandatunusualhours.Thehomecareclinicianshouldreviewhisorherorganization’protocolsregardingstaffsafetyandhomevisits.PERSONALSAFETYDURINGVISITS
A. CARSAFETY• Drivingyourcareverydayaroundtownwhilemakingvisitsincreasesyour
riskofautoaccidents.Keepyourcarinsurancecurrent.• Keepyourcaringoodworkingorder.• Keepchangetofeedparkingmeters.• Alwayshaveamapofthegeographicareayouserve.• Youmaycallpatientssotheycanwatchforyou.Askaboutparking.• Donotkeepyourpurse,suppliesorothervaluablesontheseat.Lockthemin
thetrunkofyourcar.• Knowthedirectionstoahomebeforeyougetinyourcar.Itmayhelpto
writethemout.Keepthemaponaseatnexttoyouforeasyreference.• Ifyougetlostinadangerousneighborhood,gotothenearestpoliceorfire
stationfordirections.• Donotparkinadangerousneighborhoodtouseyourcellphoneorchart.
Youareaneasytarget.• Ifyoufeelunsafe,youprobablyare.Trustyourfeelings.
B. SAFETYINTHECOMMUNITY
• Iftherearegunsorotherweaponsinthehome,askfamilymemberstoputthemawaypriortoyourvisit.Iftheydonotcomply,discussalternativeswithyoursupervisor.
• Identifyhighriskneighborhoodsordangerouslocationsyouragencyserves.Requestanescortifyouragencyprovidesthem.
• Letthepatientknowwhenyouwillbevisitingandaskifsomeonecanmeetyououtsidetheirhome.
• Nevergotoahomeifdrugtraffickingisgoingon,iftherehasbeenarecentgangshootingintheneighborhoodorifthepatientsaysitisunsafetovisit.
• Donotmakethevisitifyoufeelunsafe.Callyoursupervisor.• Askthepatienttoremovepets/watchdogsfromtheyardorhomebefore
youarrive.
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PATIENTSAFETY
A. FollowUniversalPrecautionPoliciesandProceduresinHomeCare• Washhandsbeforeandaftervisit.• Instructthepatienttoprovideliquidsoapandpapertowels.• Donotusethepatient’sbarsoaporpersonaltowels.• Turnfaucetsoffusingpapertowelsonhandles.• Wearglovesduringproceduresinvolvingbodyfluids.
B. NursingBagPolicy
• Thenursingbagshouldcontainalladditionalsuppliesyouwillneedforthevisit.
• Thepatientmayhavesomeorallofhis/herownsupplies• Neverlaythenursingbagonthepatient’sbedoronthefloor.Spreada
pageofnewspaperonatableorchairandsetthenursingbagonit,ifyoucannotfindaclearsurfaceonwhichtoputthebag.
C. DisposingofSharpObjects
• Placeneedles,syringes,lancets,andothersharpobjectsinahardplasticormetalcontainerwithascrew-onortightlysecuredlid.Acoffeecanmaybeusedifyoureinforcetheplasticlidwithheavy-dutytape.Donotuseglassorclearplasticcontainers.(aliquidlaunderdetergentorfabricsoftenercontainerworkswell)Sometimestheagencywillprovidetheappropriatecontainer.
D. DisposingofContaminatedWastes
• Soiledbandages,disposablesheets,andmedicalexaminationglovesshouldbeplacedinsecurelyfastenedplasticbagsbeforeyouputtheminthegarbagecanwithothertrash.
E. GuardingAgainstInjury
Teachthepatientandfamilymembersto:• Cleanwalkingareas.Makesureallcordsandcluttersuchastoys,boxes,
books,areoutoftheway.• Securearearugs.Usetacks,rubberpadsorcarpettapetokeeprugsin
placeorremovethemcompletely.• Keepstairwayswelllit.Usenon-glarelights• Repairanyholesincarpetingandfixwarpedorbuckledflooring.• Installnonskidtreadsonstairsandnonskidstripsinshower.• Installgrabbarsonbathroomwallsforweakandfrailpatients.• Insuresmokealarmsarefunctional• Keepbedinlowposition• Don’twearlongclothing• Wearnonskidshoes• Properapplicationofprotectivedevices
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F. MonitorMedication• Sortingmedicationshomecarepatientsaretakingversusonesthey
shouldbetakingversusnewprescriptionsisdifficult.Severalphysiciansmaybeprescribingmedicationsandnotbeawareofothermedicationsthepatientistaking.
• Obtainalistofprescribedandover-the-countermedicationsthepatientistaking.Comparethelabelsonprescribedmedicationbottleswithwhatthepatientstatesthathe/sheistaking.Ifthereisadiscrepancythatcannotbereasonablyunderstood,callthephysician.
• Sometimesthepatienthasthegenericmedicationandabrandnamemedicationandnotrealizingtheyarethesamedrug,istakingthemboth.Checkallthelabelsagainstthemedicationsheet.
• Setupasystemforthepatient.Forexample,usetraysoramulti-compartmentpillboxtoorganizedifferentmedicationsandindicatethetimestheyshouldbetaken.Writeoutamedicationschedulefortakingmeds.
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TESTYOURSELF
1. Youarethehomehealthnurseassignedtoapatientwholivesinaneighborhood
knownforgangactivity.Whenyouarriveatthepatient’sresidence,younoticeseveralgangmembersdrinkingandsmokingmarijuanainfrontofthebuilding.Youwould:
a. Leavetheareaimmediatelyb. Callyoursupervisorandtellherwhat’shappeningbeforeyougoin.c. Gointothehomeanyway,butbeonyourguardd. Notworryaboutit.Theyprobablylivethereandwon’tevennoticeyou
2. Whencaringforapatientinhishome,youwould:a.Layyournursingbagonasheetofnewspaperonthefloorb. Placeusedneedlesinasturdyglassjarwiththelidsecuredwithtape
c. Weargloveswhiletakingvitalsignsd. Usethepatientsliquidsoaptowashyourhandse. Alloftheabovearecorrect
Answers:1-a;2-d
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TypicalHomeHealthNurseDay
v Arriveatwork,handinyesterday’spaperwork,checkcomputerforpatientstobeseenthatday,checkinwithsupervisor.
v Callpatientstosetupvisittimes.Introduceselftonewpatients,explainthattheirhealthcareproviderorderedahomevisitandaskpermissiontovisit.Verifyaddress.Asknewpatienttotakeoutallinsuranceinformationandmedicationsthattheyarecurrentlytaking.Checkonstatusofneededsupplies,newhealthissuesforongoingpatients,andsoforth.
v Callhealthcareproviders,pharmacy,DMEprovidersasneeded.v Checkbag,caresupplies,obtainneededsupplies.v Gathernecessarypaperwork/computer.v Seeeachpatientandcompletepaperworkaftereachvisit.v Gohomewhenfinished.
(NOTE:sequenceofabovemayverypereachHomeHealthAgency)MakingtheHomeHealthNurseVisit:
v Don’tshowupunannouncedunlessyouareconcernedaboutpatientsafety.v Putyourvaluablesincartrunkbeforeyouleavehome/office.v Wearanamebadge.AdheretodresscodeofspecificHomeHealthAgency.v Greetpatient,handhygieneandcheckthecareplan,ifongoingpatient.v Doahead-to-toeassessmentorfocusedassessment(pertinenttowhyyouareseeing
thatpatient).v Makeahomesafetyassessment.v Assessmedicationeffectivenessandanysafetyissues.v Assessfunctionalcapacityandactivitylevel.v Assessnutritionalintakeandeliminationpatterns(askdateoflastbowelmovement).v Teachappropriately.v Callpatient’shealthcareproviderfromhomeasnecessaryv Schedulenextvisit(makesureitisincompliancewithhealthcareprovidersorders
andchangeifindicated).v Handhygiene.v Document.
WhatAretheAdvantagesofHomeHealthNursing:
v Autonomy.v NursingthewayyoulearnedaboutitinNursingschool(youaremoreincontrolof
yourtimewithyourpatientandfamily).v Flexiblescheduling.v Carryingyourowncaseload.v Keepupskillsinmanydifferentareas–ultimate“generalist”nurse.
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WhatAretheDisadvantagesofHomeHealthNursing?v Requiresaminimumofoneyearofmedicalsurgicalnursingbeforeyoucanapply.v Paperwork.v Lackofcolleaguesaroundallday(e.g.ifyoucan’tstartanIV,thereisnotsomeone
downthehallyoucancalltostartitforyou).v Beingoutonthestreetsonyourown.v Usingyourowncar.v Increasingcostoffuel(agenciesusuallyreimburseforgas,butitdoesnotcoverthe
highcostofgasoline).WhoWouldMakeaGoodHomeHealthNurse?
v Self-starterandlikestoworkalone–confidentwithskills.v Strongassessmentskills.v Wellorganized.v Likestodrive.v Veryflexible,thrivesontheunexpected.v Goodsenseofhumor.v Strongpatientadvocate.v Enjoysbeingadetective.v Verytolerantworldview(e.g.dirtyhousesdonotreflectthepatientlivinginside).v Likesanimals(willfindmanyinthehomestheyvisit).
WhoWouldNotEnjoyBeingaHomeHealthNurse?
v Requiresstructure,routine,andalotofsupport.v Sloworinadequatedocumentationskills.v Doesnotpossessstrongassessmentskills.v Someonewhoneedsto“control”theprofessionalsituation(remember:youarethe
guestinthatpatient’shouseandyouneedtorespecttheirpreferences+thetimeinwhichtheyprefertodothings).
v Theperfectionist.
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LOSANGELESHARBORCOLLEGENURSING339
STUDENTNURSEPROCEDURESStudentsmayperformthefollowingproceduresunderthesupervisionoftheRN:
v VitalSignsassessmentv Suctioning–Oral,nasotracheal,andtrachealv ChangingIVtubing/bagv Centrallinedressingchangev DiscontinueIV/salinelockv FoleyCatheterizationinsertion/irrigation/care/discontinuationv Enemav Harrisflushv Feedingviagastrostomyornasogastrictubesv Fingerstickbloodsugarv Irrigationofwoundsandapplicationofdressingsv Nasogastrictubeinsertion/feeding+discontinuationv Collectionofurine/stoolspecimenv Colostomy/urostomybagchangev Givemedications:PO,IVPB,SC,IM
STUDENTSMAYNOT:
v StartIVsv Drawbloodv Givebloodv Flushcentrallinesv Signpermitsv ReadECG
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HomeHealth
PatientHandouts
PrintedwithpermissionfromLittleCompanyofMaryHomeHealthandTorranceMemorialHomeHealth&Hospice.ThesearejustasampleofformsthataregiventoeachPatientonserviceintheformofaPatientHandbook.Inreviewingthisinformationthestudentshouldalsoremembertoreviewthe:
Ø TheJointCommissionsafetyguidelinesØ TheBradenScaleforpredictingpressuresoreriskØ HIPAAinformationØ SignsofgeriatricabuseØ HighalertmedicationlistØ Variouspainassessmenttools
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