Advanced Practice Nursing

Advanced Practice RN’s in the Home Health Care Arena

Identification of the phenomenon.

There is an urgent need for APRN services in the home health care environment. That is the pivotal position this paper proposes to pursue. In a general sense, it is clearly evident that there is an urgent need for quality home care that exceeds the minimum expectations of patients and their families; this need exists because excellence and integrity in the delivery of home health care can help erase (and overshadow) the negative publicity perpetuated by incidents of malpractice, of gross incompetence, and of scandalous acts of patient abuse at the home care level. There can be no equivocation on the issue of the existing demand by consumers for the highest quality of service available when it comes to home health care; the cost of health care has been going up and up, and hence, the quality of service should be rising too – even faster than the cost.

II. Review of Literature

A. Relevant Literature reviewed as appropriate for the qualitative study planned.

The Basics of Home Health Care Services. The trend towards home health care (HHC) has been gaining widespread acceptance and momentum over the past few years. The reasons for the growth of HHC are numerous; families would certainly rather have their elderly members in the comfort of their own home (rather then in a nursing care facility), where love and familiarity are plentiful, and where grandma’s rocking chair still has those same hand-crocheted doilies on the arms that were there when grandpa was alive. HHC is also the preferred choice when a younger family member is injured or ill, and the doctor has offered the patient a chance to heal at home rather in the stale atmosphere of a hospital. Costs are a consideration as well: it’s certainly more economical for a family on a budget (as most families are) to have their loved member at home.

An explanation for the literature reviewed in this paper: there is a dearth of data relating to the specific training and planning for, and results of, placing advanced practice nursing talent in home health care situations; therefore some of the literature in this paper is being reviewed to demonstrate the increasing need for advanced practice nurses in home care environments, and to illustrate the gaps in quality medical care now being offered by some home care agencies.

Meanwhile, as an introduction to the issue at hand, it may be useful to take a condensed look at HHC and some of its particulars. There are two main categories of HHC – intermittent and continuous. Intermittent care is “a periodic home visit where nurses concentrate their time on assessment, intervention, and patient/family teaching” (Madigan, 1997).

A typical example of intermittent care would be, say, a child may be in traction at home following a skateboard accident, having already spent a week in a hospital. At least one mature member of his family is in the home at all times (dispensing appropriate/prescribed medications, toileting, changing bed clothing), and the visiting nurse comes to the home perhaps twice a week, to check on the boy and the care being given to him. A typical continuous care situation involves “nursing care where the nurse provides the bulk of the care to the child,” Madigan writes, in the Journal of the Society of Pediatric Nurses. The child, in the continuous care instance, might be ventilator- dependent, and thus requires the continuous care. The nurse’s shift in this kind of situation is usually 8 to 12 hours in length, and family members fill in the gaps when the nurse is not present (albeit HHC agencies nearly always provide 24-hour on-call services, if there is a problem while the nurse is not present).

And there are more considerations, such as: A) what if the child lives in a rural area outside the community where he was hospitalized, and that particular area is not serviced by the hospital’s home health care agency? In that case, there should be a home health care trade association in the state which can provide a list of agencies to choose from. B) And, key questions have to be asked prior to the family accepting the services of an agency, such as: does the agency have nurses with pediatric nursing experience? Do they have on-call services 24 hours a day, 7 days a week? Do they provide care on weekends? Are they accredited by either JCAHO or CHAP? Ms. Madigan’s article goes on to suggest these additional questions: what services are available, from the HHC provider and outside providers contracting with the HHC agency? What is their experience with high technology cases? What are their administrative and staff credentials? What is the process for staff supervision (lines of authority)? Does the agency care for Medicaid patients, how are payments determined prior to delivery of service, what precisely is the billing process – and exactly what are the costs of services?

Nurses providing HHC spend a good deal of their time teaching children and their families about the illness or condition of the home-bound patient, and about treatment regimens and of course medications. The goal of HHC is to “discharge the child from home health care with sufficient patient/family knowledge for the early detection of problems” (Madigan, 1997). There are five “general categories of patients and families” for which HHC is necessary, Madigan writes. The first category is the technology-dependent patient (on ventilators, for example). Category #2 (still in the pediatrics genre) is the patient “whose condition makes leaving the home burdensome”; for example, a child in a skeletal traction at home, or a child with a cast that makes sitting in an automobile difficult, or those with multiple burns making movement very painful. In the 3rd category are those whose family members’ ability to learn care-giving is in serious doubt, for physical, emotional, intellectual – or other numerous reasons. The 4th category of a child who benefits from HHC is in the event the family cannot, or will not, follow-up on nursing instructions for proper care. And in this group, there also may be a question of “abuse or neglect” on the part of the family – or, they may simply state flatly they do not wish to provide follow-up care. And number five on this list is for children who live in outlying areas where the doctor is 25 or more miles away.

Integrating Advanced Practices Nurses into Home Care Environments

There is a growing and indeed in some cases an “overwhelming” preference for home care (vs. institutionalizing) among the elderly, especially for those with chronic illnesses and those who are physically dependent, according to an article in Nursing and Health Care Perspectives (Mitty & Mezy, 1998). And the federal government’s Medicare and Medicaid financing is available for many older people, to promote their “independent living” and hence to match the demand for home care. But according to the journal article, there is a dearth of linkages between home care delivery agencies and academic nursing programs, and the article urges changes in health care to “support the expanded role of NPs as primary care providers.”

After all, NPs have a “proven efficacy in health promotion, early identification and prevention of complications,” as well as patient compliance and education – so, it is a logical argument to bring advanced practice nurses into the home care environment, and in order to plan for the future, more specifically targeted nursing teaching programs are proposed as a solid strategy for integrating primary care by NPs into the home care genre. The growth of home care services was tremendous between 1988 and 1995, as the number of Medicare home health visits jumped from 37 million to 252 million. Money spend through Medicare home health care visits also leaped during that period – from $2.1 billion to about $16 billion, which is the fastest-growing budget item in Medicare.

To the authors of the article, this data indicates that skilled care nursing – which entails “nursing judgment” beyond merely “hands-on” service – is being expanded into home care environments. The authors also note that the “quality and cost” of home health care services have “come under heavy attack from policymakers and regulators” (albeit authors don’t say why this is true). And while studies to date have not shown any “significant savings” for home care, other studies report “significant functional improvement and/or institutional cost savings” within sixty days of admission to home health for those with “chronic illness, for recipients at high risk for hospitalization, and for elderly persons receiving comprehensive geriatric assessment.”

The point of the article under review is to promote the fact that advanced practice nursing care is needed in the home environment more than ever, and yet there is not a big push within the nursing education community to provide curricula specifically tailored towards training NPs for home care work. And in addition, the article points out that between 1992 and 1996, RNs in public health centers increased by 42%, but there’s no data to reflect the growth of RNs in home care services. Right within those numbers is a sign that it’s so much a new field that not enough attention is being paid to it. The article breaks down information on the 70,000 nurses currently certified by the American Nurses Credentialing Center, showing that 2,000 of those 70,000 are trained in geriatrics. And of those 2,000, nearly 80% work in nursing homes; the others are stationed in hospitals and ambulatory settings. No numbers were given for the number of nurses working in home care settings. And yet the importance of having NPs in the home is clear”; their presence in the home “has been shown to delay the development of disability and reduce permanent nursing home stays.”

Moreover, when NPs follow high-risk patients from hospitalization to care at home following discharge, there are “significant improvements in outcomes” and also lower costs associated with that service than with patients who received “customary care.” But, in the surveys these authors have conducted (four centers selected by the Health Care Financing Administration [HCFA]), NPs do not provide primary care services; instead, their time is spent on “case management, consultation, and in-service programs for staff.” And four of the 15 agencies the authors contacted do employ GNPs, but they provide case management rather than direct care. Case management nurses are like “brokers” wheeling and dealing within agencies to provide staffing – and they are primarily based in offices; they are not primary providers, which, as the article points out, they should be.

Also, the article points out, while NPs offer an “attractive solution” to the home health care market, it is not clear that “physicians can easily make the transition from hospital and office-based practice” to delivering home care services.

And what will the potential role be for NPs as primary care givers in the home? Direct care, and supervision of high-technology medical and nursing care, plus “medication management and health counseling,” along with the supervision and training of paid caregivers, as well as informal, family-based caregivers.

And how are schools of nursing progressing in terms of the training needed for NPs in the home? Of the 80 nursing schools in the U.S. that prepare nurses for advanced practice, the article states that community health nursing programs rank 4th in enrollment. But the statistic that is most revealing in terms of the urgent need for advance practice nurses in the home is that of the 50,000 nurses certified (by the American Nurses Credentialing Center) – at the time this article was published – a scant 46 were certified as advanced practice home health nurses. Once again, the literature shows the dearth of trained advanced practice nurses ready and available for home care service.

The model for the teaching of home care programs is the Teaching Nursing Home Program (TNHP), and the authors have listed six “obstacles” which will have to be overcome. They are: 1) “Evidence of effectiveness of NPs in home care”; 2) “Financial and regulatory support for NP primary care home service”; 3) “Evidence of the benefits of an affiliation between home care agencies and a THCP”; 4) “Compensation for staff time”; 5) “Development of curriculum and faculty capacity” to teach; 6) “Development of the home care agency as a clinical site.”

Effects of a relationship-enhancing program of care on outcomes

Meaningful relationships” between caregivers and older patients – whether the patient is in a home care environment or in a long-term care facility – have not received much attention from researchers, according to research in the Journal of Nursing Scholarship.

And this is a prime example of why nursing schools need to be preparing advanced practice nurses for the work – in particular, home care health services – that is demanding, challenging, and growing by leaps and bounds as the U.S. population grows ever older. According to the article (McGilton, et al., 2003), “Care providers are not being taught how to form these relationships, nor how to develop rational skills, which might be a necessary first step in relationship building.”

The article offers three potential ways to “enhance care providers’ relational behaviors and their relationship” with patients. One can’t help but think this training of caregivers should – and probably will – fall into the hands of advanced practice nurses. The first way of positive intervention for care providers is “training…aimed at improving their interactional skills…using positive statements more frequently, initiating more verbal contact.” Secondly, introducing “continuity of care provider models that were developed to improve the general quality of care…” And the third way to enhance relational care authors suggest is “the establishment of clinically supervised…staff motivational systems,” which, of course, will be led by advanced practice RNs.

Validity and Community-Health Nursing Sensitivity of Six Outcomes for Community Health Nursing with Older Clients very recent research article in Public Health Nursing (Head, et al., 2003) included a survey in which 239 experts rated outcomes (from the Nursing Outcomes Classification, NOC) relevant for the elderly community of patients. “Evaluating the effectiveness of health care has become an urgent imperative in the United States,” the article states. It further declared that nursing research into the effectiveness of nursing interventions “with vulnerable populations” is an important yet under-prioritized issue. “Although members of vulnerable groups…including elderly clients who receive home health care, have been the subjects of community health nursing intervention studies, effectiveness research has not been possible in the absence of large data sets that include standardized outcomes data.” And, the article continues, although the Centers for Medicare and Medicaid Services (CMS) have mandated that home care agencies gather and database the standardized outcomes and assessment information, the Outcome and Assessment Information Set (OASIS) has subsequently been criticized “as inadequate to fully document the effect of [home care] nursing.” Plus, the responsiveness to nursing interventions to the outcome measures has not been specifically evaluated.

The bottom line here is more research is needed to see if home nursing care agencies are keeping accurate records and patient data.

Review: home visitation by nurses beginning prenatally and extending through in infancy prevents child abuse and neglect.

Home nursing by qualified professionals prevents abuse to kids. It’s as simple as that. The Evidence-Based Nursing research (MacMillian, 2001), conducted through analysis of existing studies on the issue shows that: 1) home visitation by nurses for first time mothers (in low socioeconomic groups, of single parents, or teenaged parents) “reduced child abuse and neglect” when the nurse made consistent visits throughout pregnancy and into infancy – and this study was verified by a 15-year follow-up of the families; 2) another study indicated “reduced injuries and ingestions at 4 years follow-up” in the group that had received regular nurse home visitation and care. The authors, in their conclusion, state that home nursing is “good,” but “strong evidence” to support studies can be gathered only through “programs of high intensity and duration, with specific content and implementation by nurses.” Which is to say, once again, that future home health care program research cries out for advanced practice nursing talent.

Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: a randomized controlled trial.

In another even more dramatic study, reported in the Journal of the American Medical Association (Kitzmann, et al., 1997), it has been shown that a qualified visiting home nurse “can prevent many childhood injuries in low-income families,” when the RN visited the family “during pregnancy and throughout the child’s first two years.” Compared with the women who did not have a home care nurse, women who did have a visiting nurse had “a lower rate of pregnancy-induced hypertension and were less likely to get pregnant again,” the authors report.

Specifically, this survey was done in Memphis among 1,139 “primarily African-American woman at less than 29 weeks’ gestation, with “no previous live births, and at least 2 sociodemographic risk characteristics (unmarried, less than 12 years’ education, unemployed).” In the interest of space for this paper, all the measures checked throughout the study – such as low birth weight, ingestions – will not be mentioned. But, the outcomes for these women is important; to wit, in contrast to counterparts assigned to the comparison condition, “fewer women visited by nurses during pregnancy had pregnancy-induced hypertension (13% vs. 20%)”; during the first 2 years after delivery, “women visited by nurses during pregnancy and during the first 2 years of the child’s life had fewer health care encounters for children in which injuries or ingestions were detected (0.43 vs. 0.55)”; and in terms of days that children were hospitalized with injuries or ingestions (0.03 vs. 0.16); and fewer “second pregnancies (36% vs. 47%).”

Home Health Care: Improving Quality, Tightening Standards

The Centers for Medicare and Medicaid Services (CMS) published a report (updated in 2002) that indicates about 9,000 home health service providers served Medicare beneficiaries (as of 1996) at a cost of $18 billion. Meantime, in their “Fact Sheet” they call for all home care agencies to meet “Conditions of Participation” prior to receiving Medicare benefits for their patients. The home care agency must “conduct background investigations for all employees” and also must use “standard measurements for the quality and outcomes of patient care,” the memo asserts. (According to the study mentioned earlier in this paper (Head, et al., 2003), CMS, which of course is a branch of H&HS, has not enforced those rules requiring agencies to keep data on their services. Again, we see a lack of professionalism in HHC services.)

Worse than that, the insidious tentacles of fraud have crept into home health care; indeed, the “Fact Sheet” from CMS reports that “in four of the five states reviewed by the Inspector General (IG) on home health agencies,” some 40% of Medicare payments for home health “should not have been made.” As a result of the IG’s findings, providers who pay kickbacks to induce referrals are fined $50,000 per violation, and home care providers now must put up $50,000 surety bonds, so that “fly-by-night” operators are kept outside looking in.

Case Study in Care: APRN home nursing service goes beyond “nursing”

Nursing folks in their homes entails more than changing dressings, giving IV therapy, checking blood pressure and perhaps drawing blood. An article in RN (Kennison, 1999) points out through an actual case how much more goes into home nursing than the stereotypical tasks mentioned above. In fact, advanced practice nurses today are qualified to, according to the literature, administer chemotherapy, do physical and neurological assessments, and care for patients with “feeding tubes, ostomies, ventilators and catheters of all kinds.”

Meanwhile, Patty, a student nurse, fell hard on the cement, putting her full weight on her left elbow. Pain, unbearable pain, “10” on a scale of “1-10” kind of pain, visited Patty with unbelievable intensity, a week after she was sent home with a cast to heal. It was so severe, she had to drop out of nursing school, and was forced to assume a “more passive role in caring for her husband, Brad, who was wheel-chair bound from multiple sclerosis, and their two daughters, 12 and 14 years of age.” Incredibly, it took months of false diagnosis before a doctor finally diagnosed her problem correctly: she had reflex sympathetic dystrophy syndrome (RSDS), a disorder of the sympathetic nervous system.

First there was painful surgery, then a catheter was tunneled into the epidural space so constant infusions of bupivacaine (anesthetic and narcotic) could be administered. There’s much more to the story, but when Patty began responding to the local anesthetic and narcotic with vomiting and nausea, her home care nurse, Marie, knew it was time to come up with some holistic-style solutions, beyond basic nursing services. What Marie did was show the true value of a highly trained advanced practice nurse, and become a poster girl for the issue of more APRNs needed in home care. Marie was extremely positive; she calmed the children, brought quiet to the house during her visits by turning off the TV. She taught Brad to assist Patty in learning self-catheterization (for Patty’s urinary retention problems) by holding the mirror and collection container for her. Marie encouraged Patty to draw strength from her spirituality, and she talked Patty through “progressive relaxation” – and when the family budget was drained, Marie helped Patty find a pharmacist that would accept installment payments. And when Patty needed a shot of self-esteem, Marie invited her to share her painful experience with groups of nurses and nursing students at the school Marie had attended. It was a therapeutic presentation for all in attendance.

And when Patty developed a serious complication (“her epidural catheter migrated into the subarachnoid space, putting her at risk for bacterial meningitis, drug overdose, and cardiac complications,” according to the author), Marie rushed her to the hospital. Without the catheter into her arm, the pain returned, and so, more surgery was prescribed, to implant a spinal cord stimulator – to block pain messages to the brain. In the end, Maria helped Patty develop “coping skills, encouraged inner strength,” allowed her to retain a degree of optimism, helped Brad manage his own illness more effectively, and even encouraged the couple to “recommit themselves to their marriage” when times were the darkest and they began to talk about divorce.

Practical Guide to Caring for Caregivers

Who’s going to train the caregivers? No secret here: it’s going to be medical staff, and more than likely, advanced practice nurses in home care will shoulder the bulk of the responsibilities when it comes to teaching families how to give good care to their loved ones. The literature shows how old America is becoming: according to an American Family Physician article (Parks, et al., 2000), “by the year 2030, an estimated 20% of the U.S. population will be 65 years or older.” And as American populations grow older, more and more people will be serving as caregivers for family members suffering dementia and other impairments. Today, dementia “is present in 10% of individuals older than 65 years, and in 47% of those older than 85 years.” Up to 80% of persons with dementia, the research shows, “are cared for in their homes by family members.”

In one study, mentioned by the authors, it was estimated that persons with Alzheimer’s disease required “an average of 70 hours of care per week, with 62 of those hours provided by the primary caregiver.” Further, the incidence of depression in caregivers “ranges from 18 to 47%, and caregivers who are depressed experience higher degrees of burden.” Indeed, caregivers have been described as “hidden patients” – and there is nothing hidden in the fact that the need for good home health care nursing services will be greater and greater, as the population grows older and older.

References

Centers for Medicare & Medicaid Services (2002). Home Health Care: Improving

Quality, Tightening Standards. http://www.cms.hhs.gov.

Fischer, Linda (1997). Lessons in Home Health. RN, 60, 55-57.

Head, Barbara J. Ph.D., R.N.; Maas, Meridean, Ph.D., R.N., FAAN; & Johnson,

Marion, Ph.D., R.N. (2003). Validity and Community-Health Nursing

Sensitivity of Six Outcomes for Community Health Nursing with Older

Clients. Public Health Nursing, 20, 385-398.

Kennison, Monica (1999). A Case Study in Care. RN, 62, 46-49.

MacMillan, H.L. (2001). Review: home visitation by nurses beginning prenatally

And extending through infancy prevents child abuse and neglect. Evidence-

Based Nursing, 4, 80.

McGilton, Katherine S.; O’Brien-Pallas, Linda L.; Darlington, Gerarda; Evans,

Martin; Wynn, Francine; & Pringle, Dorothy M. (2003). Effects of a Relationship-Enhancing program of care on outcomes. Journal of Nursing

Scholarship, 35, 151-156.

Mitty, Ethel; & Mezey, Mathy (1998). Integrating Advanced Practice Nurses

In Home Care. Nursing and Health Care Perspectives, 19, 264-265.

Olds, David L.; Henderson, Charles R. Jr.; Hanks, Carole; Cole, Robert;

Tatelbaum, Robert; McConnochie, Kenneth M.; Sidora, Kimberly; Luckey,

Dennis W.; Shaver, David; Engelhardt, Kay; James, David; & Barnard,

Kathryn (1997). Effect of prenatal and infancy home visitation by nurses

On pregnancy outcomes, childhood injuries, and repeated childbearing: a Randomized controlled trial. The Journal of the American Medical

Association, 278, 644-653.

Parks, Susan Mockus, & Novielli, Karen D. (2000). A Practical Guide to Caring

For Caregivers. American Family Physician, 62, 2613.

Tammelleo, David A. (2002). Benign neglect in home healthcare leads to death.

Nursing Law’s Regan Report, 43, 1-3.