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Nursing Moves Into the Home

Monday December 17, 2007
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Lillian Wald experienced a watershed moment early in her career. When she happened to visit a mother at home and found her hemorrhaging after childbirth, Wald realized she had no idea what disadvantaged women faced in their daily lives. Wald began visiting clients in their homes and teaching them how to care for themselves.

Wald and Mary Brewster started the Henry Street Visiting Nurse Service in 1893, and within 10 years they had a team of 20 nurses and had established innovative health, educational, and recreational programs. The nurses from the Henry Street Settlement Visiting Nurse Service became The Visiting Nurse Service of New York in 1944, one of the templates for home care nursing services everywhere.

The more things change ...

The tree that grew from those roots in New York is huge. Care that used to occur in the hospital now happens in either a rehabilitation setting or in the home. This process, along with a tightening reimbursement climate, has changed home care forever.

These changes have affected the way home care is delivered, says Sherl Brand, RN, BSN, CCM, president and CEO of the Home Care Association of New Jersey, an alliance of more than 150 home health providers in the state. Agencies are confronted with the need to meet the increasingly complex requirements of patients in a strict reimbursement atmosphere.

"We have always been focused on ensuring people get the care they need; that has never changed," says Brand. "What is changing is that patients are discharged earlier from the hospital with multiple and complex problems. Agencies are constantly challenged to provide that care in the most efficient and cost-effective way possible."

The association has a number of committees, with membership drawn from providers throughout the state, focusing on issues such as wound care, infection control, and telehealth. These groups work together to share information and to identify and establish best practices in the field.

"Nurses have always done this," says Brand. "We've shared information to establish the best way to provide care. The association is proactive in helping agencies get the information they need as easily as possible."

The more they stay the same

The skill of the visiting nurse, who goes to the patients' homes to assess their condition, the home environment, and support system, has become an important part of the continuum of care. Since Lillian Wald started her classes, home care has been about teaching and helping clients achieve independence. That goal has never changed, although the complexity of care has certainly increased over the years, says Donna Fry, RN, BSN, MPH, president, Valley Home Care, Inc., Paramus, N.J.

"Sometimes the patient has a particularly complicated wound care regimen or has a fragmented home support system. When that happens, the visiting nurse steps in and provides the care," Fry adds.

At times, the care seems overwhelming to families, but they may want to have the patient at home. When that happens, the agency personnel take action and do everything they can to give the patient and family a chance to succeed, says Ellen McAndris, RN, MPA, CNA, director of Professional Clinical Services at Valley Home Care. The care and reassurance often mean the world to the patient and his or her family. Some patients have multiple needs, like total parenteral nutrition (TPN), IV therapy, ostomies, and wound care. McAndris says the key is to take each problem, one at a time, and develop a care plan.

"Recently, we had a patient who required a drainage tube from the pleural space. Initially, we were uncertain whether the family would be able to manage the care," she says. "We taught them and felt comfortable with their ability. If there's any possible way [something] can be done, we do it."

Type 2 diabetes has reached epidemic proportions in the U.S. Its complications affect almost every organ of the body; however, controlling the disease can make a difference in the patient's later life. Valley Home Care has a diabetic self-management program for those who are interested in controlling their disease in the early stages. There are two programs, one for the traditional homebound patients and the other one for those who are not homebound but need help in developing long-term home management plans.

Never alone in care

Valley Home Care has a team of APNs who specialize in cardiac, wound, and ostomy care and IV therapy. They see patients and are a resource for the field staff. Karen Grant, RN, MS, CPHQ, director of QI and staff education at Valley Home Care, says that they are a tremendous resource for the field staff.

"They are proactive and are always available to the staff. For example, in an effort to keep everyone up-to-date, the wound care nurses offer information about the latest products and techniques. Next week, they are holding a product fair, with demonstrations for staff," says Grant.

In the hospital, a staff nurse can ask a colleague to look at a wound and give an opinion. The visiting nurse has no such luxury, but technology has offered a solution. The field nurse uses a camera phone to document wounds and e-mails the image to the clinician through a secure account. The nurse then consults with another experienced consultant about the patient in a timely and efficient way.

Phoning it in

Brand says that the emergence of telehealth systems has been a boon to many home care agencies. Nurses collect information from the patient about vital signs, blood sugar, and weight that was previously available only from self-reporting or direct observation. Sometimes, having this information prevents an unnecessary visit, and sometimes it triggers an unscheduled visit.

"Certainly, telehealth will not replace the need for an RN but can complement the nurse by providing important patient information between visits," Brand says. "For example, because a nurse can monitor a patient with CHF for weight gain, he or she can intervene immediately and prevent a hospitalization."

McAndris agrees. Valley Home Care uses its telehealth system as a complement to visits for patients with cardiac conditions and diabetes, and the agency finds the combination is cost-effective and better for patients. The APNs use their time more effectively by focusing on those patients who need their attention in person.

Brainstorming for solutions

At JerseyCare Home Health, West Orange, N.J., an affiliate of the Saint Barnabas Health Care System, the professional team has an advantage: affiliations with three other New Jersey home care agencies. Medical Center Health Care Services, West Orange; Community Medical Center Home Health, in Tom's River; and Community Kare in Lakewood are all part of the Saint Barnabas Health Care System, and each has distinct perspectives and patient populations.

"We began to see a need for a program for patients who had joint replacements but didn't want to go to a subacute facility or rehabilitation center," says Patricia Toglia, RN, MS, vice president of Home Care, Saint Barnabas Health Care System, West Orange. "Technology and surgical techniques have changed over the years, and we see more individuals who go home but need an intensive home care program. We worked collaboratively with nursing and rehab professionals in our system to design one that offers intense care so patients get back to their routines as quickly as possible."

Susan Trotter, RN, BSN, administrative director of JerseyCare, is enthusiastic about the Joint Replacement Recovery Program and sees it as one part of the home care mosaic. The agency recently launched a Stroke Recovery Program for patients who choose to return to their homes as quickly as possible. She says there are new home techniques and treatments all the time, from new wound care equipment to new types of drainage tubes. The home care intake coordinators in the hospital are responsible for making sure that the patient receives all of the necessary equipment and that the agency is alerted to the patient's needs.

"I have daily contact with the JerseyCare Home Care intake coordinators in the hospitals," Trotter says. "We review any case that has special needs to be sure the agency is prepared to receive the patient at home with an appropriate plan."

As patterns of patient needs change, the agency responds proactively to provide care that is disease-specific. One fruit of this is the Cardiac Rehabilitation Program, developed by the JerseyCare staff of physicians, nurses, and therapists. The program is designed to bridge time between coronary artery bypass graft surgery and outpatient cardiac rehabilitation, which is typically about six weeks. Step by step, patients are moved through the recovery process.

That has been the focus of home care since Lillian Wald started the Henry Street Settlement so long ago. The nurses who have followed are still out in the field — assessing, treating, comforting, teaching, and advising. Teaching patients and their families to manage care that is complex and difficult is just one more part of the tool kit in that famous shoulder bag.

To comment, e-mail editorFL@nursingspectrum.com.

Marylisa Kinsley, RN, BSN, is a frequent contributor to Nursing Spectrum.