COMMUNITY SETTING AND COMMUNITY HEALTH NURSING ROLES

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CHAPTER34HOMEHEALTHANDHOSPICE.docx

CHAPTER 34: HOME HEALTH AND HOSPICE PAGES: 674-689

KEY TERMS advance directive durable power of attorney home health care living will Home visits have been an integral part of nursing for more than a century, originating with Florence Nightingale’s “health nurses” in England. Following Nightingale’s vision, Lillian Wald founded the Henry Street Settlement in 1893. In addition, Wald, the “mother of public health nursing,” launched the Visiting Nurse Service of New York, which has become the nation’s largest nonprofit home- and community-based health care organization (Ruel, 2014). Home health care includes a wide range of health care services provided to people in their homes to help them through an illness or injury (Medicare.gov, 2016a). Home health care is typically more affordable than and just as effective as care that people receive in a hospital or skilled nursing facility. In addition, home health care is more convenient for people and their families, as the care they need is brought to them. Examples of home health care services include wound care, education, IV therapy, nutrition therapy, follow-up with a patient after discharge from the hospital, and monitoring of an unstable or chronic illness. The goal of home health care is to help people get better in their own homes to regain as much independence as possible (Medicare.gov, 2016a). Hospice care focuses on caring for people facing a terminal illness when the goal is no longer curing the disease (National Hospice and Palliative Care Organization [NHPCO], 2016). Most hospice care occurs in the home with support given to clients and their families. The goal of hospice care is that each person will die pain free and with dignity. Ongoing support is provided to the family after the patient dies (NHPCO, 2016) Purpose of Home Health Services The primary purpose of home health services is to provide nursing care to individuals and their families in their homes. The specific objectives and services nurses offer vary according to the type of agency providing services and the population served. Nurses who work for public health departments, visiting nurse associations, home health agencies, hospice agencies, or school districts usually provide home visits. Nurses who make home visits receive referrals from a variety of sources, including the patient’s physician, nurse practitioner or nurse midwife, hospital discharge planner or case manager, schoolteacher, and clinic health care provider. The patient or the patient’s family can also originate requests for nursing visits to assess and assist in the client’s health care. Nurses from clinics or health departments often conduct home visits as part of patient follow-up. These public health nurses make visits to follow patients with communicable diseases and to provide health education and community referrals to patients with identified health problems. Home health nurses who work for home health agencies that are affiliated with hospitals or nursing registries often make home visits to assist patients in their transition from the hospital to home. In addition, health care providers in private practice may order these visits when patients experience exacerbation of chronic conditions. The focus of all home visits is on the individual for whom the referral is received. In addition, the nurse assesses the individual–family interaction and provides education and interventions for the family and the client. The nurse evaluates how the individual and family interact as part of an aggregate group in the community. The nurse identifies the need for referrals to community services and performs the referrals as necessary. Healthy People 2020 2020 Objectives for Home Health and Hospice Care MICH HP2020-14: Increase the proportion of children with special health care needs who receive their care in family-centered, comprehensive, coordinated systems. MICH HP2020-24: Increase the percentage of women giving birth who attend a postpartum care visit with a health worker. OA-HP2020-2: Reduce the proportion of unpaid caregivers of older adults who report an unmet need for caregiver support services. OA-HP2020-4: Reduce the proportion of noninstitutionalized older adults with disabilities who have an unmet need for long-term services and supports. From HealthyPeople.gov: Healthy People 2020: topics & objectives, 2013. http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspxAccessed 2017. Home health care has changed dramatically in the last 20 years in relation to changes in Medicare home health reimbursement. “The Balanced Budget Act of 1997 (BBA) (Public Law 105–33), which was enacted on August 5, 1997, significantly changed the way Medicare pays for home health services” (Department of Health and Human Services [DHHS], 2017, p. 3). Prior to the BBA, home health care agencies (HHAs) were reimbursed using a retrospective payment system for services rendered. HHAs are now reimbursed using the home health prospective payment system (PPS). Under the PPS, HHAs receive a fixed amount of money based on reasonable cost given the client’s diagnosis and plan of care. Since the PPS was implemented in 2000, the Centers for Medicare & Medicaid Services (CMS) made revisions in 2008 and 2012. The changes included providing coverage for more diagnosis groups and certain secondary diagnoses, different resource costs depending on the timing of the home health episodes as well as certain wound and skin conditions, and changes to the therapy schedule from a single 10-visit threshold to multiple thresholds to allow for more visits if needed (DHHS, 2017). Home health care services have changed to address the needs of the population. Home health nurses visit clients of all ages and races. They visit clients who are acutely, chronically, or terminally ill; were recently discharged from the hospital or a rehabilitation facility; need wound care or intravenous therapy; have a feeding tube or tracheostomy; or high-risk pregnant women. Home health care continues to focus on the care of sick patients and is expanding to include health promotion and disease prevention interventions, including client and family education. Currently, most reimbursement for nursing services is based on the patient’s need for skilled nursing. On each patient visit, the nurse must document that the care provided is of a skilled nature that requires the knowledge and assessment skills of a nurse and must verify that the patient or a family member could not provide the same level of care. Services coordinated in the home include not only skilled nursing care provided by registered nurses (RNs), but also the services of physical, occupational, and speech therapists; social workers; and home health aides. The broader home care industry definition of home health care includes supportive social services, respite care, community nursing centers, group boarding homes, homeless shelters, adult day care, intermediate-skilled extended care facilities, and assisted living facilities (American Nurses Association [ANA], 2008). In addition, telephone support services are becoming an increasingly important aspect of home health care (Kelly and Godin, 2014). In telephone support programs, nurses contact clients through regularly scheduled telephone calls to assess how the client is doing, how well they are following the plan of care, and if they need additional support services or a home visit. Telephone support programs are beneficial in improving client outcomes and decreasing hospitalizations (Kelly and Godin, 2014). Types of Home Health Agencies Home health agencies differ in financial structure, organizational structure, governing board, and population served. The most common types of home health agencies are official (i.e., public), nonprofit, proprietary, chains, and hospital-based agencies. The number of freestanding proprietary agencies has grown faster than that of any other type of Medicare-certified home health agency. Freestanding proprietary agencies now account for 62% of all home health agencies, and hospital-based agencies for 12% of all certified home health agencies (National Association for Home Care and Hospice [NAHC], 2010). There continues to be an increase in the number of managed care agencies, which may have any type of financial structure. Managed care agencies contract with payers, such as insurance companies, to provide specified services to the enrolled clients at predetermined prices. Managed care agencies receive payment before offering services and are responsible for taking the financial risk of providing care to patients within the budgeted allotment. This arrangement works well with large numbers of enrolled clients, because the financial risk is spread across a larger number of people, many of whom are healthy and will not require skilled services. Official Agencies Local or state governments organize, operate, and fund official (i.e., public) home health agencies. These agencies may be part of a county public health nursing service or a home health agency that operates separately from the public health nursing service but is located within the county public health system. Taxpayers fund official home health agencies, but the agencies also receive reimbursement from third-party payers such as Medicare, Medicaid, and private insurance companies. Nonprofit Agencies Nonprofit home health agencies include all home health agencies that are not required to pay federal taxes because of their exempt tax status. Nonprofit groups reinvest any profits into the agencies. Nonprofit home health agencies include independent home health agencies and hospital-based home health agencies. Not all hospital-based home health agencies are nonprofit, even if the hospital is nonprofit. The home health agency can be established as a profit-generating service and serve as a source of revenue for the hospital or medical center. In this situation, the home health agency is categorized organizationally as for-profit and it pays federal taxes on the profits. Proprietary Agencies Proprietary home health agencies are classified as for-profit and pay federal taxes on the profits generated. Proprietary agencies can be individually owned agencies, profit partnerships, or profit corporations. Provided that the agencies make profits, investors in corporate proprietary partnerships receive financial returns on their investments in the agencies. A percentage of the profits generated are also reinvested into the agencies. Agencies within chains have a financial advantage over single agencies. The chains have lower administrative costs, because a larger single corporate structure provides many services. For example, a multiagency corporation has greater purchasing power for supplies and equipment because it purchases a larger volume. A single corporate office can provide administrative services such as payroll and employee benefits for all chain employees, thereby avoiding duplication of these services at each location. Criticism of proprietary and chain agencies includes concerns over the quality of services provided by agencies that are profit driven. Hospital-Based Agencies Since the implementation of the home health PPS, the number of hospital-based home health agencies has significantly increased (NAHC, 2010). This trend is not surprising in light of the fixed reimbursement under PPS and the hospitals’ incentive to decrease patients’ length of stay. By establishing home health agencies, hospitals are able to discharge patients who have skilled health care needs, provide the necessary services to the patients, and receive reimbursement through third-party payers such as Medicare, Medicaid, and private insurance companies. The rising number of home health agencies affiliated with hospitals indicates that these agencies are profitable endeavors that provide hospitals with an additional revenue source. Certified and Noncertified Agencies Certified home health agencies meet federal standards; therefore they are able to receive Medicare payments for services provided to eligible individuals. Not all home health agencies are certified. The noncertified home care agencies, home care aide organizations, and hospices remain outside the Medicare system. Some operate outside the system because they provide non–Medicare-covered services. For example, they do not provide skilled nursing care and are not eligible to receive Medicare reimbursement. Active Learning Contact a local home health agency and interview the agency director. Ask what type of agency it is, the profit status, and whether it is Medicare certified. Report findings to classmates. Special Home Health Programs Many home health agencies offer special, high-technology home care services. Offering high-tech services at home is both beneficial to the patient’s health and financially advantageous. Through the implementation of these special programs, patients who require continuous skilled care in an acute or skilled nursing institution are able to return to receive care in their homes. From the financial perspective, skilled services provided at home are less costly than hospitalization. Examples of special services are home intravenous therapy programs for patients who require daily infusions of total parenteral nutrition or antibiotic therapy, pediatric services for children with chronic health problems, follow-up for premature infants who are at risk for complications, ventilator therapy, and home dialysis programs. The key to the success of all these programs is the patient’s, family’s, or caregiver’s ability to learn the care necessary for a successful home program and the motivation of these individuals to provide the care. If family or caregiver support is not available in the home, the patient cannot be a candidate for any of these programs, and other arrangements for care must be found. Home dialysis programs are a growing trend. Through such programs, patients learn how to do dialysis at home with a helper who is often a family member or friend. Patients and their helpers receive 3 to 8 weeks of training from the dialysis clinic to learn how to use the equipment, monitor their vital signs, and keep good records of their treatment. The clinic provides the machine and all of the supplies and furnishes 24-hour telephone support. The patient follows up at the clinic monthly to ensure that treatments are working and to discuss any issues or concerns (National Kidney and Urologic Diseases Information Clearinghouse [NKUDIC], 2016). Reimbursement for Home Care Any individual older than 65 years who is homebound, under the care of a physician, and requires medically necessary skilled nursing care or therapy services may be eligible for home care through a Medicare-certified home health agency. These services must be intermittent or part-time and require physician authorization and periodic review of the plan of care. The only exception is hospice care. Any individual older than 65 years who is certified by a physician or a nurse practitioner (NP) to be terminally ill with a life expectancy of 6 months or less is eligible to receive the Medicare Hospice Benefit (DHHS, 2016). There is no requirement for the individual to be homebound or in need of skilled care or for the services to be intermittent or part-time. The hospice physician or hospice NP must recertify the patient after the first 90 days and then every 60 days to determine whether he or she is still eligible for hospice care (DHHS, 2016). The rapid growth of the home health market is reflective of the following: • Increasing proportion of people aged 65 years and older • Lower average cost of home health care compared with institutional costs • Active insurer support for home care • Medicare promotion of home health care as an alternative to institutionalization Patient or family payments comprise 46% of the private financing (12% of total spending) for home health services. Private health insurance and nonpatient revenue pay the remaining private financing. Private health insurance includes managed care plans that often involve preapproval of services and referrals from primary care providers. Private insurance companies require precertification to verify patient eligibility for services. The home care RN speaks to the RN at the insurance company, who determines the number of visits that the insurance company covers. In contrast, for Medicare patients, the home care RN determines the schedule and number of visits without calling Medicare to get preapproval. Medicare pays the home care agency a predetermined amount based on the health condition and needs of the patient. Medicare pays for home care services based on 60-day episodes. If a patient is still eligible for home care services after the first episode, a second episode can begin. There are no limits to the number of episodes for each patient. However, if the patient receives four visits or fewer per episode, the HHA is paid a standardized per-visit amount instead of an episode payment. These payment adjustments are called low utilization payment adjustments (CMS, 2016). Between 1967 and 1985, the number of home health agencies certified to provide care to Medicare recipients tripled, from 1753 to 5983 (NAHC, 2010). In the mid-1980s, this number leveled off at 5900 as a result of an increase in the volume of paperwork required and unreliable payment policies. This led to a lawsuit against the Health Care Financing Administration (HCFA) charged by Representatives Harley Staggers (D-WV) and Claude Pepper (D-FL) and a coalition of members of the U.S. Congress, consumer groups, and the NAHC. The successful conclusion of the lawsuit gave NAHC the opportunity to participate in rewriting the Medicare home care payment policies. New payment policies brought an increase in the home health benefit and increased the number of Medicare-certified home health agencies to more than 10,000. The number is now declining as a direct result of the changes in Medicare home health reimbursement enacted as part of the Balanced Budget Act of 1997. However, because of this decline, the CMS enacted a new payment system whereby home care agencies are reimbursed on a prospective payment system based on the patient’s diagnosis. The amount provided to home health agencies is determined on the basis of the average national cost of treating a home health client for 60 days. The goal of this system is to encourage efficient use of home health services without sacrificing quality (NAHC, 2010). OASIS The Outcome and Assessment Information Set (OASIS) is a data set that determines Medicare pay rate and measures outcomes for adult home care patients to monitor outcome-based quality improvement (CMS, 2008). The data set includes sociodemographic, environmental, support system, health status, and functional status attributes of adult patients as well as information about service utilization. These items are used to monitor outcomes, plan patient care, provide reports on patient characteristics for each agency, and evaluate and improve clinical performance. Nurses must use OASIS for all patients receiving skilled care that is reimbursed by Medicare and Medicaid (CMS, 2008). Nursing Standards and Educational Preparation of Home Health Nurses According to the ANA (2008), the generalist home care nurse should be educated at the baccalaureate level because of the autonomy and critical thinking skills that are necessary in home care. The generalist home health nurse must have community health assessment skills to assess client and caregiver needs, provide client and caregiver education, perform nursing actions following the client’s plan of care, manage resources to facilitate the best possible outcomes, provide and monitor care, collaborate with other disciplines and providers to coordinate client care, and supervise ancillary staff and caregivers. In home care, the nurse has a primary function of managing an interdisciplinary team that includes physical therapists, occupational therapists, social workers, nurse assistants, chaplains, and so on. In addition, the responsibilities of the generalist home health nurse include, but are not limited to, performing holistic, periodic assessments of client and family/caregiver resources; participating in performance improvement activities; collecting and using research findings to evaluate the plan of care; educating clients and families on health promotion and self-care activities; being a client advocate; promoting continuity of care; using the Scope and Standards of Home Health Nursing Practice to guide clinical practice; and identifying ethical issues and exploring options with the necessary individuals and staff members to achieve resolution (ANA, 2008). In addition to the ANA standards, home health nurses should use the competencies developed by the QSEN (Quality and Safety Education for Nurses) Institute as a guide for best practices in home care (QSEN Institute, 2014). The QSEN competencies were developed by a national advisory board that included distinguished faculty to establish effective teaching approaches to ensure that nurses graduate with essential competencies in (1) patient-centered care, (2) teamwork and collaboration, (3) evidence-based practice, (4) quality improvement, (5) safety, and (6) informatics. These six competencies in QSEN are being used by several health care institutions to monitor and ensure that their nurses are providing safe, high-quality patient care (QSEN Institute, 2014). The advanced practice home health nurse has a master’s or doctoral degree in nursing and can perform all of the duties of the generalist home health nurse (ANA, 2008). In addition, the advanced practice nurse contributes significant clinical expertise to home health patients and their families; demonstrates proficiency in care management and consultation; and is an expert in implementing and evaluating health programs, resources, services, and research for clients with complex conditions. The duties of the advanced practice home health nurse include, but are not limited to, prescribing pharmacological and nonpharmacological treatment to manage chronic illnesses, providing consultation and serving as a resource to the generalist home health nurse, participating at all levels of quality improvement and research, educating all members of the health care team about emerging trends in home health care, performing direct care of the client and family, managing and evaluating the care the client is receiving from caregivers, monitoring trends in reimbursement for home health services, consulting with staff about any ethical issues that may arise, managing an interdisciplinary team, and disseminating practice and research findings to colleagues (ANA, 2008). Albrecht’s conceptual model (1990) for home care clearly identifies educational content areas for students in undergraduate and graduate nursing programs that have specialties in home health care. An underlying premise of the model is that professional satisfaction and effective patient outcomes depend on the education and experience of the home health nurse. Implications that are apparent in the model include the following (Albrecht, 1990, p. 125): • Nursing programs at the undergraduate and graduate levels must prepare competent providers of home health care. • Curricula must include concepts related to the suprasystem, health service delivery system, and home subsystem, which includes structural, process, and outcome elements. • Students at the undergraduate level need at least one clinical observation or experience in a home care agency. • Graduate-level students need specific courses that cover concepts present in the model, including knowledge of education; preventive, supportive, therapeutic, and high-tech nursing interventions for home health care; a multidisciplinary approach to home health care; health law and ethics; systems theory; economics covering supply, demand, and productivity; and case management and coordination. The home health nurse serves as a case manager for patients who receive care either from the staff of the home health agency or through contract services. The success of the case management plan is contingent upon the nurse’s ability to use the nursing process to develop a plan of treatment that best fits the individual needs of the patient and the patient’s family or caregiver. Patient and family assessment is the first step in developing the treatment plan and nursing care plan. The Albrecht nursing model for home health care provides a framework for nurses, patients, and their families to interact and identify mutual goals of interventions and promote the patient’s self-care capability at home (Fig. 34.1) (Albrecht, 1990). Three major elements for measuring the quality of home health care patient outcomes are structural, process, and outcome elements. Structural elements include the client, family, provider agency, health team, and professional nurse. The process elements include the type of care, coordination of care, and intervention. Outcome elements consist of patient and family satisfaction with care, quality of care, cost-effectiveness of care, health status, and self-care capability. In the Albrecht model for home care, the relationship between the structural elements and the process elements directs the interventions. The nurse executes the nursing process, including assessment, nursing diagnosis, planning, intervention, and evaluation, and then the nurse coordinates patient care (Albrecht, 1990). Conducting a Home Visit Visit Preparation It is important that the nurse prepare for the home visit by reviewing the referral form, which should furnish the purpose of the visit, the geographic residence of the family, and any other pertinent information. The first home visit gives the nurse the opportunity to establish a trust relationship with the client and family to establish credibility as a resource for health information and community referrals in a nonthreatening environment. The Referral The referral is a formal request for a home visit. Referrals come from a variety of sources, including hospitals, clinics, health care providers, individuals, and families. The type of agency that receives the referral varies, depending on the necessary client services. Home health referrals are requested to provide clients with short-term, intermittent, skilled services and rehabilitation. Visits can last from 30 to 90 minutes and are scheduled on an intermittent basis according to the specific needs of the client. For example, a client who had a stroke requires skilled nursing assessments, physical therapy visits for gait training, speech therapy for speech deficit improvement, and occupational therapy for retraining in activities of daily living (ADLs) such as bathing and cooking. By reviewing the referral form before the first visit, the community health nurse (CHN) obtains basic information about the client, such as name, age, diagnosis or health status, address, telephone number, insurance coverage, and reason for the referral. The form also specifies the source of the referral—clinician, health care provider, communicable disease service, hospital, client, or client’s family. Additional information provided in the home health referral includes current client medications, prescribed diet, physician’s orders, care plan goals, and other disciplines involved in the client’s care. This information is important because it helps the nurse become familiar with the client’s condition. FIG. 34.1 Albrecht nursing model for home health care.  Based on Albrecht MN: The Albrecht model for home health care: implications for research, practice, and education. Public Health Nurs 7:118–126, 1990. Reprinted by permission of Blackwell Scientific Publications, Inc. Public health referrals are made for clients who are in need of health education (e.g., infant care education and resource allocation) or for follow-up of clients with communicable diseases. Public health referrals usually provide information on the client’s condition that necessitates public health nurse (PHN) visits. For example, for a client who is positive for tuberculosis (TB), the PHN is notified of the client’s place of residence, type and location of employment, and any known contacts, including family and friends. Another example of a public health referral is one to a 16-year-old girl for antepartum visits because she is 7 months’ pregnant and has just initiated prenatal care. Initial Telephone Contact The nurse contacts the client and informs him or her about the service referral. The first telephone contact with the client or family consists of an exchange of essential information, including an introduction by the nurse, identification of the agency that received the referral, and the purpose of the visit. After the initial exchange of information, the nurse informs the client of his or her desire to make the home visit, the client gives permission, and the group sets a mutually acceptable time for the visit. The nurse is a guest in the client’s home; therefore it is important that the client agrees to the visit. The nurse then verifies the client’s address and asks for specific directions to the client’s home. During a home health visit, the nurse requests proof of insurance, such as a Medicare, Medicaid, health maintenance organization membership identification, or insurance card. The nurse should forewarn the client so the client or family can locate the information before the visit. If the client is unable to provide this verification, the nurse assists with locating the information during the visit. Clients who receive a public health home visit do not require evidence of insurance coverage because these services are not billed directly. County public health budgets or state or federally funded programs generally cover these visits. Not all clients have telephones. For a client without one, the nurse should check the referral for a telephone number where messages can be left. It is also worthwhile to contact the health care provider who made the referral to see whether the telephone number was omitted unintentionally. If the client does not have a telephone, the nurse may choose to make a drop-in visit. This type of visit consists of an unannounced visit to the client’s home, during which the nurse explains the purpose of the referral, receives the client’s permission for the visit, and appoints a time for a future visit with the client. The client may agree to have the first visit while the nurse is there. If the client is not at home for the drop-in visit, the nurse should leave an official agency card and a brief message asking the client to contact the agency to schedule a nursing visit. The nurse informs the referring agency that the visit was attempted but that the client was not available for contact. A formal agency letter, identifying the agency and the reason for the referral, is often sent to clients who are difficult to contact. The nurse’s primary responsibility, when he or she has been unsuccessful in locating the client, is to keep the clinic, physician, or referring agency informed of efforts to establish contact with the client. Environment An environmental assessment begins as the nurse leaves the agency and travels to the client’s home. While driving, the nurse should observe the area surrounding the client’s home. The nurse should look for the location of grocery stores, drug stores, gas stations, etc., in relation to the client’s home. The nurse should observe the condition of the client’s home as well as the surrounding neighborhood. In addition, the nurse should note the client’s dwelling; for example, whether the client lives in a single-family home, in a single room in a home or hotel, in an apartment, or in a shared apartment or house. Upon arrival to the client’s home, the nurse should note the accessibility of the home relative to the client’s condition such as stairs, railings, handicapped facilities, lighting, etc. In addition, the nurse should note potential trip hazards, including uneven pavement, cracked cement, small rocks, etc. The nurse should also observe potential safety concerns, such as the client lives alone, the neighborhood has a high crime rate, the building or home is not secure, trip hazards inside the home (such as rugs, clutter on the floor), unclean environment, etc. It is also important for the nurse to note if the client’s home has hot running water, heat, sanitation facilities, and adequate ventilation. The nurse should also observe if the client has food in the home and should make note of the client’s primary caregiver and support system. Improving Communication When the nurse meets with the client, whether in the home or at another mutually agreeable location, the initial conversation revolves around social topics. The nurse assumes a friendly manner and asks general questions about the client, the client’s family, and health care services that will benefit the client. These questions help the nurse assess the client’s needs and create a comfortable atmosphere for communication. Building Trust Many clients in need of nursing visits do not trust the health care system and are uncomfortable with the representative from an agency visiting their home. For example, a client who is pregnant and does not have legal status in the United States will be hesitant to allow a nurse to visit; the client will be afraid of being reported to immigration authorities. The nurse’s role in visiting this client is to focus on the health and safety of the client and her fetus. The nurse must build a trust relationship early in the visit or the client will not allow additional visits. If a trust relationship is not established and the client believes that the nurse will report her to immigration authorities, it is highly probable that the client will move to another location to avoid future contact. Documentation of Home Care Many home health nurses would probably identify documentation issues as the most frustrating part of providing home health care. The nurse documents assessment data and interventions for all home visits. The patient record also contains a copy of the nursing care plan. “A patient MUST meet these Conditions of Participation to qualify for home health care: 1) confined to home, 2) under the care of a physician, 3) receiving services under a plan of care established and reviewed by a physician, and 4) need of skilled nursing care on an intermittent basis” (Acello and Brown, 2015, p. 8). It is critical that the nurse document that the patient meets all of these criteria at each visit. Medicare holds a prominent position as a home health care payer; therefore the HCFA’s regulations determine the home health industry’s documentation. Correct and accurate completion of required Medicare forms is the key to reimbursement. For more information, the reader should visit http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html. Payment or denial of payment for visits is based on the information presented on the forms. If the nurse does not clearly document the provided skilled care in the electronic nursing notes, the fiscal intermediaries will argue that the care was either unnecessary or not performed and will deny reimbursement. The home health nurse must have an excellent clinical foundation and the ability to identify and document actual and potential patient problems that require skilled nursing interventions (Acello and Brown, 2015). Documenting the care provided to record the patient’s quality of care is just as important as documenting for reimbursement purposes. The documentation of home visits records the nurse’s observations, assessments of the patient’s condition, provided interventions, and the patient’s and family’s ability to manage the care at home. In addition, documentation of patient visits serves as a formal communication system among other home health professionals who also interact with the patient and family. Application of the Nursing Process Assessment During the first home visit, the type of client assessment will vary depending on the purpose of the home visit. The home health nurse assesses the client’s knowledge of his or her health status. The nurse identifies knowledge deficits and uses this information to develop a care plan. Subjective information is obtained from the client and the client’s family and includes the client’s perception of the situation and what the client identifies as problems. The nurse assesses whether the client is isolated from others physically or socially and whether the client is a member of a close-knit, nurturing, supportive family or kinship network. The amount of support the client perceives as available may or may not be accurate; therefore the nurse asks several questions about the client’s family, friends, and daily routine to assess the client’s level of social support. During the first home visit, the home health nurse assesses the client’s health knowledge; his or her physical, functional, and psychosocial status; physical environment; and social support. The nurse collects information through observations and questions the patient and family or caregivers in the home environment. It is not unusual to find inconsistencies between information the patient provides during hospitalization about the amount of physical and emotional support available to the patient in the home and the amount of help actually available to the patient in the home. The nurse validates or modifies the referral information to reflect the actual home situation. Home health nurses often use contracts that the nurse, patient, and family jointly develop to delineate the responsibilities of the patient in the home. The client’s physical assessment is generally performed in the home health visit and includes a review of all systems, with an emphasis on the systems affected by the client’s present condition. The nurse obtains objective data through the use of essential physical assessment skills such as observation, palpation, auscultation, and percussion. The physical assessment also includes information regarding the client’s functional status. Assessment of the functional status is important for Medicare reimbursement and for the development of an individualized plan of care. This assessment includes information regarding the client’s ability to ambulate, to perform ADLs independently, and to use an assistive device such as a cane or wheelchair. Specific functional limitations, such as shortness of breath and muscle weakness, are assessed at this time. Information obtained during the assessment phase is used to identify nursing diagnoses and develop a plan of care. Data collection continues while the patient receives home health services. Changes in the patient’s condition, environment, or social structure necessitate modifications in the treatment plan and the nursing care plan. There are differences between the treatment plan and the nursing care plan. The plan of treatment includes the type of home health services received, the projected frequency of visits by each discipline, and the necessary interventions (Medicare.gov, 2016b). The nursing care plan addresses specific nursing interventions designed to treat the patient’s actual or potential problems and includes identified goals with measurable outcomes. Diagnosis and Planning Develop a Plan for the Client and Family After the assessment phase of the home visit, the nurse identifies the nursing diagnoses that address the patient’s problems and identifies actual or potential problems. The identification of nursing diagnoses serves as the basis for the nursing care plan. This plan is developed in consultation with the client and the family. The plan identifies short-term and long-term goals and measurable outcomes for the patient. Goals are identified that the client is willing to work toward with the nurse’s assistance. The plan identifies nursing interventions that are necessary and additional home health services that are appropriate to help the patient achieve the identified goals. To maximize the plan’s success, it is important that the patient and family are involved in the planning process and that they access community resources. Planning is a dynamic process that continues while the patient receives nursing services. The plan is modified as needed, depending on the patient’s condition, until the identified goals are met. Outline the Client and Family Roles The goal of home visits for both public health and home health nursing is to involve the client and family in taking an active role in health promotion. The nurse is careful not to allow the client to become dependent on the nurse’s interventions, because the nurse’s involvement is short term. The nurse leaves a written copy of the plan of care with the client as a reminder for the client and family of their role as well as the nurse’s role in the plan of care. Intervention Implementation of the plan of care begins during the first home visit. The nurse begins to provide the client and family with health information concerning the client’s health status and informs them about the availability of and access to community resources. In the case of the home health visit, the nurse provides skilled nursing care. At the end of the initial home visit, the nurse discusses the need for another home visit. The nurse and client discuss the goal of the next visit; specifically, they discuss what the client should do before the visit. The nurse informs the client and family about any information or skills he or she will provide during the next visit, and the nurse and client agree on a day for the next visit. Referral for Community Services During the first visit, the nurse provides the client and family with information regarding community resources, including the purpose of the resources, their eligibility for the services provided, any involved expense, and agency telephone numbers. Referrals depend on the availability of community resources, the client’s eligibility for the services, the client’s and the family’s willingness to use the services, and the resources’ suitability for the client and family. Examples of such services are immunization clinics for children in the family; adult day care or senior centers for elderly clients who could benefit from socialization; adult education classes or continuation of high school for pregnant teen clients who have dropped out of high school; Meals on Wheels (MOW) services for clients who are not able to prepare meals; homeless shelters for men, women, and families; soup kitchens; resources for clothing and housing; mental health clinics; resources for battered spouses; and primary care clinics for low-income clients with and without insurance. If necessary, the client or client’s family may request the nurse’s assistance in contacting the community resources. The client and family are encouraged to make the contacts, but if the client and family are unable to make the calls or do not speak English, the nurse needs to intervene on behalf of the client. By providing referral information during the first home visit, the nurse can follow up on the client’s or the family’s success in contacting and using community services. Terminating the Visit The nurse terminates the first visit when the assessment is completed and a care plan has been established with the client. The average visit should not exceed 1 hour. The client receives a great deal of information during that hour, and the nurse collects a great deal of information. Most clients are tired at the end of a 1-hour visit and often cannot retain additional information. It is preferable to set a date for another home visit to reinforce the information provided and to work progressively toward achieving goals. Evaluation Evaluation of Progress toward Goals The evaluation phase occurs when the nurse can determine whether the mutually established goals are realistic and achievable for the patient and the patient’s family. The evaluation process is continuous and allows the nurse to determine the success or progress toward the patient’s identified goals. The nurse can identify the need for revisions in the nursing care plan and treatment plan through the collection of additional data during the evaluation phase. The nurse can intervene to make necessary changes. An example is an elderly wife who, during the initial home visit, stated that she preferred to provide the physical care for her frail, nonambulatory husband. On a subsequent visit, the nurse assessed that the patient was not receiving the care required for the patient’s personal care, specifically bathing. The nurse discussed the problem with the wife and presented her with available options. These included the services of a home health aide to provide personal care and bathing three times a week. A new plan was developed, and it included the home health aide. The plan was implemented and evaluated during future visits. Input from the client is critical to determine whether the goals established are realistic and achievable for the client. Modification of the Plan as Needed The evaluation process also allows the nurse and client or family to discuss what is working well and where modifications are necessary in the plan. Evaluation occurs through open communication between the nurse and client, and the nurse asks questions about specific parts of the care plan. If a trust relationship exists, the client feels comfortable telling the nurse about problems in the care plan. When Goals Are Achieved The overall purpose of home visits is to assist the client with necessary information and nursing care to enable the client to function successfully without nursing interventions. When the plan-of-care goals are achieved, the client does not need the nurse any longer. The client knows what community resources are available and how to access health care services for primary, secondary, and tertiary interventions. Formal and Informal Caregivers Formal caregivers include professionals and paraprofessionals who provide in-home health care and personal services. They are compensated for the services they provide. The largest number of employees consists of home care aides and RNs. Informal caregivers are family members who are caring for the client. The presence or absence of an involved family member can make the difference between the successful completion of the plan of treatment, with the patient remaining in the home, and the need to transfer the patient to an extended-care facility or board-and-care facility. When a capable family member or caregiver is available to assist the patient, the home health nurse spends much of the visit assessing the skills of the caregiver. The home health nurse instructs the caregiver in the correct procedures for providing care and in recognizing the signs and symptoms of problems that must be reported to the health care provider. The goal of the home health nurse’s instruction is to provide the caregiver with the skills necessary to care for the patient successfully in the home without intervention of the nurse or other members of the home health team. The home health nurse faces a special challenge with patients who lack a family member or caregiver capable of learning and providing necessary care. When the patient lives alone and does not have caregivers, the nurse explores other resources available to supplement the patient’s self-care activities in the home. For example, if the patient has extensive physical care needs and sufficient financial resources, the nurse may suggest hiring an attendant. Medicare and private insurance companies do not pay for attendant care. If the patient’s income is low enough, in-home county support services may be an option. The nurse may consider other services for the patient, such as MOW for nutritious meals delivered to the patient’s home. Friendly Visitors, a volunteer service, sends a volunteer to the patient’s home once a week or more to provide socialization for the patient. Other options that are available in some communities are adult day health centers and senior service centers. Both of these options require arranged patient transportation to and from the centers. A variety of transportation methods are available in different communities; volunteers may transport patients to the centers, or public transportation systems may be available, such as minivans, that provide door-to-door service. Selected services and referrals are based on the patient’s individual needs and on the patient’s level of functional ability. Ethical Insights Home Health and Hospice Care • Most legal and ethical issues in home health care involve the care of terminally ill patients. • Early education about these issues is essential to the prevention of problems. • Early education also gives patients the opportunity to make decisions for themselves and to communicate those decisions to family members and health care providers. • All competent adults have the right to make decisions that will direct health care providers in the type of care they administer. • This communication can occur through the completion of advance directives, durable power of attorney for health care, and living wills. Advance Directive An advance directive is a written document in which a competent person gives instructions about future health care in the event that the individual is unable to make decisions. These directives are completed on a voluntary basis. Medicare-certified health care agencies must ask patients about advance directives and must provide the patient with the advance directive form if the patient is interested in completing it. Durable Power of Attorney for Health Care A durable power of attorney for health care is one type of advance directive. Also called a health care proxy, the durable power of attorney for health care gives another person the power to make medical decisions related to care of the patient. This person, as identified by the patient, acts as the patient’s agent in all decisions regarding health care, personal care, and custody in the event that the patient becomes incompetent or disabled and is unable to make decisions. Living Will A living will is a written document in which a patient voluntarily informs doctors and family members about the type of medical care desired should the patient become terminally ill or permanently unconscious and unable to communicate. In the living will, the patient can describe the type of care desired, depending on the clinical situation. For example, if the patient is terminally ill and unconscious, the patient can direct the health care team to perform only those measures that will provide comfort and nothing further. The patient can specifically indicate his or her opposition to lifesaving measures; for example, the patient may request the denial of cardiopulmonary life support in the event of a cardiac arrest. Other examples are indicating the exclusion of chemotherapy, blood transfusions, and respirator use in an attempt to prolong life. Hospice Home Care Hospice and palliative nursing care is becoming increasingly important, as there is a tremendous need to improve end-of-life care for the terminally ill. Nurses who work with the terminally ill seek to enhance the patient’s quality of life by focusing on relieving suffering throughout the illness, supporting the patient and family through the dying process, and providing grief support to the family after the patient has died (ANA, 2007). Hospice and palliative care nurses have a holistic approach to their patients and are responsible for taking a comprehensive health history and physical examination, including an evaluation of mental status; evaluating functional abilities; performing appropriate laboratory and diagnostic studies; determining effective pharmacological and nonpharmacological therapies to manage symptoms; identifying patient and/or family/caregiver goals; providing culturally competent care that is consistent with the patient’s health beliefs, values, and practices; evaluating the patient’s emotional state and the response to his or her illness and impending death; identifying coping strategies and support systems; evaluating financial resources; and conducting a spiritual assessment (ANA, 2007). The advanced practice hospice and palliative nurse is an important role for nurses with a master’s degree or higher in nursing (ANA, 2007). The advanced practice hospice and palliative nurse functions as an expert clinician who performs the duties of the generalist hospice nurse in addition to assuming the responsibilities of advanced-level care, which may include prescribing pharmacological treatment to manage symptoms. It is recommended that all advanced practice hospice and palliative nurses obtain certification in advanced practice hospice and palliative nursing (ANA, 2007). Patients are admitted into hospice care when they have a life expectancy of 6 months or less, and the focus of care shifts from curative to comfort care. However, many patients with terminal illnesses want to continue curative treatments and are not ready to be admitted into a hospice program. Those patients who do not have a life expectancy of 6 months or less and/or want to continue curative treatment can receive the benefits of palliative care. Palliative care focuses on symptom management while the patient is still receiving other treatments, such as chemotherapy. It is important to note that Medicare fully covers all hospice-related expenses, including medications, related to the terminal diagnosis. However, Medicare does not cover any expenses, including medications, related to other diagnoses. Hospice and palliative nursing care is provided in a variety of settings, including hospitals, nursing homes, residential homes, and palliative care clinics. For the patient receiving hospice services in the home, the goal is to keep the client as comfortable at home as long as possible and to provide support and instruction to caregivers. Some patients stay home until they die, and for others their caregivers decide whether they should remain at home or be admitted to an extended-care facility or a hospital. Each family unit has different needs, and each must be supported in its decisions. Home death should not be the standard that determines excellence in any case, nor should home death be the ultimate measure of “successful” home care. It is vital to realize that caring for a terminally ill person also includes caring for the family or caregivers. Not all caregivers want their loved one to die at home, and not all caregivers are capable of allowing that to happen. The goal of having a home death must be the goal of the patient and family, regardless of the nurse’s personal preference. When caring for a terminally ill person at home, the hospice nurse must be skilled in physical and psychosocial care for both the patient and the caregiver. The patient is viewed as a whole person, not as an isolated disease. Caring for a terminally ill person at home demands that the nurse view the family system as a unit. In addition, it is important to note that hospice care is a team approach. Each patient has a physician, a nurse, a social worker, a nurse assistant, and a spiritual counselor to provide a multidisciplinary, holistic approach to caring for that patient and his or her family. The team coordinates care with each other and additional resources, such as pain management, as necessary. Furthermore, many hospice agencies have weekly interdisciplinary meetings in which the various members of the hospice team meet to discuss the patients and work together to resolve issues and make sure the patients are receiving the best possible care. Caring for the Caregiver Although the dying patient is the focus of all skilled nursing care, the experienced home care nurse knows that a careful assessment of the caregiver’s mental and physical health is important. The spouse, lover, children, friends, and neighbors who have made the commitment to stay until the end need the nurse’s time and attention as much as, if not more than, the patient. Although the patient’s wishes are important, all decisions regarding care are made considering the health of the caregivers. Camak (2015) found that caregivers are at increased risk for developing mental and physical health problems. Caregiver burden is a significant concern; therefore nursing interventions must be directed toward preventing a decline in the caregiver’s health. Caregivers need reassurance that their judgment is sound, and they need reminders that they cannot do anything “wrong” if it is done for the patient’s comfort. The caregivers must understand that they will not mistakenly overdose the patient, and they must be reminded repeatedly that the patient will not die from something they did or did not do. Caring for the terminally ill requires that the home care nurse is willing to nurse the entire family. In addition, the nurse must involve all members of the hospice team to ensure that the caregivers receive the care they need. Pain Control and Symptom Management Pain control is an important goal for hospice nurses and their patients. Hospice nurses perform regular pain assessments that involve asking patients the following questions about their pain: (1) history; (2) character (such as sharp, dull, aching); (3) severity or intensity, which is most commonly rated on a pain intensity scale from 0 to 10 with 0 being no pain and 10 being the worst pain imaginable; (4) location; (5) effects on quality of life; (6) precipitating factors; and (7) relieving factors (Norlander, 2008). It is vital that the hospice nurse not only performs regular pain assessments but also remembers that pain is highly subjective and every person experiences pain differently and uniquely; therefore the patient’s pain is whatever he or she says it is, regardless of the nurse’s objective evaluation of the situation. Pain medication is administered in doses sufficient to keep the patient free of pain and is administered on a regular schedule to prevent pain from recurring before the next dose. Hospice methods of pain control are particularly well suited to home care. The vast majority of patients can be pain free until their deaths. The key to successful pain control for the terminally ill is to persuade patients to take their medications on a regular basis, not just when they “can’t stand it any longer.” Generally, these medications are long acting and are administered every 8 to 12 hours. In addition, patients have fast-acting pain medications to take for “breakthrough pain,” which happens when the patient experiences an increase in pain before it is time for the next dose of scheduled pain medication. The fast-acting medications are generally administered every 1 to 2 hours as needed. Many patients, especially the elderly, are afraid of becoming “junkies” or “druggies” and want to delay using pain medication until they “get really bad.” Many people believe that using these medications signals “the end of the line,” and they are amazed to learn that patients do well while receiving such agents for months, even years, before death occurs. Almost every family must learn that addiction is not the same as tolerance and that their physicians will not “cut off the supply” if they “take too much.” In addition to pain control, hospice nurses help in managing other symptoms such as nausea and vomiting, constipation, diarrhea, fatigue, and decreased appetite. Nurses assist patients in management of these symptoms through medications and/or strategies to help cope with the symptoms. Strategies include such things as increasing fluids to prevent constipation, frequent rest periods to minimize fatigue, and eating small amounts as desired to cope with the decrease in appetite. In addition, the nurse educates the patient and family that some of these symptoms, such as fatigue and decreased appetite, are related to the dying process and are signs that the patient is declining. Furthermore, the nurse, along with other members of the hospice team, provides emotional support to patients and families as they adjust to the patient’s impending death. The nurse educates the patient and family about what physical symptoms the patient will most likely experience as he or she approaches death. In addition, the nurse, along with the social worker and spiritual counselor, provides emotional support and helps the patient and family work through any anxiety or fears they have about dying. Finally, the nurse is there to support the family immediately after the patient dies, and hospice provides bereavement support to families up to a year after the patient’s death. Cultural Differences Related to Death and Dying When caring for patients and their families in hospice, the nurse must remember that beliefs, attitudes, and values about death, dying, grief, and loss are influenced by society and culture (Cancer.net, 2015). However, these societal and cultural influences are often difficult to recognize. Furthermore, many individual differences within a cultural group, such as spirituality, age, and gender, affect a person’s interpretation about the meaning of death. Although there are these individual differences, some general characteristics regarding death and dying are common to people of a certain cultural group. It is important to understand some of these differences to provide culturally sensitive care and ensure a peaceful and dignified death. For example, among African Americans, health status should be reported to the eldest family member, spouse, or parents, and there is often open and public displays of emotion, although this possibility varies from person to person. African Americans generally care for dying elders at home until death is imminent and then they bring their loved one to the hospital, because some believe that death in the house brings bad luck. Among Mexican Americans, the extended family takes care of the sick and dying person, and there are often several family members present at the same time. In general, Mexican Americans prefer to die at home because the hospital environment may be too restrictive in meeting the needs of the extended family and because some believe that their spirit may get “lost” if they die at the hospital. In comparison, among American Indians, some tribes prefer to remain close to the dying person, but other tribes avoid contact with the dying. Similarly, those tribes that prefer to avoid contact may prefer that their loved one dies in the hospital, whereas those tribes that prefer to remain close may prefer to have the person die at home. These are just some examples of cultural characteristics that influence death and dying beliefs and practices. It is important to understand and respect the differing values and beliefs of patients and their families. Furthermore, it is essential to ask patients and/or families about their beliefs and practices to avoid overgeneralizations and to ensure that nursing care is patient centered and culturally sensitive. Active Learning 1. Make arrangements to accompany a PHN, a home health nurse, and/or a hospice nurse on home visits. 2. Interview a PHN about the types of client referrals received, and ask what interventions are usually performed. Repeat this activity with a home health nurse and a hospice nurse. Ask the nurses what they like best about their jobs. 3. Attend a team meeting in a home health agency or a hospice program to see how the roles of the various team members blend together to provide family-centered care. 4. Interview a PHN and a home health nurse, and ask how the community affects the care they provide. Case StudyPublic Health Visit Communicable Disease Follow-Up The PHN received a referral from the county hospital to see Ray, a 57-year-old white man with newly diagnosed TB. The first purpose of the referral was for the PHN to meet with the client to ensure that he received the appropriate information about TB and received follow-up medical care on a regular basis. The second purpose of the referral was for the PHN to meet with Ray and identify the people with whom he had been in close contact. The nurse then established contact with these people, notified them that they had been exposed to TB, and encouraged them to have follow-up tests for TB. The nurse contacted Ray and established a time for the home visit. The nurse noted that he resided in a residential hotel in a lower-middle-class neighborhood of a large urban area. During the initial visit, the nurse discovered that the client was an unemployed construction worker. He did not know where he might have contracted TB. Ray assured the nurse that he was taking his medication as directed. He gave the nurse the names of the friends he played poker with every week at a hotel and told the nurse that he advised his friends to be tested for TB. The nurse made a note of the names and later talked with them individually by telephone. During these subsequent conversations, the nurse was very careful to maintain the client’s confidentiality. The nurse informed these individuals that they could have been exposed to TB and that they should seek testing through their health care providers or through their local health department. Ray indicated that he did not have family and he had minimal contact with other people besides his friends at the hotel. The nurse recorded this information on the communicable disease form and returned the information to the public health department’s communicable disease division. Assessment The PHN’s assessment of the client with a communicable disease involved the individual, family, and community. The PHN assessed whether the client received appropriate information and regular medical care for TB and whether the client followed the prescribed treatment regimen. Although Ray stated that he did not have family, his friends in the hotel constituted a working support network. The PHN knows that the client’s support network is whomever the client identifies. Nursing assessment of Ray’s support network involved determining whether the members were tested for TB. In addition, the PHN assessed the client’s network for the following: • Network composition • Network’s knowledge of TB • Functional capacity • Network stressors • Network strengths and weaknesses • Network’s ability to provide support for Ray • Health beliefs and practices • Use of health services The PHN was aware that the number of new cases of TB in the community had increased over the past 12 months. The PHN further noted that there was an increase in the number of area residents immigrating from various developing countries and that this population might be at increased risk for development of TB. Diagnosis Individual Lack of awareness regarding the disease process and transmission of TB Family Lack of awareness regarding the disease process and transmission of TB, location of communicable disease clinics, and the importance of screening those exposed to TB Community Potential for development of TB among community residents, indicated by an increased incidence of new cases of TB over the past 12 months Planning A plan of care is established with mutually agreed-upon goals based on the nurse’s assessment of the individual, family, and community. Individual Long-Term Goal • Client will perform self-care activities related to treatment of TB and follow up as necessary with appropriate health care professionals. Short-Term Goal • Client will verbalize knowledge of transmission of TB; signs and symptoms of complications of TB; purpose, administration schedule, and side effects of medications. Family Long-Term Goal Support network members with positive test results will receive appropriate treatment Short-Term Goal Support network members will demonstrate basic knowledge of cause and transmission of TB and will agree to be tested for TB. Community Long-Term Goal Incidence of TB in the community will decrease over the next 3 years. Short-Term Goal Community members will demonstrate knowledge of increased incidence of TB in their community and of available community resources for treatment and prevention of TB. Intervention Implementation of the plan of care for the client with TB occurs at the individual, family, and community levels. Individual The PHN referred Ray to the communicable disease clinic at the local health department. TB is a reportable communicable disease; therefore the PHN obtained information from the client regarding people with whom he had been in close contact. Family The PHN contacted members of Ray’s support network and referred them to the communicable disease clinic as appropriate. The nurse provided these people with information concerning TB transmission and the importance of early treatment and follow-up. Community The PHN met with professionals from the communicable disease clinic and the health department and with members of the community to establish a program to raise public awareness about the increased incidence of TB in the community. The public was informed about the importance of preventive measures, the availability of community screening services for TB, and the existing health care resources in the community. Evaluation Individual The client’s knowledge of the disease process, transmission, treatment, and signs and symptoms of TB is an indicator in evaluating the care plan. Confirmation of the client’s follow-up with the communicable disease clinic can also be used for evaluation. Family The support network’s knowledge of the disease process, transmission, treatment, and signs and symptoms of TB is an indicator in evaluating the care plan. Confirmation of the support network’s follow-up with the communicable disease clinic can also be used for evaluation. Community The incidence rate of TB in the community and the rate at which TB clinics and related resources are used are measures that can be used to evaluate the effectiveness of interventions at the aggregate level. Levels of Prevention The PHN is actively involved in all three levels of prevention through education programs, early detection programs, and appropriate referrals for patients with TB. Examples of each of these levels of prevention are as follows: Primary Goal: Prevention of specific disease occurrence such as TB. • Development of programs that increase public awareness of the disease process and of the transmission, diagnosis, and treatment of TB. Secondary Goal: Early detection of existing conditions. • Tuberculin skin testing and subsequent follow-up of positive test results. Tertiary Goal: To reduce the effects and spread of TB. • Referral for early, effective treatment and education of clients for self-care. Case Study Public Health Home Visit: Antepartum Client The PHN received a referral to see a 17-year-old African American woman named Ali, who was referred by the county prenatal clinic. Ali was 5 months pregnant with her third pregnancy within the past year. Ali miscarried the previous two pregnancies during the first trimester. When the nurse made the home visit, she noted that Ali was 5 feet 9 inches tall and weighed 120 lb. She resided in a two-room apartment with her boyfriend, who was the father of the baby. The nurse began the first visit with social talk, asking Ali general questions about her employment, education, and the duration of her residence in the area. Ali appeared to be pleased that the nurse was interested in her. Once a trusting relationship was initiated, the nurse asked Ali how she felt about the pregnancy. Ali revealed that she was happy about the pregnancy but was worried that there would be problems because she had had two previous miscarriages. She had not planned any of the pregnancies, but she did not use contraceptives to prevent the pregnancies either. Ali’s boyfriend worked and was able to pay the rent and buy food for her. Ali dropped out of high school during her junior year, but she wanted to complete her high school education. She had Medicaid coverage for her health care. During the initial home visit, the nurse assessed that Ali was underweight and had several knowledge deficits in the areas of prenatal nutrition, infant care, breastfeeding, and contraception. The nurse also identified the need for a referral to the public school for the continuation of Ali’s high school education. The nurse briefly discussed her assessment with Ali in a nonthreatening, nonjudgmental manner. The nurse informed Ali that, if she was interested, she could schedule future home visits to provide Ali with more information and answer her questions. Ali agreed to receive future visits to discuss the topics the nurse identified during the assessment phase. They mutually agreed upon the plan for future visits. As the visits progressed, the nurse and Ali modified the plan on the basis of progress evaluation. The nurse terminated home visits with Ali when the mutually established goals were achieved. The nurse scheduled a postpartum visit with Ali after the baby was born to assess infant care and answer any questions Ali had concerning infant care. Assessment Although it was important to perform an individual assessment of Ali, the PHN assessed Ali as a member of a family and as a member of the community. Community in this case referred to the aggregate of publicly insured adolescent pregnant women. Assessment of Ali revealed an underweight 17-year-old pregnant woman who was unable to demonstrate knowledge of nutrition in pregnancy, infant care, breastfeeding, contraception, or educational options for pregnant teenagers. An individual assessment of Ali mandated the need for an assessment of the composition and function of Ali’s family. The PHN assessed the following factors with regard to Ali’s family: • Family composition and support network • Family’s and support network’s attitude toward mental and physical health and use of health care services • Family’s and support network’s attitude toward Ali’s physical, mental, social, spiritual, and economic support Family’s and support network’s beliefs and attitudes regarding infant care, breastfeeding/bottle feeding, immunizations, and nutrition Attitude of infant’s father regarding involvement with Ali and their baby, his health beliefs, and his ability to assume the role of parent The PHN was aware of the need to see the larger, aggregate picture. Identifying the aggregate as the pregnant adolescent community, the PHN used the following techniques in an ongoing assessment (Lewenson and Truglio-Londrigan, 2010) • Observations • Resource analysis • Key informant interviews • Environmental indexes Using these techniques, the PHN gathered information regarding the following: • Educational and employment options for pregnant teens and teens with infants • Availability of health services targeting low-birth-weight infants • Availability of support groups for this aggregate • Availability of teen parenting classes Diagnosis The PHN formulated nursing diagnoses based on thorough individual, family, and community assessments. Individual • Lack of awareness regarding nutrition in pregnancy, infant care and feeding, contraception, availability of community resources, and educational options for pregnant teenagers • Inadequate nutritional support related to low-income status and inadequate knowledge of nutritional requirement for pregnancy Family • Lack of family support related to Ali’s living away from home • Altered family communication patterns related to role confusion among family members Community • Minimal availability of health care services, parenting classes, contraception counseling, and educational opportunities for pregnant teenagers • Lack of coordination of existing services Planning Planning health services and interventions for pregnant teenagers involves formulation of mutually agreed-upon short-term and long-term goals for the individual, family, and community. Individual Long-Term Goal • Ali will carry her infant to term without evidence of maternal or fetal complications. Short-Term Goals • Ali will gain at least 3 lb per month. • Ali will demonstrate knowledge of community resources for pregnant adolescents by the next nursing visit. Family Long-Term Goal • Ali, her partner, and other family members will be able to perform mutually determined role responsibilities. Short-Term Goal • Ali and her partner will attend teen parenting classes. Community Long-Term Goals • Establishment of effective, comprehensive prenatal health, contraception, and education services for pregnant teenagers • Decline in rate of teen pregnancies and birth of compromised neonates over the next 24 months Short-Term Goals • Increased community awareness of resources for pregnant teenagers • Increased awareness of contraception counseling services for adolescents Intervention Individual Implementation of Ali’s individual care plan involved visits by the PHN with a referral to existing prenatal services for pregnant teenagers. Family Family intervention was composed of Ali’s and the father’s referral to a support group for pregnant teenagers and partners. Community Implementation of the care plan for the aggregate of adolescent pregnant women included the following: • Meeting with community leaders • Meeting with local school administrators and faculty to disseminate information for pregnant teenagers • Formation of community organizing groups Evaluation Individual Evaluation included measures of the client’s nutritional status and her use of support groups and educational and nutritional services. Family Evaluation included measures of the family’s use of support groups and educational and services. Community Evaluation of the effectiveness of interventions at the aggregate level focused on measurement of available options for pregnant teenagers, measures of teen awareness and use of services, and determination of changes in incidence rates of teen pregnancy and compromised neonates. Levels of Prevention The PHN not only works with the patient and the patient’s support network, but also provides care to the entire community through education and intervention programs. The PHN is actively involved in working with individual teenagers, their friends and families, and the community in reducing the incidence of teenage pregnancy and assisting pregnant teenagers with prenatal care and available resources. Examples of providing care at the three levels of prevention are listed here. Primary • Activities that prevent teen pregnancy from occurring, such as individual and family counseling and school and community education programs Secondary • Interventions for early detection of teen pregnancy and early intervention, such as counseling for prenatal care Tertiary Goal: To reduce the effects of adolescent pregnancy • Provision of prenatal education in areas such as nutrition, parenting, and infant care Case Study Hospice Home Visit Anne McMillan is 80 years old and is terminally ill with metastatic breast cancer. She has been a widow for 5 years and has three daughters and two sons. All of her children are married with kids of their own, except one son who is handicapped and lives with Anne. Anne is too weak to care for herself and is moving in with her youngest daughter. Her daughter’s house is a colonial with all bedrooms upstairs. There is a first-floor bathroom. During her first visit, the hospice nurse talks with Anne and her daughter and explains what hospice is all about. The nurse then admits Anne into the hospice program and begins her initial assessment. Anne’s primary physical complaints are back pain and constipation. She is still eating and drinking regularly. The nurse immediately recognizes that Anne will need a hospital bed. Anne already has a walker, but the nurse informed Anne and her daughter that they could have a bedside commode if needed in the future as Anne becomes weaker. Anne’s biggest concern is her handicapped son, saying, “He can’t be by himself for long and I don’t know where he can go now that I can’t take care of him.” Except for the handicapped son, all of her children and many of her grandchildren are active in her care. Assessment On her initial visit, the hospice nurse collects the following data about Anne, her family, and her community. In this case, the community consists of Anne’s social support outside of her family, such as her neighborhood and church. • Pain assessment, including history, character, severity, location, effects on quality of life, precipitating factors, and relieving factors • Other physical symptoms, such as fatigue, nausea, vomiting, constipation, diarrhea, decreased appetite, and decreased mobility • Client and family fears, anxiety about dying and the dying process • Support network and family dynamics • Client’s anxiety about situation concerning handicapped son • Additional support network outside of family • Effect of diagnosis and prognosis on Anne’s social support, including her neighbors and her church community Diagnosis Individual • Pain related to disease process • Potential for constipation and discomfort related to decreased mobility • Apprehension related to concerns about safety and well-being of handicapped son Family • Strong support system indicated by active family participation in Anne’s care Community • Anticipatory grieving related to social isolation after leaving neighborhood and moving in with daughter Planning Individual Long-Term Goals • Pain will remain controlled until client expires. • Client will have regular bowel movements for the next 2 months. • Client will verbalize satisfaction about resolution of situation concerning handicapped son. Short-Term Goals • Pain will be well controlled within 24 to 48 hours. • Client will have a bowel movement within 24 to 48 hours. • Client will have decreased anxiety about handicapped son within 24 to 48 hours because the social worker will have found a place for the son to live. Family Long-Term Goals • Family will remain active in Anne’s care until she is buried. • Family will provide a support network for each other and use hospice services for continued support through Anne’s death and burial and for months afterward. Short-Term Goal • Family will actively participate in Anne’s care. Community Long-Term Goal • Client will continue to receive support from friends. Short-Term Goal • Client will verbalize feelings about moving in with daughter and leaving friends behind. Intervention Individual After talking with the doctor, the hospice nurse starts Anne on methadone 20 mg daily and Roxanol 5 mg as needed for breakthrough pain. The nurse explains to Anne and her daughter that she is constipated because of her decrease in mobility. The nurse obtains an order for a stool softener and instructs Anne to take it twice daily. The nurse also explains to Anne and her daughter that, as Anne declines, her appetite will decrease and she will eat less and less and may not have bowel movements very frequently. Anne should let the nurse know if she ever feels uncomfortable because she has not had a bowel movement in a few days. The nurse talks to the social worker, who finds a group home for Anne’s handicapped son. Family The nurse and social worker talk with the family and help them develop a system so that Anne always has someone with her and to help ensure that all of the responsibility for Anne’s care does not fall on one person. They also inform the family about resources to support them. Community Anne has a nurse, social worker, spiritual counselor, and nurse assistant assigned to her care. Each of these hospice workers helps Anne discuss her feelings about her situation and works with her to continue to receive support from her friends and neighbors. Evaluation Individual All of Anne’s goals are met, because she has good pain control until she dies, she no longer experiences discomfort and problems with constipation, and she expresses less anxiety and worry about her handicapped son. Although she still has some concerns, she feels much better about the situation. Family The family’s goals are met, because they remain active in Anne’s care until she dies. In addition, they use hospice resources appropriately and as necessary, and they support one another through the entire process. Community The goals are met, because Anne expresses her feelings about her situation, and her closest friends remain supportive to Anne through visits and phone calls. Levels of Prevention In this case, the three levels of prevention focus on helping the client and family through all phases of hospice care from admission until death. Some examples are as follows. Primary • Anticipating needs and intervening early on to prevent problems such as skin breakdown and lack of pain control • Educating the client and family about hospice and the dying process Secondary • Responding quickly to needs as they arise • Continued education about the hospice and dying experience Tertiary • Assisting the client and family through the active phase of dying • Providing follow-up bereavement support to the family Summary This chapter presents information on performing public health, home health, and hospice nursing visits to clients in their homes. A general overview of the nursing process for clients in the home setting is presented and expanded to include the individual, family, and community. Case studies involving communicable disease, teen pregnancy, and terminal cancer are described. The home visit is the foundation of community health nursing and provides a forum for important interventions with individuals, families, and communities. The CHN is responsible for bringing the concerns of individuals and families into the community.