Introduction to Home Health Care

Often, seniors undergo a lot of stress with long-term hospitalization and rehab stays. Prolonged in-patient stays in seniors are common and secondary to various factors, such as, poor management of chronic disease processes, non-healing wounds, falls, repeated infections, and both planned & unforeseen surgeries with accompanying complications. With hospitalization and rehab stays, patients may not recover completely and often fall short on goal accomplishment by the time they are discharged from the in-patient facility. Patients could need continuing support for instructions and education regarding patient safety, disease and medication management, changes with dietary limitations and nutritional requirements, infection control, and many more aspects. Patients also need continuing support to cover for needs, such as, wound care, lab draws, profound weakness and compromised endurance, performance limitation on activities of daily living (ADL) and instrumental activities of daily living (IADL), pain management, training on use of newly recommended assistive devices like walkers and prosthetics, training on use of newly prescribed medication delivery units like inhalers, nebulizers, and oxygen delivery equipment, instructions on fall prevention, and so on. Visiting multiple sites such as, doctors’ offices, wound care centers, labs, and therapy clinics to cover for all their needs can prove a hectic task, especially during the immediate phase of discharge from long-term hospitalization and rehab stays. Also, if the seniors are homebound and do not drive, maintaining so many visits on schedule could be even more challenging for the individual and exhausting for the caregivers as well.

Home health care fills this gap by providing a wide range of health care and supportive services for patients, covering most of these continuing needs in the comfort of patient’s home. While discussing the introduction to home health, a brief statement on homebound state deserves a mention. An individual MUST be HOMEBOUND and is a condition an individual MUST invariably meet, to qualify for receiving home health services. Homebound state is a topic we will discuss more in detail in a separate presentation on Homebound Status.

Services Offered by Home Health Care

Home comprises both clinical and non-clinical disciplines, offering services as applicable. Clinical disciplines are significantly led by nursing and supported by therapy groups, such as physical therapy (PT), occupational therapy (OT), and speech therapy (ST). Non-clinical disciplines could include home health aides helping with maintaining personal hygiene, medical social workers offering support and guidance for patient resources on emotional, social, and financial needs, and volunteers offering company & transportation for patients.

Benefits of Home Health Care

General statistics indicate that patients have a chance for quicker recovery being at home and in their natural milieu versus an in-patient setting. Also, as the services are provided in the patient’s home, it is far less taxing for the homebound individual. Providing services at patient’s home also proved to be a cost-effective option for Medicare. During the service period, home health agency regularly communicates with the ordering physician and keeps the physician periodically updated on issues concerning patient care, such as, deterioration of health conditions, challenges encountered, medication issues, patient safety, noncompliance with the treatment plan suggested, unforeseen happenings like falls and infections, any new wounds or injuries, deterioration of existing injuries, progress made or deterioration towards goals accomplishment, and so on. This helps with periodically updating the treatment plan in the wake of new issues and challenges encountered and obtaining new orders from the physician with the end goal of promoting patient compliance with the plan and improving on the final outcome.

Goals of Home Health Care

To start with, home health services are initiated to address short-term goals such as stabilizing blood sugar numbers in a healthy range, controlling blood pressure and heart rate numbers in a safe range, treating a wound, providing peripherally inserted central catheter line care and administration of new intravenous medication, training the patient on medication management, addressing muscle weakness, and reinforcing patient safety and security etc. While working on the short-term goals, home health services increasingly focus on long-term goals of improving patient’s overall function, restoring self-sufficiency, and promoting and securing patient’s independence. Upon accomplishment of the established goals, home health plans for discharging the individual from service to self or caregiver responsibility.

A patient could as well be discharged from home health service on the following grounds

  • If the patient were noncompliant with the treatment plan suggested
  • If the patient reached maximum potential with no room for further improvement
  • If the patient or family requests for a discharge
  • If the physician or insurance orders for a discharge.

OASIS Assessment

  • As the home health industry is significantly nursing dependent, patient assessments are usually done by a registered nurse (RN). An exception to this could be patients needing only therapy services.
  • Patient assessment in home health industry involves filling in the OASIS document, as required by the federal agency CMS (Centers for Medicare & Medicaid Services).
  • OASIS stands for Outcome and Assessment Information Set and involves collecting detailed information on patient’s health, nutrition, living conditions, and emotional & social support.
  • This information can be used to answer the mandatory questions on the OASIS document appropriately and establish reasonable goals, which guide the services to be ordered for the patient, thus contributing towards goal accomplishment.
  • Also, not all patient details are furnished, and needs are addressed by merely answering the mandatory questions on the OASIS. So, the document provides space for clinical narrative and comments to be added, in support of the choices made while answering mandatory questions on the OASIS.

Home Health OASIS Education

The goal of home health is to educate patient or caregiver on the disease states, instruct on medication changes and lifestyle measures for management, promote patient safety and independence regarding care, improve overall patient outcomes, and ultimately discharge the patient from service upon goal accomplishment. To provide the needed patient education and training, a good patient assessment and identification of patient and caregiver shortcomings regarding care is primary. Poor patient assessment can lead to deficiencies in identifying real patient needs and providing appropriate services, which directly transform into poor patient care, thus compromising goal accomplishment in the long run. Many new nurses come into the home health field each day and face hardships with assessing the patient, eliciting the required information from the patient or caregiver, interpreting the mandatory questions on OASIS, picking the right choices while answering the questions, adding much needed comments, and completing the documentation in a timely manner. As mentioned earlier, merely answering mandatory questions on the OASIS by selecting from the choices given does not provide a clear picture of the patient’s health care needs and requirements. Clinicians MUST add clinical narrative and comments on patient’s health conditions justifying the selections made on mandatory questions of the OASIS. Home Health OASIS Education is essentially built to assist the nurses with the OASIS document and help them on how to do a good patient assessment, what information to collect from the patient, how to interpret and answer the mandatory questions on the OASIS, and what information need to be added on the comments section in support of the patient assessment. All this input on patient’s health status will ultimately guide the services to be ordered on the patient, helping towards accomplishment of established goals.