Identification of factors contributing to the utilization of home health agencies in North Dakota
by LaVerne Elizabeth Lee
A thesis submitted in partial fulfillment of the requirements for the degree of MASTER OF NURSING
Montana State University
© Copyright by LaVerne Elizabeth Lee (1975)
Abstract:
The purpose of this study was to identify those factors contributing to the limited utilization of the
home health agencies in North Dakota.
Data were collected by use of an open-ended questionnaire devised by the researcher and sent to 228
physicians, 52 public health nurses, and 60 hospital nurses, employed in the geographic areas of the
nine home health agencies in North Dakota.
A total of 151 questionnaires were returned. This included 39 percent of physicians, 62 percent of
public health nurses, and 45 percent of hospital nurses.
The respondents identified those factors limiting the effectiveness of the home health programs to be:
1. limited physician referrals 2. cost to the home health agency as well as to the patient 3. restrictive
government regulations 4. lack of knowledge of the program by physicians, hospital nurses and the
public In spite of obvious problems, the prevailing feeling is that there is a future for the home health
programs in North Dakota. STATEMENT OF PERMISSION TO COPY
I n p r e s e n tin g t h i s t h e s i s i n p a r t i a l f u l f i l l m e n t o f th e r e ­
q u ir e m e n ts f o r a n a d v a n c e d d e g r e e a t M ontana S t a t e U n i v e r s i t y , I a g r e e
t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r i n s p e c t i o n .
I
f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y in g o f t h i s t h e s i s f o r
s c h o l a r l y p u r p o s e s may b e g r a n t e d by my m a jo r p r o f e s s o r , o r , i n h i s
a b s e n c e , by t h e D i r e c t o r o f L i b r a r i e s .
I t i s u n d e r s to o d t h a t any
c o p y in g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t
b e a llo w e d w i t h o u t my w r i t t e n p e r m i s s i o n .
S ig n a tu re
D a te ;
I
IDENTIFICATION OF FACTORS CONTRIBUTING TO THE
UTILIZATION OF HOWE HEALTH AGENCIES
IN NORTH DAKOTA
S'
I
by
LAVERNE ELIZABETH LEE
A t h e s i s s u b m i t te d in . p a r t i a l f u l f i l l m e n t
o f t h e r e q u i r e m e n ts f o r t h e d e g r e e
of
MASTER OF NURSING
A p p ro v ed :
H e a d , M a jo r D e p a rtm e n t .
^
C hairtrfdn, E x a m in in g C o m m itte e "
G r a d u a te i D ean
MONTANA STATE UNIVERSITY
Bozem an, M ontana
M a rc h , 1975
iii
ACKNOWLEDGMENT
S i n c e r e a p p r e c i a t i o n i s e x te n d e d t o M rs. M a r g a r e t V o jn o v ic h ,
c h a ir m a n o f my c o m m itte e , t o M iss S u s a n D o w e ll, D r. D o u g la s B is h o p ,
an d D r. R ic h a r d H o r s w e ll f o r t h e i r g e n e r o u s a s s i s t a n c e w h ic h made t h e
c o m p le tio n o f t h i s p a p e r p o s s i b l e .
In a d d itio n , a d eb t o f g ra titu d e
i s owed t o M iss I rm a B lo c k , D i r e c t o r , D i v i s i o n o f N u r s in g , N o rth
D a k o ta S t a t e D e p a rtm e n t o f H e a l t h and M rs. Mary L a n c a s t e r , E x e c u tiv e
S e c r e t a r y , N o r th D a k o ta S t a t e N u rs e s A s s o c i a t i o n , f o r t h e i r s u p p o r t and
a s s is ta n c e i n t h i s e n d e av o r.
iv
TABLE OF CONTENTS
Page
V I T A ................. ....................................................................................... .....................................
ii
ACKNOWLEDGMENT ........................................................................................................... ............i l l
L IST OF TABLES ......................................................................................................... ..
vi
ABSTRACT........................................ .................................................................................. . . . . v i i i
C h a p te r
1.
2.
INTRODUCTION............................
I
M a jo r P u r p o s e o f t h e S tu d y ...................................................................
2
S p e c i f i c O b j e c t i v e s ............................................................
2
Need f o r t h e S t u d y ........................ .............................................................
3
A s s u m p tio n s o f t h e S tu d y
5
................................................ ..
L i m i t a t i o n s o f t h e S tu d y ................. .................................................
6
D e f i n i t i o n of. Term s ......................................
6
REVIEW OF LITERATURE ....................................................................
M e d ic a re ....................................
Home C a re T oday ...................... ...... ........................................................... ....
3.
4.
METHODOLOGY ......................................................................................
9
9
16
19
P i l o t S tu d y ...............................
19
S e l e c t i o n o f t h e P o p u l a t i o n ..........................................................
20
M ethod o f C o l l e c t i n g t h e D a t a ...................... .....................................
21
PRESENTATION OF DATA ................
23
V
•
C h a p te r
5.
Page
CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS ................. ......
42
Summary ...................... .................... ..................................... ........... ....
42
G e n e r a l C o n c lu s io n s .................................. .................. ...............................
43
S p e c i f i c C o n c lu s io n s ........................ .............................. .......................
44
Im p lic a tio n s
45
.......................................................................... ................ ..
R eco m m en d atio n s f o r P ro g ra m D ev elo p m en t and
F u r t h e r S tu d y .................................................. ............................ ..............
46
P ro g ra m D e v e l o p m e n t .............*................ ...............................................
46
F u r t h e r S t u d y .......... ...............
47
APPENDIXES
A.
COVER LETTERS AND SURVEY QUESTIONNAIRE ...................... ................
4f8
B.
MAP OF NORTH DAKOTA INDICATING THE LOCATIONS OF
HOME HEALTH AGENCIES ................. ........................................................ ..
55
C.
CATEGORIZATION OF RESPONSES ......................................... ................
57
D.
HOME HEALTH RELATED SECTIONS OF TITLE X V III HEALTH
INSURANCE FOR THE AGED P .L . 8 9 -9 7 OF THE SOCIAL
SECURITY ACT ......................................... ............................................ .............
67
VERBATIM STATEMENTS MADE BY RESPONDENTS TO .
"ADDITIONAL COMMENTS" ON QUESTIONNAIRE .....................................
74
E.
SELECTED BIBLIOGRAPHY .....................................................................................................
77
vi •
LIST OF TABLES
T a b le
Page
1.
RESPONSES TO QUESTIONNAIRE BY GROUPS OF RESPONDENTS ............
22
2.
EFFECTIVENESS OF HOME HEALTH PROGRAMS IN NORTH
DAKOTA AS PERCEIVED BY PHYSICIANS, PUBLIC HEALTH
NURSES, AND HOSPITAL NURSES ........................................ ........... ...........
24
INDICATORS OF THE EFFECTIVENESS OF THE HOME HEALTH
PROGRAMS IN NORTH DAKOTA AS PERCEIVED BY THE
PHYSICIANS, PUBLIC HEALTH NURSES, AND
HOSPITAL NURSES ........................ ...................................................................
25
3.
4 . . FACTORS LIMITING THE EFFECTIVENESS OF THE HOME
HEALTH PROGRAMS IN NORTH DAKOTA AS. PERCEIVED BY
THE PHYSICIANS, PUBLIC HEALTH NURSES AND
HOSPITAL NURSES ...................
5.
6.
7.
8.
27
FACTORS CONTRIBUTING TO.THE SUCCESS OF THE HOME
HEALTH PROGRAMS IN NORTH DAKOTA, AS PERCEIVED
. EY THE PHYSICIANS, PUBLIC HEALTH NURSES AND
HOSPITAL NURSES .........................................................
29
PHYSICIANS' REACTIONS TO THE HOME HEALTH PROGRAMS
IN NORTH DAKOTA, AS PERCEIVED BY PHYSICIANS,
PUBLIC HEALTH NURSES, AND HOSPITAL NURSES ................................
31
PHYSICIANS' RESPONSIBILITIES IN THE HOME HEALTH
PROGRAMS IN NORTH DAKOTA, AS PERCEIVED BY
PHYSICIANS, PUBLIC HEALTH NURSES, AND
HOSPITAL NURSES ..............................................................................................
32
FACTORS THAT MIGHT CONTRIBUTE TO GREATER UTILIZATION
OF THE HOME HEALTH PROGRAMS IN NORTH DAKOTA, BY
PHYSICIANS, AS PERCEIVED BY PHYSICIANS, PUBLIC.
. HEALTH NURSES AND HOSPITAL NURSES ............ .. .... .............. ................
33
v ii
T a b le
9.
10.
11.
12.
Page
HOSPITAL NURSES' RESPONSIBILITIES IN THE HOME
HEALTH PROGRAMS IN NORTH DAKOTA, AS
i
PERCEIVED BY PHYSICIANS, PUBLIC HEALTH
NURSES, AND HOSPITAL NURSES .......... ................................. .................. V
35
MOST EFFECTIVE METHOD OF PROMOTING THE HOME HEALTH
PROGRAMS WITH THE HOSPITAL NURSES, IN NORTH
DAKOTA, AS PERCEIVED BY PHYSICIANS, PUBLIC HEALTH
NURSES, AND HOSPITAL NURSES ..................................................................
36
FUTURE OF THE HOME HEALTH PROGRAMS IN NORTH DAKOTA,
AS PERCEIVED BY THE PHYSICIANS, PUBLIC HEALTH
NURSES, AND HOSPITAL NURSES ..............................
38
POSSIBLE CHANGES WHICH COULD BE MADE IN THE HOME
HEALTH PROGRAMS IN NORTH DAKOTA, AS PERCEIVED
BY PHYSICIANS, PUBLIC HEALTH NURSES, AND
HOSPITAL NURSES .............................................
40
v iii.
ABSTRACT
The p u r p o se o f t h i s s tu d y w as t o i d e n t i f y t h o s e f a c t o r s c o n ­
t r i b u t i n g t o t h e l i m i t e d u t i l i z a t i o n o f t h e hom e h e a l t h a g e n c i e s i n
N o r th D a k o ta .
D a ta w e re c o l l e c t e d by u s e o f an o p e n -e n d e d q u e s t i o n n a i r e
d e v is e d by t h e r e s e a r c h e r and s e n t t o 228 p h y s i c i a n s , 52 p u b l i c h e a l t h
n u r s e s , a n d 60 h o s p i t a l n u r s e s , em ployed i n t h e g e o g r a p h ic a r e a s o f t h e
n i n e home h e a l t h a g e n c i e s i n N o rth D a k o ta .
A t o t a l o f 151 q u e s t i o n n a i r e s w e re r e t u r n e d . T h i s in c lu d e d
39 p e r c e n t o f p h y s i c i a n s , 62 p e r c e n t o f p u b l i c h e a l t h n u r s e s , and
45 p e r c e n t o f h o s p i t a l n u r s e s .
T he r e s p o n d e n t s i d e n t i f i e d t h o s e f a c t o r s l i m i t i n g t h e
e f f e c t i v e n e s s o f t h e home h e a l t h p ro g ra m s t o b e :
1.
lim ite d p h y s ic ia n r e f e r r a l s
2.
c o s t t o t h e home h e a l t h a g e n c y a s w e l l a s t o t h e p a t i e n t
3.
r e s t r i c t i v e g o v e rn m e n t r e g u l a t i o n s
4.
l a c k o f k n o w le d g e o f t h e p ro g ra m by p h y s i c i a n s , h o s p i t a l
n u rs e s and th e p u b lic
.
I n s p i t e o f o b v io u s p r o b le m s ,. t h e p r e v a i l i n g f e e l i n g i s t h a t
t h e r e i s a f u t u r e f o r t h e home h e a l t h p ro g ra m s i n N o r th D a k o ta .
. u
C h a p te r I
INTRODUCTION
A d v an ces i n m e d ic a l s c i e n c e h a v e made i t p o s s i b l e f o r human
b e in g s t o a t t a i n s e n e s c e n c e i n w ays n e v e r , b e f o r e t h o u g h t p o s s i b l e .
l o n g e v i t y h a s r e s u l t e d h o w e v e r i n m y ria d h e a l t h p r o b le m s .
T h is
Such h e a l t h
p ro b le m s a r e com pounded by t h e f a c t t h a t t h e m a j o r i t y o f t h e ag ed p o p u ­
l a t i o n i s e c o n o m ic a lly d e p r i v e d a n d , t o a l a r g e e x t e n t , m e d i c a l l y
in d ig e n t.
B e c a u s e o f t h i s t h e e l d e r l y o f t e n f o r e g o n e e d e d m e d ic a l
tre a tm e n t.
I t was w i t h t h e s e p e o p le i n m ind t h a t t h e g o v e rn m e n t e n v is i o n e d
h e a lth in s u ra n c e f o r th e ag ed .
A lth o u g h s u c h i n s u r a n c e was. c o n s id e r e d
a s e a r l y a s 1935 j i t was n o t u n t i l t h i r t y y e a r s l a t e r ,
i n 1965., t h a t
am endm ents t o t h e S o c i a l S e c u r i t y A ct ( e n a c te d i n P u b l i c Law 8 9 -9 7 )
e s t a b l i s h e d a c o m p re h e n s iv e p ro g ra m o f h e a l t h i n s u r a n c e , commonly known
a s " M e d ic a r e ,"
f o r i n d i v i d u a l s 65 y e a r s and o v e r .
T h is law p r o v id e d a
m ech an ism f o r f i n a n c i n g a n a r r a y o f h e a l t h s e r v i c e s , i n c l u d i n g i n h o s p i t a l c a r e , e x te n d e d c a r e b e n e f i t s , and home h e a l t h s e r v i c e s .
re s u lt of th is
As a
l e g i s l a t i o n home h e a l t h a g e n c ie s w e re e s t a b l i s h e d t h r o u g h ■
•
o u t t h e c o u n t r y , n in e o f w h ich a r e l o c a t e d i n N o rth D a k o ta .
U n f o r t u n a t e l y t h e home h e a l t h a g e n c i e s , s p e c i f i c a l l y i n N o rth
D a k o ta , a r e e x p e r i e n c i n g l i m i t e d u t i l i z a t i o n .
c o n tr ib u tin g to t h is
O f t h e many p ro b le m s
lim ite d u t i l i z a t i o n th e g r e a t e s t o f th e s e a p p e ars
■■ I
t o b e l i m i t e d u n d e r s t a n d in g (a n d t h u s , l i m i t e d s u p p o r t ) o f ; t h e home
.
2
h e a l t h p ro g ra m by t h o s e p h y s i c i a n s an d n u r s e s who a r e i n a p o s i t i o n t o
im p lem e n t t h e p ro g ra m a t th e l o c a l l e v e l .
W ith o u t r e f e r r a l s from
p h y s i c i a n s and f o llo w - u p fro m t h e n u r s e s , home h e a l t h a g e n c i e s c a n n o t,
s u rv iv e .
T h is s tu d y w i l l a tt e m p t t o i d e n t i f y t h e r e a s o n s why home
h e a l t h a g e n c i e s i n N o rth D a k o ta a r e u n d e r u t i l i z e d .
I t i s h o p ed t h e
r e s u l t s o f t h i s s tu d y w i l l p r o v id e b o t h p h y s i c i a n s and n u r s e s w ith
in s ig h t r e le v a n t to th e d e liv e ry o f h e a lth c a re s e rv ic e s to th e e ld e r ly
i n t h e i r h o m e s.
M a jo r P u r p o s e o f t h e S tu d y
The. m a jo r p u r p o s e o f t h i s s tu d y i s t o i d e n t i f y t h o s e f a c t o r s
w h ic h a r e c o n t r i b u t i n g t o t h e l i m i t e d u t i l i z a t i o n o f t h e home h e a l t h
a g e n c i e s i n N o rth D a k o ta ..
S p e c if ic O b je c tiv e s
1.
To d e te r m in e t h e a c c e p ta n c e o f and w i l l i n g n e s s t o
p a r t i c i p a t e i n t h e home h e a l t h p ro g ra m b y :
a.
b.
c.
2.
p h y s ic ia n s
h o s p ita l n u rses
p u b lic h e a lth n u rse s
To d e te r m in e t h e i n d i v i d u a l s ' u n d e r s t a n d in g o f t h e i r r o l e
i n t h e u t i l i z a t i o n o f t h e home h e a l t h p ro g ra m b y:
a.
b.
c.
p h y s ic ia n s
h o s p ita l n u rses
p u b lic h e a lth n u rse s
<
3
Need f o r t h e S tu d y
Home h e a l t h p ro g ra m s a r e d e s ig n e d t o s e r v e t h e p a t i e n t i n h i s
hom e, b y o f f e r i n g a n a r r a y o f s e r v i c e s t o a c h ie v e and s u s t a i n an
optim um s t a t e o f h e a l t h , a c t i v i t y , and in d e p e n d e n c e f o r t h e i n d i v i d u a l s
Some a d v a n ta g e s o f t h e home h e a l t h p ro g ra m s a r e t o :
1.
r e d u c e t h e l e n g t h o f h o s p i t a l i z a t i o n by m ak in g e a r l y
d is c h a rg e p o s s ib le .
2.
d i m i n is h t h e n e e d f o r r e a d m is s i o n t o t h e h o s p i t a l .
3.
p r e v e n t many a d m is s io n s t o n u r s i n g hom es.
4.
I
p r o v id e a m ore e c o n o m ic a l a l t e r n a t i v e t o i n s t i t u t i o n a l
c a re .
5.
r e l e a s e h o s p i t a l and i n s t i t u t i o n b e d s f o r t h e a c u t e l y i l l
p a tie n ts .
.6 .
p r o v id e p a t i e n t c a r e i n t h e n o rm a lc y o f t h e home e n v i r o n ­
m e n t.
7.
t e a c h hom ebound p a t i e n t s t o l i v e i n d e p e n d e n t l y . ^
A lth o u g h home h e a l t h p ro g ra m s w ould a p p e a r t o p r o v id e t h e s o l u ­
t i o n t o many h e a l t h n e e d s o f t h e e l d e r l y , t h e s e p ro g ra m s a r e u n d e r
u t i l i z e d , u n d e r - f i n a n c e d , and d i m i n i s h i n g a s t h e n e e d i n c r e a s e s .
T h e re a r e c u r r e n t l y e i g h t home h e a l t h a g e n c ie s , i n N o rth D a k o ta ,
s e v e n o f w h ic h a r e s t i l l o p e r a t i n g .
(S e e A p p e n d ix B f o r a map i d e n t i ­
f y in g t h e l o c a t i o n s o f t h e home h e a l t h a g e n c i e s i n N o rth D a k o ta .)
^ B r a ja n T r a g e r , Home H e a l th S e r v i c e s i n t h e U n ite d S t a t e s , A
R e p o r t t o t h e S p e c i a l C om m ittee o n A g in g , G overnm ent P r i n t i n g O f f i c e ,
W a s h in g to n , D .C ., 1 9 7 2 , p . 6 0 .
4
The home h e a l t h a g e n c i e s i n N o rth D a k o ta a r e c o n f r o n t e d w ith
lim ite d p h y s ic ia n r e f e r r a l s , i n s u f f i c i e n t p u b lic h e a lth n u rs in g s t a f f ,
g r e a t d i s t a n c e s t o t r a v e l fro m t h e home h e a l t h a g e n c y t o t h e p a t i e n t ' s
hom e, and in a d e q u a te f u n d in g .
A l l t h e s e p ro b le m s a p p e a r t o b e c o n ­
t r i b u t i n g t o t h e l i m i t e d u t i l i z a t i o n o f t h e home h e a l t h a g e n c i e s .
G overnm ent f u n d in g f o r t h e d e v e lo p m e n t o f v i a b l e home h e a l t h s e r v i c e s
h a s b e e n m in im a l.
The r e g u l a t o r y c o n d i t i o n s a r e s o n a rro w t h a t th e y
make t h e p r o d u c t n e g l i g i b l e i n te r m s o f m e e tin g r e a l n e e d . ^
,
1
.
O f t h e a b o v e m e n tio n e d p ro b le m a r e a s , l i m i t e d p h y s i c i a n
r e f e r r a l s h a s h a d t h e g r e a t e s t im p a c t.
home h e a l t h a g e n c i e s c a n n o t s u r v i v e .
W ith o u t p a t i e n t r e f e r r a l s t h e
T he f e d e r a l law s t a t e s t h a t home
h e a l t h s e r v i c e s may b e f u r n i s h e d t o an y i n d i v i d u a l who i s u n d e r t h e
c a re o f a p h y s ic ia n ; i t . r e q u i r e s t h e r e f o r e , t h a t th e a tte n d in g p h y s ic ia n
e s t a b l i s h a w r i t t e n p l a n o f c a r e a lo n g w i t h a s t a t e m e n t c e r t i f y i n g t h a t
t h e r e i s a n e c e s s i t y f o r t h e home h e a l t h s e r v i c e s .
(S e e A p p e n d ix D
f o r t h e p o r t i o n s o f t h e S o c i a l S e c u r i t y A c t r e l a t i n g t o home h e a l t h
s e r v i c e s .)
T h e re a p p e a r s t o b e a n a p p r e c i a b l e l a c k o f u n d e r s t a n d in g o f t h e
home h e a l t h p ro g ra m by t h e p h y s i c i a n s .
It
i s a w id e ly a c c e p t e d f a c t
t h a t some p h y s i c i a n s n e e d p ro m p tin g t o i n i t i a t e a r e f e r r a l .
W ith o u t
p h y s i c i a n p r o m p tin g , a r e f e r r a l i s n o t fo rth c o m in g and t h e p a t i e n t , i s 2
2I b i d . , p . 5 .
5
d e n ie d home h e a l t h c a r e .
T h e re a r e o t h e r p h y s i c i a n s who s e e m in g ly
r e f e r e v e r y p a t i e n t f o r home h e a l t h c a r e , a p p r o p r i a t e l y o r n o t , and
w i l l n o t a c c e p t th e l im it a ti o n s o f th e s e r v i c e s .^
A l a c k o f u n d e r s t a n d in g and i n t e r e s t i n t h e home h e a l t h
p ro g ra m by t h e n u r s i n g p r o f e s s i o n i s a n o t h e r a r e a c o n t r i b u t i n g t o t h e
l i m i t e d u t i l i z a t i o n o f t h e home h e a l t h p ro g ra m s .
Some h o s p i t a l n u r s e s
a p p e a r u n a w a re t h a t t h e r e i s s u c h a p ro g ra m a v a i l a b l e f o r t h e i r p a t i e n t s
u p o n d i s c h a r g e w h i l e o t h e r h o s p i t a l n u r s e s a p p a r e n t l y l a c k th e .k n o w ­
le d g e and u n d e r s t a n d in g o f t h e home h e a l t h p ro g ra m and t h e ty p e s o f
p a t i e n t s who a r e e l i g i b l e
fo r s e rv ic e s .
I d e a l l y , p l a n s f o r home
h e a l t h c a r e s h o u ld b e g in when t h e p a t i e n t i s a d m itte d t o t h e h o s p i t a l .
T h is i s n o t o c c u r i n g i n a m a j o r i t y o f h o s p i t a l s i n N o rth D a k o ta .
S t i l l o th e r f a c t o r s c o n tr ib u tin g to th e lim ite d u t i l i z a t i o n o f
t h e home h e a l t h p ro g ra m s i n c l u d e l i m i t e d p u b l i c h e a l t h n u r s i n g s t a f f ,
t h e g r e a t d i s t a n c e s t o b e t r a v e l e d fro m t h e home h e a l t h a g e n c i e s t o
t h e p a t i e n t s ' h o m es, and i n s u f f i c i e n t f u n d i n g .
A s s u m p tio n s o f t h e ,S t u d y
I t was assum ed by t h e r e s e a r c h e r a t t h e b e g in n i n g o f t h e s tu d y
th a t:
j M a rie B r e n n a n , "Home H e a lth A g e n c ie s i n R u r a l C o m m u n itie s ,"
( u n p u b li s h e d p a p e r , N p r t h . D a k o ta S t a t e D e p a rtm e n t o f H e a l t h , 1 9 7 3 ),
p. 3.
6
1.
t h e home h e a l t h a g e n c i e s i n N o rth D a k o ta a r e e x p e r i e n c i n g
l i m i t e d u t i l i z a t i o n , r e s u l t i n g i n d im in is h e d b e n e f i t s
b e in g o f f e r e d t o t h e e l d e r l y .
2.
t h e s u c c e s s o f t h e home h e a l t h p ro g ra m i s d e p e n d e n t upon
t h e p h y s i c i a n s a n d n u r s e s i n a p o s i t i o n t o im p lem e n t t h e
p ro g ra m i n t h e i r a r e a .
.3 .
4.
g e n e r a l l y , t h e e l d e r l y a r e e c o n o m ic a lly d e p r i v e d and
m e d ic a lly in d ig e n t.
e l d e r l y p e o p le w is h t o m a i n t a i n t h e i r in d e p e n d e n c e ,
p r e f e r r i n g t o re m a in i n t h e i r own hom es.
L i m i t a t i o n s o f t h e S tu d y
The l i m i t a t i o n s o f t h i s s tu d y a r e t h o s e i n h e r e n t i n s u rv e y
r e s e a r c h u t i l i z i n g a m a i l e d , o p e n -e n d e d q u e s t i o n n a i r e .
It
i s a g r e e d by r e s e a r c h e r s t h a t t h e s u b j e c t i v e ty p e o f
q u e s tio n n a ir e , as u sed i n t h i s s tu d y , le n d s i t s e l f to p o s s ib le m is in ­
te rp re ta tio n .
D e f i n i t i o n o f Term s
The f o l l o w i n g d e f i n i t i o n s w e re f o r m u la te d f o r t h e p u r p o s e s o f
t h i s s t u d y t o p r o v id e c l a r i f i c a t i o n o f t h e te r m in o lo g y u s e d .
1.
P u b l i c H e a l th N u rs e - a r e g i s t e r e d n u r s e , em ployed by a
com m unity o r h o s p i t a l t o o f f e r home h e a l t h c a r e .
2.
P r o v i d e r o f S e r v i c e s - a h o s p i t a l , e x te n d e d c a r e f a c i l i t y ,
o r a home h e a l t h a g e n c y .
3.
Home H e a l th A gency - a p u b l i c o r p r i v a t e o r g a n i z a t i o n , o r
a s u b d i v i s i o n o f s u c h a h a g e n c y o r o r g a n i z a t i o n , w h ic h :
a.
i s p r i m a r i l y e n g a g e d i n p r o v id i n g s k i l l e d n u r s i n g and
o th e r th e ra p e u tic s e r v ic e s ,
7
4.
b.
h a s p o l i c i e s e s t a b l i s h e d by a p r o f e s s i o n a l g ro u p
a s s o c ia te d w ith th e agency o r o r g a n iz a tio n ,
c.
m a i n t a i n s c l i n i c a l r e c o r d s on a l l p a t i e n t s .
4
Home H e a l th S e r v i c e s - i n c l u d e t h o s e ite m s and s e r v i c e s
f u r n i s h e d t o a n i n d i v i d u a l , who i s u n d e r t h e c a r e o f a
p h y s i c i a n , and a home h e a l t h a g e n c y , w h ic h g i v e s c a r e on a
v i s i t i n g b a s is in th e c l i e n t 's p la c e o f r e s id e n c e :
a.
p a r t tim e o r i n t e r m i t t e n t s k i l l e d n u r s i n g c a r e ;
b . . p h y s ic a l, o c c u p a tio n a l, o r sp eech th e ra p y ;
c.
m e d ic a l s o c i a l s e r v i c e s ;
d.
i n t e r m i t t e n t s e r v i c e s o f a home h e a l t h a i d e ;
5
m e d ic a l s u p p l i e s .
e.
i
5.
C o v e re d S e r v i c e - t h o s e home h e a l t h s e r v i c e s f o r w hich
re im b u rs e m e n t w i l l b e r e c e i v e d from M e d ic a re .
6.
B e n e f i t P e r i o d - a p e r i o d o f c o n s e c u t i v e d a y s d u r in g w h ic h
s e r v i c e s f u r n i s h e d t o a p a t i e n t , up t o a c e r t a i n s p e c i f i e d
maximum, am o u n t, c a n b e p a id f o r by t h e h o s p i t a l i n s u r a n c e
p la n .
7.
F i s c i a l I n t e r m e d i a r y - B lu e C ro s s o f N o rth D a k o ta h a n d le s
t h e M e d ic a re c la im s f o r t h e home h e a l t h a g e n c i e s i n N o rth
D a k o ta . *56
U n ite d S t a t e s D e p a rtm e n t o f H e a l t h , E d u c a ti o n and W e lf a r e ,
S o c i a l S e c u r i t y A d m i n i s t r a t i o n , T i t l e 18 H e a lth I n s u r a n c e f o r th e A g ed ,
P u b l i c Law 8 9 -9 7 o f t h e S o c i a l S e c u r i t y A c t , G overnm ent P r i n t i n g O f f i c e ,
W a s h in g to n , D .C ., J u l y 3 , 1 9 6 5 , p . 3 8 .
5I b i d . , p . 3 7 .
6
U n ite d S t a t e s D e p a rtm e n t o f H e a l t h , E d u c a tio n and W e lf a r e ,
S o c i a l S e c u r i t y A d m i n i s t r a t i o n , S o c i a l S e c u r i t y H an dbook, 4 t h e d i t i o n ,
G overnm ent P r i n t i n g O f f i c e , W a s h in g to n , D .C ., 1 9 6 9 , p . 3 5 2 .
8
8.
H o s p i t a l B a se d Home H e a l th A gency - t h o s e a g e n c i e s f in a n c e d
by a h o s p i t a l and h a v in g t h e i r o f f i c e s i n t h e s p o n s o r in g
h o s p ita l.
9.
Community B ased Home H e a l th A gency - t h o s e home h e a l t h
a g e n c i e s w h ic h a r e a p a r t o f a g e n e r a l i z e d p u b l i c h e a l t h
n u r s i n g p ro g ra m i n a c i t y o r c o u n ty . T h e s e a g e n c i e s a r e
s u p p o r t e d by l o c a l t a x e s .
^
10.
G e n e r a l iz e d P u b l i c H e a l th N u r s in g P ro g ra m - t h i s i n v o lv e s
a l l a s p e c ts o f p u b lic h e a lth n u r s in g , in c lu d in g sc h o o l
h e a l t h , h e a l t h c o u n s e l i n g arid t e a c h i n g , v a r i o u s c l i n i c s
( i . e . , i m m u n iz a tio n ) , a s w e l l a s home h e a l t h s e r v i c e s .
11.
Homebound - a c l i e n t who i s c o n f in e d t o h i s hom e, u n a b le
t o l e a v e w i t h o u t a s s i s t a n c e an d t h e n o n ly f o r o u t - p a t i e n t
c a re .
12.
S k i l l e d N u r s in g - t h o s e s e r v i c e s w h ic h m u st b e f u r n i s h e d
by o r u n d e r t h e d i r e c t s u p e r v i s i o n o f a l i c e n s e d n u r s e
t o a s s u r e t h e s a f e t y o f t h e p a t i e n t and t o a c h ie v e t h e
m e d ic a lly d e s ir e d r e s u l t s . .
C h a p te r I I
i
I
•
REVIEW OF LITERATURE
I
.
The 1965 am endm ents t o t h e S o c i a l . S e c u r i t y A c t e n a c t e d i n
P u b l i c Law 8 9 -9 7 e s t a b l i s h e d a c o m p re h e n s iv e p ro g ra m o f h e a l t h i n s u r ­
a n c e , commonly known a s " M e d ic a r e ," f o r i n d i v i d u a l s s i x t y - f i v e y e a r s
I
o f a g e and o v e r . T h is law p r o v id e s a m ech an ism f o r f i n a n c i n g an a r r a y
o f h e a l t h s e r v i c e s , i n c l u d i n g i n - h o s p i t a l c a r e , e x te n d e d c a r e b e n e f i t s ,
and home h e a l t h s e r v i c e s .
The c o n c e p t e n v is i o n e d by M e d ic a re i s t o
a llo w f o r c o n t i n u i t y , o f c a r e a s t h e p a t i e n t moves fro m o n e l e v e l o f
i
c a re to a n o th e r.
MEDICARE
Its
In c e p tio n
A t t h e o n s e t o f M e d ic a r e , t h e r e w e re few r e g u l a t i o n s s p e c i f y i n g
t h e k in d s o f c a r e w h ic h w o u ld be c o v e r e d .
As a r e s u l t , any p e r s o n
s i x t y - f i v e y e a r s o f a g e and o v e r h a v in g m e d ic a r e i n s u r a n c e , c o u ld
r e c e i v e up t o one h u n d re d f r e e v i s i t s
upon t h e o r d e r o f a p h y s i c i a n .
fro m a p u b l i c h e a l t h n u r s e ,
Much o f t h e c a r e g i v e n c o n s i s t e d o f
p e r s o n a l c a r e , s u c h a s a s s i s t a n c e w i t h b a t h i n g , sham poo, and a m b u la tio n .
S k i l l e d n u r s i n g was n o t a lw a y s a p a r t o f t h i s c a r e .
At t h i s p o in t,
many o f th e n e e d s o f t h e e l d e r l y w e re b e in g m e t, and t h e p ro g ra m was
w id e ly u s e d .
I n A u g u st o f 1 9 6 9 , I n t e r m e d i a r y L e t t e r No. 395 was s e n t
t o a l l t h e p a r t i c i p a t i n g home h e a l t h a g e n c i e s .
T h is l e t t e r u s h e r e d i n
.
,
10
a d r a s t i c c h a n g e i n t h e c o v e r e d s e r v i c e s a v a i l a b l e u n d e r M e d ic a re .
T h is l e t t e r s t a t e d :
j
I
. . . . p a y m e n t s may n o t b e made f o r home h e a l t h s e r v i c e s u n l e s s th e
s e r v i c e s w e re r e q u i r e d b e c a u s e t h e i n d i v i d u a l n e e d e d " s k i l l e d
n u r s i n g c a r e " on a n i n t e r m i t t e n t b a s i s , o r p h y s i c a l o r s p e e c h
th e r a p y .7
'
B ecause o f t h i s
l e t t e r t h e te r m " s k i l l e d n u r s in g " h a s p la y e d an im p o r­
ta n t r o le in p a tie n t c a r e .
E v e ry o n e , in c lu d in g th e p h y s ic ia n s , p u b lic
h e a l t h n u r s e s , h o s p i t a l n u r s e s a n d t h e p u b l i c , in v o lv e d w i t h M e d ic a re ,
h a s h a d a d i f f e r e n t i n t e r p r e t a t i o n o f t h e te r m .
R e c e n tl y t h e ra n g e
o f n u r s i n g and o t h e r s e r v i c e s c o v e re d b y M e d ic a r e .h a s b e e n n a rro w e d
s t i l l m ore by " t e c h n i c a l d e f i n i t i o n s . "
T hese d e f i n i t i o n s have been
a p p l i e d w i t h o u t c o g n iz a n c e o f n u r s i n g c a r e o r t h e p a t i e n t s ' n e e d s ,
e x c lu d i n g a l l c a r e g i v e n t o m a i n t a i n o r p ro m o te h e a l t h o r p r e v e n t
.
'
.
r e g r e s s i o n o f m e n ta l o r p h y s i c a l w e l l b e i n g .
Thus a c o n f l i c t a r o s e b e tw e e n t h e c a r e o r d e r e d and t h e ty p e s
o f c a r e .w h i c h a r e c o v e re d u n d e r M e d ic a r e .
The c o v e ra g e a v a ila b le *
u n d e r M e d ic a re i s d i v i d e d i n t o two p a r t s , P a r t A and P a r t B.
P a rt A
P a r t A , known a s h o s p i t a l i n s u r a n c e , c o v e r s i n - p a t i e n t c a r e i n
7
U n ite d S t a t e s D e p a rtm e n t o f H e a l t h , E d u c a ti o n , and W e lf a r e ,
S o c i a l S e c u r i t y A d m i n i s t r a t i o n , B u re a u o f H e a l th I n s u r a n c e , " I n t e r ­
m e d ia ry L e t t e r No. 3 9 5 ," G overnm ent P r i n t i n g O f f i c e , W a s h in g to n , D .G .,
A u g u s t, 1969.
11
. h o s p i t a l s , e x te n d e d c a r e f a c i l i t i e s , and i n t e r m i t t e n t c a r e i n t h e
hom e.
The h o s p i t a l i n s u r a n c e d e s c r i b e d i n P a r t A p a y s f o r a l l
c o v e re d s e r v i c e s , f o r a s many a s o n e h u n d re d home v i s i t s a f t e r th|e
s t a r t o f o n e b e n e f i t p e r i o d and b e f o r e t h e s t a r t o f a n o t h e r .
T h e se
b e n e f i t s c a n b e p a i d f o r up t o one y e a r a f t e r t h e m o st r e c e n t d i s ­
c h a r g e fro m a h o s p i t a l o r p a r t i c i p a t i n g s k i l l e d n u r s i n g f a c i l i t y , b u t
o n ly i f t h e f o l l o w i n g c o n d i t i o n s a r e m et:
C o s t.
1.
t h e p a t i e n t was i n a p a r t i c i p a t i n g h o s p i t a l f o r a t l e a s t
th r e e c o n s e c u tiv e d a y s.
2.
t h e c o n t i n u i n g c a r e n e e d e d i n c l u d e s p a r t tim e s k i l l e d
n u rs in g c a r e , p h y s ic a l, o r sp eech th e ra p y .
j
3.
t h e p a t i e n t i s hom ebound.
4.
th e p h y s ic ia n e s ta b l is h e s a w r i tt e n p la n o f c a re w ith in
f o u r t e e n d a y s a f t e r t h e p a t i e n t ' s d i s c h a r g e fro m t h e ■
h o s p it a l o r p a r t i c i p a t i n g s k i l l e d n u rs in g f a c i l i t y .
!
5.
t h e home c a r e i s f u r t h e r t r e a t m e n t o f a c o n d i t i o n f o r
w h ic h t h e p a t i e n t was h o s p i t a l i z e d .
The p a t i e n t m u st p a y t h e f i r s t $ 6 0 .0 0 .
I
i
j
A f t e r t h e $ 6 0 .0 0
d e d u c t i b l e h a s b e e n m e t, t h e p a t i e n t i s n o t r e q u i r e d t o make any
I
a d d i t i o n a l p a y m e n ts f o r home h e a l t h v i s i t s , i f t h e c a r e n e e d e d i s ' a
8
c o v e re d s e r v i c e . 8
8
U n ite d S t a t e s D e p a rtm e n t o f H e a l t h , E d u c a tio n and W e lf a r e ,
S o c i a l S e c u r i t y A d m i n i s t r a t i o n , Y o u r M e d ic a re H an d b o o k , P u b l i c a t i o n
# (SSA) 7 3 0 1 0 0 5 0 , U. S . G overnm ent P r i n t i n g O f f i c e , W a s h in g to n , D .C .,
1 9 7 3 , p . 11.
12
P a rt B
P a r t B, known a s S u p p le m e n ta ry M e d ic a l I n s u r a n c e , a s s i s t s
w i t h p a y m e n ts o f p h y s i c i a n s ' f e e s , o u t - p a t i e n t s e r v i c e s , and some home
h e a lth b e n e f its .
h e a lth v i s i t s
P a r t B e n t i t l e s t h e p a t i e n t up t o o n e h u n d re d home
f o r each c a le n d a r y e a r , w ith o u t r e q u ir in g p r io r h o s p i t a l i ­
z a t i o n , b u t o n ly i f t h e f o ll o w i n g c o n d i t i o n s a r e m et:
C o s t.
1.
t h e p a t i e n t n e e d s p a r t tim e s k i l l e d n u r s i n g c a r e , p h y s i c a l
o r sp eech th e ra p y .
2.
t h e p a t i e n t i s hom ebound.
3.
t h e p h y s i c i a n d e te r m i n e s t h a t t h e p a t i e n t n e e d s home c a r e .
4.
t h e p h y s i c i a n i n i t i a t e s and p e r i o d i c a l l y r e v ie w s t h e p l a n
o f c a re .
U n d er P a r t B, t h e p a t i e n t m u st p a y t h e f i r s t $ 6 0 .0 0 and 20 p e r -
c e n t o f t h e t o t a l c o s t o f t h e c o v e re d s e r v i c e s .
9
U tiliz a tio n
W ith t h e p a s s a g e o f tim e and t h e m ore r e s t r i c t i v e r e g u l a t i o n s ,
a p p r o p r i a t e p a t i e n t r e f e r r a l s h a v e b e g u n t o d e c r e a s e , u n t i l a num ber
o f t h e home h e a l t h a g e n c i e s i n N o rth D a k o ta a r e s t r u g g l i n g f o r s u r v i v a l .
T he l i m i t e d u t i l i z a t i o n o f home h e a l t h a g e n c ie s i s a c o n c e r n
o f many s t a t e s ,
i n c l u d i n g N o rth D a k o ta .
Home h e a l t h s e r v i c e s a r e t h e
l e a s t c o s t l y o f a l l t h e m e d ic a l s e r v i c e s , y e t i t i s t h e o n e s e r v i c e
r ~
I b i d . , p . 20.
13
t h a t i s se ld o m u s e d .
Ambrose*® e m p h a s iz e s t h a t , a f t e r d i s c h a r g e , a
p a t i e n t u s u a l l y g o e s . t o h i s home o r t h a t o f a r e l a t i v e f o r w eeks o r
m o n th s o f r e c u p e r a t i o n .
I t h a s becom e a p p a r e n t t h a t h o s p i t a l s a r e
n o t p r e p a r in g p a t i e n t s f o r c o n tin u ity o f c a re upon d is c h a r g e .
To
r e c e i v e c o n t i n u i t y o f c a r e , t h e h e a l t h c a r e s y s te m a s a w h o le m u s t.u s e
a l l t h e e x i s t i n g p u b l i c and p r i v a t e s e r v i c e s , f a c i l i t i e s , and a g e n c ie s .
t h a t w i l l i n a v e r y r e a l way make h e a l t h c a r e a v a i l a b l e and a c c e s s i b l e .
The d e c i s i o n f o r home c a r e l i e s w i t h a v a r i e t y o f i n t e r e s t s , m a in ly
t h e p h y s i c i a n s and n u r s e s , b u t a l s o w i t h t h e p a t i e n t .
T he p a t i e n t
c a n b e i n f l u e n t i a l i n t h e d e c i s i o n t o r e c e i v e home c a r e b u t o n ly i f
h e i s in fo rm e d o f t h e v a lu e o f s u c h s e r v i c e s and i s a b l e t o a r t i c u l a t e
h i s n e e d t o t h e n u r s e s an d d o c t o r s .
L ew is
11 s t r e s s e s t h a t c o o p e r a t i o n i s a n e s s e n t i a l a s p e c t o f
any home h e a l t h p ro g ra m .
The m e d ic a l s t a f f m u st c o o p e r a te i n r e f e r ­
r i n g and e d u c a t in g t h e p a t i e n t s r e g a r d i n g t h e b e n e f i t s o f t h e home
h e a l t h p ro g ra m .
P h y s ic i a n s 1 R o le .
I n r e c e n t m o n th s home c a r e h a s r e c e i v e d c o n s i d e r a ­
t i o n by t h e A m e ric an M e d ic a l A s s o c i a t i o n .
An a r t i c l e
i n t h e A m erican
*®Anne A m b ro se, S r . , " D i s c h a r g e P l a n s - - T h e W e a k e st L in k ,"
H o s p i t a l P r o g r e s s , M a rc h , 1 9 7 3 , p . 5 8 .
11
D av id L ew is and M a rie M ackey, "Home C a re P ro g ra m s C u ts
D o l l a r s an d D a y s ," C a n a d ia n H o s p i t a l s , May 1 9 7 3 , p . 3 7 .
14
M e d ic a l News
i n d i c a t e s t h a t home c a r e p ro g ra m s c a n n o t b e s u c c e s s f u l
u n l e s s t h e q u a l i t y o f c a r e i s h i g h and i t i s e f f e c t i v e l y u t i l i z e d .
P h y s i c i a n s , i n d i v i d u a l l y and c o l l e c t i v e l y h a v e i m p o r ta n t r e s p o n s i b i l i ­
t i e s i n a s s u r i n g t h a t t h i s s t a n d a r d i s m e t.
T he a u t h o r s t a t e d t h a t :
The m e d ic a l s o c i e t i e s ' r o l e s h o u ld be g iv e n t o s t i m u l a t i n g
p h y s i c i a n s ' i n t e r e s t i n and a c c e p t a n c e o f home c a r e . The s o c i e t y
m u st a l s o t a k e t h e l e a d i n im p ro v in g t h e c o o r d i n a t i o n o f e x i s t i n g
home c a r e s e r v i c e s and s t i m u l a t i n g t h e d e v e lo p m e n t o f new o n es
w h e re t h e y a r e n e e d e d .13
I t m u st b e k e p t i n m ind t h a t e f f e c t i v e p ro g ra m s c a n o f f e r
h i g h q u a l i t y c a r e and be a n e x t e n s i o n o f t h e p h y s i c i a n s a t l i t t l e
cost
an d e f f o r t t o t h e p h y s i c i a n and a t c o n s i d e r a b l e s a v in g s t o t h e p a t i e n t .
B u t home c a r e p ro g ra m s c a n n o t f l o u r i s h w i t h o u t t h e s u p p o r t and g u id a n c e
o f t h e m e d ic a l com m unity.
A m b r o s e ^ s t a t e s t h a t " m e d ic a r e c o v e ra g e i s
p r e d i c a t e d u p o n t h e p h y s i c i a n s p r o f e s s i o n a l ju d g m e n t and h i s p l a n o f
t r e a t m e n t ; some p h y s i c i a n s a r e s t i l l s k e p t i c a l o r , a t b e s t , p a s s i v e . "
N u rs e s' R o le .
P r o f e s s i o n a l n u r s i n g i s r e s p o n s i b l e f o r m e e tin g t h e
n e e d s o f a l l p e o p le r e g a r d l e s s o f a g e .
The r a p i d l y i n c r e a s i n g num bers
o f i n d i v i d u a l s i n t h e o l d e r a g e g ro u p m u st b e a c o n c e r n o f a l l p r o ­
f e s s i o n a l n u r s e s , i f t h i s seg m en t o f t h e p o p u l a t i o n i s t o r e c e i v e
\
E d i t o r i a l , A m e ric a n M e d ic a l N ew s, J a n u a r y 8 , 1 9 7 3 , p . 5 .
Ib id .
4A m brose, o p . c i t . , p . 5 9 .
15 '
a d e q u a te n u r s i n g c a r e .
Dawson
16
b e l i e v e s t h a t c o n t i n u i t y o f c a r e i s d e p e n d e n t on t h e
n u r s i n g p r o f e s s i o n 's a w a re n e s s o f p a t i e n t s ' n e e d s and t h e p r o f e s s i o n s
p l a n n i n g f o r w ays o f m e e tin g t h e s e n e e d s .
The h o s p i t a l n u r s e i s i n a
p o s i t i o n t o i d e n t i f y p o s t - h o s p i t a l n u r s i n g n e e d s o f p a t i e n t s t h a t may
b e m et by p u b l i c h e a l t h n u r s i n g i n t e r v e n t i o n .
The h o s p i t a l n u r s e i s
a ls o i n f l u e n t i a l in a id in g th e p h y s ic ia n in i n i t i a t i n g a p p ro p ria te
r e f e r r a l s t o t h e home h e a l t h a g e n c i e s .
Upon r e c e i p t o f a p h y s i c i a n 's r e f e r r a l , t h e p u b l i c h e a l t h
n u r s e i s a b l e t o p r o v id e home h e a l t h c a r e t o t h e p a t i e n t i n h i s hom e.
An a r t i c l e
i n NLN News
17
f a c e tio u s ly s ta te d th a t,, " p u b lic h e a lth
n u r s e s do f a r m ore t h a n w ash and i r o n t h e p a t i e n t and c a r r y o u t th o s e
t a s k s w h ic h a r e deem ed s k i l l e d . "
The a r t i c l e s t r e s s e d t h a t , i n
a d d i t i o n t o m e d ic a l o r d e r s and p r o v i d i n g d i r e c t n u r s i n g c a r e t r e a t m e n t s
t h e p u b l i c h e a l t h n u r s e m akes t o t a l a s s e s s m e n t o f p a t i e n t s ' n e e d s ,
e v a l u a t e s f a m ily r e s o u r c e s and home s i t u a t i o n s , m akes o b s e r v a t i o n s o f
d i s e a s e p r o c e s s and sy m p to m s, d e v e lo p s n u r s i n g c a r e p l a n s , d e m o n s tr a te s
15
" C h a ll e n g e s t o N u r s in g i n M e d ic a r e ," A m e ric an J o u r n a l o f
N u r s in g , N ovem ber, 1 9 6 5 , Volume 1 3 , p . 6 8 .
16
Norma Dawson and M a rth a S t e r n , " P e r c e p t i o n s o f P r i o r i t i e s f o r
Home N u r s in g C a r e ," N u r s in g R e s e a r c h , M arch - A p r i l , 1 9 7 3 , Volume 2 2 ,
p . 145.
17
E d i t o r i a l , NLN N ew s, Volume 2 1 , No. 8 , N a t i o n a l L eag u e f o r
N u r s in g , S e p te m b e r, 1 9 7 3 , p . 3 .
16
c a r e an d i n s t r u c t s t h e p a t i e n t ' s f a m i l y , s u p e r v i s e s c a r e p r o v id e d by
a u x i l i a r y p e r s o n n e l , and c o o r d i n a t e s s e r v i c e s .
A long w i t h t h e s e s e r ­
v ic e s th e p u b lic h e a lth n u rse i s r e s p o n s ib le f o r th e e d u c a tio n o f
p h y s i c i a n s , h o s p i t a l n u r s e s * and t h e p u b l i c r e g a r d i n g t h e M e d ic a re
b e n e f i t s a v a i l a b l e th r o u g h t h e home h e a l t h p ro g ra m .
T he A m e ric an
H o s p i t a l A s s o c i a t i o n s u p p o r t s t h e i d e a t h a t " t h e p u b l i c s h o u ld b e
in fo rm e d o f t h e p o t e n t i a l f o r e x p e r t c a r e i n t h e home t h r o u g h v a r i o u s
t y p e s o f home c a r e p r o g r a m s ."
18
HOME CARE TODAY
N a tio n w id e
I n a r e c e n t r e p o r t R yder
19
s ta te d :
. . . . h o m e c a r e o f f e r s a p e r s o n a l c h o ic e i n m e d ic a l c a r e . S t u d i e s o f
o l d e r p e o p le show t h a t up t o 50 p e r c e n t o f t h o s e i n i n s t i t u t i o n s
w o u ld r e a l l y r a t h e r b e i n t h e i r own h o m e s. Home c a r e m o st im p o r­
t a n t l y p r o v i d e s u s w i t h a way o f a llo w in g t h e i n d i v i d u a l t o re m a in
i n c o m f o r t and d i g n i t y i n h i s own home w h i l e a t t h e same tim e i t
p r e v e n t s d e p e n d e n c y and l o s s o f hum an r e s o u r c e s .
D e s p i te t h e s e v i r t u e s , home c a r e i n t h e U n ite d S t a t e s a t t h i s
moment i s a t a s t a n d s t i l l , i f n o t i n r e g r e s s i o n . T h e re a r e a b o u t
2 ,3 0 0 home h e a l t h a g e n c i e s c e r t i f i e d f o r M e d ic a re , r e im b u rs e m e n t,
and y e t t h e r e a r e l a r g e g e o g r a p h ic a r e a s o f t h e n a t i o n s t i l l w i t h
no s u c h s e r v i c e . F i f t y p e r c e n t o f o u r c o u n t i e s h a v e no home h e a l t h
s e r v i c e s a n d , a lt h o u g h t h e s e c o u n t i e s r e p r e s e n t a s m a l l p r o p o r t i o n
^ A m e r ic a n H o s p i t a l A s s o c i a t i o n , T he H o s p i t a l a n d t h e Home
C a re P ro g ra m , 1 9 7 2 , p . 14.
19
C l a i r e F . R y d e r , "In-H om e C a re T ow ards a N a t i o n a l P o l i c y a n d
S t r a t e g y , " P a p e r p r e s e n t e d a t 1972 R e g io n a l M e e tin g s o f Home H e a lth
A g e n c ie s and Com m unity H e a l th S e r v i c e s .
I
17
o f o u r p o p u l a t i o n , th e y p o s e p a r t i c u l a r p ro b le m s o f d i s t a n c e and
i s o l a t i o n i n r u r a l a r e a s . O ver h a l f t h e a g e n c i e s t h a t a r e c e r t i ­
f i e d h a v e o n ly o n e o r tw o n u r s e s o n s t a f f .
S in c e o v e r 60 p e r c e n t
o f t h e c e r t i f i e d a g e n c i e s a r e a d m i n i s t e r e d by h e a l t h d e p a r t m e n t s ,
t h e s e n u r s e s o f t e n h a v e many o t h e r r e s p o n s i b i l i t i e s beyond t h e
d e l i v e r y o f c a r e t o t h e p a t i e n t i n h i s h o m e ...
I n N o r th D a k o ta
Home c a r e i n N o r th D a k o ta i s e x p e r i e n c i n g d i f f i c u l t i e s .
In
1 9 6 9 , t h e r e w e re n in e a g e n c i e s c e r t i f i e d f o r M e d ic a re re im b u rs e m e n t.
As M e d ic a re r e g u l a t i o n s becam e m ore r e s t r i c t i v e and p a t i e n t r e f e r r a l s
b e g a n t o d e c l i n e , t h e home h e a l t h a g e n c i e s fo u n d i t
d i f f i c u l t t o m a i n t a i n t h e i r p r o g ra m s .
h e a lt h agency te r m in a te d i t s
D a k o ta .
in c re a s in g ly
As a r e s u l t , i n 1 9 7 4 , one home
s e r v i c e s , l e a v i n g e i g h t a g e n c i e s i n N o rth
Of t h e r e m a in in g e i g h t a g e n c i e s , o n ly s e v e n a r e c o n t i n u i n g t o
o f f e r home c a r e .
The e i g h t h a g e n c y i s i n s e r i o u s f i n a n c i a l t r o u b l e ,
w ith th e p o s s i b i l i t y o f c lo s u r e w ith in th e y e a r.
A lth o u g h N o rth D a k o ta h a s e i g h t home h e a l t h a g e n c i e s , t h e r e
a r e l a r g e a r e a s o f t h i s r u r a l s t a t e w h ic h do n o t h a v e a c c e s s t o home
c a re .
N o rth D a k o ta h a s f i f t y - o n e c o u n t i e s , tw e n ty o f w h ic h h a v e a c c e s s
t o home h e a l t h p r o g r a m s .
W ith t h e p o s s i b l e c l o s u r e o f a n o t h e r a g e n c y ,
N o rth D a k o ta w o u ld b e l e f t w i t h o n ly tw e lv e c o u n t i e s o f f e r i n g home
h e a lth c a re .
An a r t i c l e i n t h e NLN News
20
20
q u o te d S e n a to r M uskie a s s a y in g
NLN N ew s, o p . c i t . , Volume 2 1 , No. 8 , p . 3 .
18
" r e s t r i c t i v e re im b u rs e m e n t p o l i c i e s h a v e l i m i t e d p a y m e n ts f o r home
h e a l t h s e r v i c e s t o l e s s t h a n one p e r c e n t o f M e d ic a re e x p e n d i t u r e s .
VJhat s h o u ld b e a n im p o r ta n t se g m e n t o f o u r n a t i o n a l h e a l t h s y s te m h a s
b e e n b a d ly c r i p p l e d by a c o m b in a tio n o f n e g a t i v e a t t i t u d e s .V
A s t a t e m e n t fro m T r a g e r ' s
21
r e p o r t sums up t h e s i t u a t i o n w e l l .
A r e v ie w o f home h e a l t h s e r v i c e s a v a i l a b l e i n t h e U n ite d S t a t e s
m u st l e a d t o t h e c o n c l u s i o n t h a t t h e y do n o t c o n s t i t u t e a v a l i d
r e s o u r c e f o r t h e p o p u l a t i o n w h ic h c o u ld make a p p r o p r i a t e u s e o f
th em .
They a r e i n s h o r t s u p p ly , t h e y do n o t o f f e r t h e c o m p re h e n s iv e
r a n g e o f s e r v i c e s r e q u i r e d , th e y a r e l i m i t e d i n t h e i r c a p a c i t y t o
p r o v id e f o r any s i g n i f i c a n t volum e o f t h e p o p u l a t i o n i n n e e d , and
t h e y h a v e no g e o g r a p h ic c o v e r a g e . W here th e y do e x i s t , t h e
s e r v i c e s a r e . fra g m e n te d and a r e d e c r e a s i n g r a t h e r t h a n e x p a n d in g .
21
B r a ja n T r a g e r , Home H e a l th S e r v i c e s i n t h e U n ite d S t a t e s , A
R e p o r t t o t h e S p e c i a l C o m m ittee on A g in g , G overnm ent P r i n t i n g O f f i c e ,
W a s h in g to n , D. C. , 1 9 7 2 , p . 6 1 .
\
C h a p te r I I I
METHODOLOGY
The d a t a p r e s e n t e d i n t h i s s t u d y w e re c o l l e c t e d th r o u g h t h e u s e
.
o f a su rv e y in s tru m e n t.
T he w r i t t e n q u e s t i o n n a i r e w as c o n s id e r e d t o
b e t h e b e s t m eth o d f o r c o l l e c t i o n o f d a t a i n t h i s n o n e x p e r im e n ta l
d e s c rip tiv e re se a rc h e f f o r t.
T he d e s i g n i s a l s o c o n d u c iv e t o d a t a
c o l l e c t i o n o v e r a. l a r g e g e o g r a p h ic a r e a w i t h r e l a t i v e s p e e d and e a s e .
22
An o p e n -e n d e d q u e s t i o n n a i r e w as d e v is e d by t h e r e s e a r c h e r t o
be s e n t t o t h e t a r g e t p o p u l a t i o n l o c a t e d i n t h e g e o g r a p h ic a r e a s o f
t h e n i n e home h e a l t h a g e n c i e s i n N o rth D a k o ta .
PILOT STUDY
I n o r d e r t o v a l i d a t e and r e f i n e t h e p r o p o s e d t o o l f t h e i n i t i a l
q u e s t i o n n a i r e w as m a ile d t o f o u r p u b l i c h e a l t h n u r s e s , f o u r p h y s i c i a n s
and f o u r h o s p i t a l n u r s e s a s s o c i a t e d w i t h home h e a l t h a g e n c i e s i n
M o n ta n a .
S e v e r a l p ro b le m a r e a s r e l a t i n g t o c l a r i t y and e a s e o f
r e s p o n s e w e re i d e n t i f i e d i n t h e i n i t i a l q u e s t i o n n a i r e .
R e v is io n s w e re
t h e n made t o p ro d u c e t h e f i n a l v e r s i o n o f t h e q u e s t i o n n a i r e .
2^ H illw a y T y r u s , I n t r o d u c t i o n t o R e s e a r c h (B o s to n : H o u g h to n
M i f f l i n Com pany, 1 9 5 6 ) , p . 2 0 1 .
20
SELECTION OF THE POPULATION
A p u r p o s i v e sa m p le was s e l e c t e d fro m p h y s i c i a n s , p u b l i c h e a l t h
n u r s e s , an d h o s p i t a l n u r s e s em p lo y ed i n t h e g e o g r a p h ic a r e a s o f t h e
n in e home h e a l t h a g e n c i e s i n N o rth D a k o ta .
P h y s ic ia n s
T h e r e a r e a p p r o x im a te ly 500 p h y s i c i a n s i n N o r th D a k o ta .
t h i s g ro u p 228 w e re s e l e c t e d .
From
A c u r r e n t l i s t i n g o f p h y s i c i a n s was
a c q u i r e d fro m t h e N o r th D a k o ta S t a t e D e p a rtm e n t o f H e a l t h .
,
T h is l i s t ­
in g w as re v ie w e d by t h e r e s e a r c h e r and t h o s e p h y s i c i a n s w e re e l i m i n a t e d
who w e re deem ed l e a s t l i k e l y t o u t i l i z e
agency.
t h e s e r v i c e s o f a home h e a l t h
The p h y s i c i a n s e l i m i n a t e d a r e a s f o ll o w s :
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
p e d ia tric ia n s
o b s te tric ia n s
g y n e c o lo g is ts
e a r , n o s e and t h r o a t s p e c i a l i s t s
o s te o p a th s
d e rm a to lo g is ts
a lle rg y s p e c ia lis ts
d e n tis ts
p s y c h o lo g is ts
a d o l e s c e n t m e d ic in e
n e u ro su rg e o n s
ra d io lo g is ts
p s y c h ia tris ts
p h y s i c i a n s em ployed by V e te r a n s H o s p i t a l s and A i r B ase
H o s p ita ls .
21
H o s p i t a l N u rs e s
A t o t a l o f s i x t y h o s p i t a l n u r s e s w e re s e l e c t e d f o r t h e
r e s e a r c h e r by t h e e x e c u t i v e s e c r e t a r y o f t h e N o rth D a k o ta S t a t e N u rs e s
A s s o c ia tio n .
T he e x e c u t i v e s e c r e t a r y w as p r o v id e d w i t h t h e c r i t e r i a
f o r th e s e l e c t i o n o f th e s e n u r s e s .
The c r i t e r i a w e re a s f o llo w s :
1.
f o u r n u r s e s w e re t o be s e l e c t e d fro m e a c h o f t h e s p e c i f i e d
h o s p i t a l s . T he tw e n ty - tw o h o s p i t a l s s e l e c t e d f o r t h e s tu d y
w e re l o c a t e d i n t h e g e o g r a p h ic a r e a s o f t h e n i n e home
h e a lth a g e n c ie s .
2.
e a c h n u r s e m u st b e e m p lo y e d .
T he sa m p le p o p u l a t i o n s e l e c t e d t o p a r t i c i p a t e i n t h i s s tu d y
was s m a l l e r t h a n a n t i c i p a t e d .
I n some c a s e s , fe w e r t h a n f o u r n u r s e s
w e re s e l e c t e d , b e c a u s e some o f t h e s m a l l , r u r a l h o s p i t a l s d i d n o t
em ploy f o u r r e g i s t e r e d n u r s e s .
P u b l i c H e a l t h N u rs e s
T h e re w e re s e v e n t y - f i v e p u b l i c h e a l t h n u r s e s em p lo y ed i n N o rth
D a k o ta .
O f t h e s e s e v e n t y - f i v e p u b l i c h e a l t h n u r s e s , f i f t y - t w o w ork i n
l o c a l a g e n c i e s o f f e r i n g home h e a l t h s e r v i c e s u n d e r m e d ic a r e .
T h e se
f i f t y - t w o p u b l i c h e a l t h n u r s e s w e re s e l e c t e d t o p a r t i c i p a t e i n t h i s
s tu d y .
METHOD OF COLLECTING THE DATA
T he q u e s t i o n n a i r e , a c o v e r l e t t e r e x p l a i n i n g t h e p u r p o s e o f
t h e s tu d y and r e q u e s t i n g t h e p a r t i c i p a t i o n o f t h e r e s p o n d e n t , a lo n g
22
w i t h a s e l f a d d r e s s e d e n v e lo p e , w e re s e n t t o t h e sa m p le p o p u l a t i o n
s e le c te d f o r t h i s s tu d y .
E v e ry e f f o r t was made t o m a i n t a i n t o t a l
a n o n y m ity th r o u g h o u t t h e s t u d y .
One m onth f o l l o w i n g t h e i n i t i a l m a i l i n g , a f o llo w - u p l e t t e r
was s e n t t o a l l s tu d y p a r t i c i p a n t s .
and c o v e r l e t t e r s
(An ex am p le o f t h e q u e s t i o n n a i r e
a r e l o c a t e d i n A p p e n d ix A .)
The sa m p le p o p u l a t i o n f o r t h i s s tu d y t o t a l e d 340 p h y s i c i a n s ,
p u b l i c h e a l t h n u r s e s , and h o s p i t a l n u r s e s .
T a b le I i n d i c a t e s t h e
p e r c e n t a g e o f q u e s t i o n n a i r e s r e t u r n e d by t h e r e s p o n d e n t s .
T a b le I
RESPONSE TO QUESTIONNAIRE BY GROUPS OF RESPONDENTS
Number
Sent
Number
R e tu rn e d
P e rc e n ta g e
228
91
39
P u b l i c H e a l th
N u rs e s
52
32
62
H o s p ita l
N u rs e s
60
28
45
R e s p o n d e n ts
P h y s ic ia n s
C h a p te r .IV
PRESENTATION OF DATA
T he d a t a p r e s e n t e d i n t h i s s tu d y w e re c o l l e c t e d by t h e s u rv e y
q u e s t i o n n a i r e m e th o d .
th e r e s e a rc h e r.
A p p e n d ix C .)
c a n t f in d in g s .
c h a p te r.
E ach r e s p o n s e w as re v ie w e d a n d c a t e g o r i z e d by
(A c a t e g o r i z a t i o n o f r e s p o n s e s i s p r e s e n t e d i n
T he d a t a g a t h e r e d w e re t h e n a n a ly z e d f o r p o s s i b l e s i g n i f i
T h e s e f i n d i n g s a r e p r e s e n t e d i n t a b u l a r fo rm i n t h i s
I t s h o u ld b e n o te d t h a t t h e p e r c e n ta g e s i n e a c h t a b l e h a v e
b e e n ro u n d e d t o t h e n e a r e s t w h o le num ber.
T he r e a d e r w i l l n o t e t h a t e a c h t a b l e c o n t a i n s a l a r g e p e r c e n t ­
a g e o f " n o r e s p o n s e ," o c c u r i n g m o st f r e q u e n t l y i n t h e r e s p o n s e s made
by t h e p h y s i c i a n s and h o s p i t a l n u r s e s ;
I t i s t h e o p i n i o n o f th e
r e s e a r c h e r , t h a t t h e s e tw o g ro u p s w e re u n a b le t o a n s w e r t h o s e
q u e s t i o n s , d u e t o l i m i t e d k n o w le d g e o f , o r a s s o c i a t i o n w i t h , a home
h e a lth agency.
24 •
T a b le 2
EFFECTIVENESS OF HOME HEALTH PROGRAMS IN, NORTH DAKOTA
AS PERCEIVED BY PHYSICIANS, PUBLIC HEALTH
NURSES AND HOSPITAL NURSES
D e g re e o f
E ffe c tiv e n e s s
P h y s ic ia n s
PHN
N -91
N -32
No.
%
No.
8
9
6
E ffe c tiv e
25
27
In e ffe c tiv e
32
No R e sp o n se
T o ta l
V ery E f f e c t i v e
H o s p ita l
N u rs e s
N-28
T o ta l
N-151
No.
%
No.
7.
25
2
7
16
16
12
22
5
18
42
28
35
10
41
14
50
56
32
26
29
4
12
7
25
37
24
91
100
32
100
28
100
151
100
%
A f a i r l y e v e n d i s t r i b u t i o n o f r e s p o n s e s w as o b s e r v e d i n t h e
d a t a p r e s e n t e d i n T a b le 2 .
Of th o s e re s p o n d in g , th e l a r g e s t p e rc e n t
f e l t t h e home h e a l t h p ro g ra m s w e re l e s s t h a n a d e q u a te i n N o rth D a k o ta .
A f u r t h e r a n a l y s i s o f t h e r e s p o n s e s show t h a t 35 p e r c e n t o f th e
p h y s i c i a n s , 41 p e r c e n t o f t h e p u b l i c h e a l t h n u r s e s , and 50 p e r c e n t o f
t h e h o s p i t a l n u r s e s f e l t t h e home h e a l t h p ro g ra m s w e re i n e f f e c t i v e .
I t s h o u ld b e n o te d t h a t 6
o r 25 p e r c e n t o f t h e p u b l i c h e a l t h
n u r s e s f e l t t h e p ro g ra m was v e r y e f f e c t i v e , w h i l e o n ly 8
o r 9 p e rc e n t
o f t h e p h y s i c i a n s r e s p o n d in g f e l t t h e p ro g ra m was v e r y e f f e c t i v e .
25
T a b le 3
INDICATORS OF THE EFFECTIVENESS OF THE HOME HEALTH PROGRAMS
IN NORTH DAKOTA AS PERCEIVED BY THE PHYSICIANS,
PUBLIC HEALTH NURSES, AND HOSPITAL NURSES
__________________
'
'
P h y s ic ia n s
'
N -32
No.
%
Nd.
P h y s ic ia n
R e fe rra ls
I
I
10
Number o f
p e o p le s e r v e d
7
8
11
F e e d b a c k fro m
p a t i e n t s and
fa m ilie s
31
■
\
H o s p ita l
N u rs e s
N -28
PHN
In d ic a to rs
N-91
:
%
Np . ■
%
31
I
4
12
8
34
8
29
26
17 .
31
21
T h o se who w e re
a b l e t o re m a in
o u t o f th e
in s titu tio n s
2
2
M et p h y s i c i a n s '
needs
5
.5
A c c e s s a b ility o f
p ro g ra m i n r e ­
g a rd s to geo g ­
ra p h y an d s t a f f .
5
5
F o llo w up r e ­
p o r t s fro m PHN
4'
4
No r e s p o n s e
36
40
7
21
16
T o ta l
91
100
32
100
28
2
N-.151.
No.
%
34
2 .
T o ta l
6
6
2
I
7
4
6
4.
•5
3
8
'
. 5 ■’
4
3
56
59
39
100
151
100
26 •
The. d a t a i n T a b le 3 i n d i c a t e t h a t t h e l a r g e s t p e r c e n t o f t h e
r e s p o n d e n t s m e a s u re t h e i r home h e a l t h p ro g ra m ’s e f f e c t i v e n e s s by t h e
num ber o f p a t i e n t s w h ic h i t s e r v e s .
F u rth e r a n a ly s is o f th e d a ta
show t h a t 34 p e r c e n t o f t h e p u b l i c h e a l t h n u r s e s and 29 p e r c e n t o f t h e
h o s p i t a l n u r s e s f e l t t h a t t h e num ber o f p a t i e n t s s e r v e d was a good
i n d i c a t o r o f t h e i r p r o g ra m ’ s e f f e c t i v e n e s s .
T h i r t y - f o u r p e r c e n t of-
t h e p h y s i c i a n s i d e n t i f i e d f e e d b a c k fro m t h e p a t i e n t s and t h e i r
f a m i l i e s a s t h e m eans by w h ic h th e y m e a s u re t h e p r o g r a m 's e f f e c t i v e n e s s
I t i s i n t e r e s t i n g t o n o te t h a t o n l y 8 p e r c e n t o f a l l r e s p o n ­
d e n t s fo u n d p h y s i c i a n r e f e r r a l s a n im p o r ta n t m eans o f m e a s u r in g t h e
e f f e c t i v e n e s s o f t h e home h e a l t h p ro g ra m .
The p u b l i c h e a l t h n u r s e s
w e re t h e o n ly g ro u p who i d e n t i f i e d t h i s a s a n a r e a o f im p o r ta n c e .
27
T a b le 4
FACTORS LIMITING THE EFFECTIVENESS OF THE HOME HEALTH PROGRAMS
IN NORTH DAKOTA AS PERCEIVED BY THE PHYSICIANS,
PUBLIC HEALTH NURSES AND HOSPITAL NURSES
P h y s ic ia n s
L i m i ti n g
F a c to rs
N -91
No.
C o st
L im ite d
p h y s ic ia n
re fe rra ls
H o s p ita l
N u rs e s
. N-28.
PHN
N-32
%
No.
16
18
5
2
2
6
%
, No.
19
%
T o ta l
N -151 '
Np.
--
--
21
3
11
11
%
14
7.
■.
R e s tric tiv e
g o v e rn m e n t
re g u la tio n s .
11
PHN s t a f f
lim ita tio n s
15.
.
12
9
28
16
3
.
2
7
22
9
8
29
26
7
5
3
9
15
17
L ack o f
k n o w le d g e ,RN
2 .
2
I
3
2
L ack o f
k n o w le d g e ,MD
6.
7
5
16
2
• 7
13
L ack o f
k n o w le d g e ,P t .
7
8
1I
3
I
4
9
L im ite d
com m unity
p u b lic ity
2
2
I
3
I
4
4
3
No r e s p o n s e
30
33
I
3
9
32
40
26
T o ta l
91
100
32
28
100
151
100
100 .
.
.
6 .
••
28
The d a t a p r e s e n t e d i n T a b le 4 i d e n t i f y two a r e a s , c o n s id e r e d
by t h e r e s p o n d e n t s , t o b e t h e g r e a t e s t l i m i t i n g f a c t o r s o f t h e home
h e a l t h p ro g ra m s .
S e v e n te e n p e r c e n t o f t h e r e s p o n d e n ts f e l t t h a t t h e
l i m i t a t i o n s o f t h e p u b l i c h e a l t h n u r s i n g s t a f f was t h e g r e a t e s t
lim itin g f a c to r .
R e s t r i c t i v e g o v e rn m e n t r e g u l a t i o n s w e re i d e n t i f i e d
by 15 p e r c e n t o f t h e r e s p o n d e n t s t o b e t h e s e c o n d . g r e a t e s t l i m i t i n g
fa c to r.
I t s h o u ld b e n o te d t h a t 9 o r 19 p e r c e n t o f t h e p u b l i c h e a l t h
n u r s e s f e l t t h a t l i m i t e d p h y s i c i a n r e f e r r a l s was a l i m i t i n g f a c t o r f o r
t h e home h e a l t h p ro g ra m s i n N o rth D a k o ta , w h ile o n ly 2 o r 2 p e r c e n t o f
t h e p h y s i c i a n s i n d i c a t e d t h i s t o be a p ro b le m .
29
T a b le 5
FACTORS CONTRIBUTING TO THE SUCCESS OF THE HOME HEALTH PROGRAMS
IN NORTH DAKOTA, AS PERCEIVED BY THE PHYSICIANS,
PUBLIC HEALTH NURSES AND HOSPITAL NURSES
P h y s ic ia n s
H o s p ita l
N u rs e s
N-28
PHN
F a c to rs
N-91
N-32
No.
%
No.
%
No.
6
7
3
9
3
Q u a lifie d
PHNti
33
36
6
19
P u b lic
a w a re n e s s
I
I
4
In cre a se d
re fe rra ls
4
4
P a tie n t
fee d b a c k
2
C o m m u n icatio n
w ith o th e r
p ro fe s s io n a ls
.
T o ta l
.
N -151
No.
%
11
12
8
2
7
41
27
13
2.
7
7
5
2
6
3
11
9
6
2
.5
16
I
4
8
5
%
No r e s p o n s e
45
50
12
38
17
61
74
49
T o ta l
91
100
32
100
28
100
151
100
The a r r a y o f d a t a i n T a b le 5 i n d i c a t e t h a t t h e l a r g e s t p e r c e n t
o f t h e r e s p o n d e n t s f e l t t h a t t h e s u c c e s s o f t h e home h e a l t h p ro g ra m s .
was t h e r e s u l t o f q u a l i f i e d p u b l i c h e a l t h n u r s i n g s t a f f .
A d ic h o to m y
h a s o c c u r r e d , w i t h T a b le 4 p r e s e n t i n g c o n f l i c t i n g d a t a .
I t id e n tifie d
t h e g r e a t e s t l i m i t i n g f a c t o r o f t h e home h e a l t h p ro g ra m t o b e t h e
30
l im it a ti o n s o f th e p u b lic h e a lth n u rs in g s t a f f .
P u b l i c a w a re n e s s o f t h e home h e a l t h p ro g ra m s was i d e n t i f i e d by
7 o r 5 p e rc e n t o f th e re s p o n d e n ts to be a f a c t o r i n th e s u c c e s s o f th e
home h e a l t h p r o g ra m s .
k n o w led g e by p a t i e n t s
D a ta i n T a b le 4 a l s o i n d i c a t e d t h a t , l a c k o f
( p u b l i c ) was a l i m i t i n g f a c t o r .
A g a in , t h e r e
a p p e a r s t o b e d i s p a r i t y among t h e r e s p o n s e s .
I t s h o u ld b e n o te d t h a t 7 p e r c e n t o f t h e p h y s i c i a n s , 9 p e r c e n t
o f t h e p u b l i c h e a l t h n u r s e s , and 11 p e r c e n t o f t h e h o s p i t a l n u r s e s
f e l t t h a t c o m m u n ic a tio n w i t h o t h e r p r o f e s s i o n a l s was c o n t r i b u t i n g t o
t h e s u c c e s s o f t h e home h e a l t h p r o g r a m s .
I
31 .
T a b le 6
PHYSICIANS1 REACTIONS TO THE HOME HEALTH PROGRAMS IN NORTH
DAKOTA, AS PERCEIVED BY PHYSICIANS, PUBLIC
HEALTH NURSES, AND HOSPITAL NURSES
P h y s ic ia n s
P h y s ic ia n
R e a c tio n s
H o s p ita l
N u rs e s
N-28
PHN
N -32
N -91
T o ta l
N -151
No.
5
No.
F a v o r a b le .
28
31
5
16
6
21
39
25
M ixed
13
14
7
22
6
21
26
17
In d iffe re n t
17
19
8
25
11
39
36
24
I
I
I
I
32
35
12
12
5
19
49
32
91
100
32
100
28
100
151
100
N e u tra l
No r e s p o n s e
T o ta l
.
%
No.
%
No.
. %
;
.
■
E x a m in a tio n o f t h e d a t a p r e s e n t e d i n T a b le 6 show a n i n t e r e s t i n g
p i c t u r e o f t h e p h y s i c i a n s ’ r e a c t i o n s t o t h e home h e a l t h p r o g ra m s , a s
i
!
p e r c e iv e d by a l l r e s p o n d e n t s .
Of t h o s e r e s p o n d i n g , 25 p e r c e n t f e l t
t h e p h y s i c i a n s ' r e a c t i o n s w e re f a v o r a b l e , 17 p e r c e n t f e l t t h e r e a c t i o n s ;
w e re m ix e d , and 24 p e r c e n t f e l t t h e p h y s i c i a n s ' r e a c t i o n s w e re i n d i f ­
fe re n t.
I t s h o u ld b e n o te d t h a t 31 p e r c e n t o f th e p h y s i c i a n s saw t h e i r
r e a c t i o n s a s f a v o r a b l e , 14 p e r c e n t a s m ixed and 19 p e r c e n t a s i n d i f ­
fe re n t.
Of t h e n u r s e s r e s p o n d i n g , 36 p e r c e n t o f t h e p u b l i c h e a l t h
z
32 .
n u r s e s and 38 p e r c e n t o f t h e h o s p i t a l n u r s e s f e l t t h e p h y s i c i a n s '
r e a c t i o n s t o t h e home h e a l t h p ro g ra m w e re i n d i f f e r e n t .
T a b le 7
PHYSICIANS1 RESPONSIBILITIES IN THE HOME HEALTH PROGRAMS
IN NORTH DAKOTA, AS PERCEIVED BY PHYSICIANS, PUBLIC
HEALTH NURSES, AND HOSPITAL NURSES
P h y s ic ia n s
P h y s ic ia n
R e s p o n s ib ilitie s
H o s p ita l
N u rs e s
N-28
T o ta l
N -151
R e fe rra ls
S u p p o r t and
a s s is ta n c e
C om m unicate
w i t h PHN
Be a w a re o f
s e rv ic e s
a v a ila b le
No r e s p o n s e
T o ta l
T a b le 7 i n d i c a t e s t h a t 60 p e rc e n t^ o f t h e r e s p o n d e n t s f e l t t h a t .
t h e p h y s i c i a n s ' m a jo r r e s p o n s i b i l i t y w as t h e w r i t i n g o f c o m p le te
re fe rra ls .
A f u r t h e r r e v ie w o f t h e d a t a r e v e a l s t h a t o n ly 2 p e r c e n t o f a l l
r e s p o n d e n t s f e l t t h a t c o m m u n ic a tio n w i t h t h e p u b l i c h e a l t h n u r s e was a
33
r e s p o n s i b i l i t y o f t h e p h y s i c i a n , y e t T a b le 5 i n d i c a t e s t h a t com m unica­
t i o n among p r o f e s s i o n a l s was a f a c t o r i n t h e s u c c e s s o f t h e home h e a l t h
p ro g ra m s.
The d a t a c o l l e c t e d i n t h i s s t u d y c o n ti n u e t o p o i n t o u t a
d is c re p a n c y in r e s p o n s e s .
T a b le 8
FACTORS THAT MIGHT CONTRIBUTE TO GREATER UTILIZATION OF THE
HOME HEALTH PROGRAMS.IN NORTH DAKOTA, BY PHYSICIANS, AS
PERCEIVED BY PHYSICIANS, PUBLIC HEALTH
NURSES AND HOSPITAL NURSES
P h y s ic ia n s
H o s p ita l
N u rs e s
N-28
PHN
F a c to rs
N -91
No.
N -32
T o ta l
N-151
No.
%
No.
10
2
.6
3
11
14
9
28
31
11
34
12
43
51
34
Im p ro v ed
c o m m u n ic a tio n
w i t h PHN
9
10
8
25
2
7
19
13
C o n fid e n c e
i n PHN
3
3
--
—-
2
7
5
3
PHN d e m o n s tr a te
th a t th is is a
needed s e r v ic e
3
3
..
__
I
4
4
3
No r e s p o n s e
39
43
11
34
8
29
58
38
T o ta l
91
100
32
100
28
100
151
100
In cre a se d
p u b lic ity
A w a re n e ss and
u n d e r s t a n d in g
o f H .H .p ro g ra m
9
%
.
%
No.
’%
34 •
An e x a m in a tio n o f t h e d a t a p r e s e n t e d i n T a b le 8 r e v e a l t h a t t h e
l a r g e s t p e r c e n t o f r e s p o n d e n t s f e l t t h a t t h e f a c t o r w h ic h w ould c o n t r i ­
b u t e m o st t o t h e p h y s i c i a n s ’ u t i l i z a t i o n o f t h e home h e a l t h p ro g ra m
was t h e i r a w a re n e s s and u n d e r s t a n d in g o f t h e s e r v i c e s o f f e r e d by t h e
p ro g ra m .
T h i r t y - o n e p e r c e n t o f t h e p h y s i c i a n s , 34 p e r c e n t o f t h e p u b l i c
h e a l t h n u r s e s , and 43 p e r c e n t o f t h e h o s p i t a l n u r s e s i d e n t i f i e d t h i s a s
t h e m a jo r a r e a o f im p o r ta n c e .
Im p ro v e d c o m m u n ic a tio n s w i t h t h e p u b l i c h e a l t h n u r s e was a g a in
n o te d a s b e in g a c o n t r i b u t i n g f a c t o r .
T en p e rc e n t o f th e p h y s ic ia n s ,
36 p e r c e n t o f t h e p u b l i c h e a l t h n u r s e s , and 7 p e r c e n t o f fche h o s p i t a l
n u r s e s f e l t t h e p h y s i c i a n s w ould u t i l i z e t h e home h e a l t h p ro g ra m m o re ,
i f c o m m u n ic a tio n s w ere, im p ro v e d .
35
T a b le 9
,
HOSPITAL NURSES' RESPONSIBILITIES IN THE HOME HEALTH PROGRAMS
IN NORTH DAKOTA, AS PERCEIVED BY PHYSICIANS, PUBLIC
HEALTH NURSES AND HOSPITAL NURSES
P h y s ic ia n s
H o s p ita l
N u rse s1
R e s p o n s ib ilitie s
N o.
Id e n tify
p a tie n ts need­
in g home c a r e
.
N -91
%
H o s p ita l
N u rs e s
N -28
PHN
N -32
No.
7o
No.
%
T d ta l
N -1 5 1 .
No.
%
44
48
22
69
18
64
84
56.
K now .scope
o f p ro g ra m .
3
3
5
16
2
7
10
7
I n fo r m
p a tie n ts re:
H .H . b e n e f i t s
6
7
4
13
3
11
13
9
No
re s p o n s ib ility
7
8
--
--
■ --
7
5
No r e s p o n s e
31
34
I
3
5
18
37
25
T o ta l
91
100
32
100
28
100
151
100 .
The d a t a p r e s e n t e d i n T a b le 9 i n d i c a t e t h a t 56 p e r c e n t o f a l l
r e s p o n d e n t s f e l t t h e m a jo r r e s p o n s i b i l i t y o f h o s p i t a l n u r s e s was t h e
i d e n t i f i c a t i o n o f p a t i e n t s n e e d in g home c a r e .
O f t h o s e r e s p o n d i n g , 7 p e r c e n t f e l t th e . h o s p i t a l n u r s e s m u st b e
k n o w le d g e a b le r e g a r d i n g t h e s c o p e o f t h e home h e a l t h p ro g ra m .
N ine
p e r c e n t f e l t t h e h o s p i t a l n u r s e s s h o u ld in fo r m t h e p a t i e n t s o f th e
36
b e n e f i t s o f t h e p ro g ra m .
I t i s o f i n t e r e s t t o n o te t h a t 8 p e rc e n t o f th e p h y s ic ia n s
r e s p o n d in g f e l t t h a t t h e h o s p i t a l n u r s e s h a d no r e s p o n s i b i l i t y i n t h e
,
home h e a l t h p ro g ra m ,
T a b le 10
MOST EFFECTIVE METHOD OF PROMOTING THE HOME HEALTH PROGRAMS, WITH
THE HOSPITAL NURSES, IN NORTH DAKOTA, AS PERCEIVED BY
PHYSICIANS, PUBLIC HEALTH NURSES, AND HOSPITALMISES
P h y s ic ia n s
PHN
H o s p ita l
N u rs e s
N -28
M ethods
N -91
No . '
In cre a se d
p e rso n a l
c o n t a c t w ith .
RNs
.
%
38
Nr 3 2
No.
41
27
5
--
5
I
No.
%
84 .
%
T o ta l
N -151
, No.
% ..
12
43
77
50
5
18
10
7
I
4
7
5
5
18
7
5
P u b lic ity
5. ■
H o s p ita l v i s i t s
to p a tie n ts
by PHN
5
D e m o n s tra te d
u s e fu ln e ss
by PHN
2
2
No r e s p o n s e
41
45
5
16
5
18
51
33
T o ta l
91
100
32
100
28
100
151
100 .
'
.
3
.
■
37
The a r r a y o f d a t a i n T a b le 10 show t h a t 50 p e r c e n t o f t h o s e
r e s p o n d in g f e l t t h e m o st e f f e c t i v e m ethod o f p ro m o tin g t h e home h e a l t h
p ro g ra m w as f r e q u e n t p e r s o n a l c o n t a c t by t h e p u b l i c h e a l t h n u r s e w ith
I •
th e h o s p ita l n u rs e .
I t was i n t e r e s t i n g t o n o te t h a t 5 o r 5 p e r c e n t o f t h e p h y s i ­
c i a n s and 5 o r 18 p e r c e n t o f t h e h o s p i t a l n u r s e s f e l t t h a t p u b l i c i t y
p la y e d a n im p o r ta n t r o l e i n p ro m o tin g t h e home h e a l t h p ro g ra m .
o f t h e p u b l i c h e a l t h n u r s e s saw t h i s a s b e in g i m p o r t a n t .
None
E i g h te e n
p e rc e n t o f th e h o s p i t a l n u rs e s in d ic a te d a d e s ir e to have th e p u b lic
h e a l t h n u r s e d e m o n s t r a t e t h a t t h e home h e a l t h p ro g ra m i s a n e e d e d and
u s e fu l s e rv ic e .
3 8
T a b l e
F U T U R E
O F
T H E
T H E
H O M E
H E A L T H
P H Y S I C I A N S ,
1 1
P R O G R A M S
P U B L I C
I N
H E A L T H
N O R T H
N U R S E S ,
D A K O T A ,
A N D
" Y E S
P h y s i c i a n s
T h e r e
I s
a
i t
m a i n t a i n s
i t
s h o r t e n s
t h e r e
n e e d e d
i s
o f
i t s
s u c c e s s
t o
d a t e
T o t a l
o f
T h e r e
n o
Y E S
R e s p o n s e s
i s
n o
c o o p e r a t i o n
R N s
B e c a u s e
c o s t s
a r e
h i g h
B e c a u s e
r e g u l a t i o n s
a r e
r e s t r i c t i v e
t o o
B e c a u s e
TL
N o .
7.
N o .
%
N o .
7.
4
4
I
3
I
4
6
4
4
4
5
1 6
3
1 1
1 2
8
5
1 6
5
3
4 2
2 8
1 0
o f
2 2
2 5
9
2 8
1 0
1 1
4
1 3
I
4
1 5
1 3
1 4
2
6
6
2 1
2 1
1 4
5 3
6 8
2 6
8 2
3 2
7 8
1 0 1
7 6
I
I
F u t u r e :
M D s
t o o
N o .
•a—
c o m m e n t
W i t h o u t
a n d
" N O "
w i t h
T o t a l
N o
o f
n o
N O
r e s p o n s e
F i n a l
T o t a l s
1 1
3 8
R E S P O N S E S
o f
I
3
..
. .
2
2
I
3
3
I
2
2
2
2
4
3
I
I
__
2
I
——
■»*»
p o o r
m a n a g e m e n t
N o
N - 1 5 1
a
s e r v i c e
w i t h
N - 2 8
h o s p i t a l
r e f e r r a l s
i t
B e c a u s e
Y e s
N - 3 2
w e r e
i n c r e a s e d
B e c a u s e
T o t a l
N u r s e s
p a t i e n t s '
s t a y
I f
B Y
N U R S E S
H o s p i t a l
F u t u r e :
i n d e p e n d e n c e
I f
P E R C E I V E D
R E S P O N S E S
P H N
N - 9 1
I f
A S
H O S P I T A L
c o m m e n t
R e s p o n s e s
I
6
7
1 1
1 2
5
8
2 7
3 0
2
6
9 1
1 0 0
3 2
1 0 0
—■
4
——
6
4
4
1 6
1 1
5
1 8
3 4
2 3
2 8
1 0 0
1 5 1
1 0 0
I
39
The a r r a y o f d a t a p r e s e n t e d i n T a b le 11 i s d i v i d e d i n t o two
I
g e n e ra l c a te g o rie s o f re sp o n se s:
11Y ES," t h e home h e a l t h p ro g ra m s
h a v e a f u t u r e , and "N O ," t h e home h e a l t h p ro g ra m s h a v e no f u t u r e .
A
I ,
t o t a l o f 101 o r 76 p e r c e n t o f t h e r e s p o n d e n t s f e e l t h a t t h e r e i s a
I
f u t u r e f o r t h e home h e a l t h p ro g ra m i n t h e i r a r e a .
F u r t h e r e x a m in a tio n o f t h e d a t a r e v e a l s t h a t 28 p e r c e n t f e e l t h e
p ro g ra m h a s a f u t u r e , b e c a u s e i t i s a n e e d e d s e r v i c e , w h i l e 10 p e r c e n t
i n d i c a t e d t h a t t h e p ro g ra m w ould h a v e a f u t u r e b a s e d on t h e p r o g r a m 's
su c c e ss to d a te . .
:
I.
Of t h o s e r e s p o n d in g "Y E S ," o n ly 2 p e r c e n t i n d i c a t e d t h a t t h e
I
f u t u r e o f t h e home h e a l t h p ro g ra m d e p e n d s on i n c r e a s e d r e f e r r a l s , y e t
T a b le 4 i d e n t i f i e s
l i m i t e d p h y s i c i a n r e f e r r a l s a s one o f t h e f a c t o r s
,
c o n t r i b u t i n g t o t h e l i m i t e d s u c c e s s o f t h e p ro g ra m .
I
;
O n ly 16 o r 11 p e r c e n t Of t h e r e s p o n d e n t s f e l t t h e r e i s no
f u t u r e f o r t h e home h e a l t h p ro g ra m i n t h e i r a r e a .
The l a r g e s t p e r c e n t
o f r e s p o n d e n t s i d e n t i f i e d r e s t r i c t i v e g o v e rn m e n t r e g u l a t i o n s as. a
f a c t o r h i n d e r i n g t h e s u c c e s s o f t h e home h e a l t h p ro g ra m s .
40 .
T a b le 12
POSSIBLE CHANGES WHICH COULD BE MADE IN THE HOME HEALTH PROGRAMS
IN NORTH DAKOTA, AS PERCEIVED BY PHYSICIANS, PUBLIC
HEALTH NURSES, AND.HOSPITAL NURSES
.
P h y s ic ia n s
P o s s ib le
C hanges
H o s p ita l
N u rs e s
N-28
PHN
N -91
N-32
T o ta l
N-151
No.
%
No.
%
No.
U p d a te PHN
s k ills
3
3
I
3
3
11
7
5
I n c r e a s e g o v t.
r e im b u rs e m e n t
3
3
10
31
2
7
15
10
C o n tin u in g e d u ­
c a t i o n f o r MDs
and RNs r e : HHP
I
I
5
16
I
4
7
5
10
11
4
13
5
18
19
13
3
3
3
9
2
■7
8
5 -
E xpand t h e
s e rv ic e s o f
HHP
More
p u b lic ity
B e t t e r com­
m u n ic a tio n s
b e tw e e n MDs,
PHNs a n d RNs
.
%
. No.
%
.
i
I
3
I
4
2
I
4
13
I
4
6
4
4
3
More c o m p le te
re fe rra ls
I
I
No c h a n g e s
n e c e ssa ry
4
4
No r e s p o n s e
66
73
4
13
13
44
83
54
T o ta l
91
100
32
100
28
lo o
151
100
-
'
41
The d a t a p r e s e n t e d i n T a b le 12 i n d i c a t e t h a t 13 p e r c e n t o f t h e
r e s p o n d e n t s f e l t t h a t t h e m o st n e e d e d c h a n g e i n t h e home h e a l t h p r o ­
gram w o u ld b e t h e e x p a n s io n o f s e r v i c e s o f f e r e d .
T h is e x p a n s io n w o u ld
i n c l u d e a t w e n t y - f o u r h o u r c a l l s y s te m and m ore d i v e r s i f i e d s e r v i c e s
t o m ee t t h e e v e r c h a n g in g h e a l t h n e e d s o f e l d e r l y :
C o m m u n icatio n a p p e a r s a g a i n i n t h i s t a b l e , w i t h o n ly I p e r c e n t
o f a l l r e s p o n d e n t s i d e n t i f y i n g t h e n e e d f o r b e t t e r c o m m u n ic a tio n s
among p h y s i c i a n s , p u b l i c h e a l t h n u r s e s , a n d h o s p i t a l n u r s e s a s a
c h a n g e n e e d e d t o p ro m o te a n d e n c o u ra g e t h e g ro w th o f home h e a l t h
p ro g ra m s .
F u r t h e r a n a l y s i s o f t h e d a t a show t h a t 3 p e r c e n t o f t h e
p h y s i c i a n s , 36 p e r c e n t o f t h e p u b l i c h e a l t h n u r s e s , and 15 p e r c e n t o f
t h e h o s p i t a l n u r s e s f e l t t h a t i n c r e a s e d g o v e rn m e n t r e im b u rs e m e n t i s
n e c e ssa ry .
I t s h o u ld b e n o te d t h a t 16 p e r c e n t o f t h e p u b l i c h e a l t h n u r s e s
f e l t t h a t c o n t i n u i n g e d u c a t i o n f o r t h e p h y s i c i a n s and h o s p i t a l n u r s e s
was n e e d e d .
A n o th e r 13 p e r c e n t o f t h e p u b l i c h e a l t h n u r s e s i n d i c a t e d
a n e e d f o r m ore c o m p le te r e f e r r a l s .
A d d i t i o n a l Comments
. The q u e s t i o n n a i r e u t i l i z e d
i n t h i s s tu d y a llo w e d f o r a d d i t i o n a l
com m ents t o b e mdde by t h e r e s p o n d e n t s .
th e re s p o n d e n ts u sed t h i s s e c t i o n .
O nly s e v e n t e e n o r 11 p e r c e n t o f
A v e r b a t im l i s t i n g
r e l e v a n t t o t h i s s t u d y i s in c l u d e d i n A p p e n d ix E .
o f t h o s e com m ents
C h a p te r V
CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS
Summary
The p u r p o s e o f t h i s s tu d y w as t o i d e n t i f y t h o s e f a c t o r s c o n ­
t r i b u t i n g t o t h e l i m i t e d u t i l i z a t i o n o f t h e home h e a l t h a g e n c i e s i n
N o rth D a k o ta .
D a ta w e re c o l l e c t e d by u s e o f a n o p e n -e n d e d q u e s t i o n n a i r e
d e v is e d by t h e r e s e a r c h e r and s e n t t o 228 p h y s i c i a n s , 52 p u b l i c h e a l t h
n u r s e s , a n d 60 h o s p i t a l n u r s e s , em ployed i n t h e g e o g r a p h ic a r e a s o f t h e
n i n e home h e a l t h a g e n c i e s i n N o rth D a k o ta .
A t o t a l o f 151 q u e s t i o n n a i r e s w e re r e t u r n e d .
T h i s i n c lu d e d
39 p e r c e n t o f p h y s i c i a n s , 62 p e r c e n t o f p u b l i c h e a l t h n u r s e s , and
45 p e r c e n t o f h o s p i t a l n u r s e s .
T he r e s p o n d e n t s i d e n t i f i e d t h o s e f a c t o r s l i m i t i n g t h e e f f e c t i v e
n e s s o f t h e home h e a l t h p ro g ra m s t o b e :
. I.
lim ite d p h y s ic ia n r e f e r r a l s
2.
c o s t t o t h e home h e a l t h a g e n c i e s a s w e l l a s t o t h e p a t i e n t s
3.
r e s t r i c t i v e g o v e rn m e n t r e g u l a t i o n s
4.
l a c k o f k n o w le d g e o f t h e p ro g ra m by p h y s i c i a n s , h o s p i t a l
n u r s e s and t h e p u b l i c
I n s p i t e o f o b v io u s p r o b le m s , t h e p r e v a i l i n g f e e l i n g i s t h a t
t h e r e i s a . f u t u r e f o r t h e home h e a l t h p ro g ra m s i n N o r th D a k o ta .
I n l i g h t o f t h e f o r e g o i n g d a t a , t h e f o l l o w i n g c o n c lu s i o n s
43
h a v e b e e n f o r m u la te d by t h e r e s e a r c h e r .
G e n e r a l C o n c lu s io n s
1.
R e s t r i c t i v e g o v e rn m e n t r e g u l a t i o n s , c o n t r o l l i n g p a t i e n t
c a r e an d f u n d in g , i s c o n t r i b u t i n g t o t h e l i m i t e d s u c c e s s
o f t h e p ro g ra m .
2.
S i x t y p e r c e n t o f a l l t h o s e r e s p o n d in g i n d i c a t e d t h a t t h e
p h y s i c i a n s ' m a jo r r e s p o n s i b i l i t y t o t h e home h e a l t h p r o ­
gram i s t h e w r i t i n g o f c o m p le te r e f e r r a l s , i n c l u d i n g a
p la n o f c a r e .
3.
I n s p i t e o f o b v io u s p r o b le m s , t h e p r e v a l e n t f e e l i n g i s
t h a t t h e r e i s a f u t u r e f o r t h e home h e a l t h p ro g ra m s i n
N o r th D a k o ta .
4.
Home h e a l t h s e r v i c e s w o u ld b e m ore e f f e c t i v e i f th e y w ere
o f f e r e d on a t w e n t y - f o u r h o u r , s e v e n d a y a w eek b a s i s ; and
l a r g e r , m ore d i v e r s i f i e d s t a f f t t i m eet t h e h e a l t h n e e d s
o f th e e ld e r ly .
5.
F i f t y - s i x p e rc e n t o f a l l re s p o n d e n ts in d ic a te d t h a t th e
h o s p i t a l n u r s e s ' m a jo r r e s p o n s i b i l i t y t o t h e home h e a l t h
p ro g ra m i s i d e n t i f y i n g t h o s e p a t i e n t s n e e d in g home h e a l t h
s e r v i c e s a n d b r i n g i n g them t o t h e a t t e n t i o n o f t h e
p h y s ic ia n .
6.
A m a j o r i t y o f t h e r e s p o n d e n t s f e l t t h a t p r o m o tio n o f t h e
home h e a l t h p ro g ra m s c o u ld b e s t b e a c c o m p lis h e d by t h e
p u b lic h e a lt h n u rse th ro u g h p e rs o n a l c o n ta c t w ith p h y s i­
c i a n s and h o s p i t a l n u r s e s .
7.
M ost r e s p o n d e n t s i d e n t i f i e d t h e n e e d f o r im p ro v e d communi­
c a t i o n among n u r s e s and m e d ic a l s t a f f .
8.
M ore p u b l i c i t y i s n e e d e d t o in f o r m t h e p u b l i c o f s e r v i c e s
o f f e r e d th r o u g h a home h e a l t h p ro g ra m .
44 .
S p e c i f i c C o n c lu s io n s
P h y s ic ia n s
1.
The p h y s i c i a n s d i v e r g e d i n t h e i r p e r c e p t i o n o f t h e home
h e a l t h p ro g ra m s w i t h 27 p e r c e n t i n d i c a t i n g i t was e f f e c t i v e ,
and 35 p e r c e n t i n d i c a t i n g i t w as i n e f f e c t i v e . O nly 9
p e r c e n t v ie w e d t h e p ro g ra m a s v e r y e f f e c t i v e .
2.
A lth o u g h b o t h g ro u p s o f n u r s e s p e r c e iv e d t h e p h y s i c i a n s ’
r e l u c t a n c e t o make r e f e r r a l s a s a l i m i t i n g f a c t o r , t h e
p h y s i c i a n s th e m s e lv e s d i d n o t s e e i t a s a l i m i t i n g f a c t o r
i n t h e e f f e c t i v e n e s s o f t h e home h e a l t h p r o g ra m s .
3.
G r e a t e r a w a re n e s s and u n d e r s t a n d in g o f t h e s e r v i c e s a v a i l ­
a b l e th r o u g h t h e home h e a l t h p ro g ra m s w o u ld l e a d t o b e t t e r
u t i l i z a t i o n o f t h e p ro g ra m s by t h e p h y s i c i a n s .
4.
A d ic h o to m y e x i s t s b e tw e e n t h e p h y s i c i a n s ' p e r c e p t i o n o f
t h o s e f a c t o r s w h ic h l i m i t t h e p r o g r a m 's s u c c e s s and t h o s e
f a c t o r s c o n t r i b u t i n g t o i t s s u c c e s s . On t h e o n e h a n d , t h e y
i d e n t i f i e d th e g r e a t e s t lim it in g f a c t o r as t h e i r la c k o f
c o n f id e n c e i n t h e p u b l i c h e a l t h n u r s e s ' a b i l i t y t o c a r e
f o r p a t i e n t s i n t h e hom e.
(S e e T a b le 4 ) On t h e o t h e r h a n d ,
th e y i n d i c a t e d t h a t t h e o n e f a c t o r c o n t r i b u t i n g m ost t o
t h e s u c c e s s o f t h e home h e a l t h p ro g ra m was t h e q u a l i f i e d
p u b lic h e a lth n u rs in g s t a f f .
(S e e T a b le 5)
H o s p i t a l N u rs e s
1.
R e g u la r i n s e r v i c e e d u c a t i o n , p r o v id e d by t h e p u b l i c h e a l t h
n u r s e , w o u ld e n l a r g e t h e i r u n d e r s t a n d in g and a c c e p ta n c e o f
t h e p ro g ra m , e n a b l i n g them t o i d e n t i f y p a t i e n t s n e e d in g
home h e a l t h s e r v i c e s .
2.
A m a j o r i t y o f t h e h o s p i t a l n u r s e s v iew e d t h e home h e a l t h
p ro g ra m a s i n e f f e c t i v e .
3.
T w e n ty - n in e p e r c e n t o f t h e h o s p i t a l n u r s e s p e r c e iv e d t h e
p u b lic h e a lth n u rse s a s n o t p o s s e s s in g th e n e c e s s a ry s k i l l s
n e e d e d t o p r o v id e t h e r e q u i r e d h e a l t h c a r e i n t h e hom e.
4.
The h o s p i t a l n u r s e s f e l t t h a t g r e a t e r u n d e r s t a n d in g o f t h e
s e r v i c e s p r o v id e d t h r o u g h t h e home h e a l t h p ro g ra m s w ould
45
a s s i s t h e r i n e x p l a i n i n g t h e p ro g ra m t o p a t i e n t s and
th e ir fa m ilie s .
P u b l i c H e a l th N u rs e s
1.
T h e re i s a d i s c r e p a n c y i n t h e p u b l i c h e a l t h n u r s e s ' p e r ­
c e p t i o n o f t h e home h e a l t h p ro g ra m . F o r t y - o n e p e r c e n t
v ie w e d t h e p ro g ra m a s i n e f f e c t i v e , 22 p e r c e n t a s e f f e c t i v e ,
and 25 p e r c e n t v iew e d i t a s v e r y e f f e c t i v e .
2.
The p u b l i c h e a l t h n u r s e s i d e n t i f i e d t h e l i m i t e d k n o w le d g e .
and u n d e r s t a n d i n g o f t h e home h e a l t h p ro g ra m by t h e
p h y s i c i a n s , a s w e l l a s l a c k o f p h y s i c i a n r e f e r r a l s , t o be
im p o r ta n t f a c t o r s c o n t r i b u t i n g t o t h e l i m i t e d s u c c e s s o f
t h e home h e a l t h p ro g ra m .
Im p lic a tio n s
The f o l l o w i n g i m p l i c a t i o n s h a v e b e e n draw n fro m t h e f i n d i n g s
o f t h i s s t u d y a n d t h e r e s e a r c h e r 's p a s t e x p e r i e n c e w i t h t h e home
h e a l t h p ro g ra m s i n N o r th D a k o ta .
1.
B e c a u s e t h e home h e a l t h p ro g ra m s i n N o r th D a k o ta w e re f e l t
t o b e g r e a t l y n e e d e d , b u t a t t h e sam e tim e i n e f f e c t i v e , i t
w o u ld a p p e a r t h a t t h e r e i s a d i s p a r i t y i n r e c o g n i z i n g t h e
n e e d and a c t u a l l y p r o v i d i n g t h e c a r e .
2.
I f g o v e rn m e n t r e g u l a t i o n s c o n t r o l l i n g p a t i e n t c a r e and
f u n d in g c o n ti n u e t o b e r e s t r i c t i v e , t h e home h e a l t h p r o ­
gram s w i l l f i n d i t d i f f i c u l t , i f n o t i m p o s s i b l e , t o m a in ­
t a i n o r im p ro v e t h e i r s e r v i c e s .
3.
B e c a u s e t h e home h e a l t h p ro g ra m s i n N o rth D a k o ta a r e
v ie w e d a s i n e f f e c t i v e by many o f t h e r e s p o n d e n t s , i t w ould
a p p e a r t h a t a m a jo rity o f th e h e a lth n eed s o f th e e ld e r ly
a r e n o t b e in g m e t.
4.
T he home h e a l t h p ro g ra m s w i l l c o n ti n u e t o e x p e r i e n c e
d i f f i c u l t i e s a s lo n g a s p h y s i c i a n s , n u r s e s , an d t h e p u b l i c
r e m a in u n in fo rm e d r e g a r d i n g t h e s e r v i c e s a v a i l a b l e
th r o u g h t h e home h e a l t h p r o g r a m s .
46
5.
Home h e a l t h p ro g ra m s w i l l c o n ti n u e t o f l o u n d e r w i t h o u t
im p ro v e d c o m m u n ic a tio n among t h e n u r s e s and p h y s i c i a n s .
R ecom m endations f o r P ro g ra m
D ev elo p m en t and F u r t h e r S tu d y
The f o l l o w i n g re c o m m e n d a tio n s a r e b a s e d on t h e r e s e a r c h e r 's
f i n d i n g s , h e r k n o w le d g e o f t h e r e l a t e d
l i t e r a t u r e and r e s e a r c h , h e r
k n o w led g e g a in e d i n c o n d u c tin g t h i s s t u d y , a s w e l l a s h e r p a s t
e x p e r i e n c e w i t h t h e home h e a l t h p ro g ra m s i n N o rth D a k o ta .
P ro g ra m D ev elo p m en t
1.
E d u c a t i o n a l p ro g ra m s r e l a t i n g t o M e d ic a re s h o u ld be
p r o v id e d f o r t h e f o l l o w i n g :
a.
p h y s ic ia n s
b.
p u b lic h e a lth n u rse s
c.
h o s p ita l n u rses
d.
p u b lic
2.
R e g u la r p u b l i c i t y i n l o c a l news m e d ia s h o u ld b e u t i l i z e d
t o a c q u a i n t t h e p u b l i c w i t h t h e s e r v i c e s a v a i l a b l e th r o u g h
t h e home h e a l t h p r o g ra m s .
3.
P e r i o d i c m e e tin g s b e tw e e n p u b l i c h e a l t h n u r s e s and t h e
N o rth D a k o ta i n t e r m e d i a r y s h o u ld b e h e l d t o re v ie w t h e
r e g u l a t i o n s g o v e r n in g t h e home h e a l t h p r o g r a m s .
4.
Home h e a l t h , s e r v i c e s s h o u ld be ex p a n d ed t o i n c l u d e a
t w e n t y - f o u r h o u r c a l l s y s te m .
5.
T he S t a t e D e p a rtm e n t o f H e a l t h s h o u ld p r o v id e r e g u l a r
c o n s u l t a t i v e s e r v i c e s t o t h e home h e a l t h s t a f f .
6.
T h e re s h o u ld b e m ore p u b l i c h e a l t h n u r s i n g in v o lv e m e n t i n
o n - g o in g , p e r s o n a l c o n t a c t w i t h h o s p i t a l n u r s e s and
47
p h y s ic ia n s .
7.
W orkshops an d f o llo w - u p f o r p u b l i c h e a l t h n u r s e s s h o u ld
b e p r o v id e d t o a id e th em i n e f f e c t i v e d o c u m e n ta tio n o f
p a t i e n t s ' n e e d s , t o j u s t i f y paym ent by t h e i n t e r m e d i a r y .
F u r t h e r S tu d y
The f o ll o w i n g re c o m m e n d a tio n s a r e b a s e d on t h e r e s e a r c h e r 's
f i n d i n g s , a s w e l l a s h e r p a s t e x p e r i e n c e w i t h t h e home h e a l t h p ro g ra m s
i n N o rth D a k o ta .
T h e r e s h o u ld b e :
1.
a su rv e y o f in te r m e d ia r ie s r e g a rd in g t h e i r i n t e r p r e t a t i o n
o f g o v e rn m e n t r e g u l a t i o n s .
2.
a s u r v e y c o n t r a s t i n g and c o m p a rin g h o s p i t a l - b a s e d p ro g ra m s
and c o m m u n ity -b a se d p r o g r a m s .
3.
a s u r v e y o f p o t e n t i a l c l i e n t s , e v a l u a t i n g t h e i r k n ow ledge
o f home h e a l t h p r o g ra m s , a s w e l l a s t h e i r e x p e c t a t i o n s
o f t h e p ro g ra m .
4.
a p i l o t o r d e m o n s t r a t i o n p ro g ra m , i l l u m i n a t i n g t h e r o l e
and im p o r ta n c e o f t h e home h e a l t h p ro g ra m s > t o t h e
fo llo w in g :
a.
p h y s ic ia n s
b.
p u b lic h e a lth n u rse s
c.
h o s p it a l n u rse s.
d.
p u b lic
APPENDIX A
COVER LETTERS AND SURVEY QUESTIONNAIRE
49
8 1 6 17 t h . A v e n u e N o r th
B o z e m a n , M o n ta n a 5 9 7 1 5
J u n e 1 2 , 1974
D ear
As a g r a d u a t e s t u d e n t a t M o n tan a S t a t e U n i v e r s i t y , I am
w r i t i n g my t h e s i s o n t h e " U t i l i z a t i o n o f Home H e a l th A g e n c ie s i n
N o rth D a k o ta ."
I n a n e f f o r t t o a c q u i r e s i g n i f i c a n t i n f o r m a t i o n , I am r e ­
q u e s t i n g y o u r a s s i s t a n c e . . I w o u ld a p p r e c i a t e y o u r c o m p le tin g t h e
e n c lo s e d q u e s t i o n n a i r e and r e t u r n i n g i t t o me i n t h e s e l f - a d d r e s s e d
sta m p e d e n v e lo p e a t y o u r e a r l i e s t c o n v e n ie n c e . P l e a s e f e e l f r e e t o .
e x p re s s y o u r o p in io n o p e n ly , as th e q u e s tio n n a ir e need n o t be s ig n e d .
May I e x p r e s s i n a d v a n c e my s i n c e r e a p p r e c i a t i o n f o r t h e tim e
a n d e n e rg y you h a v e i n v e s t e d i n m aking t h i s a m e a n in g f u l s tu d y .
x
S in c e re ly ,
( M i s s ) L a V e r n e L e e , R .N .
LL: Im
50
QUESTIONNAIRE
UTILIZATION OF HOME HEALTH AGENCIES IN NORTH DAKOTA
I.
2.
3.
a)
I n y o u r p e r s o n a l o p i n i o n , how e f f e c t i v e i s t h e Home H e a lth
P ro g ra m i n y o u r a re a ?
b)
How do you m e a s u re i t s e f f e c t i v e n e s s ?
W hat do y o u f e e l a r e t h e g r e a t e s t l i m i t i n g , f a c t o r s a n d / o r p ro b le m s
i n t h e Home H e a l th P ro g ra m i n y o u r a r e a ?
W hat a s p e c t s o f t h e P ro g ra m i n y o u r a r e a a r e c o n t r i b u t i n g t o i t s
. success?
4.
W h at, i n y o u r o p i n i o n , h a s b e e n t h e r e a c t i o n o f t h e p h y s i c i a n s t o
t h e Home H e a l t h P ro g ra m i n y o u r a r e a ?
5.
W hat do you f e e l a r e t h e p h y s i c i a n s ' r e s p o n s i b i l i t i e s
H e a l th P rogram ?
6.
W h at, i n y o u r o p i n i o n , w ould c o n t r i b u t e to w a rd g r e a t e r u t i l i z a t i o n
by t h e p h y s i c i a n s o f . t h e Home H e a l t h P ro g ra m i n y o u r a re a ?
7.
What do y o u f e e l a r e t h e r e s p o n s i b i l i t i e s o f t h e h o s p i t a l n u r s e s
i n t h e Home H e a l th Program ?
i n t h e Home
51
8.
W hat do y o u f e e l a r e t h e m o st e f f e c t i v e m eth o d s o f p ro m o tin g t h e
Home H e a l th P ro g ra m w i t h h o s p i t a l n u r s e s ?
9.
Do y o u f e e l t h a t . t h e Home H e a l th P ro g ra m , i n y o u r a r e a , h a s a
f u tu r e ?
YES
NO
P le a s e g iv e re a s o n s f o r y o u r a n sw e r.
10.
W hat c h a n g e s do y o u f e e l s h o u ld b e made i n t h e Home H e a l th P rogram ?
ADDITIONAL COMMENTS
52
8 1 6 N o r t h 1 7 t h A v en u e
B o z e m a n , M o n ta n a 5 9 7 1 5
A u g u st 2 7 , 1974
D ear N u rs e :
Some tim e ago you w e re s e n t a q u e s t i o n n a i r e c o n c e r n in g a s tu d y
on "T h e U t i l i z a t i o n o f Home H e a l th A g e n c ie s i n N o rth D a k o ta ."
Many o f t h e c o m p le te d q u e s t i o n n a i r e s h a v e b e e n r e t u r n e d .
S in c e
o n ly a s e l e c t e d num ber o f n u r s e s w e re in c l u d e d i n t h e s t u d y , i t i s
i m p o r ta n t t h a t I r e c e i v e y o u r r e p l y . W ould you t a k e a few moments t o
c o m p le te t h e q u e s t i o n n a i r e ?
I n t h e e v e n t t h a t you h a v e a l r e a d y r e t u r n e d t h e q u e s t i o n n a i r e
p le a s e d is re g a rd t h i s l e t t e r .
T hank you f o r y o u r a s s i s t a n c e i n m aking t h i s a m e a n in g fu l
stu d y .
S in c e re ly ,
( M is s ) L a V ern e L e e , R .N .
53
8 1 6 N o r t h 1 7 t h A v en u e
B o z e m a n , M o n ta n a 5 9 7 1 5
A u g u st 2 7 , 1 9 7 4 '
D ear D o c t o r ,
Some tim e ago y o u w e re s e n t a q u e s t i o n n a i r e c o n c e r n in g a
s tu d y on "T h e U t i l i z a t i o n o f Home H e a l t h A g e n c ie s i n N o r th D a k o ta ."
Many o f t h e c o m p le te d q u e s t i o n n a i r e s h a v e b e e n r e t u r n e d .
S in c e o n ly a s e l e c t e d num ber o f d o c t o r s w e re i n c l u d e d i n t h e s t u d y ,
i t i s i m p o r ta n t t h a t I r e c e i v e y o u r r e p l y . W ould y o u t a k e a few
m om ents t o c o m p le te t h e q u e s t i o n n a i r e ?
. I n th e e v e n t t h a t you have a lr e a d y r e tu r n e d th e q u e s tio n n a ir e
p le a s e d is re g a rd t h is l e t t e r .
T h an k y o u f o r y o u r a s s i s t a n c e i n m aking t h i s a m e a n in g f u l
stu d y .
S in c e re ly ,
( M is s ) L a V ern e L e e , R .N
54
8 1 6 N o r t h 1 7 t h A v en u e
B o z e m a n , M o n ta n a 5 9 7 1 5
A u g u st 2 7 , 1974
D e a r P u b l i c H e a l th N u rs e :
Some tim e ago you w e re s e n t a q u e s t i o n n a i r e c o n c e r n in g a
s t u d y on "T h e U t i l i z a t i o n o f Home H e a l t h A g e n c ie s i n N o r th D a k o ta ."
Many o f t h e c o m p le te d q u e s t i o n n a i r e s h a v e b e e n r e t u r n e d .
S in c e o n ly a s e l e c t e d num ber o f p u b l i c h e a l t h n u r s e s w e re in c lu d e d
i n t h e s t u d y , i t i s i m p o r ta n t t h a t I r e c e i v e y o u r r e p l y . W ould you
t a k e a few m om ents t o c o m p le te t h e q u e s t i o n n a i r e ?
I n . t h e e v e n t t h a t you h a v e a l r e a d y r e t u r n e d t h e q u e s t i o n n a i r e
p le a s e d is re g a rd t h is l e t t e r .
T h an k y o u f o r y o u r a s s i s t a n c e i n m aking t h i s a m e a n in g f u l
stu d y .
S in c e re ly ,
( M is s ) L a V e r n e L e e , R . N .
APPENDIX B
MAP OF NORTH DAKOTA INDICATING THE LOCATIONS
OF HOME HEALTH AGENCIES
;
HOME H E A L T H
- H O S P I T A L
T h e
B A S E D
a g e n c y
I n
H O M E
W
H E A L T H
i l l i a m s
C o .
A G E N C IE S
IN
NORTH
DAKOTA
A G E N C I E S
d i s c o n t i n u e d
I t s
p r o g r a m
a s
o f
A p r i l
I ,
1 9 7 4 .
APPENDIX C
CATEGORIZATION OF RESPONSES
58
CATEGORIZATION OF RESPONSES
The f o llo w in g
a c c o r d in g t o
I.
a.
a r e e x a m p le s o f r e s p o n s e s m ade t o e a c h q u e s t i o n ,
c a te g o r ie s .
I n y o u r p e r s o n a l o p i n i o n , how e f f e c t i v e i s t h e Home H e a l th
P ro g ra m i n y o u r a re a ?
V ery E f f e c t i v e
E ffe c tiv e
.
1.
2.
v e r y good
v e r y much so
-
I . q u i t e good
2 . . m o d e r a te ly
3 . a d e q u a te
In e ffe c tiv e
1.
2.
3.
4.
I.
b.
lukew arm
so -so
o f m in o r im p o r ta n c e
g a in in g e f f e c tiv e n e s s
How do y o u m e a s u re i t s e f f e c t i v e n e s s ?
P h y s ic ia n s ' r e f e r r a ls
I,
la c k o f p a tie n t r e f e r r a l s
Number o f p e o p le s e r v e d
1 . - num ber o f p e o p le s e e n
2.
f o ll o w up r e p o r t s
F e e d b a c k fro m p a t i e n t and f a m ily
1.
2.
p e r s o n a l c o n ta c t, w i t h p a t i e n t and f a m ily
resp o n se s o f p a tie n t
T h o se who w e re a b le t o re m a in o u t o f i n s t i t u t i o n s
1.
2.
3.
4.
end r e s u l t s o f c a r e
n e e d p r o v id e d i n t h e home
la c k o f r e t u r n v i s i t s
re c u rrin g illn e s s
59
C a t e g o r i z a t i o n o f R e s p o n s e s ., ( c o n t i n u e d )
Met p h y s i c i a n s n e e d s
1.
2.
s a tis fa c tio n
s e rv ic e s to p a tie n ts as o rd ered
A c c e s s i b i l i t y o f p ro g ra m i n r e g a r d s t o g e o g ra p h y and s t a f f
1.
2.
3.
a v a i l a b i l i t y o f home h e a l t h p ro g ra m
p a t i e n t s n e e d in g h e l p g e t i t
p ro m p t u s e o f s e r v i c e
. F o llo w up r e p o r t s fro m p u b l i c h e a l t h n u r s e
1.
2.
2.
w r i t t e n r e p o r t s fro m p u b l i c h e a l t h n u r s e s
c o m m u n ic a tio n w i t h p u b l i c h e a l t h n u r s e r e g a r d i n g
p a tie n ts
W hat do y o u f e e l a r e t h e g r e a t e s t l i m i t i n g f a c t o r s a n d / o r p ro b le m s
i n t h e Home H e a l th P ro g ra m i n y o u r a re a ?
C ost
1.
2.
d i s t a n c e , and tim e
o v e rh e a d
L im ite d p h y s i c i a n r e f e r r a l s
I.
la c k o f r e f e r r a l s
R e s t r i c t i v e g o v e rn m e n t r e g u l a t i o n s
1.
2.
3.
d e f i n i t i o n o f s k i l l e d n u rs in g
lim ita tio n s on s e r v ic e s
p h y s ic ia n s ' v i s i t s lim ite d
P u b lic h e a lth n u rs in g s t a f f l im ita tio n s
I.
2 ..
3.
4.
s t a f f e d by n o n - d e g r e e d p e o p le
lim ite d s t a f f
l a c k o f e q u ip m e n t
n o t e n o u g h a d e q u a t e ly t r a i n e d p e r s o n n e l
C a te g o r iz a tio n o f R e sp o n se s,
(c o n tin u e d )
L a c k o f k n o w le d g e , RN
1.
2.
l i m i t e d k n o w led g e o f p ro g ra m
n e e d e d u c a t i o n a l p ro g ra m r e g a r d i n g home h e a l t h s e r v i c e s
L a c k o f k n o w le d g e , M.D.
1.
2.
lim ite d need
n o t many p a t i e n t s n e e d i t
L a c k o f k n o w le d g e , p a t i e n t
1.
2.
p a t i e n t u n a w a re o f s e r v i c e s
p u b l i c i t y f o r t h e com m unity r e g a r d i n g home h e a l t h b e n e f i t s
L im ite d com m unity p u b l i c i t y
1.
2.
3.
n e e d m ore p u b l i c i t y
p e o p le do n o t know a b o u t t h e p ro g ra m
W hat a s p e c t s o f t h e P ro g ra m i n y o u r a r e a a r e c o n t r i b u t i n g t o i t s
success?
C o m m u n ic a tio n s w i t h o t h e r p r o f e s s i o n a l s
I.
f r e q u e n t c o m m u n ic a tio n w i t h p u b l i c h e a l t h n u r s e r e g a r d in g
p a tie n t c a re
Q u a lif ie d p u b lic h e a lth n u rse s
1.
2.
in te r e s te d n u rses
good p a t i e n t c a r e
. P u b l i c a w a re n e s s
I.
p u b l i c a s k in g f o r c a r e
,
In cre a se d r e f e r r a ls
1.
2.
3.
home h e a l t h a g e n cy l o c a t e d i n h o s p i t a l
h o s p ita l n u rse s r e f e r p a tie n ts
' . e f f o r t s o f d i s t r i c t m e d ic a l s o c i e t y
61
C a te g o r iz a tio n o f R e sp o n se s,
(c o n tin u e d )
P a t ie n t feed b ack
I.
4.
p a t i e n t p le a s e d w ith s e r v ic e s
W h a t, i n y o u r o p i n i o n , h a s b e e n t h e r e a c t i o n o f t h e p h y s i c i a n s t o
t h e Home H e a l th P ro g ra m i n y o u r a re a ?
F a v o ra b le
I.
2.
3.
in te re s te d
p o s itiv e
re c e p tiv e
In d iffe re n t
I.
2.
3.
slo w t o a c c e p t
lukew arm
r e f u s e to use i t
M ixed
1.
2.
3.
4.
5.
5.
some u s e — some n o t
im p ro v in g
w arm er
m o d e ra te t o f a v o r a b l e
some a p a th y
W hat do you f e e l a r e t h e p h y s i c i a n s ' r e s p o n s i b i l i t i e s i n t h e Home
H e a l th P rogram ?
C o m p le te r e f e r r a l s
I,
' 2.
3.
w rite o rd e rs
make r e f e r r a l s
p la n o f c a re
S u p p o r t and a s s i s t a n c e
1.
2.
3.
g iv e s u p p o rt
be a v a ila b le to n u rse s
c o o p e ra tio n
C o m m u n icatio n w i t h p u b l i c h e a l t h n u r s e s
1.
2.
d is c u s s p a tie n t c a re
fre q u e n t c o n ta c t w ith p u b lic h e a lth n u rse
62
C a te g o r iz a tio n o f R e sp o n se s,
(c o n tin u e d )
Be a w a re o f s e r v i c e s a v a i l a b l e
1.
2.
6.
know a b o u t home h e a l t h p ro g ra m
aw are o f p ro g ra m
W h a t, i n y o u r o p i n i o n , w o u ld c o n t r i b u t e to w a rd g r e a t e r u t i l i z a t i o n
by t h e p h y s i c i a n s o f t h e Home H e a l t h P ro g ra m i n y o u r a re a ?
In c re a se d p u b lic ity
1.
2.
3.
p r o m o tio n
m ore p u b l i c i t y
h e e d PR w ork
A w a re n e ss and u n d e r s t a n d in g o f p ro g ra m
1.
2.
3.
a w a re n e s s
e d u c a tio n
d is c h a r g e p la n n in g
Im p ro v e d c o m m u n ic a tio n w i t h p u b l i c h e a l t h n u r s e
. I.
2.
PHN i n v o lv e d i n d i s c h a r g e p l a n n i n g
team w ork
C o n f id e n c e i n p u b l i c h e a l t h n u r s e
1.
2.
3.
s k il l e d p u b lic h e a lth n u rse s
q u a lif ie d p u b lic h e a lth n u rse s
b e t t e r p re p a re d p u b lic h e a lth n u rse s
P u b l i c h e a l t h n u r s e s d e m o n s tr a te t h a t t h i s i s a n e e d e d s e r v i c e
1.
2.
3.
d e m o n s t r a t io n p ro g ra m
show n e e d
i d e n t i f y need
63
C a te g o r iz a tio n o f R e sp o n se s,
7.
(c o n tin u e d )
W hat do you f e e l a r e t h e r e s p o n s i b i l i t i e s o f t h e h o s p i t a l n u r s e s
i n t h e Home H e a l th P rogram ?
I d e n t i f y p a t i e n t s n e e d in g c a r e
1.
2.
3.
recommend home h e a l t h s e r v i c e s
d is c h a rg e p la n n in g
c o o rd in a tio n
Know s c o p e o f t h e p ro g ra m
I.
know w h a t s e r v i c e s a r e o f f e r e d by t h e Home H e a l th P ro g ra m
I n f o r m p a t i e n t s r e g a r d i n g Home H e a l th b e n e f i t s
1.
2.
8.
te a c h p a t i e n t s
i n t e r p r e t Home H e a l th P ro g ra m t o p a t i e n t s
W hat do y o u f e e l a r e t h e m o st e f f e c t i v e m eth o d s o f p ro m o tin g t h e
Home H e a l t h P ro g ra m w i t h h o s p i t a l n u r s e s ?
I n c r e a s e d p e r s o n a l c o n t a c t w i t h RNs
1.
2.
f r e q u e n t i n s e r v i c e g i v e n by PHN
PHN v i s i t h o s p i t a l w e e k ly
P u b lic ity
1.
2.
d i s t r i b u t e m a t e r i a l s r e g a r d i n g t h e Home H e a l th P ro g ra m
PR w ork
H o s p i t a l v i s i t s t o p a t i e n t s by PHN
I.
e x p la in s e r v ic e s to p a ti e n ts
D e m o n s tra te d u s e f u l n e s s by PHN
I.
\
show t h a t t h e Home H e a l th P ro g ra m w o rk s
64
C a te g o r iz a tio n o f R e sp o n se s,
9.
(c o n tin u e d )
Do you f e e l t h a t t h e Home H e a l th P r o g r a m ,in y o u r a r e a , h a s a
fu tu re ?
YES
_______
NO___________
P l e a s e g i v e r e a s o n s f o r y o u r a n s w e r.
Y es t h e r e i s a f u t u r e :
I f i t m a i n t a i n s p a t i e n t in d e p e n d e n c e
1.
2.
3.
k e e p s p a t i e n t s i n t h e i r homes
g iv e s , c a r e t o p a t i e n t s a t home
k e e p s p a t i e n t s o u t o f h o s p i t a l s and n u r s i n g homes
I f s h o rte n s h o s p ita l s ta y
1.
2.
f r e e s h o s p i t a l b e d s by e a r l y d i s c h a r g e
a llo w s c o n t i n u i t y o f d a r e
I f re fe rra ls
1.
2.
in c re a s e
n e e d m ore r e f e r r a l s
m ore r e f e r r a l s from p h y s i c i a n s
B ecause i t i s a needed s e r v ic e
1.
2.
3.
g r e a t need
f i l l s a need
v e r y b a d ly n e e d e d
B ecause o f i t s
1.
2.
3.
s u c c e ss to d a te
m e e tin g t h e n e e d s o f t h e e l d e r l y
s u c c e s s f u l up t o now
w o rk in g w e l l
65 •
C a te g o r iz a tio n o f R e sp o n se s,
(c o n tin u e d )
N o, t h e r e i s no f u t u r e :
W ith o u t c o o p e r a t i o n o f p h y s i c i a n s and h o s p i t a l n u r s e s
1.
2.
3.
4.
c o o p e ra tio n
feed b ack
m u st know and u s e p ro g ra m
m ore r e f e r r a l s
B e c a u s e c o s t s a r e t o o h ig h
1.
2.
to o c o s t l y
e x p e n s iv e s e r v i c e
B e c a u s e g o v e rn m e n t r e g u l a t i o n s a r e to o r e s t r i c t i v e
1.
2.
3.
r e g u la tio n s v e ry r e s t r i c t i v e
r e g u l a t i o n s l i m i t c a r e g iv e n
r e g u l a t i o n s r e s t r i c t paym ent
B e c a u s e o f p o o r m anagem ent
1.
2.
10.
m anaged p o o r ly
n e e d s b e t t e r m anagem ent
W hat c h a n g e s do you f e e l s h o u ld b e made i n t h e Home H e a lth
Program ?
U p d a te p u b l i c h e a l t h n u r s i n g s k i l l s
1.
2.
3.
h i g h l y t r a i n e d PHN
b e t t e r q u a l i f i e d PHN
m ore k n o w le d g e a b le PHN
I n c r e a s e g o v e rn m e n t re im b u rs e m e n t
1.
2.
3.
b e t t e r pay m en t by i n t e r m e d i a r y
im p ro v e d r e g u l a t i o n s r e l a t i n g t o re im b u rs e m e n t
i n c r e a s e d c o v e ra g e
66
C a t e g o r iz a t io n o f R e s p o n s e s , (c o n tin u e d )
C o n tin u in g e d u c a t i o n f o r p h y s i c i a n s and h o s p i t a l n u r s e s
r e g a r d i n g t h e Home H e a lth P ro g ra m
1.
2.
3.
i n s e r v ic e e d u c a tio n
o n g o in g i n s e r v i c e e d u c a t i o n
p e r s o n a l c o n t a c t by PHN t o e x p l a i n Home H e a lth P ro g ra m
E xpand t h e s e r v i c e s o f t h e Home H e a l th P ro g ra m
1.
2.
3.
4.
i n c l u d e 24 h o u r d a y , 7 d a y s p e r week
h a v e 24 h o u r c a l l s y s te m
i n c l u d e m ore n u r s i n g p r o c e d u r e s
o f f e r m ore a i d e s e r v i c e s
More p u b l i c i t y
1.
2.
3.
4.
w ord o f m outh
p r in te d m a te ria ls
n e w sp a p e r a r t i c l e s
r a d i o and TV s p o t s
B e t t e r c o m m u n ic a tio n s b e tw e e n PHN, MDs and RNs
1.
2.
3.
4.
r e g u l a r m e e tin g s b e tw e e n PHN, MDs, and RNs
one t o one c o n t a c t
p e rs o n a l c o n ta c t
w r i t t e n r e p o r t s o f p a t i e n t c a r e from PHN t o MDs and RNs
More c o m p le te r e f e r r a l s
1.
2.
3.
4.
c o m p le te o r d e r s
p la n o f c a re
r e f e r r a l s c o m p le te d
a l l in c lu s iv e r e f e r r a ls
No c h a n g e s n e c e s s a r y
I.
. 2.
3.
no c h a n g e n e e d e d
O.K. t h e way i t i s
n o th in g t o c h a n g e
APPENDIX D
HOME HEALTH RELATED SECTIONS OF TITLE X V III
HEALTH INSURANCE FOR THE AGED
P .L . 8 9 -9 7 OF THE SOCIAL
SECURITY ACT
68
HOME HEALTH RELATED SECTIONS OF
SOCIAL SECURITY ACT
S ec. 1831.
E s t a b l is h m e n t o f s u p p le m e n ta r y m e d ic a l i n s u r a n c e p ro g ra m
f o r th e a g e d .
T h e re i s h e r e b y e s t a b l i s h e d a v o l u n t a r y i n s u r a n c e p ro g ra m t o
p r o v id e m e d ic a l i n s u r a n c e b e n e f i t s i n a c c o r d a n c e w i t h t h e p r o v i s i o n o f
t h i s p a r t f o r i n d i v i d u a l s 65 y e a r s o f a g e o r o v e r who e l e c t t o e n r o l l
u n d e r s u c h p ro g ra m , t o be f in a n c e d from prem ium p a y m e n ts by e n r o l l e e s
t o g e t h e r w i t h c o n t r i b u t i o n s from f u n d s a p p r o p r i a t e d by t h e F e d e r a l
G o v e rn m e n t.
S ec.
1832.
S co p e o f b e n e f i t s .
( a ) The b e n e f i t s p r o v id e d t o an i n d i v i d u a l by t h e . i n s u r a n c e
p ro g ra m e s t a b l i s h e d i n t h i s p a r t s h a l l c o n s i s t o f —
1. e n t i t l e m e n t t o h a v e p ay m en t made t o him o r on h i s b e h a l f
( s u b j e c t t o t h e p r o v i s i o n o f t h i s p a r t ) f o r m e d ic a l and o t h e r h e a l t h
s e r v i c e s , e x c e p t t h o s e d e s c r i b e d i n p a r a g r a p h (2 ) ( B ) ; and .
2.
e n t i t l e m e n t t o h a v e paym ent made on h i s b e h a l f ( s u b j e c t
to th e p ro v is io n s o f t h i s p a r t) f o r —
(A)
home h e a l t h s e r v i c e s f o r up t o 100 v i s i t s d u r in g a
c a le n d a r y e a r;
(B) m e d ic a l a n d o t h e r h e a l t h s e r v i c e s ( o t h e r t h a n
p h y s i c i a n s ' s e r v i c e s u n l e s s f u r n i s h e d by a r e s i d e n t o r i n t e r n
o f a h o s p i t a l and t h e s e r v i c e s f o r w h ic h paym ent may be made
p u r s u a n t t o s e c t i o n 1 8 3 5 ( b ) (2 ) f u r n i s h e d by a p r o v i d e r o f
s e r v i c e s o r by o t h e r s u n d e r a rr a n g e m e n ts w i t h them made by a
p r o v i d e r o f s e r v i c e s ; and
(C ) . o u t p a t i e n t p h y s i c a l t h e r a p y s e r v i c e s .
(b ) F o r d e f i n i t i o n s o f " s p e l l o f i l l n e s s " , " m e d i c a l and o t h e r
h e a l t h s e r v i c e s " , and o t h e r te rm s u s e d i n t h i s p a r t , s e e s e c t i o n 1861.
Sec.
1834.
L i m i t a t i o n on home h e a l t h s e r v i c e s .
( a ) P ay m en t u n d e r t h i s p a r t may be made f o r home h e a l t h
s e r v i c e s f u r n i s h e d a n i n d i v i d u a l d u r in g any c a l e n d a r y e a r f o r 100
69
v i s i t s d u r in g s u c h y e a r . T he num ber o f v i s i t s t o b e c h a rg e d f o r
p u r p o s e s o f t h e l i m i t a t i o n i n t h e p r e c e d in g s e n t e n c e , i n c o n n e c t io n
w i t h ite m s and s e r v i c e s d e s c r i b e d i n s e c t i o n 186I(m ) s h a l l b e d e t e r ­
m ined i n a c c o r d a n c e w i t h r e g u l a t i o n s .
(b ) F o r p u r p o s e s o f s u b s e c t i o n ( a ) , home, h e a l t h s e r v i c e s s h a l l
b e t a k e n i n t o a c c o u n t o n ly i f paym ent u n d e r t h i s p a r t i s o r w o u ld b e ,
e x c e p t f o r t h i s s e c t i o n o r t h e f a i l u r e t o com ply w i t h t h e r e q u e s t , and
c e r t i f i c a t i o n r e q u i r e m e n ts o f o r u n d e r s e c t i o n 1835 ( a ) , made w ith
r e s p e c t to su ch s e r v i c e s .
S e c . 18 3 6 .
E lig ib le in d iv id u a ls .
E v e ry i n d i v i d u a l who---(1 ) h a s a t t a i n e d t h e a g e o f 6 5 , and
(2 ) (A) i s a r e s i d e n t o f t h e U n ite d S t a t e s , and i s e i t h e r
( i ) a c i t i z e n o r ( i i ) a n a l i e n l a w f u l l y a d m i tt e d f o r p e rm a n e n t
r e s i d e n c e who h a s r e s i d e d i n t h e U n ite d S t a t e s c o n ti n u o u s ly
d u r in g t h e 5 y e a r s im m e d ia te ly p r e c e d in g t h e m onth i n w h ich h e
a p p l i e s f o r e n r o l l m e n t u n d e r t h i s p a r t , o r (B) i s e n t i t l e d t o
h o s p i t a l i n s u r a n c e b e n e f i t s u n d e r p a r t A, i s e l i g i b l e t o e n r o l l
i n t h e i n s u r a n c e p ro g ra m e s t a b l i s h e d by t h i s p a r t .
S ec. 1861.
D e fin itio n s o f s e r v ic e s , in s titu tio n s ^
e tc .
F o r p u rp o se s o f t h i s t i t l e —
S p e ll o f I lln e s s
( a ) T he te r m " s p e l l o f i l l n e s s " w i t h r e s p e c t t o any i n d i v i d u a l
m eans a p e r i o d o f c o n s e c u t i v e d a y s —
(1 ) b e g in n in g w i t h t h e f i r s t d ay ( n o t i n c l u d e d i n a p r e ­
v i o u s s p e l l o f i l l n e s s ) (A) o n w h ic h s u c h i n d i v i d u a l i s f u r ­
n i s h e d i n p a t i e n t h o s p i t a l s e r v i c e s o r e x te n d e d , c a r e s e r v i c e s ,
and (B) w h ic h o c c u r s i n a m onth f o r w h ich h e i s e n t i t l e d t o
b e n e f i t s u n d e r p a r t A, and
(2 )
e n d in g w i t h t h e c l o s e o f t h e f i r s t p e r i o d o f 60
c o n s e c u t i v e d a y s t h e r e a f t e r o n e a c h o f w h ic h h e i s n e i t h e r an
i n p a t i e n t o f a h o s p i t a l n o r a n i n p a t i e n t o f a n e x te n d e d c a r e
fa c ility .
70
Home H e a l th S e r v i c e s
(m)
The, te rm "hom e h e a l t h s e r v i c e s " m eans t h e f o ll o w i n g ite m s
and s e r v i c e s f u r n i s h e d t o a n i n d i v i d u a l , who i s u n d e r t h e c a r e o f a
p h y s i c i a n , by a home h e a l t h a g e n cy o r by o t h e r s u n d e r a r r a n g e m e n ts w i t h
them made by s u c h a g e n c y , u n d e r a p l a n ( f o r f u r n i s h i n g s u c h ite m s
and s e r v i c e s t o s u c h i n d i v i d u a l ) e s t a b l i s h e d and p e r i o d i c a l l y re v ie w e d
by a p h y s i c i a n , w h ich ite m s and s e r v i c e s a r e , e x c e p t a s p r o v id e d i n
p a r a g r a p h ( 7 ) , p r o v id e d on a v i s i t i n g b a s i s i n a p l a c e o f r e s i d e n c e
u s e d a s s u c h i n d i v i d u a l 's home---(1 ) p a r t - t i m e o r i n t e r m i t t e n t n u r s i n g c a r e p r o v id e d by o r
u n d e r th e s u p e r v is io n o f a r e g i s t e r e d p r o f e s s io n a l n u rs e ;
(2 ) p h y s i c a l , o c c u p a t i o n a l , o r s p e e c h t h e r a p y :
(3 ) m e d ic a l s o c i a l s e r v i c e s u n d e r t h e d i r e c t i o n o f a p h y s i c i a n ;
(4 ) t o t h e e x t e n t p e r m i t t e d i n r e g u l a t i o n s , p a r t - t i m e o r i n t e r ­
m i t t e n t s e r v i c e s o f a home h e a l t h a i d e ;
(5 ) m e d ic a l s u p p l i e s ( o t h e r t h a n d r u g s and b i o l o g i c a l s ) , and
t h e u s e o f m e d ic a l a p p l i a n c e s , w h i l e u n d e r s u c h a p l a n ;
(6 ) i n t h e c a s e o f a home h e a l t h a g e n cy w h ic h i s a f f i l i a t e d o r .
u n d e r common c o n t r o l w i t h a h o s p i t a l , m e d ic a l s e r v i c e s p r o v id e d
by an i n t e r n o r r e s i d e n t - i n - t r a i n i n g o f s u c h h o s p i t a l , u n d e r a
t e a c h i n g p ro g ra m o f s u c h h o s p i t a l a p p ro v e d a s p r o v id e d i n t h e
l a s t s e n te n c e o f s u b s e c t i o n ( b ) ; and
(7 ) any o f t h e f o r e g o i n g ite m s and s e r v i c e s w h ic h a r e p r o v id e d
on an o u t p a t i e n t b a s i s , u n d e r a rr a n g e m e n ts made by t h e home
h e a l t h a g e n c y , a t a h o s p i t a l o r e x te n d e d c a r e f a c i l i t y , o r a t
a r e h a b i l i t a t i o n c e n t e r w h ic h m e e ts su c h s t a n d a r d s a s may be
p re s c rib e d in r e g u la tio n s , a n d -(A) t h e f u r n i s h i n g o f w h ic h in v o lv e s t h e u s e o f e q u ip m e n t
o f s u c h a n a t u r e t h a t t h e ite m s and s e r v i c e s c a n n o t r e a d i l y
b e made a v a i l a b l e t o t h e i n d i v i d u a l i n s u c h p l a c e o f
re s id e n c e , o r
(B) w h ic h a r e f u r n i s h e d a t s u c h f a c i l i t y w h i l e h e i s t h e r e
t o r e c e i v e any su c h ite m o r s e r v i c e d e s c r i b e d i n c la u s e (A ),
b u t n o t in c lu d in g t r a n s p o r t a ti o n o f th e in d iv id u a l in con­
n e c t i o n w i t h any s u c h ite m o r s e r v i c e s ; e x c l u d i n g , h o w ever
71
any ite m o r s e r v i c e i f i t w o u ld n o t be in c l u d e d u n d e r
s u b s e c t i o n (b ) i f f u r n i s h e d t o an i n p a t i e n t o f a h o s p i t a l .
P o s t - H o s p i t a l Home H e a l th S e r v i c e s
(n )
The te r m " p o s t - h o s p i t a l home h e a l t h s e r v i c e s " m eans home
h e a l t h s e r v i c e s f u r n i s h e d a n i n d i v i d u a l w i t h i n I y e a r a f t e r h i s m ost
r e c e n t d i s c h a r g e fro m a h o s p i t a l o f w h ic h h e was a n i n p a t i e n t f o r n o t
l e s s t h a n 3 c o n s e c u t i v e d a y s o r ( i f l a t e r ) w i t h i n I y e a r a f t e r h i s m o st
r e c e n t d i s c h a r g e from a n e x te n d e d c a r e f a c i l i t y o f w h ic h h e was a n
i n p a t i e n t e n t i t l e d t o paym ent u n d e r p a r t A f o r p o s t h o s p i t a l e x te n d e d
c a r e s e r v i c e s , b u t o n ly i f t h e p l a n c o v e r i n g t h e home h e a l t h s e r v i c e s
( a s d e s c r i b e d i n s u b s e c t i o n (m) i s e s t a b l i s h e d w i t h i n 14 d a y s a f t e r
h i s d i s c h a r g e fro m s u c h h o s p i t a l o r e x te n d e d c a r e f a c i l i t y .
Home H e a l th A gency
(0 ) The te r m "hom e h e a l t h a g e n cy " m eans a p u b l i c a g e n cy o r
p r i v a t e o r g a n i z a t i o n j o r a s u b d i v i s i o n o f s u c h a n a g e n cy o r o r g a n i z a ­
t i o n , w h ic h -(1 ) i s p r i m a r i l y e n g a g e d i n p r o v id i n g s k i l l e d n u r s i n g s e r v i c e s
and o t h e r t h e r a p e u t i c s e r v i c e s ;
(2 ) h a s p o l i c i e s , e s t a b l i s h e d by a g ro u p o f p r o f e s s i o n a l
p e rs o n n e l ( a s s o c ia te d w ith th e agency o r o r g a n i z a t i o n ) , i n ­
c l u d i n g one o r m ore p h y s i c i a n and one o r m ore r e g i s t e r e d
p r o f e s s i o n a l n u r s e s , t o g o v e rn t h e s e r v i c e s ( r e f e r r e d t o i n
p a r a g r a p h ( I ) ) w h ic h i t p r o v i d e s , and p r o v id e s f o r s u p e r ­
v i s i o n o f s u c h s e r v i c e s by a p h y s i c i a n o r r e g i s t e r e d p r o f e s ­
s io n a l n u rse ;
(3 ) m a i n t a i n s c l i n i c a l r e c o r d s on a l l p a t i e n t s ;
(4 ) i n t h e c a s e o f a n a g e n cy o r o r g a n i z a t i o n i n any su c h S t a t e
o r a p p l i c a b l e l o c a l law p r o v id e s f o r t h e l i c e n s i n g o f a g e n c ie s
o r o r g a n i z a t i o n s o f t h i s n a t u r e , (A) i s l i c e n s e d p u r s u a n t t o .
s u c h la w , o r (B) i s a p p r o v e d , by t h e ag en cy o f s u c h S t a t e o r
l o c a l i t y r e s p o n s i b l e f o r l i c e n s i n g a g e n c ie s o r o r g a n i z a t i o n s
o f t h i s n a t u r e , a s m e e tin g t h e s t a n d a r d s e s t a b l i s h e d f o r s u c h
l i c e n s i n g ; and
( 5 ) m e e ts s u c h o t h e r c o n d i t i o n s o f p a r t i c i p a t i o n a s t h e
S e c r e t a r y may f i n d n e c e s s a r y i n t h e i n t e r e s t o f t h e h e a l t h and
s a f e t y o f. i n d i v i d u a l s who a r e f u r n i s h e d s e r v i c e s by s u c h a g e n cy
72
o r o rg a n iz a tio n ;
e x c e p t t h a t su c h te r m s h a l l n o t i n c l u d e a p r i v a t e o r g a n i z a t i o n w h ic h
i s n o t a n o n p r o f i t o r g a n i z a t i o n exem pt from F e d e r a l incom e t a x a t i o n
u n d e r s e c t i o n 501 o f t h e I n t e r n a l R evenue Code o f 1954 ( o r a s u b d i ­
v i s i o n o f su c h o r g a n i z a t i o n ) u n l e s s i t i s l i c e n s e d p u r s u a n t t o S t a t e
law and i t m e e ts s u c h a d d i t i o n a l s t a n d a r d s and r e q u i r e m e n ts a s may be
p r e s c r i b e d i n r e g u l a t i o n s ; and e x c e p t t h a t f o r p u r p o s e s o f . p a r t A
s u c h te r m s h a l l n o t i n c l u d e any a g e n c y o r o r g a n i z a t i o n w h ic h i s p r i ­
m a r i ly f o r t h e c a r e and t r e a t m e n t o f m e n ta l d i s e a s e s .
S ec, 1862.
E x c l u s i o n fro m c o v e r a g e .
( а ) N o t w i t h s t a n d in g any o t h e r p r o v i s i o n o f t h i s t i t l e , no
paym ent may b e made u n d e r p a r t A o r p a r t B f o r any e x p e n s e s i n c u r r e d
f o r ite m s o r s e r v i c e s —
(1 ) w h ic h a r e n o t r e a s o n a b l e and n e c e s s a r y f o r t h e d i a g n o s i s
o r t r e a t m e n t o f i l l n e s s o r i n j u r y o r t o im p ro v e t h e f u n c t i o n ­
in g o f a m a lfo rm e d body m em ber;
(2 ) f o r w h ic h t h e i n d i v i d u a l f u r n i s h e d su c h ite m s o r s e r v i c e s
h a s no l e g a l o b l i g a t i o n t o p a y , and w h ic h no o t h e r p e r s o n
(b y r e a s o n o f s u c h i n d i v i d u a l 's m em b ersh ip i n a p re p a y m e n t p l a n
o r o t h e r w i s e ) h a s a l e g a l o b l i g a t i o n t o p r o v id e o r p ay f o r ;
(3 ) w h ic h a r e p a id f o r d i r e c t l y o r i n d i r e c t l y by a g o v e rn m e n ta l
e n t i t y ( o t h e r t h a n u n d e r t h i s A c t and o t h e r th a n u n d e r a h e a l t h
b e n e f i t s o r i n s u r a n c e p l a n e s t a b l i s h e d f o r e m p lo y e e s o f su c h
a n e n t i t y ) , e x c e p t i n s u c h c a s e s a s t h e S e c r e t a r y may s p e c i f y ;
(4 ) w h ic h a r e n o t p r o v id e d w i t h i n t h e U n ite d S t a t e s ( e x c e p t f o r
em erg en cy i n p a t i e n t h o s p i t a l s e r v i c e s f u r n i s h e d o u t s i d e t h e
U n ite d S t a t e s u n d e r t h e c o n d i t i o n s d e s c r i b e d i n s e c t i o n 1814
(f);
( 5 ) w h ic h a r e r e q u i r e d a s a r e s u l t o f w a r , o c c u r r i n g a f t e r t h e
e f f e c t i v e d a t e o f su c h i n d i v i d u a l 's c u r r e n t c o v e ra g e u n d e r
su ch p a r t ;
(б ) w h ic h c o n s t i t u t e p e r s o n a l c o m f o r t ite m s ;
(7 ) w h e re s u c h e x p e n s e s a r e f o r r o u t i n e p h y s i c a l c h e c k u p s ,
e y e g l a s s e s o r e y e e x a m in a tio n s f o r t h e p u r p o s e o f p r e s c r i b i n g ,
f i t t i n g , o r c h a n g in g e y e g l a s s e s , p r o c e d u r e s p e rfo rm e d ( d u r in g
.
73
t h e c o u r s e o f a n e y e e x a m in a tio n ) t o d e te r m in e t h e r e f r a c t i v e
s t a t e o f t h e e y e s , h e a r i n g a i d s o r e x a m in a tio n s t h e r e f o r , o r
im m u n iz a tio n s ;
(8 ) w h ere s u c h e x p e n s e s a r e f o r o r t h o p e d i c s h o e s o r o t h e r
s u p p o rtiv e d e v ic e s f o r th e f e e t ;
(9 ) w h ere s u c h e x p e n s e s a r e f o r c u s t o d i a l c a r e ;
(1 0 ) w h ere s u c h e x p e n s e s a r e f o r c o s m e tic s u r g e r y , o r a r e
i n c u r r e d i n c o n n e c t io n t h e r e w i t h , e x c e p t a s r e q u i r e d f o r t h e
p ro m p t r e p a i r o f a c c i d e n t a l i n j u r y o r f o r im p ro v em en t o f t h e
f u n c t i o n i n g o f a m alfo rm ed body member;
(1 1 ) w h ere s u c h e x p e n s e s c o n s t i t u t e . c h a n g e s im posed by im m e d ia te
r e l a t i v e s o f s u c h i n d i v i d u a l o r m em bers o f h i s h o u s e h o ld ;
(1 2 ) w h e re s u c h e x p e n s e s a r e f o r s e r v i c e s i n c o n n e c t io n w i t h t h e
c a r e , t r e a t m e n t , f i l l i n g , r e m o v a l, o r r e p la c e m e n t o f t e e t h o r
s tr u c tu r e s d i r e c t l y s u p p o rtin g te e th ; o r
(1 3 ) w h e re s u c h e x p e n s e s a r e f o r ---(A) t h e t r e a t m e n t o f f l a t f o o t c o n d i t i o n s and t h e p r e s ­
c r i p t i o n o f s u p p o rtiv e d e v ic e s t h e r e f o r .
(B) t h e t r e a t m e n t o f s u b l u x a t i o n s o f t h e f o o t , o r
(C) r o u t i n e f o o t c a r e ( i n c l u d i n g t h e c u t t i n g o r re m o v a l o f
c o r n s , w a r t s , o r c a l l u s e s , t h e trim m in g o f n a i l s , and o t h e r
h y g e n ic c a r e )
(b ) P aym ent u n d e r t h i s t i t l e may n o t b e made w i t h r e s p e c t t o
any, ite m o r s e r v i c e t o t h e e x t e n t t h a t p aym ent h a s b e e n m ad e , o r c a n
r e a s o n a b ly be e x p e c te d t o b e made ( a s d e te r m in e d i n a c c o r d a n c e w ith
r e g u l a t i o n s ) , w i t h r e s p e c t t o s u c h ite m o r s e r v i c e , u n d e r a w o rk m en 's
c o m p e n s a tio n law o r p l a n o f t h e U n ite d S t a t e s o r a S t a t e .
Any paym ent
u n d e r t h i s t i t l e w i t h r e s p e c t t o any i te m o r s e r v i c e s h a l l b e c o n d i­
t i o n e d on r e im b u rs e m e n t t o t h e a p p r o p r i a t e T r u s t Fund e s t a b l i s h e d by
t h i s t i t l e w hen n o t i c e o r o t h e r i n f o r m a t i o n i s r e c e i v e d t h a t paym ent
f o r s u c h ite m o r s e r v i c e h a s b e e n made u n d e r su c h a law o r p l a n .
APPENDIX E
VERBATIM STATEMENTS MADE BY RESPONDENTS TO
"ADDITIONAL COMMENTS" ON QUESTIONNAIRE
75
VERBATIM STATEMENTS MADE BY RESPONDENTS TO
"ADDITIONAL COMMENTS" ON QUESTIONNAIRE
P h y s ic ia n s
" . . . E d u c a t i o n o f n u r s e s and p h y s i c i a n s i s p r o b a b ly t h e k ey t o
d e m o n s t r a t in g w h a t c a n b e done by an a g e n c y o f t h i s s o r t , p l u s t h e home,
h e a l t h n u r s e m u st make w e e k ly c o n t a c t w i t h t h e p h y s i c i a n s t o k e e p i t .
a liv e .V
" T h e r e n e e d s t o be a c a r e f u l l y s c r e e n i n g o f i n d i v i d u a l s who
p e r f o r m t h i s s e r v i c e , t o make s u r e t h a t th e y a r e c a p a b le o f com pre­
h e n d in g t h e p ro b le m s o f o t h e r s , t h a t th e y a r e c o m p a s s io n a te and u n d e r ­
s t a n d i n g , y e t h a v e a f ir m n e s s t o g e t a c r o s s t h e i r p o i n t and t o f i n d a
way t h a t i s a c c e p t a b l e t o e a c h p h y s i c i a n i n v o l v e d , s o t h a t th e y c a n
r e p o r t t o him a t a n a p p r o p r i a t e t i m e , e i t h e r i n w r i t i n g o r v e r b a l l y ,
a t a tim e w h ere h i s p a t i e n t s a r e n o t i n t e r r u p t e d by i n a p p r o p r i a t e o r
u n tim e ly c o m m u n ic a tio n s .."
" I n my m in d , i n t h i s a r e a , t h e p ro g ra m i s a FLOP!"
"T oo much p a p e r w ork i n v o l v e d ."
" P u b l i c h e a l t h n u r s e s s h o u ld b e in v o lv e d i n d i s c h a r g e p la n n in g
and p o s t d i s c h a r g e c a r e c o n f e r e n c e s ."
(
"O u r p ro g ra m d i e d f o r l a c k o f fu n d s and l a c k o f u t i l i z a t i o n . ”
P u b l i c H e a l th N u r s e s
"We a r e p a y in g m ore f o r p a p e r w ork t h a n n u r s i n g s e r v i c e s . "
"M o st p h y s i c i a n s r e f e r p a t i e n t s who n e e d lo n g te r m c a r e , b u t
t h o s e who w o u ld b e n e f i t fro m j u s t a few v i s i t s a r e n o t b e in g r e f e r r e d
o f t e n t i m e s ."
"We h a v e d i s c o n t i n u e d o u r p ro g ra m a s o f A p r i l I , 1 9 7 4 , due t o
l a c k o f r e f e r r a l s ."
1
76
. V e rb a tim S t a te m e n t s Made by R e s p o n d e n ts t o " A d d i t i o n a l Comments" on
Q u e s tio n n a ir e , (c o n tin u e d )
H o s p i t a l N u rs e s
" I n many s i t u a t i o n s . . . . d o c t o r s d o n 't n e c e s s a r i l y l i k e s u g ­
g e s t i o n s fro m h o s p i t a l n u r s e s . "
" T h e r e n e e d s t o b e a good r e c o r d k e e p in g s y s te m t h a t c u t s
down on t h e m u l t i t u d e o f p a p e r w ork t h a t i s done by m o st home h e a l t h
a g e n c ie s ;"
»
"T h e p ro g ra m s h o u ld b e g i v e n m ore p u b l i c i t y t o a c q u a i n t th e
m e d ic a l and n u r s i n g p r o f e s s i o n s a s w e l l a s t h e p u b l i c o f i t s
s e rv ic e s ."
SELECTED BIBLIOGRAPHY
78
'
SELECTED BIBLIOGRAPHY
Books
T y r u s , H illw a y .
In tr o d u c tio n to R e se a rc h .
Com pany, 1956.
B o s to n : H o u g h to n M i f f l i n
P e rio d ic a ls
A n d r u s , L .H . "Home C a re f o r R u r a l P o o r ," H o s p i t a l s , Volum e 5 ,
M arch I , 1 9 7 0 , p . 4 3 .
;
I
•
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M O N T A N A S T A T E U N IV E R S IT Y L IB R A R IE S
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