Chapter 12: Care Management, Case Management, and Home Healthcare Care management: Coordination of a plan or process to bring health services together as a common whole in a cost-effective way. Care management and utilization management are often used as synonyms. Case management: Development and coordination of care for a selected patient and family. Case management involves an intensive process called disease management A case manager’s responsibilities include the following functions: 1. Advocacy and education—ensuring that the client has a representative who can speak up and represent their needs for needed services and education 2. Clinical care coordination/facilitation—coordinating multiple aspects of care to ensure that the client progresses 3. Continuity/transition management—transitioning of the client to the appropriate level of care needed 4. Utilization/financial management—managing resource utilization and reimbursement for services 5. Performance and outcomes management—monitoring and, if needed, intervening to achieve desired goals and outcomes for both the client and the hospital 6. Psychosocial management—assessing and addressing psychosocial needs, including individual, familial, and environmental 7. Research and practice development—identifying practice improvements and using evidence-based data to influence needed practice changes One important area where practices of care management and case management occur is in the home. People facing an acute or chronic illness or a new health-related situation may be candidates for home healthcare. This service involves caring for patients and their families wherever they may call “home,” regardless of economic and class divisions. Home healthcare is part of a continuum of care to which nurses contribute. It has evolved over time on the basis of three distinct needs: (1) quality healthcare in places and spaces where people live most of their lives (homes and communities), (2) (2) continued development of ways to inform healthcare providers what realities affect health promotion and prevention in the diverse, complex lives of people and families, and (3) (3) cost containment in the healthcare industry. The development of health insurance, rising costs in healthcare in general, and medical and nursing specialization all have played a part in the development of home healthcare as it is today Role and Scope of Home Health Practice The ANA has provided nurses in home health practice with an official document called the Scope and Standards of Home Health Nursing Practice (American Nurses Association, 2014). It provides guidelines for nurses involved in home healthcare practice, including standards of care and standards of professional practice. The standards of care include the key elements of the nursing process: 1. Assessment by collecting data about home care patients 2. Diagnosis through the analysis of data 3. Outcome identification that helps home care nurses identify nurse-sensitive measures 4. Planning in the form of nurse-sensitive interventions directed to the identified outcomes 5. Implementation-identified, nurse-centered actions in collaboration with patients and families 6. Evaluation outcome accomplishment through nurse-sensitive interventions Standards of professional performance described in the ANA document are areas that home care nurses must address in the context of their practice. They include the following: 1. Evaluating quality of care 2. Evaluating their performance in the agency or home care work in which they are involved, maintaining current competency 3. Helping develop nursing students and other colleagues who aspire to become home care nurses, as well as collaborating with others in the care of home care patients 4. Being ethical in their practice, as well as using evidence-based practice in their encounters with patients and families Interprofessional Care Home care, like many areas of healthcare, is made up of workgroups where interprofessional collaboration occurs. Various members of the healthcare team, not just nurses, contribute their expertise to patient management in the home. Generally, the following groups receive care from home health agencies: adults with acute or chronic illnesses, older adults, mothers and newborns, and children and their parents. The challenge of interprofessional work and teams is to be able to work together in a complementary way to help patients and families on the basis of their assessed needs. This is not always easy because many members of various healthcare disciplines see only the unique contribution they make as an isolated involvement with patients and families (Chatfield, Christos, & McGregor, 2012). In reality, all healthcare professionals, regardless of discipline, must work together and find common outcomes so that patients and families can achieve wellness. For example, a woman diagnosed with a cerebrovascular accident may be a patient of a home health agency. In this case, she may have speech difficulties and restricted use of her upper and lower extremities. Together with coping with the loss of control, she also needs to make healthier food choices directly related to the pre-existing condition that is thought to have caused the “stroke” (hypertension). The nurse who makes the home visit would immediately consult with a speech and language expert, physical therapist, occupational therapist, and a nutritionist in conjunction with a physician as a team. The home care nurse, acting as a clinical leader, would talk together formally at case conferences, or informally with a group of experts, about the need to change or to maintain the plan of care to meet identified outcomes. Medical home model An example and extension of interprofessional collaboration with shared outcomes that includes the use of home care services is the “medical home” model. five components: (1) comprehensive care, refers to the accountability of meeting each patient’s physical and mental health needs including prevention and wellness, acute care, and chronic care (2) patient-centered care, means that the care is relationship-based. Partnership with patients and families to learn to manage their care with consideration of their values and culture is central to the care given. (3) coordination of care, is an effort to organize care across services that can include home care, hospitals, and other community services. The key skill for successful coordination is clear and open communication (4) accessible services, and refers to every effort to be responsive in terms of timing (shorter waiting periods to see a care provider on the team), availability (24/7), and responsive to the particular preference patients and families request (5) quality and safety. is a comprehensive commitment to the use of evidence-based clinical care and decision-making with attention to outcomes and the practice of population health management. Population health management as defined as a component of a medical home is a system within any model of delivery of care that creates a way to manage care comprehensively. Population health management is focused on the analysis of data from patients that are organized in a record where providers and researchers can make efforts to understand and improve health and financial outcomes. Telehealth is an operational component of a population health management approach that gathers data to contribute to the larger system or aggregate of data to help nurses and other health professionals understand effectiveness and efficiencies of care for the better. form of electronic communication used to deliver (1) acute care and specialty consultations, (2) home telenursing, and (3) electronic referrals to specialists in expert health facilities. Home Care Models Assisted Living Long-term supportive services have evolved and currently include assisted living and continuing care communities, as well as nursing homes. Assisted living is a type of community-based long-term care that combines quasi-independent living with the availability of nursing care onsite and through home care visits (CDC Long Term Care Services, 2018). It generally is a level of care for people who cannot live on their own, but are not yet ready for a nursing home. This type of living arrangement is different from living independently in one’s own apartment, such as living in a senior living facility, in that many activities are provided communally (e.g., eating, recreation). There is an organized effort to create a “caring community” where residents are supervised and help is available for day-today living tasks. Many older community dwellers find assisted living or continuing care communities to be places where gradual changes in physical, cognitive, and emotional abilities can be addressed with centralized services. In many cases, this choice is made on the basis of financial ability to support such an option. Many people may want to stay in their own homes as a way to protect long-term investments financially and emotionally. Home Visits to the Homeless The thought of making a home visit to a person who may not have a home seems counterintuitive, but home care nurses do visit many homeless people (Pijl-Zieber & Kalischuk, 2011). There are unique challenges related to timing, location, and clean conditions in making a visit and providing care to someone who is homeless, but it is possible and quite rewarding. Many facilities provide shelter to homeless patients, including shelters devoted to posthospitalization care, until the patients are strong enough to return to their usual way of surviving in the community. These shelters may be where the home visit occurs. “Home” care for stasis ulcer care or follow-up related to tuberculosis or HIV is not unusual. There are also groups of interprofessional caregivers who make visits to patients throughout the streets of the community, especially at times when many homeless people are at great risk for injury and may need care. This includes during very cold or hot weather, natural disasters, and during unstable conditions related to violence in communities. The comorbidities that are often present pose challenges (National Health Care for the Homeless Council, 2012). Many homeless people have two or more medical and/or surgical conditions, along with mental health problems or addiction histories, including smoking (Okuyemi et al., 2013). For example, people may have mental health problems as well as alcoholism and other addictions. Special skills are required to understand how to assist these people while trying to obtain affordable and safe housing for them. Parish/Faith Community Nursing According to Carson and Koenig (2011), parish nursing is an approach to holistic care for patients and families in the community. The seminal work of Westberg (1999) identified seven key roles of the parish or faith community nurse: (1) health educator, (2) personal health counselor, (3) referral agent, (4) coordinator of volunteers, (5) developer of supportive groups, (6) integrator of faith and health, and (7) health advocate. Faith community nursing can be delivered in several ways in communities. One aspect of faith community nursing is that of home visiting. The home visits are focused on care given in the context of the seven roles identified by Westberg (1999) and are often negotiated with a faith leader in a community parish, congregation, or synagogue. In many cases, these roles are not reimbursed by insurance, but serve as ways to coordinate care to families as needed. Home Visit There are five phases to a home visit: (1) initiating the visit, (2) preparation, (3) the actual visit, (4) termination of the visit, and (5) post-visit planning Initiating the Visit Community health nurses initiate home visits for a variety of reasons. Many home care agencies receive referrals from physicians or their designees (discharge planners from other healthcare institutions). Referrals can be sent to home health agencies at any time (24/7). Generally, home care agencies make sure that an initial visit is made within 24 hours after receiving a referral. The patient’s situation must satisfy the reimbursement criteria mentioned earlier if Medicare funding is to be used. Often, these conditions are validated during the first home visit, and plans or alternatives are discussed if these are not met. When receiving a referral, it is particularly important to make sure that the orders and directions for care are clear and accurate. If necessary, a clarifying phone call should be made prior to the visit to the person who has referred the patient to the agency. Preparation Documentation is critical. All appropriate paperwork required for the assessment of the patient and family must be available in electronic format if the nurse plans to use a laptop computer for charting, or as hard copy. EQUIPMENT The home care nurse must bring supplies and equipment that may be needed for the visit, depending on the patient’s diagnosis and specific skilled need. Examples include sterile or clean dressings, urinary catheters, a walker, sterile saline solution, and distilled water, as well as antimicrobial agents and paper towels that can be used for handwashing. A home care nurse does not use patient sink areas to wash his or her hands in order to decrease the chance of cross-contamination. Many nurses use alcohol-based cleansers as a reasonable and aseptic way to cleanse their hands in home situations. In addition, the nurse must keep equipment that is often used and may be needed unexpectedly (e.g., dressings, sterile solutions if weather permitting, catheters) in his or her vehicle. These articles should be secured in the trunk or hatch of the car so that they are not visible; this decreases the potential for theft and damage to the vehicle used for the home visit. DIRECTIONS AND VISIT VERIFICATION SYSTEMS Getting directions for the home visit is very important. Portable or vehicle-installed global positioning systems (GPSs) are available, which work via a satellite, or generic maps or hard copy maps in areas where there is little or poor connectivity can help home care nurses locate patients. However, becoming familiar with the directions of routes (north, south, east, west), using landmarks, and making sure that unusual locations are explained before one leaves for a visit are important. More sophisticated systems are evolving currently in the form of apps. These include electronic visit verification tracking the type of service once it occurs. The term “Electronic Visit Verification” with respect to personal care services or home healthcare services is a system under which visits conducted as part of such services are electronically verified with respect to type of service, patient receiving the service, as well as date, time, delivery and provider giving the service (my Geo Tracking, 2018). Geofences also known as geozones can predefine areas on a map and assist with finding patients’ homes in communities and verifying a visit that has been made to decrease fraudulence (my Geo Tracking, 2018). PERSONAL SAFETY Safety prevention for home care nurses is part of preparing for a home visit. Many issues need to be considered. Some key advice is given in Box 12.4. Home care nurses must think about questions such as, “When and where will I go to the bathroom? When and where will I eat? What will I do if I get lost? What will I do if I am involved in an automobile accident?” Generally, home care nurses locate public restrooms in the community where they can stop for a bathroom break safely. Stopping in the community for eating breaks is also a decision that requires familiarity and safety as part of a process during the average work day, although many nurses bring their own break food from home. In both cases, this not only allows the nurse privacy but also does not expose them to conditions where they could contaminate patients and their families and vice versa. Carrying a functioning cell phone and having a list of emergency numbers to call is critical. A cell phone can also help if directions are lost or if an accident occurs. Safety Tips for Home Care Nurses: Be alert and aware of your surroundings. Act like you know where you are going. Do not let your guard down. Trust your gut; if you feel unsafe, leave the area. Go to high-risk areas early in the day. Carry a whistle. Keep car doors locked at all times. Vary your parking spot or route. Keep your keys in your hand en route to and from your car. Dress comfortably and conservatively, and wear comfortable and sturdy shoes. Make connections in the community. Do not carry large amounts of cash or valuables. The In-Home Visit The actual home visit includes introducing home care services to the patient and family, as well as the process of obtaining help from the home care agency when a planned home visit is not occurring. Details are given orally and in writing about when, whom, and how to call in an emergency or nonemergency. It also includes the application of the standards of care for home care practice, which includes the use of the nursing process with defined initial outcomes. The key component of the first in-home visit is assessment. The home care nurse is a guest in the patient’s home, and must obtain the patient’s permission and ask for the patient’s guidance about how to carry out the initial assessment in the context of the home. It is necessary to carry out an overall assessment of the patient’s and family’s strengths, weaknesses, and challenges. In addition, it is also essential to assess home safety risks—medication errors, falls, and abuse and neglect. ASSESSING FOR RISK OF MEDICATION ERRORS The risk of errors associated with medications is inherently high. Medications may be taken incorrectly (wrong medication, wrong route, wrong dose) and may have adverse effects or interactions. These negative side effects include hypotension/bradycardia/syncope, dizziness, ataxia, adverse bleeding, confusion/sedation, and urinary urgency (Romagnoli, Handler, Ligons, & Hochheiser, 2013). Taking the wrong medication/wrong dose/wrong route can occur because of errors in prescribing, errors in transcribing during the referral phase of the home care visit process, and errors in hearing the medication order; patient and family confusion; pharmacy errors; and cultural beliefs. Although all of the various kinds of medication errors can occur in hospitals as well as homes, there are some unique circumstances that make home care medication safety particularly challenging. Sometimes, in the freedom of their own home, patients refuse to take medications, forget to take medications, do not fill prescriptions because of cost, lack of knowledge about how to renew a prescription, or lack of access to a pharmacy. Sometimes, medication errors occur because of multiple physician involvement in care, transitions from hospital to home, patient or family error, or the use of over-the-counter (OTC) drugs in addition to prescribed medication that may cause adverse reactions. ASSESSING FOR RISK OF FALLS Falls are a major health problem in home care. One-third of older adults fall every year with serious consequences that include death, fractures, and head injuries. For the elderly, there are even more consequences when a fall is sustained. These include an ongoing fear of falling, loss of function and mobility, disability, restriction of activity, decreased independence, increased social isolation, depression, and nursing home placement (Leveille et al., 2009)). Fifty-five percent of fall-related injuries occur inside the home (Greene, Sample, & Fruhauf, 2009). The most common rooms where people fall include the living room (31%), bedroom (30%), kitchen (19%), bathroom (13%), and hallway (10%). Fall rates for the elderly are related to intrinsic and extrinsic factors (Table 12.2). In the context of the first home visit, many of these factors are modifiable. For example, the home care nurse can make plans with the family or home care agency to make environmental modifications that can decrease the chance of a fall. For example, this may involve having handrails installed in the bathroom and removing scatter rugs or putting nonskid pads under them. The initiation of an exercise program, medication adjustments, and the management of pain, orthostatic hypotension, and corrected vision all can begin at this first visit (multimodal exercise programs for older adults [Baker, Atlantis, & Fiatarone-Singh, 2007]). ASSESSING FOR RISK OF ABUSE AND NEGLECT Unfortunately, in community settings, there can be instances when patients and family members can be victims of abuse and neglect. This is often hidden until home care nurses or other home care personnel enter the home and observe the potential, or actual, abuse, or neglect. In thinking about the difference between abuse and neglect, there are not only subtle differences between the two conditions but also differences in motivating factors behind the situations. Some authors define abuse as blatant disregard for the safety and welfare of a patient versus neglect as a chronic, eroding lack of physical, psychosocial, and spiritual support of another (Stark, 2011). Abuse can be physical, emotional (often in the form of verbal abuse), and, especially with the elderly, financial. This is often true when caregivers are responsible for the financial management of the household. Neglect is not always the responsibility of others. Some patients, for a variety of reasons that include diagnosed and undiagnosed depression, can be victims of self-neglect (Underwood et al., 2013). Self-neglect can take the form of not taking care of personal hygiene, refusing to take medications that may improve their physical or mental condition(s), and refusing to eat. Termination In terminating the initial visit, it is critical to make sure that patients and families know how to reach the home care nurse at any time of the day, and that an emergency plan is understood by the patient and the family. This understanding may involve the neighbors. It is equally important to establish an initial plan of care, and to make a plan for the next scheduled visit. If there are any circumstances that would impede future visits, it is important to address these at this time. For example, if the patient or family members smoke, and the home care nurse is allergic to smoke or cannot tolerate smoking, the home care nurse should make a contract related to a “no smoking” visit policy. If there are pets that disrupt the visit, the home care nurse needs to make a contract that the pet will be put in another area during future home visits. Post-Visit Planning After the initial visit, the home care nurse establishes, through the nursing process and the use of the initial assessment protocol, a specific plan of care that may include other healthcare disciplines and home health aide services. Outcome goals are established, and a schedule of planned visits is organized. The most crucial post-visit activity is the establishment of outcome measures, so that the home health team can plan an intervention approach that allows reasonable time and effort for healthcare providers and the patient and family to achieve these measures. This is accomplished through the expert judgment of the home care nurse, who manages the home care effort, and consideration of the constraints of Medicare, Medicaid, and other health insurance policies. Case Management, Home Healthcare, and Current Healthcare Reform The healthcare home model is an evolving, comprehensive, and cost-saving model that includes home care and case management. This model was introduced originally in the late 1960s as a model of healthcare delivery for children with special needs and was a way to coordinate multiple services to children with complex developmental and physical challenges. Outcomes of the model, beyond family-centered comprehensive care, included a way to coordinate care effectively while being culturally relevant and sensitive. This model is currently referred to as the PCMH and includes a chronic care model congruent with home care services described in this chapter. The distribution of services was originally introduced as a way to address those populations who were underserved and at high risk who needed coordinated care when they could not access primary care easily. The current terminology referring to this model is “healthcare home” versus “medical home” so that the true nature of the coordination is interprofessional with nursing as a central role (American Nursing Association, 2014). The healthcare home model intends to reduce barriers to access by providing services such as enrollment into healthcare services, transportation, and coordination with service providers that include home care services. As healthcare reform continues, the home care nurse will play a significant role in reducing emergency department and hospital use by improving outcomes in chronic care. In a recent study of all home healthcare agencies, Medicare-certified agencies offered training in outcomebased quality improvement to their professional staff, particularly nursing, as a way to ensure outcomes that did not involve expensive and unnecessary interventions (Pace & Johnson, 2006). Those that addressed (1) pain interfering with activity, (2) improvement in transferring, (3) improvement in managing oral medications, and (4) improvement in ambulation and locomotion demonstrated improved outcomes in comparison with national rates. Improvement continues to be needed in (1) emergent care needs, (2) dyspnea, (3) acute care hospitalization, (4) care of surgical wounds, (5) bathing, and (6) incontinence as home care progresses in its scope and standards of care to the public. Types of Agencies Private/Voluntary Agencies Voluntary agencies are generally established as not-for-profit entities, although they operate with the same fiscal objectives as “for-profit agencies.” The difference is that they are often governed by a voluntary board of directors and community-based advisory boards that are interested in fiscally sound, high-quality care for patients they decide will be their service population. Any profit margin that is acquired is reinvested in the operations of the home healthcare service. The advisory and legislative members of the boards direct the chief executive and fiscal officers in how home healthcare should be offered to the service population. A good example is a VNA. Hospital-Based Agencies Hospital-based agencies have developed within the past 25 years to save money and maintain control of patient care costs. In addition, a key objective is to maintain levels of quality and increase collaboration by establishing home healthcare services as part of a continuum of care offered by the hospital. As a healthcare system, hospitals embraced an approach to care that included prevention and health promotion through divisions that offer primary care, emergency care, acute care, and chronic care in various onsite or offsite facilities. The home is one such site. The principal idea was to establish plans of care that were congruent with a hospital system philosophy. Hospital-based home healthcare agencies are governed by not only the same board that governs the hospital but also an advisory board similar to that of a VNA; this helps match their care initiatives to the realities of the population they serve. Depending on the hospital, hospital-based agencies can be “for-profit” or “not-for-profit.” An example of a home healthcare agency associated with a hospital is the Home Health Care Department of Boston General Hospital. All Boston General Hospital patients who need skilled nursing care at home are referred to the home healthcare department of the hospital and followed over time. People that have been readmitted and others may also be referred to this group. Proprietary Agencies Proprietary agencies are private agencies that plan to and want to make a profit. They can be part of a local, national, or international chain of home healthcare agencies directed toward any group of patients with particular healthcare problems or challenges. For example, an agency that has as its goal the provision of home health aides and homemaking services to people in need of personal care and housekeeping services will provide for profit trained home health aides and homemakers to assist people and families with these needs. Their services are often paid for privately by families, and any profit margin is used to benefit the owner of the agency or chain of agencies. Official Agencies Official agencies are supported by public monies that often come from taxes. The public monies can come from local, state, or federal governments. Essentially, citizens and legislators identify a need for home health services that are often part of a larger public health approach to certain populations. For example, a county health department may be established with several goals and objectives to promote the health of people in the area for which they are responsible. This may include lead paint screening for children, tuberculosis treatment and follow-up, well-child clinics, water-testing facilities, and a public home care agency. Generally, there is a mandate to serve all people without exception. Thus, public home health programs often care for many patients that may not be admitted to private, voluntary, or proprietary home health programs. However, with the constant rise in public health problems such as obesity, diabetes, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), low–birth-weight births, and infant mortality, many public home health agencies are supported financially for the care they give to citizens who may have little access to any other care.
