In-home wound care management utilizing information technology

Chronic wounds are a major healthcare crisis, presenting challenges for home health agencies lacking specially trained staff to properly monitor and manage these wounds. Consequently, the home health industry needs to improve wound management methods and technologies to properly care for patients with chronic wounds. Saint Francis University's Center of Excellence for Remote and Medically Under-Served Areas partnered with a home health agency (University of Pittsburgh Medical Center Lee Regional Community Nursing Service) to identify a solution to this problem.     

Putting the pieces together: private-duty home healthcare and geriatric care management: one home health agency's model

This article examines how one home health agency successfully launched a geriatric care management program. The methods of market assessment, the necessary staff to implement the program, and an overview of geriatric care management in general are presented together with an actual case study.     

Integrating case management and palliative care

Most seriously ill Americans live at home under the care of their primary physician and with the support of family caregivers. To reduce costs while simultaneously improving the quality of patient care, insurers have increasingly turned to the concept of case management. While case management is targeted to individuals with life-threatening illnesses, palliative care assessment and interventions are typically not included in the management protocols. An academic/care management/health plan partnership between Mount Sinai School of Medicine, Franklin Health, a care management organization, and South Carolina Blue Cross Blue Shield, was formed in 1998 to test the utility of integration of case management with formal palliative care assessment, feedback and recommendations to treating physicians, and ongoing support for implementation of a palliative care plan. The goal of the project was to ensure identification and optimal care of seriously ill patients' complex needs, while facilitating doctor-patient continuity, improving patient/family/physician communication, providing assistance with decision-making, ensuring quality care at home, and promoting efficient use of health care resources. Care management nurses were randomly assigned to a control (usual care) group or to the intervention (palliative care) group. Intervention nurses were trained in formal palliative care assessment and interventions, supported by treatment protocols and communication strategies with treating physicians. Measurements included symptom burden, prescribing practices, advance care planning status, satisfaction, and health care utilization. These results are pending completion of study run-out and analysis. Preliminary programmatic results indicate that combining palliative care with the case management approach is a logical, feasible, and effective strategy to improve the care of seriously ill patients living in the community. Franklin Health has offered the program to their entire client base because they feel that the integration of palliative care into their case management program improved the standard of patient care. Blue Cross Blue Shield of South Carolina has also chosen to sustain this enhanced model of care management for seriously ill patients.     

Selecting a home care agency.

Selecting a home care agency must be a collaborative effort on the part of families and the discharging facility. Guidelines for selecting home care providers eases the transition from the acute care facility to home.     

Improving end-of-life care education in home care

A training program for home care professionals, HOPE (Home care Outreach for Palliative care Education), was designed to improve the knowledge and skills of those providing care to patients and family caregivers at home. This article presents an overview of the pilot HOPE training program and a case study to illustrate the complex end-of-life (EOL) care needs in nonhospice home care settings. HOPE was designed as five training modules based on a needs assessment survey completed by 134 home care agencies. The training modules were composed of (a) General Overview of End of Life Care; (b) Pain Management; (c) Symptom Management; (d) Communication with Patients and Families; and (e) the Death Event. The program was implemented for clinical staff (N = 52), predominantly nurses, in two home care agencies and evaluated with pre- and postcourse surveys. Pre- and postcourse evaluations demonstrated an increase in the overall rating of EOL care from a mean rating of 5.97 to 7.42 for self-assessment and from 6.59 to 7.94 for agency assessment (on a scale of 0 = not at all effective to 10 = very effective). Future palliative care education should also include evaluation of the impact of such programs on patient care. We concluded that increasing palliative care knowledge of home care professionals is necessary to improve patient care at the EOL.     

Home care nursing orientation model. Justification and structure.

An orientation program for new nurses in a home care agency can be an effective tool that increases job satisfaction, alleviates a potentially high employee attrition rate, boosts morale, and thereby improves overall quality of patient care.     

Low-technology heart failure care in home health: improving patient outcomes

This article reports a study that pilot tested the effectiveness of a low-technology structured intervention to standardize home healthcare management of patients with heart failure (HF) within a home health agency (HHA). The purpose of this study was to use low-technology equipment to improve care for patients with HF enrolled in a home health agency. The 9-week intervention was targeted toward the home health nurses and included telephone and home visits, a teaching tool, digital scales, and a log/notebook filled out by the patients in the study. Patient outcomes included decreased rehospitalization, decreased symptoms of HF, and increased quality of life.     

Computerized knowledge management in diabetes care

INTRODUCTION: Many scientific achievements become part of usual diabetes care only after long delays. The purpose of this article is to identify the impact of automated information interventions on diabetes care and patient outcomes and to enable this knowledge to be incorporated into diabetes care practice. METHODS: We conducted systematic electronic and manual searches and identified reports of randomized clinical trials of computer-assisted interventions in diabetes care. Studies were grouped into 3 categories: computerized prompting of diabetes care, utilization of home glucose records in computer-assisted insulin dose adjustment, and computer-assisted diabetes patient education. RESULTS: Among 40 eligible studies, glycated hemoglobin and blood glucose levels were significantly improved in 7 and 6 trials, respectively. Significantly improved guideline compliance was reported in 6 of 8 computerized prompting studies. Three of 4 pocket-sized insulin dosage computers reduced hypoglycemic events and insulin doses. Metaanalysis of studies using home glucose records in insulin dose adjustment documented a mean decrease in glycated hemoglobin of.14 mmol/L (95% confidence interval [CI], 0.11-0.16) and a decrease in blood glucose of.33 mmol/L (95% CI, 0.28-0.39). Several computerized educational programs improved diet and metabolic indicators. DISCUSSION: Computerized knowledge management is becoming a vital component of quality diabetes care. Prompting follow-up procedures, computerized insulin therapy adjustment using home glucose records, remote feedback, and counseling have documented benefits in improving diabetes-related outcomes.     

Palliative care management: a Veterans Administration demonstration project

As part of a Veterans Health Administration (VA) commitment to improve end-of-life care the VA Greater Los Angeles Healthcare System (GLA) implemented Pathways of Caring, a 3-year demonstration project targeting patients with inoperable lung cancer and advanced heart failure and chronic lung disease. The program utilized case-finding for early identification of poor-prognosis patients, interdisciplinary palliative assessment, and intensive nurse care coordination to optimize symptom management, continuity and coordination of services across providers and care settings, and support for families. Program evaluation used patient and family surveys as well as reviews of medical records and administrative databases to assess processes and outcomes of care. Despite significant programmatic challenges including organizational instability and evaluation design issues, the program achieved measurable success including high rates of advance care planning, hospice enrollment, and death at home, and low end-of-life hospital and Intensive Care Unit (ICU) use. As a result of its success, the program will be expanded and its care model extended institution-wide.     

Outcomes of care from the professional's perspective.

Patient satisfaction is considered an important indicator of the quality of care provided by a home healthcare agency. Increased emphasis is now placed on patient outcomes of care by certification and accreditation standards. This detailed analysis of the outcomes of care by the patient, the family, and the professionals through the use of unsolicited patient letters of commendation and the clinical record did not reveal any specific pattern. The visiting nurse association's home care services are available on a nondiscriminatory basis. This fact is noted in the agency's literature and policy manual. The data analysis for this project supports this policy statement. Patients, family members, and a physician wrote letters of commendation regardless of the LOS, payer source, total charges, time spent with the patient, and personnel who provided the care.     

Relationships of rurality, home health care use, and outcomes

Rural elders have a disproportionate prevalence of illness and limited access to health services. The purpose of this study is to determine whether degree of rurality and home health care use influences home health care patient outcomes. An adaptation of the Outcomes Model for Health Care Research provided the framework for the study. A stratified random sample was selected from a database of risk-adjusted publicly reported patient outcomes from Medicare-certified home health care agencies and merged with agency factors from Medicare cost reports and U.S. Census data. Path analysis was performed to evaluate the relationships in the model. Hospitalization is the only outcome variable associated with community and agency characteristics or home health care use. Rurality does not have a direct effect on hospitalization; however, increased visits per patient and low-income community status are associated with increased hospitalization. Rurality may not have a direct effect on outcomes but instead acts through health care services.     

Home ventilator care.

The need for continuous home ventilatory care can arise when patients who are otherwise stable cannot be weaned from mechanical ventilatory support. Two cases are presented that show these patients can be cared for at home at a cost less than their care in the hospital. Before deciding on home ventilatory care for a patient, one should carefully consider all supportive measures, including drug therapy and psychosocial factors. The choice of home care equipment depends on many individualized considerations. The successful management of a patient on a home ventilator requires careful preparation, extensive home instruction, and continued follow-up by a home health care team.     

Using the linkage model for integrating evidence into home care nursing practice

A home care agency's patient population with heart failure demonstrated improved outcomes after the agency implemented an evidence-based protocol. The model holds promise for use in other agencies working to improve patient outcomes as well as have an impact on decreasing costs.     

Involving patients in care decisions improves satisfaction: an outcomes-based quality improvement project

A home care agency used quality improvement processes to improve patient satisfaction survey ratings. The focus was on involving patients in decisions about their care. A multidisciplinary team developed creative strategies to increase staff awareness and enhance customer service skills, which had dramatic results.     

Adults with sickle cell disease: an interdisciplinary approach to home care and self-care management with a case study

The complexity of caring for adults with sickle cell disease (SCD) strains the confines of a care-segregated medical system. As treatment protocols have dramatically improved since 1990, many patients with SCD are now living well beyond their 6th decade of life. This improved survival rate presents opportunities and challenges for the home healthcare nurse in the management of adult patients with SCD. The home healthcare nurse is essential in the coordination of interdisciplinary health team members to reduce pain episodes and the potentially catastrophic complications of renal failure, pulmonary disease, and cardiovascular events. In addition, the home healthcare nurse serves as patient advocate for the transition from acute care to home, as well as advocate for healthcare maintenance of vision, musculoskeletal involvement, and social and psychological support. This article seeks to provide a viable network for home healthcare nurses to establish self-care management and support of the adult patient with SCD.     

Barriers to pain management by home care nurses

This study examined home care nurses' perceived barriers to pain management. Major barriers included lack of knowledge, inadequate pain assessment, and difficulty managing opioid-related side effects. Home care nurses with more knowledge about pain management had significantly lower scores on the Barriers Questionnaire. The study documented the need for continued pain management education for home care nurses. Practice implications are provided.     

Improving heart failure in home care with chronic disease management and telemonitoring

Home Health Compare rates for Emergent Care and Acute Hospitalization increased undesirably for Athens Regional Home Health. Data revealed that the increase was due to heart failure exacerbation. It was hypothesized that a chronic disease management program with telemonitoring, to include chest fluid bioimpedance, would allow for earlier intervention, thus preventing emergency department visits and acute care readmissions. This article describes the agency's performance improvement initiative that resulted in a decrease in these rates while improving patient outcomes and increasing agency referrals.     

Factors influencing home care nursing problems and nursing care

This study was conducted to determine the contributions of sociodemographic factors, medical conditions, and nursing dependency to nursing problems identified and nursing care provided to patients during a home care nursing visit. Patient interviews, direct observation of nursing care, record abstraction, and nurses' reports were used to obtain data from 438 patients receiving nursing visits from a certified home health agency. Nursing dependency was the strongest predictor of the nursing problems of and nursing care provided to home care patients. Measures of nursing dependency should be incorporated in models to determine the extent of nursing problems and nursing care provided in the home and in models of home care nursing reimbursement. © 1993 John Wiley & Sons, Inc.     

Implementing a pediatric asthma program: enabling self-care management through education

This article provides an overview of asthma prevalence among children, presents a summary of asthma triggers based on past research, outlines the essential components of a pediatric asthma home care model implemented by a large urban home health agency, and details the types of clinical documentation needed for care plan development and monitoring of asthma in the home.