Cost analyses of home care and nursing home services in the southern Taiwan area

This study compares the cost of long-term care provided at patient homes with that of long-term care provided in nursing homes in southern Taiwan. Caring for a patient with a high degree of dependence at home is more expensive than caring for a patient in a nursing home facility when family costs and provider costs are considered together. This phenomenon is not demonstrated for patients with medium degrees of dependence. To be cost-effective, home care services should target patients with medium physical disability, and nursing home care should focus on patients with high levels of dependence.     

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.     

Psychiatric home care and family therapy: a window of opportunity for the psychiatric clinical nurse specialist

This article discusses use of the Developmental-Interactional Model of family therapy by a Psychiatric Clinical Nurse Specialist (CNS) for selected patients receiving psychiatric home care services. This form of family therapy is an integrative approach to working with individuals, couples, and families that combines elements of structural-strategic family therapy with life cycle and intergenerational approaches. Applied to patients and families in a home care setting, this model permits the CNS to assess relational dynamics over time, determining how these transitions relate to a family's problem-solving capability. Case studies are provided to show the application of this model for desired outcomes.     

Telehealth: a policy analysis for quality, impact on patient outcomes, and political feasibility

Telehealth is seen as a venue for improving healthcare access in vulnerable populations through use of electronic devices in the patient's home that monitor and assess for early complications. Major technological advances have improved telehealth services, prompting introduction of federal legislation for reimbursement of telehealth care. Yet, policymakers have stalled passage based on several concerns. This article conducted a policy analysis of HR1601, one of the most recent Congressional proposals for telehealth. The policy analysis was based on 3 criteria: quality of telehealth services, impact of telehealth on patient outcomes, and political feasibility. Overall, the concerns regarding quality, impact on patient outcomes, and feasibility are outweighed by the benefits of using telehealth to extend care. Federal funding of telehealth through passage of legislation, such as HR1601, is a good first step to establishing further evidence for its capabilities, and it could lead to a more comprehensive approach to quality care.     

End of life in intensive care: Is transfer home an alternative?

The past decade has witnessed an increased focus on improving the quality of end of life care internationally. This has resulted in the development of specific health policy work streams to support patient choice and improve standards of care and patient experience. One concept well explored in areas outside of critical care is that of home care at the end of life. This paper seeks to challenge assumptions and practices about the options for transferring the critically ill patient home at end of life. As a piece of collaborative writing from a bereaved family member and critical care nursing team, this paper explores care given to one gentleman at the end of his life. In this, his journey is detailed, the decisions made are outlined and the experience for him and his family are examined with a retrospective narrative account from his wife that is woven throughout the paper. In this paper, we are not asserting that transfer home at end of life is desirable or feasible for all critically ill patients. We are challenging practitioners to consider when and how the initiative of transferring critically ill patients home at end of life, may occur.     

Families and hospitalized elders: A typology of family care actions

The extensive care provided by families to their elderly relatives in the home is well documented. Although family caregiving is likely to be continued during hospitalization of elderly relatives, limited research has been conducted to address the nature of family care for hospitalized elders. The main purpose of this qualitative study was to refine the content domain of family care for hospitalized elders. Altogether 25 interviews were done. Of the 16 participants, 6 were family members, 6 were patients, and 4 were nurses; 7 participants were interviewed once and 9 participants were interviewed twice. Qualitative analysis based on Lofland and Lofland's (1984, 1995) approach resulted in the identification of three major content domains: family members providing care to the patient, working together with the health care team, and taking care of themselves. This typology suggests a shift of research in this area from its current focus on family needs to a view of family caregivers as partners with the health care team.     

Managing the care of patients discharged from home health: a quiet threat to patient safety?

Threats to patient safety can originate from the overuse or underuse of care, in addition to provider-initiated errors. The past decade has seen a dramatic decrease in the duration and volume of home health services provided per patient by Medicare-certified home health agencies (HHAs). Research findings have been mixed with respect to the impact of home health utilization on patient safety and outcomes. This study aimed to explore a related yet fundamental question: How confident are home health nurses that their patients can manage their care when discharged from home health services?     

The home as a setting for care. Clarifying the boundaries of practice

This article has outlined the need for clarification of home care nursing practice to retain the elements essential to professional practice. Home care that is nursing focused, based on concepts of community health nursing, and client/family centered forms the core of professional home care nursing. Technical services that are provided in the home should be clearly delineated so that consumers, payors, and practitioners can determine the roles and functions of the various providers. Professional home care, practiced not just by nursing but by all licensed providers, is practice driven. The boundaries of practice are determined by professional standards with a basis in scientific theory and research. The foundation for this type of practice is strong and should continue to be practiced in the future. Technical house call services, on the other hand, are product driven, often with a zeal for the bottom line profits that does not take into account what is the best product for a specific patient situation or how well that product has been tested. There is definitely a need for both services in delivering health care to people in their homes. It is also hoped that both areas of service can work together to facilitate the management of patient and family needs. It is important, though, to fully define the type and substance of care that is provided in the home setting. Without this ongoing clarification, home care will continue to be fragmented and interpreted differently by everyone involved.     

A comparison of the cost-effectiveness of hospital-based home care with that of a conventional outpatient follow-up for patients with mental illness

The purpose of this study was to compare the outcomes of a hospital-based home-care model with those of a conventional outpatient follow-up for mentally ill patients in Taiwan by means of cost-effectiveness analysis. The study design was a two group posthoc design. We interviewed 40 mentally ill patients who were followed up in the psychiatric outpatient department. Another 40 mentally ill patients who participated in a hospital based home care program were also interviewed. The outcome measures we used for interviews were disease maintenance behavior, psychotic symptoms, social function, service satisfaction, and cost. The cost for each patient was the sum of costs for all direct mental health services. The cost-effectiveness ratio showed that the costs of the hospital-based home care model (4.3) were lower than those of conventional outpatient follow-up (13.5) and that over a one-year period, the hospital-based home care model was associated with improvements in mental conditions, social functional outcomes, and service satisfaction. The improved outcomes and the lower costs in the hospital-based home care program support the view that it is the most cost-effective of the two. Policy makers may consider this analysis as they allocate resources and develop policy for the care of mentally ill patients.     

Psychiatric rehabilitation: a framework for psychiatric home care

Psychiatric home care offers excellent opportunities to help the psychiatric patient achieve positive outcomes. Home care agencies need to develop a treatment model that supports the type of care provided to the psychiatric patient, such as psychiatric rehabilitation. This model purports that mental illness is a biologic illness affected by stress and inadequate problem-solving and coping skills. These patients have inadequate social skills, but they can improve. This article describes interactive tools and methods that the home care staff can use with such patients and their families.     

Refinement of the Shared Care Instrument-Revised: a measure of a family care interaction

This study's purpose was to evaluate the psychometric properties of the Shared Care Instrument-Revised (SCI-R) in a sample of family care dyads. The SCI-R was developed to measure the construct of shared care, which is a system of three constructs (communication, decision making, reciprocity) used in family care to exchange support. An important aspect of evaluating the SCI-R was to create a measure that is statistically sound and meaningful for patient and caregivers. Surveys were mailed to randomly selected home health dyads, which included 223 patients and 220 caregivers. Reliability and confirmatory factor analysis, and concurrent validity were examined. Internal consistency reliability of the patient subscales ranged from 0.74 to 0.76, and from 0.72 to 0.78 for caregiver subscales. Factor analysis supported the underlying theoretical basis of the SCI-R. Construct validity also was supported using the hypothesis-testing approach. One major challenge in family care research is to develop methods and tools to study the dynamic characteristics of close relationships. The findings from this study support further use of SCI-R to study how shared care facilitates the exchange of support and the influence shared care has on outcomes for both patients and caregivers.     

The future of home and hospice care. Linking interventions to outcomes

The pressure on home care and hospice nurses to reach successful outcomes in a cost-effective manner mandates that they become well versed in how to analyze data. The goal of outcome research is to relate patient outcomes to the interventions provided. This article discusses the challenges of outcomes research and how it differs from and relates to performance improvement, and it explores solutions to common problems.     

Using Standardized Nursing Languages in End‐of‐Life Care Plans

PURPOSE: This case study demonstrates the challenges to achieve dignified life closure and a comfortable death for a middle‐aged woman with terminal cancer and her family. DATA SOURCES: Data were obtained from a patient known through the author's clinical experiences, personal family experiences, and published sources. DATA SYNTHESIS: The appropriate nursing diagnosis, patient outcomes, and nursing interventions were identified through the use of NANDA‐International, the Nursing Outcomes Classification, and the Nursing Interventions Classification. CONCLUSIONS: This case study illustrates the appropriate nursing diagnosis, interventions, and outcomes pertinent to an individual with emotional distress at the end of life. IMPLICATIONS FOR NURSING PRACTICE: Employing the NANDA‐International standardized nursing diagnosis, the Nursing Interventions Classification and the Nursing Outcomes Classification provided the needed constructs for considering and improving a dying patient's care in a primary and home setting.     

What to do when the end is near: ethical issues in home health care nursing

As managed care shortens the length of hospital stays, home settings for the practice of nursing will become increasingly important. In spite of community health nursing's long tradition of family-centered care delivered in the home, many discussions of the nurse/patient relationship in the medical ethics literature assume the hospital setting for the practice of nursing and seem to neglect the impact of family and significant others for the nurse/patient relationship. Through a case-based analysis, this article highlights the special ethical and legal issues encountered in caring for patients who are dying at home. This analysis demonstrates that traditional frameworks for the nurse/patient relationship are inadequate for capturing the richness of the relationship the home health care nurse has with both patient and family. By developing a new framework for the nurse/patient/family relationship that (a) recognizes the patient's decision-making authority and autonomy, (b) allows the exercise of the nurse's moral rights, and (c) recognizes the patient's relationships to significant others, the authors attempt to resolve some challenging legal and ethical questions concerning who should be allowed to decide what to do when the end is near. The discussion details the implications of this framework for nursing assessment in the home care setting.     

Nursing care of the person having bariatric surgery.

The increasing incidence of morbid obesity suggests that the quantity of bariatric surgical procedures will continue to multiply each year. Bariatric surgery has become an accepted approach to weight management with the additional benefit of resolution of several co-morbidities. However, quality nursing care and effective patient teaching are essential to achieve positive patient outcomes. Nursing care along the continuum of the bariatric surgical experience is key to positive outcomes for these patients. Throughout the process from selection for surgery to follow-up visits in the physician's office, the nurse can have a significant impact on the response of the patient and family to the surgical procedure. During the selection process, the nurse can explain the required diagnostic tests and their rationale and conduct a thorough medical history, informing the physician of pertinent information that might affect the patient's outcomes. Patient and family teaching begins at this stage with information about the peri-operative experience. Bariatric surgery results in a major lifestyle change for the patient. This change will evolve over time as weight is lost, and the patient adjusts to changes in eating patterns, body image, and the perceptions of others. The nurse should see that the patient has appropriate referral information for support services and should follow up to see that the patient and family availed themselves of these services. The patient's stay in acute care is usually very short. Clearly the patient and family need to go home with specific information about drinking/eating, caring for drainage tubes, skin and wound care, ambulation, self-care, and signs and symptoms that require medical attention. Nursing care should include written information and demonstrations of such activities as care of the wounds and drains. The nurse should assure that the patient leaves the hospital with a call number if questions arise at home. Ideally the nurse, patient, and family should have an opportunity for private education sessions prior to discharge. During the postoperative period, the nurse in the physician's office can serve as a source of information and a monitor of patient progress. Follow-up calls to patients and families after surgery are very helpful in determining the welfare of the patient, offering suggestions for managing the patient's care, and learning if any complications are developing. At the same time, the nurse can assess the psychological condition of the patient and his or her adjustment to a new way of living.     

Comparison of home health care outcomes and service use for patients with wound/skin diagnoses

The purpose of this comparative study was to evaluate patient outcomes for wound healing and home health care service use for patients whose care was paid for by the traditional Medicare program versus a Medicare managed care organization (MCO). Results showed that there were no differences between the groups in wound healing at discharge, functional ability at discharge, or the numbers of home visits. Changes in the Medicare reimbursement system for home health care may have provided an equalizing effect between Medicare MCO and traditional Medicare patients with wound/skin diagnoses in home health care agencies in the Midwest.