Jacqueline Thimoleon

May 5, 200

Home Health Care

The primary goal of home health care is to provide quality health care services to patients or clients in their home setting, thus minimizing dependence on hospitals as the basis ongoing treatment.

The restructuring of the home health care delivery environment adds new dimensions to the ethical issues involved in the practice of nursing. These issues are particularly relevant to the delivery of health care services in the home. Health care professionals must become aware of these issues, and they must integrate their knowledge of nursing practice with the requirements of home health care so that these issues are addressed effectively. As a profession, Therapists and Nurses must develop and promote licensing and accreditation criteria, which assure quality health and care delivery in the home.

PATIENT SELECTION

Numerous areas should be considered when discharging a patient to a home care program in order to meet those goals and achieve the benefits of home care. Not every patient is a candidate for home care and not every patient who needs home care receives it. What is appropriate for one may not be indicated for another, therefore a "prepackaged" program will not meet the needs of all patients. Home care must be individualized for each patient, but there are guidelines to help with this customization.

As stated earlier, many factors must be considered when determining the feasibility of home care for a particular patient. The hospital discharge planner or an RCP knowledgeable in discharge planning usually assesses these factors. This process begins when the physician determines that the patient is able to go home. The discharge planner starts by evaluating the patient to determine if he or she is a candidate for home care. The patient who has been hospitalized frequently for a recurring problem, such as chronic obstructive pulmonary disease or terminally ill patients are ideal candidates for home care program. The ongoing assessment and education that are provided can identify and prevent problems before they become unmanageable and require hospitalization. A home care program can be beneficial for:

-Patients requiring wound care, intravenous therapy, enterostomal therapy, or assessment to prevent postoperative complication such as pneumonia or infection.

-Patients needing physical and pulmonary rehabilitation.

-Patients who require home medical equipment.

SERVICE COORDINATION

In spite of the widely accepted public perception, the home health care concept is nothing new (Caring, 1988,p.6). Physicians who make house calls are providing home health care, as are midwives who assist women in giving birth at home. Both physician house calls and midwifery were standard forms of medical practice in the United States until around 1941 (Murphy, 1982, p. 190). Further, prior to the end of the Second World War, the usual locus of treatment for chronically ill patients, and the elderly was in the home (Murphy, 1982, p. 192). Thus, the home health care concept in the contemporary environment is not so much an innovation, as it is a revival of an old idea.

In the contemporary environment, home health care is oriented toward those individuals requiring long-term care (LTC), where the condition of the patient does not require constant access to either sophisticated hospital facilities, or health care professionals (Risser, 1989, p. 44).

The delivery of health care services in the home is a complex process. There are four major areas of activity - infusion therapy, personnel services, the provision and operation of durable medical equipment in the home, and self-care (Edmondson, 1985,p. 23). In addition to these four major areas of activity, the vital function of medical record keeping must be performed in the home care environment, just as it is performed in the hospital environment.

Both the establishment and the monitoring of home health care must be coordinated by a primary health care team (Weinberg, 1988). A primary care physician typically heads such a team, whether or not it is a formally constituted team (Weinberg, 1988). Many other types of health care professionals and workers, however, will usually be involved in the delivery of health care services in the home.

Once the patient has been identified as a candidate for home care, and he is willing to cooperate with the providers, and has insurance to pay for home care, the program can be fully customized. The medical needs of the patient determine the types of professional services required. A multidisciplinary team of home care experts is often involved in providing the nursing and equipment services that may be ordered by the physician. The home care program developed for the patient with end-stage chronic obstructive pulmonary disease may require home oxygen therapy for the treatment of hypoxemia, bronchodilator therapy via a compressor nebulizer, and visits by the respiratory therapist nurse, or both, for assessment, evaluation of compliance, and re-education as necessary. This patient may also require physical and occupational therapy for training in activities of daily living and physical conditioning, a home health aide for assistance with bathing and personal care, and visits by social worker for assessment of psychosocial issues such as chronic depression. Therefore the members of the health care team must work together to assure the quality of services delivered to the patient

There are several significant implications associated with the delivery of health care services through a team approach. Among the more important of these implications are the following:

1. Each member of the primary health care team has a special contribution to make. Professional animosity does not promote effective home health care.

2. Each member of the primary health care team may, under certain circumstances, deliver health care services to patients independently of any of the other members of the team. In all instances, however, such treatment should be consistent with the health care plan established by the primary health care team (Weinberg, 1988).

3. Consultation and collaboration among members of the primary health care team are essential elements in the delivery of effective health care services. Each member of the team requires maximum feedback from each other team member (Weinberg, 1988).

CONFIDENTIALITY

In the delivery of health care in the home, a care plan is required, just as a care plan is employed in the delivery of health care in a hospital setting. Complete and up-to-date medical records are required, if an effective care plan is to be developed and maintained.

The maintenance of medical records in the home environment requires the use of a chart book. A daily record of patient food and medication intake, along with eliminations, must be maintained. Additionally, any information related to the patient who might prove useful at a later point in the treatment must be recorded.

Confidentiality becomes an increasingly significant factor, with respect to medical records maintained in the home health care environment (Nassif, 1985,p.89). Personnel involved in the delivery of health care services in the home must be aware of the necessity to maintain complete confidentiality outside of the home care environment, with respect to (1) the patient's medical records maintained in the home care environment, and (2) the home environment itself.

PATIENT ABUSE

Abuse of patients has become a significant issue for health care professionals in the year 2001. Problems of abuse are most critical with respect to the wives, children and elderly. For the health care professionals, patient abuse is not a situation, which simply demands the extension of care to the victims. On one hand, health care professionals have a moral obligation to these victims to insure that the victims are removed, to the extent possible, from abusive situations (Salladay, & Haddad, 1987,p. 165). On the other hand, the professional Therapist and nurses feel a traditional obligation to protect the privacy of patients and their families. Between these extremes of an ethical continuum, contemporary society is demanding increased accountability from its health care professionals (Wagner, 1988, p. 209). Health care professionals who fail to report instances of abuse expose themselves to potential legal problems. This ethical dilemma appears destined to grow in significance. It is also one which will more likely encountered in a home health care situation than in the hospital environment. For example, 1999 in Philadelphia a case of 69 year-old woman Nancy Welde who was stabbed to death by a home health aide Juan Smith after being hired to care for her ailing husband. In home health care you have no audience. If people are abused or stolen from, they tend not to report it themselves because they are afraid they will end up in a nursing home. Therefore most cases of abuse are not reported.

PATIENT RIGHTS

Significant ethical dilemmas confront the health care professional in a home health care situation with respect to patient rights. A patient's right to die poses a highly relevant ethical problem in many home health care situations especially when there are other alternatives such as hospice care. The health care professional in such situations is often involved in parenteral feeding, or total parenteral nutrition (TPN) for patients. TPN, in the late-1990s to the present, is a part of the controversy involving the termination of life support activities (Steinbrook, & Lo, 1988). With respect to TPN, the question involves how TPN is viewed - as ordinary care, or as optional care. Many health care professionals view TPN as ordinary care. In such a context, it would be impermissible to withdraw TPN from patients in a vegetative state (Steinbrook, & Lo, 1988). Many patients, family members, and, increasingly, the courts, however, view TPN as an optional type of care for patients in a terminal or vegetative condition. For example, 1975 in Missouri, a young woman named Karen Ann Quilan illustrates the type of ethical dilemma that emerged in this era of modern medicine. The same year her family undertook a prolonged legal battle in which they argued that their daughter, in a permanent vegetative state, due to a car accident, would not have wanted to be kept alive in this condition with no hope of recovery. They asked the court for permission to remove her life support and eventually were granted that right. When viewed in this context, it is permissible to withdraw TPN, which is, in effect, to withdraw the individual patient's basic requirements for food and water (Steinbrook, & Lo, 1988).

The question of viewing TPN as either ordinary care or as optional care is a significant and an emotional problem. The question is far from settled. It is one which will likely increasingly be involved in the delivery of health care services in the home.

HOSPICE

When people are confronted with terminal illness, they are forced to make some tough decisions about how they will live the rest of their lives. Over the years, the philosophy of hospice care has evolved to become a viable alternative for many people. In many situations it is the last resort for some patients. Hospice consists of organized programs that offer dying persons and their families an alternative for traditional care for terminal illness. As stated in Aging "Hospice care is exclusively for dying people. It therefore brings expertise to help patients and their families face issues of death and dying" (James 1990, p.180). Receiving a diagnosis that includes a probable life expectancy of less than six months is one of the worst moments imaginable for everyone involved. No special words of comfort or philosophical discussion is going to make it all better. However, they can make the most of the time that is left and make the quality of life the best possible under the circumstances. The will to live is one of the strongest instincts within us, but all of us will die one day. Hospice offers a positive approach to coping with all the changes that accompany the dying process. Hospice enables the patient to receive palliative medical care at home, while meeting the psychosocial and spiritual needs of the patient, their families and friends. Hospice programs also offer bereavement services for 13 months or beyond if required, following the patient’s death for any family members or friends who wish to receive the service.

The article "The Continuum of Long term Care" emphasizes "The philosophy of hospice is that terminally ill individuals should be allowed to maintain life during their final days of their lives as comfortably as possible," (Lightman, 1993, p. 198). Therefore health care providers, who are involved in hospice care, must recognize the special needs inherent in this treatment setting. These needs can range from providing home based respiratory care to help keep patient comfortable during the terminal phases of an unrelated illness.

The quality of life of the terminally ill patients relies heavily on the psychosocial skills and other health care professionals. The health care team consists of a physician, nurse, respiratory therapist, social worker, chaplain, home health aide and volunteers. The team develops an individual care plan, which will provide an appropriate support system for the patient and their family up to and beyond patient’s death. Weekly meetings allow the team to focus on the changing needs of the patient and make adjustments to their plan.

Hospice care can be received in a variety of organizational settings. The most preferred setting is of course within patient’s own home, but nursing homes, hospitals and long-term care facilities are few that can also provide hospice care. Hospice care is a covered benefit under Medicare and most private insurance companies.

ACCESS TO SERVICES

Health care Professionals have traditionally taken quite seriously their commitment to the general welfare of patients. In this context, the traditional attitude of therapists and nurses have been that no changes should be made in the management of the delivery of health care services, if such changes would cause the general public to feel that other considerations take priority over patients' interests with professional therapists and nurses (Sargis, 1985, p. 24).

The expansion of home health care holds the potential to impinge upon the professional therapist and nurses traditional commitment to patient welfare (Ostwald, & Williams, 1987). Problems associated with confidentiality, health care charting, funding, professional prerogatives, and quality of care are among the significant issues involved (Logan, & Dawkins, 1986; Stanhope, & Lancaster, 1988). While it is vitally important for any health care professional to assure that such considerations do not affect their commitment to the general welfare of their home care patients; it is easy to visualize situations in the home care environment where just such outcomes may develop. A major consideration in this context in the home health care is access to services.

Increasing costs related to both health care and health care insurance, together with growing restrictions on government funding for health care services for the needy create an environment in which more and more people lose access to healthcare services. Changes on either the funding side or the treatment side of the equation may easily lead to a situation wherein a home care patient may be denied access to a specific treatment therapy. A serious implication of this situation is the potential denial of access to necessary health care services for a large segment of the population.

The AIDS (acquired immunity deficiency syndrome) crisis provides one illustration of the access problem (Burgess, & Ragland, 1983, p. 50). Many AIDS victims are ideal candidates for the home delivery of health care services. AIDS victims without health insurance, however, are generally denied coverage. Those with health insurance often find their coverage curtailed. Due to the nature of the syndrome, however, AIDS victims do not simply require access to health care services - they also require access to humane alternatives to traditional care. Humane care alternatives (to hospital care) for AIDS victims have been found to be (1) hospice care, (2) home health care, and (3) out-patient care (Taravella, 1986). Happily, these alternative approaches to the delivery of health care services to AIDS victims have also been found to be more effective medically than hospital delivered health care services. Additionally, the alternative approaches to the delivery of health care services have been found to be significantly

less costly than the delivery of the services through hospitals. Nevertheless, within the existing environment, such patients may find access to needed health care services curtained, if they are receiving such care in the home. Mushrooming medical technology also threatens access for many individuals (Pera, & Gould, 1989, p. 38). The high costs associated with this technology places it outside the reach of millions of individuals, particularly those individuals who depend upon home health care (Stuart-Siddall, 1986).

The access dilemma is, from the late-1990s to the present, developing into a major health issue in the United States. In the rush to embrace home health are as a better alternative to nursing homes, some of the nation’s most frail and vulnerable residents end up victims unable to defend themselves in their own homes, too afraid to speak or confused to speak out. The problems associated with access to home health care services will likely worsen significantly, before beginning to improve.

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