Question

What are the environmental differences between direct care staff working in a long-term care facility and those direct care working in private homes and in the community? Why would home health aides need additional training, and what type of training is required?

Answer 1

Home health care is a system of care provided by skilled practitioners to patients in their homes under the direction of a physician. Home health care services include nursing care; physical, occupational, and speech-language therapy; and medical social services.
The goals of home health care services are to help individuals to improve function and live with greater independence; to promote the client’s optimal level of well-being; and to assist the patient to remain at home, avoiding hospitalization or admission to long-term care institutions.
Physicians may refer patients for home health care services, or the services may be requested by family members or patients.
The home health care environment differs from hospitals and other institutional environments where nurses work. For example, home health care nurses work alone in the field with support resources available from a central office. The nurse-physician work relationship involves less direct physician contact, and the physician relies to a greater degree on the nurse to make assessments and communicate findings.
Home health care nurses spend more time on paperwork than hospital nurses and more time dealing with reimbursement issues. Certain distinctive characteristics of the home health care environment influence patient safety and quality of outcomes: the high degree of patient autonomy in the home setting, limited oversight of informal caregivers by professional clinicians, and situational variables unique to each home.
Respect for patient autonomy is valued in hospital-based care. Nonetheless, many decisions are made by clinicians on behalf of hospitalized patients. In home health care, clinicians recognize that the care setting the home is the inviolable domain of the patient. Therefore, compared to the hospitalized patient, the home health care patient often has a greater role in determining how and even if certain interventions will be implemented. For example, in a hospital, nurses, physicians, and pharmacists may all play a role in ensuring that the patient receives antibiotics at therapeutically appropriate intervals.
At home, however, the patient may choose to take the medication at irregular times, despite advice about the importance of a regular medication schedule. Thus, interventions to promote patient safety and quality care must account for the fact that patients will sometimes choose to act in ways that are inconsistent with the relevant evidence, and the clinician’s best efforts may not result in desired outcomes.
In addition to deliberate choices made by informed and capable patients regarding their care, individual patient variables may also influence home-based outcomes in ways that are different from those patients who are hospitalized. Ellenbecker and colleagues reported that reading skill, cognitive ability, and financial resources all affect the ability of home health care patients to safely manage their medication regimens. Yet, none of these variables may play a meaningful role in the safe administration of medications to hospitalized patients.
In addition to self-care, some home-bound patients receive assistance from family members or other informal caregivers. Professional clinicians have no authority over these caregivers.
Further, the home environment and the intermittent nature of professional home health care services may limit the clinician’s ability to observe the quality of care that informal caregivers deliver unlike in the hospital, where care given by support staff may more easily be observed and evaluated. For example, because of limited access to transportation, a husband may decide not to purchase diabetic supplies for his dependent wife. This behavior may not come to the clinician’s attention until an adverse event has occurred.
Evidence-based interventions are predicated on careful assessment. However, limited opportunity to directly observe the patient and informal caregivers may hinder efforts to quickly determine the etiology of an adverse event. If a home health care patient is found with bruises that the patient can’t explain, is the cause a fall, physical abuse, or a blood dyscrasia? In both self-care by patients and care by informal caregivers, safety and quality standards may not be understood or achieved.
Another distinctive characteristic of home health care is that clinicians provide care to each patient in a unique setting. There may be situational variables that present risks to patients that may be difficult or impossible for the clinician to eliminate. Hospitals may have environmental safety departments to monitor air quality and designers/engineers to ensure that the height of stair risers is safe. Home health care clinicians are not likely to have the training or resources to assess and ameliorate such risks to patient safety in the patient’s home.
Finally, given the large number of elderly persons who receive care from Medicare-certified home health care agencies, it is reasonable to anticipate that some patients will be in a trajectory of decline. Due to both normal aging and pathological processes that occur more frequently with advancing age, some elderly persons will experience decreasing ability to carry out activities of daily living , even when high-quality home health care is provided. Thus, an implicit goal of home health care is to facilitate a supported decline. That is, patients who do not show clinical signs of improvement may nonetheless receive quality care that results in a decelerated decline or increased quality of life.