What is home care? |

Skilled and Nonskilled Home Care

Just as people have different care needs, varied types of home care organizations offer diverse services to meet those needs. For example, some people need nonskilled services to remain in their home. Communities and private companies offer continuous care services such as sitters/attendants who can stay with the person for eight- to twelve-hour shifts. These attendants may provide personal care such as bathing or hair washing. Some agencies connect live-in companions that are available twenty-four hours a day with people needing home care help. Homemaker services are offered through community programs for light house cleaning, clothes washing, grocery shopping, and preparing of simple meals. Home care agencies may align with volunteer groups who have visitation programs and assist with light yard work or transportation to the grocery store or doctor’s office. These types of services are important, as they provide help with activities of daily living (ADL) necessary for a dependent person to stay in his or her residence. Most nonskilled home care services are self-pay unless covered by a grant, long-term care insurance, or government-sponsored program such as Medicaid.

Many patients are discharged from hospitals earlier than they once were to recuperate from illness or surgery at home. Home health care is a less costly alternative to institutional care. Medically necessary skilled home care services are often covered by full or partial reimbursement through private insurance or by government-sponsored programs like Medicare or Medicaid; others may access home care services through self-pay. The home care team is usually an interdisciplinary team of professionals and support staff that work together to maintain a person in his or her home and out of the hospital or other institutional care. The interdisciplinary team may include the registered nurse, licensed practical nurse, home health aid/assistant/attendant, physical therapist, occupational therapist, speech therapist, and medical social worker. Chaplains and volunteers may be part of the home care team. The group works under the direction of the agency administrator, providing care with a medical plan and orders from the attending physician.

Services delivered are based on the patient’s condition, individual needs, home location, and sources of reimbursement. Home health care services are provided on an intermittent basis, with care delivered several times each week for an average of thirty minutes to an hour per visit. The patient, along with his or her caregiver, remains responsible for daily care. Intermittent care means the nurse or physical therapist will come to the home to teach or provide specific care but will not stay in the home. The skilled provider will teach the caregiver how to perform necessary tasks. Skilled home health care services are not designed to provide home care for extended periods of time but to assist the person to regain independence or optimal functioning.

Skilled nursing services are provided in the home by a Registered Nurse (RN). Examples of nursing care include monitoring of vital signs such as blood pressure and pulse; teaching the patient and other caregivers medication indications, dosage, and side effects; encouraging medication and treatment compliance; changing dressings; and providing infusion or intravenous (IV) therapy. Patients who need IV antibiotics, chemotherapy, or home parenteral nutritional can receive these safely at home. The RN performs a physical assessment of the patient and a safety assessment of the home, making recommendations to keep the patient safe while recovering at home. The RN is responsible for teaching necessary care to both the patient and the family or significant support person in the home. The RN might teach the patient and family how to manage pain or give medications safely, watching for any untoward side effects. The RN also supervises the Licensed Practical Nurse (LPN) and home health aides (HHA) who may provide home care services.

Physical therapists provide in-home skilled services that strengthen and restore movement of bones, muscles, and joints. Physical therapists set reasonable goals with the patient and family and monitor progress toward those goals. The physical therapist helps the patient regain strength and function to minimize decline and further injury. Sometimes the patient needs special equipment. The physical therapist can recommend what equipment is best for the individual patient and teach the patient how to use the equipment to maintain or increase function and to gain independence.

Another home care team member is the occupational therapist. This professional teaches the critical skills needed to accomplish daily living activities at home. The occupational therapist helps the patient compensate for loss of function. For example, the occupational therapist may assess the layout of the kitchen in the patient’s home and reorganize the placement of dishes and cooking pans for patient accessibility. Occupational therapists show patients how to utilize adaptive equipment such as prostheses or eating utensils and garden tools designed for those with arthritis. The goal is to attain and maintain the highest level of patient functioning to live a productive life.

Speech therapists work in-home with patients who have experienced strokes or accidents, have difficulty swallowing or communicating, or have some form of neurological health problem. The goal is to get the patient to the optimal level of receptive and expressive communication possible for normal life at home.

The medical social worker can be one of the most useful members of the home care team. This professional knows the community resources and helps the patient and family access additional care services. The medical social worker serves as a facilitator and liaison, making referrals to community agencies for the patient and family. Trained to provide support and counseling, the medical social worker is an advocate for the patient now living at home.

Home health aides are a vital part of the home care team. In fact, many patients and families consider the home health aide the most valuable care provider in their homes. Supervised by the RN, home health aides provide personal care and hygiene services such as bathing, hair washing, feeding, and dressing. They can assist in ambulation of the patient and provide light housekeeping or a simple meal if covered by the patient’s reimbursement source. Home health aides can be critical to positive home care outcomes.

Other professionals may be available for in-home consultation at some home care agencies. Registered dietitians or nutritionists may offer home visits to discuss diet compliance and special cooking considerations. Nutrition and proper diet are important for achieving healthy outcomes at home. When a patient has a prescribed diet that represents a significant lifestyle change, such as a low-salt or low-fat diet, the registered dietitian can support the patient to success.

Hospice is a special type of care often provided within the home. Hospice home care is for patients diagnosed with end-stage or life-threatening disease with a prognosis of six months or less. Like home health care, hospice home care is coordinated by a multidisciplinary team of providers. Many are the same types of professionals and support staff as with home health care, but the purpose of hospice care is different. The goal in hospice home care is quality of life, not restoration of function and wellness. Additional members of the hospice home care team will include spiritual or pastoral counselors or chaplains, bereavement and grief counselors, and volunteers. All hospice home care services are designed to support and maintain the patient and family at home during the illness and death. Hospice home care is usually reimbursed by private insurance, Medicare, and Medicaid. Most hospice programs accept donations and raise funds to cover nonreimbursed care so that patients are not denied care due to inability to pay.

Perspective and Prospects

The start of home care in the United States can be traced to the Charleston Ladies Benevolent Society in 1813. These female volunteers are credited with the early efforts that led to public health nursing in South Carolina. After the Civil War, home care evolved into the British visiting nurse or district nursing model. Home care nurses worked six days a week for eight to twelve hours each day providing bedside care for the patient while holistically supporting the family as well. In 1877, trained home care nurses were sent by the New York Mission to care for the sick poor in their homes. By 1890, the United States boasted twenty-one visiting nurse associations. Lillian Wald, a nurse from New York, established and directed the Henry Street Settlement. In 1911, her organization consisted of fifty-five home care nurses who made over 175,000 home visits. She is credited with defining the term “public health nursing.” The year 1919 brought the first reimbursement for home care nursing services through the Metropolitan Life Insurance Company. However, when the economy crashed in the late 1920s, many home care agencies closed. Home care was then provided primarily by charities. Change came when Medicare laws, established in 1966, included coverage for home care services. By 1988, home care agencies had increased their numbers by 48 percent. Medicare-certified home care agencies expanded their services but became subject to more regulation.

Home care is a significant part of the health care delivery system in the United States. In 2007, more than 7.6 million people in the United States received some form of home care. That same year, the projected expenditures on home care services were $57.6 billion. The Bureau of Labor Statistics claimed in 2012 that by 2020, the number of individuals in the home health and personal care industry will be over 1.3 million, which is a 70 percent increase from 2010 numbers. Many analysts attribute this projected increase to the number of aging baby boomers who will need additional help at home.

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