KEY TERMS advance directive durable power of attorney home health care living will Home visits have been an integral part of nursing for more than a century, originating with Florence Nightingale’s “health nurses” in England. Following Nightingale’s vision, Lillian Wald founded the Henry Street Settlement in 1893. In addition, Wald, the “mother of public health nursing,” launched the Visiting Nurse Service of New York, which has become the nation’s largest nonprofit home- and community-based health care organization (Ruel, 2014). Home health care includes a wide range of health care services provided to people in their homes to help them through an illness or injury (Medicare.gov, 2016a). Home health care is typically more affordable than and just as effective as care that people receive in a hospital or skilled nursing facility. In addition, home health care is more convenient for people and their families, as the care they need is brought to them. Examples of home health care services include wound care, education, IV therapy, nutrition therapy, follow-up with a patient after discharge from the hospital, and monitoring of an unstable or chronic illness. The goal of home health care is to help people get better in their own homes to regain as much independence as possible (Medicare.gov, 2016a). HOME HEALTH AND HOSPICE

Hospice care focuses on caring for people facing a terminal illness when the goal is no longer curing the disease (National Hospice and Palliative Care Organization [NHPCO], 2016). Most hospice care occurs in the home with support given to clients and their families. The goal of hospice care is that each person will die pain free and with dignity. Ongoing support is provided to the family after the patient dies (NHPCO, 2016) Purpose of Home Health Services The primary purpose of home health services is to provide nursing care to individuals and their families in their homes. The specific objectives and services nurses offer vary according to the type of agency providing services and the population served. Nurses who work for public health departments, visiting nurse associations, home health agencies, hospice agencies, or school districts usually provide home visits. Nurses who make home visits receive referrals from a variety of sources, including the patient’s physician, nurse practitioner or nurse midwife, hospital discharge planner or case manager, schoolteacher, and clinic health care provider. The patient or the patient’s family can also originate requests for nursing visits to assess and assist in the client’s health care. Nurses from clinics or health departments often conduct home visits as part of patient follow-up. These public health nurses make visits to follow patients with communicable diseases and to provide health education and community referrals to patients with identified health problems. Home health nurses who work for home health agencies that are affiliated with hospitals or nursing registries often make home visits to assist patients in their transition from the hospital to home. In addition, health care providers in private practice may order these visits when patients experience exacerbation of chronic conditions. HOME HEALTH AND HOSPICE

The focus of all home visits is on the individual for whom the referral is received. In addition, the nurse assesses the individual–family interaction and provides education and interventions for the family and the client. The nurse evaluates how the individual and family interact as part of an aggregate group in the community. The nurse identifies the need for referrals to community services and performs the referrals as necessary. Healthy People 2020 2020 Objectives for Home Health and Hospice Care MICH HP2020-14: Increase the proportion of children with special health care needs who receive their care in family-centered, comprehensive, coordinated systems. MICH HP2020-24: Increase the percentage of women giving birth who attend a postpartum care visit with a health worker. OA-HP2020-2: Reduce the proportion of unpaid caregivers of older adults who report an unmet need for caregiver support services. OA-HP2020-4: Reduce the proportion of noninstitutionalized older adults with disabilities who have an unmet need for long-term services and supports. From HealthyPeople.gov: Healthy People 2020: topics & objectives, 2013. http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspxAccessed 2017. Home health care has changed dramatically in the last 20 years in relation to changes in Medicare home health reimbursement. “The Balanced Budget Act of 1997 (BBA) (Public Law 105–33), which was enacted on August 5, 1997, significantly changed the way Medicare pays for home health services” (Department of Health and Human Services [DHHS], 2017, p. 3). Prior to the BBA, home health care agencies (HHAs) were reimbursed using a retrospective payment system for services rendered. HHAs are now reimbursed using the home health prospective payment system (PPS). Under the PPS, HHAs receive a fixed amount of money based on reasonable cost given the client’s diagnosis and plan of care. Since the PPS was implemented in 2000, the Centers for Medicare & Medicaid Services (CMS) made revisions in 2008 and 2012. The changes included providing coverage for more diagnosis groups and certain secondary diagnoses, different resource costs depending on the timing of the home health episodes as well as certain wound and skin conditions, and changes to the therapy schedule from a single 10-visit threshold to multiple thresholds to allow for more visits if needed (DHHS, 2017).

Home health care services have changed to address the needs of the population. Home health nurses visit clients of all ages and races. They visit clients who are acutely, chronically, or terminally ill; were recently discharged from the hospital or a rehabilitation facility; need wound care or intravenous therapy; have a feeding tube or tracheostomy; or high-risk pregnant women. Home health care continues to focus on the care of sick patients and is expanding to include health promotion and disease prevention interventions, including client and family education. Currently, most reimbursement for nursing services is based on the patient’s need for skilled nursing.


On each patient visit, the nurse must document that the care provided is of a skilled nature that requires the knowledge and assessment skills of a nurse and must verify that the patient or a family member could not provide the same level of care. Services coordinated in the home include not only skilled nursing care provided by registered nurses (RNs), but also the services of physical, occupational, and speech therapists; social workers; and home health aides. The broader home care industry definition of home health care includes supportive social services, respite care, community nursing centers, group boarding homes, homeless shelters, adult day care, intermediate-skilled extended care facilities, and assisted living facilities (American Nurses Association [ANA], 2008). In addition, telephone support services are becoming an increasingly important aspect of home health care (Kelly and Godin, 2014). In telephone support programs, nurses contact clients through regularly scheduled telephone calls to assess how the client is doing, how well they are following the plan of care, and if they need additional support services or a home visit. Telephone support programs are beneficial in improving client outcomes and decreasing hospitalizations (Kelly and Godin, 2014). HOME HEALTH AND HOSPICE

Types of Home Health Agencies Home health agencies differ in financial structure, organizational structure, governing board, and population served. The most common types of home health agencies are official (i.e., public), nonprofit, proprietary, chains, and hospital-based agencies. The number of freestanding proprietary agencies has grown faster than that of any other type of Medicare-certified home health agency. Freestanding proprietary agencies now account for 62% of all home health agencies, and hospital-based agencies for 12% of all certified home health agencies (National Association for Home Care and Hospice [NAHC], 2010). There continues to be an increase in the number of managed care agencies, which may have any type of financial structure. Managed care agencies contract with payers, such as insurance companies, to provide specified services to the enrolled clients at predetermined prices. Managed care agencies receive payment before offering services and are responsible for taking the financial risk of providing care to patients within the budgeted allotment. This arrangement works well with large numbers of enrolled clients, because the financial risk is spread across a larger number of people, many of whom are healthy and will not require skilled services. Official Agencies Local or state governments organize, operate, and fund official (i.e., public) home health agencies. These agencies may be part of a county public health nursing service or a home health agency that operates separately from the public health nursing service but is located within the county public health system. Taxpayers fund official home health agencies, but the agencies also receive reimbursement from third-party payers such as Medicare, Medicaid, and private insurance companies. Nonprofit Agencies Nonprofit home health agencies include all home health agencies that are not required to pay federal taxes because of their exempt tax status. Nonprofit groups reinvest any profits into the agencies. Nonprofit home health agencies include independent home health agencies and hospital-based home health agencies. Not all hospital-based home health agencies are nonprofit, even if the hospital is nonprofit. The home health agency can be established as a profit-generating service and serve as a source of revenue for the hospital or medical center. In this situation, the home health agency is categorized organizationally as for-profit and it pays federal taxes on the profits. Proprietary Agencies Proprietary home health agencies are classified as for-profit and pay federal taxes on the profits generated. Proprietary agencies can be individually owned agencies, profit partnerships, or profit corporations. Provided that the agencies make profits, investors in corporate proprietary partnerships receive financial returns on their investments in the agencies. A percentage of the profits generated are also reinvested into the agencies. Agencies within chains have a financial advantage over single agencies