In April an event to celebrate the International Year of the Nurse was held at the International Cathedral in Washington, DC. This celebration commemorated not only the 2010 International Year of the Nurse but also the 100th anniversary of Florence Nightingale's death. In fact, there is a stained-glass window there in honor of her. After hearing from participants who attended, it sounded to me like a very special day and celebration.
The U.S. Department of Health and Human Services' Health Resources and Services Administration (HRSA) recently released their latest "Initial Findings from the 2008 National Sample Survey of Registered Nurses" (HRSA, 2010). This survey initially began in 1977 and is the largest survey of RNs in the United States: "The survey is sent to a small percent of the actively-licensed RNs in each state. Nurses are asked to report on their education, employment, intentions regarding nursing work, and demographics. These data are used by policymakers and numerous stakeholders, both domestic and international, to assess the status of and trends in the U.S. nursing workforce" (HRSA, 2010, p. 1). Just a few facts: there are an estimated 3,063,163 RNs, and this number is an increase of 5.3%. The good news is that "an estimated 444,668 RNs, or 14% of the RN population, received their first U.S. license from 2004 through 2008" (HRSA, 2010, p. 2). Thank you, nurse educators!! Not surprisingly, "by 2008, 16.2% of RNs were 50 to 54 years old. This aging trend in the RN population has raised concerns that future retirements could substantially reduce the size of the U.S. nursing workforce at the same time the general population is growing and the proportion who are elderly is increasing, raising demand for health care and nurses' services across the nation" (HRSA, 2010, p. 8.). The implications are clear: the demographics will demand more home healthcare nurses.
Perhaps some of you participated in this survey, which has implications for us all, especially in home healthcare. Figure 1 shows a pie chart entitled "Registered Nurse Population by Employment Setting, 2008" and, not surprisingly, the greatest number of nurses are employed in the hospital setting, followed by "ambulatory care," which is defined as including medical/physician practices, health centers and clinics, and other types of "nonhospital" types of clinical care. [Editor's note: It is interesting that hospitals define the world of healthcare since patients do not live in hospitals.] This is followed by public/community health at 7.8% and then home health at 6.4%. Because some health departments and community-based organizations also provide home healthcare (care to people in their homes), I took the liberty of adding these last two together, and this adding of home health with/to public/community health equals 14.2%. Whatever the real numbers are, how the data were collected, and who fit into which category, the stage is now set for healthcare in the home, whatever it is called, to be viewed with a different and clearer lens.
Healthcare reform (HCR) has passed, and although we will not know the details of the operationalization and "what it means" practically, we do know that there will be some kind of systematic coordinated change. This change will continue on through state levels and alter some belief systems about the "best setting" for healthcare. Entitled the "Patient Protection and Affordable Care Act," H.R. 3590 (2010) has components that may remap home healthcare from a complex, Byzantine set of hoops to a more rational process that would be good for both clinicians and patients. Readers are referred to Thomas.gov for a Web site to review the entire HCR legislation. But there are pieces in HCR that when gathered together, create more of a fundamental platform for more provision of healthcare at home. Some of these elements include funding related to comprehensive geriatric education, advanced nursing education grants (which mention public health nurses), nursing retention grants, and maternal, infant, and early childhood home-visiting programs. Other provisions are
* Authorizing "states to offer home and community-based attendant services" and supporting Medicaid beneficiaries who would otherwise require care in an institutional setting ([S] 2401).
* Giving "states the option of (1) providing home and community-based services to individuals eligible for services under a waiver; and (2) offering home and community-based services to specific, targeted populations" and creating "an optional eligibility category to provide full Medicaid benefits to individuals receiving home and community-based services under a state plan amendment" ([S] 2402).
* Amending "the Deficit Reduction Act of 2005 to (1) extend through FY2016 the Money Follows the Person Rebalancing Demonstration; and (2) reduce to 90 days the institutional residency period" ([S] 2403).
* Applying "Medicaid eligibility criteria to recipients of home and community-based services, during calendar 2014 through 2019, in such a way as to protect against spousal impoverishment" ([S] 2404).
* "Requires the Secretary, starting in 2014, to rebase home health payments by an appropriate percentage, among other things, to reflect the number, mix, and level of intensity of home health services in an episode, and the average cost of providing care. Directs the Secretary to study and report to Congress on home health agency costs involved with providing ongoing access to care to low-income Medicare beneficiaries or beneficiaries in medically underserved areas, and in treating beneficiaries with varying levels of severity of illness" ([S] 3131).
* "Requires a physician, nurse practitioner, clinical nurse specialist, certified nurse-midwife, or physician assistant to have a face-to-face encounter with an individual before issuing a certification for home health services or DME. Authorizes the Secretary to apply the same face-to-face encounter requirement to other items and services based upon a finding that doing so would reduce the risk of fraud, waste, and abuse" ([S] 6407).
* "Directs the Secretary to conduct a demonstration program to test a payment incentive and service delivery model that utilizes physician and nurse practitioner directed home-based primary care teams designed to reduce expenditures and improve health outcomes in the provision of items and services applicable beneficiaries" ([S] 3024).
Whatever the future holds, HCR, in some ways, is here to stay. I believe we all-those practicing, managing, and educating in the areas of healthcare at home and home healthcare and hospice at home-will be in the forefront of this revised vision. We will become the change we all seek to see: the best healthcare (interdisciplinary, timely, and evidence-based) provided where patients and their families want to be, at home.
This July/August issue of Home Healthcare Nurse demonstrates the depth and breadth of healthcare provided at home. Pediatric home care continues to be a growth area. Kathleen Cervasio, in her article "The Role of the Pediatric Home Healthcare Nurse: One Case Study Approach in New York City," presents a challenging case study. Because cardiovascular disease is the leading cause of death in the U.S. and a leading cause of rehospitalization for home health patients, one continuing education article addresses that particular healthcare problem. This article by Darlene Welsh and coauthors addresses "Theory-based Low-Sodium Diet Education for Heart Failure Patients." Ethics is always a good topic in the arena of healthcare generally, and Paul D. Longenecker's continuing education article is entitled "The Ethical Balancing Act of Hospice Care." Home health and hospice aides are important members of the interdisciplinary team. In Sandra S. Butler and coauthors' article entitled "Home Care Aides' Voices from the Field: Job Experiences of Personal Support Specialists-the Maine Home Care Worker Retention Study," the authors provide information about aides, their important work, and their thoughts about providing services at home. Judith Smith provides an overview of the "Area Agencies on Aging," which also provides important community resources for patients and families across the U.S.
We hope you enjoy this issue of Home Healthcare Nurse and, as always, I look forward to your feedback. I can be reached at [email protected].
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