Home healthcare clinicians are witnessing several rapid changes in the delivery of home care service. Standardization has taken precedence in organizations' structures (e.g., the electronic health record) and processes (e.g., when to perform designated assessments or provide a specific intervention)-all in efforts to meet the expectation and challenges of government, payers, and consumers of services. A primary impetus behind the rapid change lies within the findings of two critical reports and subsequent recommendations to improve the quality of healthcare in the United States.
In 2001, the Institute of Medicine (IOM) published Crossing the Quality Chasm: A New Health System for the 21st Century, a detailed examination of the immense divide between what we know to be good healthcare and the healthcare that people actually receive. Aims to improve the quality of healthcare were proposed by the IOM and adopted by the Centers for Medicare & Medicaid Services (CMS; see http://www.nap.edu/openbook.php?isbn=0309072808). In keeping with this theme of improving quality of care, the VNAA's Voice column in this issue of Home Healthcare Nurse, "In Healthcare Quality, Improvement Starts with Passionate Leadership" by Andy Carter, emphasizes your role in using your passion to improve the healthcare quality. Additionally, in accordance with the mission adopted by CMS, healthcare quality is viewed to encompass several properties.
Effectiveness: Providing Care Through a Process to Achieve Outcomes as Supported by Evidence-Based Standards
It is no longer acceptable for home care clinicians (or others in healthcare) to rely on knowledge learned from past clinical practice, school, conferences, or casual reading. The care being provided is expected to be evidence-based in standards and impact the patient's outcome and health status.
To identify and track patient outcomes, data need to be collected, reviewed, analyzed, and interpreted-such as through the use of the Outcome and Assessment Information Set-C (OASIS-C) (CMS, 2011). Home healthcare clinicians are encouraged to become involved in the agency's quality improvement program to look at their data and begin to learn the process of interpreting, analyzing, and perhaps identifying and recommending needed changes. If that seems a bit scary-consider volunteering to be part of a pilot program based on quality improvement recommendations of a clinical process.
Home healthcare is still in the early stages of creating its own library of evidence-based research on which to build home care specific clinical standards, and this will come with time. One complex problem in home care is related to cognition and medications and their management. The authors of "Cognitive Impairment and Medication Self-Management Errors in Older Adults Discharged Home from a Community Hospital," Debra Hain, Ruth Tappen, Sanya Diaz, and Joseph Ouslander, follow patients across the transition from hospital to home looking at these two important issues.
Another article in this month's issue, titled "A Pilot Study Using Electronic Communication in Home Health: Implications on Parental Well-Being and Satisfaction Caring for Medically Fragile Children," by Tina Haney and Kimberly Adams Tufts, considers electronic communication as a tool to improve coordination and overall effectiveness of the care of medically fragile children at home.
Efficiency: Maximizing the Quality of Care and Service Delivered or Health Benefit Achieved for a Given Unit of Healthcare Resources-The Dollar
In light of the current economic status of the country, including government health programs, being efficient is not a choice. Using standardized guidelines to promote the best possible patient outcome reduces waste through eliminating a trial and error approach to care and service.
Equity: Providing Equal Quality of Healthcare to Those Who May Differ in Personal Characteristics Other Than Their Clinical Condition or Preference for Care
As global mobility has increased, so too has cultural and ethnic diversity. Understanding the culture and what it encompasses is critical to effective communication. Home care services are based on communication and relationship-building and, so, to be successful among a diverse population, home health clinicians need to be culturally competent. Judith Young's article, "Online Resources for Culturally and Linguistically Appropriate Services (CLAS) in Home Healthcare and Hospice: Resources for Asian Patients," provides a plethora of online resources to help further this goal of cultural competency. The extensiveness of the resources provided is to be lauded and should be used in practice and operations!
Patient-Centeredness: Providing Care and Service to Meet the Patients' Needs and Preferences and Providing Education and Support
Care planning with the patient starts by meeting the patient's identified preferences and needs first. Study evidence has demonstrated time after time that the patient must be heard first and be an active partner in care and care planning.
Safety: Preventing Actual or Potential Bodily Harm
Safety has always been a critical component of healthcare and home care services. Safety is monitored through clinical competency, observation in the field, patient adverse event reports, and complaints. The article titled "Resolving Moral Distress When Caring for Patients That Smoke While Using Home Oxygen Therapy: A Case Study Using a 3-Step Process," authored by John Kayser, Diane Nault, and Gaston Ostiguy, provides a succinct case study in dealing with home oxygen use when caring for an active smoker, including how to deal with moral distress and provides concrete actions to take to prevent harm and uphold the practice of safety.
An important aspect of safety involves issues related to infection control and prevention. In an interesting article titled "Infection Control in Home Healthcare: Issues for Patients and Providers," Irena Kenneley surveyed home care clinicians about varying aspects of infection control and prevention. The findings and implications are of interest to all practicing clinicians and managers as they seek to improve infection control related policies and processes.
Timeliness: Assuring the Patient Obtains Care With Minimal Delay
Timeliness is a key component of care operations because this includes the scheduling of visits, laboratory tests, procedures, time and length of visits, and time of assessment and reassessment.
Diabetes: A Recurrent Theme in Practice and Operations
Finally, diabetes mellitus is a disease where there are many evidence-based standards and the interventions and assessments on numerous aspects of care that must be monitored on an ongoing basis. As most home care clinicians know, diabetes is expected to grow exponentially in the coming decades. Diabetes has more than tripled (from 5.6 million to 19.7 million) from 1980 through 2009, and the Centers for Disease Control and Prevention (CDC, 2011a) recently found that it affects 26 million people (8.3%) in the United States alone. In addition, the CDC (2011b) reported prediabetes is affecting 79 million people, exposing this population to increased risk of developing Type 2 diabetes, heart disease, and stroke. If the current trend continues, by the year 2050, the CDC predicts as many as one in three (33.3%) U.S. adults could have diabetes (CDC, 2011b). This prediction indicates an increased incidence of 25% over the next four decades.
The incidence of diabetes impacts subpopulations disproportionately (CDC, 2011c) based on 2010 data. Among U.S. residents older than 20 years, 25.6 million (11.3%) people are affected-including 15.7 million (10.25%) non-Hispanic Whites and4.9 million (18.7%) non-Hispanic Blacks. Among U.S. residents older than 65 years, 10.9 million (26.9%) people are affected, as are approximately 215,000 U.S. residents younger than 20 years (type 1 or type 2) (CDC, 2011c). Depending on the home care clinician's geographic area of practice, the agency's population of persons with diabetes may vary from the national profile. Although standards of care do not differ within the adult population, the approaches to providing care and service most certainly will be based on regional, cultural, and ethnic preferences of the populations served. There are numerous national and state initiatives in progress related to diabetes prevention, education, and wellness (CDC, 2011d). A listing of the initiatives and their reports may be accessed through the CDC Web site: http://www.cdc.gov/diabetes/projects/index.htm.
Every January, the American Diabetes Association publishes revisions and additions to the Clinical Practice Recommendations, including Standards of Medical Care for diabetes. Access to the current and past recommendations is free to the public and may be found in the Diabetes Care Journal, Supplement 1. Usually available for viewing via the Internet by the end of December of the previous year, the 2012 Clinical Practice Recommendations may be accessed at:http://care.diabetesjournals.org/content/35/Supplement_1. I highly recommend home health clinicians use this resource as a basis to incorporate evidence-based interventions into practice.
An essential key to improving diabetes-related outcomes is self-management of blood glucose levels on a daily basis. The person who holds the key is the person with diabetes and, in some cases, their caregivers. Understanding the factors that may impact self-management and related behaviors is critical to supporting the person with diabetes to make healthy changes in their daily self-management practices. In the article "An Empirical Study of Self-Efficacy and Social Support in Diabetes Self-Management: Implications for Home Healthcare Nurses," Caralise Hunt, Joan S. Grant, and David A. Pritchard provide useful information about some aspects of care when caring for this complex patient population living with this chronic disease.
I hope you enjoy this edition of Home Healthcare Nurse. If you and your colleagues are making a difference in your patient's health, consider sharing your expertise with your colleagues through a submitted manuscript to Home Healthcare Nurse.
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