Home healthcare is a covered service under the Part A Medicare benefit (Centers for Medicare and Medicaid Services [CMS], 2015). Key statistics from 2010 support there were over 10,800 Medicare-certified home healthcare agencies (HHAs), 3,446,057 beneficiaries receiving services, and 122,578,603 visits made to these beneficiaries (CMS). Common home healthcare services provided to patients aged 65 years and over include: skilled nursing (84%), physical therapy (40%), assistance with daily living (37%), homemaker services (17%), occupational therapy (14%), wound care (14%), and dietary counseling (14%). The most common diagnoses treated were hypertension, heart disease, diabetes, chronic respiratory conditions, cancer, and arthritis (Jones et al., 2012).
Brent outlined in her 1989 work that home healthcare was quickly replacing hospital care and becoming an alternate delivery service for patients. She reported the growth of Medicare-certified and noncertified agencies was the fastest growing category of Medicare providers (Brent, 1989, p. 775). She advised that risk management principles be applied to ensure quality, patient safety, and a reduction of liability because of the growing need for these services, and the vast increasing number of HHAs (Brent).
It should be no surprise, therefore, that there are many recommendations revolving around these principles in the National Association for Home Care & Hospice [NAHC] 2015 Legislative Priorities. One recommendation includes asking Congress to mandate uniform accreditation or licensure standards for home healthcare. The rationale is that there is no uniformity in the licensure and accreditation requirements across the United States. This leads to varying levels of patient care, staffing, and fiscal stability (NAHC, 2015, p. 78). Other 2015 legislation recommendations include enacting: a) home healthcare program integrity measures, b) performance-based payments for Medicare home healthcare services, c) Medicaid home healthcare program integrity measures, and d) standard quality metrics and minimum mandatory uniform data sets (NAHC, p. 28, 36, 61, and 64).
Brent projected 26 years ago that these recommendations would become necessary to improve the quality of care given in the home and mitigate liability. Areas that she focused on were: a) scope of practice, b) documentation of patient care, c) patient safety, and d) consent for treatment and refusal of treatment (Brent, 1989). As the nursing profession represents a significant presence in the home healthcare practice area, this column will focus on the nursing scope of practice. Practicing without a license and exceeding the scope of practice were the top violations in 1980 home healthcare studies (Brent, p. 781).
Scope of Practice
Abbott (2012) generally defines scope of practice as the limitations to practice imposed by federal and state law, professional association requirements, and academic requirements of educational programs. The HHA is no different in requiring professionals and paraprofessionals to administer care only to the extent allowed by the law. Failure to practice within scope and with the proper clinical oversight may result in criminal charges and disciplinary action (Brent, 1989, pp. 776-781.) Distinguishing between practicing medicine and practicing nursing becomes a fine line. Practicing medicine requires a medical license. For example, when a nurse by education, licensure, and certification has no state authority to prescribe medications or treatments and does so, the nurse may be found in violation of state laws and nursing ethical standards (Brent, p. 779).
Pratt and Katz (2001) compared the definition of nurse practice and medical practice in Michigan by delineating nursing roles and responsibilities. They reported that the nursing profession centers on prevention, health promotion, patient education, and patient assistance. Any duties that a nurse performs under the medical model are done under the delegation and supervision of the physician. Although a nurse may identify diseases or conditions for the purpose of providing routine care, it is beyond their scope to diagnose, treat medical conditions, or perform invasive procedures of any kind (Pratt & Katz, p. 20 and 26).
The American Nurses Association (ANA) began developing standards for nurses in the 1960s. The first ones developed for home healthcare nurses were published in 1986 with major updates in 1992, 1999, 2007, and 2014. The current scope published in 2014 was a result of the ANA taking an active leadership role in discerning the differences between traditional and hospital care, and defining who the patient is in the home environment. Marilyn Harris, editor of the Handbook of Home Health Care Administration, 6th Edition and ANA presenter explained that, "the ANA process to review and update all of the Scope and Standards of Practice for nursing and specialty areas occurs every five years" (M. Harris personal communication, September 27, 2015). An invitation is extended to involve the nursing profession in this review through the ANA Web site and the individual state nurse associations. The final draft of the proposed standards is posted on the ANA Web site. Members are asked for feedback and given a timeframe to respond. The 2014 Scope addresses topics like the nursing process, healthy work environments, professional practice regulations, and professional competence. It asserts that primary, secondary, and tertiary home healthcare is given in a patient's residence, which is different than providing care in a more structured setting. Caregivers must have holistic skills to address the physical, functional, psychosocial, and spiritual elements of a patient (Harris et al., 2013).
Home Health Nursing standards and scope of practice support the NAHC recommendations by requiring: a) comprehensive data to be collected on a patient for assessment; b) proper diagnosing from this data; c) development of an individualized care plan that centers on the patient but involves the family; d) a plan to address alternative modalities of treatment; e) specific goals with measures for outcome evaluation; and f) a quality program that measures nursing practice and patient outcomes, involvement of leadership, and the effectiveness of communication. Lastly, the standards center on collaboration with other individuals in the home healthcare profession with evaluation of one's own practice in meeting practice standards, guidelines, and state and federal laws.
Home healthcare nurses are expected to utilize resources effectively and practice in a safe and healthy manner. Attention to the NAHC's legislative recommendations to require a uniform accreditation process focusing on quality improvement for home healthcare is imperative. Brent's recommendations to develop a quality assurance program that evaluates the structure, process, and outcomes in an HHA was good advice then and now.
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