Advanced Practice Nursing in Home Care

History

According to the National Association for Home Care (2001), about 7.6 million individuals are served by more than 20,000 home health agencies in the United States alone today. It is also estimated that home care expenditure in 2000 is $32.4 billion and predicted to grow to about $87.0 billion by the year 2010 (Centers for Medicare & Medicaid Services, 2002a).

Portillo and Schumacher (1998) defined the role of home health nurses as providers of holistic, comprehensive health care to clients and families in their homes. Their goal is to promote, maintain, or restore health or minimize the effects of illness and disability of patients. The two levels of practice are generalist and advanced (American Nurses Association’s Scope and Standards of Home Health Nursing Practice, 1999).

Prepared at the baccalaureate level, the generalist nurse provides care to clients and caregivers thorough assessment of their needs, client and caregiver education, implementation of nursing interventions, evaluation of the care provided, supervision of ancillary personnel and caregivers, and collaboration with others on the health care team. Meanwhile, the advanced practice nurse educated at the graduate level performs all the duties of the generalist nurse, but “possesses substantial clinical experience with individuals, families, and groups; expertise in the process of care management and consultation; and proficiency in planning, implementing, and evaluating programs, resources, services, and research for health care delivery to clients with complex conditions” (American Nurses Association, 1999, p. 6).

It has been noted that demographic trends influence the delivery of home health care as the population of the United States and other developed countries live longer, yet many people have chronic diseases and multiple comorbidities. By 2030, it was already estimated that the U.S. population aged 65 years and older will be around 70 million people. Likewise, more than half of those 75 years or older will be limited by chronic conditions (U.S. Department of Health and Human Services Administration on Aging, 2001).

Role Development

Lacey and Minarik (2000) suggested that clients today and in the future would require more comprehensive, specialized care and disease management as compared to home health clients of the past. Already, home health APNs are able to manage the care of these complex clients as research findings pointed out that home care provided by APNs improves client outcomes and is cost-effective (Brooten et al., 2001; Naylor et al., 1999).

There are numerous difficulties and challenges that face providers of home care. The challenges in-home care may be categorized into four: compliance with new federal regulations, responding to an ever-increasing level of patient acuity, retaining and recruiting highly skilled nursing staff in the context of a growing national nursing shortage, and advancing home care practice in a rapidly changing and often-times chaotic health care environment. Challenges affecting home care, nevertheless, are required for the development of new models of advanced practice nursing in-home care.

The federal government enacted in October 2000 a Prospective Payment System (PPS) for home care services given to Medicare beneficiaries. It mandated outcome assessment reporting (OASIS) as a condition of participation. The two initiatives are aimed at containing costs while evaluating the effectiveness of home care. Before the enactment, two major disadvantages of the fee-for-service model that existed previously: not cost-efficient and fostered patient dependence. Under the fee-for-service model, nurses worked for patients rather than teach patients to fend for themselves.

In this recent setting, PPS and OASIS proved to be a challenge as home care clinicians used to the fee-for-service model could not change and adapt from their habitual practices quickly or without resistance. Likewise, patients who have been accustomed to being cared for have not been accustomed to being cared about. It was observed that many home care nurses have yet to develop the critical thinking and care management skills needed in a prospective pay model. They are further burdened with additional paperwork accompanying the recent federal regulations that leave them little psychic energy to acquire these skills. The availability of staff resources to teach and mentor them has not been taken advantage of.

PPS and OASIS are further challenged by the increasing concerns of home care patients. Environments such as hospitals and other in-patient facilities try to keep costs down and patients are discharged home sooner but sicker. In addition, the nursing shortage makes the matter worse. In the year 2000, it has been noted that there is a shortage of nurses in all areas of practice including home care (Barnard, 2000).

As such, home care nurses have been expected to make significant improvements in their patient care practices. They need to reduce services to long-term patients, yet home care nurses have also been burdened with more paperwork and more regulations to comply with. It has been suggested that the most difficult challenge of home care providers is that of advancing home care practice in the current health care system with fast-changing regulations, financial urgencies, and scarce resources of time, energy, and personnel.

Role Today

According to Hamric (2000), “Advanced nursing practice is first and foremost characterized by excellence in direct clinical practice,” (p.61). Home health APNs perform holistic health assessments and coordinate services with the interdisciplinary team of health care professionals and the family for a client with complex needs. They refer to their specialized clinical knowledge to work properly with clients and caregivers in planning and implementing interventions for clients. Hamric (2000) enumerated six competencies that further define advanced practice nursing include: expert guidance and coaching, consultation, research, clinical and professional leadership, collaboration, and ethical decision-making skills.

Home health APNs coach the clients through transitions such as in the process of learning to live with chronic illness or becoming a parent. According to Spross, Clarke, & Beauregard, (2000), coaching is more than client/caregiver education as it includes “the complex, interpersonal processes APNs use to enlist clients’ active and effective participation in their care” (p.184).

All APNs engage in consultation offering their expert clinical knowledge to others on the health care team and by seeking and receiving advice to improve their own practice. This collaboration in client care improves outcomes.

Home health APNs evaluate and utilize research findings for evidence based practice, which is the ability to identify and use the best findings and recommendations from systematic research for decision-making about the care of clients (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996).

Leadership in home health refers to both the clinical and professional arenas as APNs work with, mentor, and guide home health generalist nurses through sharing of specialized clinical knowledge for client care and by helping to develop the physical assessment and critical thinking skills of the generalist (Milone-Nuzzo & Pike, 2001).

Collaboration is the process by which persons work together to accomplish goals or outcomes, in the case of home health, APNs work closely with physicians, other APNs, staff nurses, physical and occupational therapists, hospital discharge planners, case managers, home health aides, dieticians, and others. Collaboration improves the quality of client care, improve client outcomes, prevent duplication of services, and promote cost-effective care.

The role of the home health APN in ethical decision making is important. The factors of changes in the health care delivery system, use of high technology devices in the home setting, and reimbursement issues, have made ethical decision making more challenging. According to Reigle and Boyle (2000), the APN in home health identify, deliberate, and resolve complex value choices, in policy formation, and in teaching and mentoring other home health care staff regarding ethical decision making.

Pivotal Point

APNs are not yet widely used in homecare, but there are already several models initiated that demonstrate the effectiveness of APN care in the home setting. Some of these are programs of the health care delivery systems exemplified by the House calls model of the Visiting Nurse Association of Greater Philadelphia (VNAGP). Another model involves APNs working with home care agencies as independent practitioners; a third model use APNs as an integrated part of the care delivery team in a home care agency. These models on their own shows potential to improve the care system provided to patients in the home and to influence the cost of care per episode of illness. Inclusion of more providers with advanced clinical skills in home care will improve the service and that costs may decrease.

Advanced practice nursing in home health has started to evolve as demands, needs or capacity of clients change together with the policies on public and private health care systems. While studies point to the need for more APNs in all fields of health care, drastic changes governing health care in the point of view of a client or individual of which even nurses are not spared of should be significantly considered.

The practice itself is shown to have a need for continuing improvement and development in helping the client at most to become independent. In my personal view, while collaboration with a big team of health care providers is necessary, there is also a need to streamline roles and expectations so as to maximize an affordable service provided to clients. Quality health even in chronic or terminal cases of clients is tantamount in the service but regulations and policies should be focused on expertise to reduce requirements that limit qualification for APNs across the board.

References

National Association for Home Care. (2001). Basic statistics about home care. Web.

Centers for Medicare & Medicaid Services.(2002b). National health expenditures, by source of funds and type of expenditure: Calendar year 2000. Web.

Portillo, C.J., & Schumacher, K.L. (1998). Graduate program: Advanced practice nurses in the home. AACN Clinical Issues, 9, 355-361.

American Nurses Association. (1999). Scope and standards of home health nursing practice. Washington, DC: American Nurses Publishing.

U.S. Department of Health and Human Services Administration on Aging. (2001). A profile of older Americans: 2001. Washington, DC: Author.

Lacey, K.O., & Minarik, P.A. (2000). Medicare reimbursement of APNs. American Journal of Nursing, 100, 24AAA-24DDD.

Brooten, D., Youngblut, J.M., Brown, L., Finkler, S.A., Neff, D.F., & Madigan, E. (2001). A randomized trial of nurse specialist home care for women with high risk pregnancies: Outcomes and costs. The American Journal of Managed Care, 7, 793-803.

Barnard, A. (2001). Needed: RNs to aid ailing profession. The Boston Globe, pp. A1, A21.

Hamric, A.B. (2000). A definition of advanced nursing practice. In A.B. Hamric, J.A. Spross, & C.M. Hanson (Eds.), Advanced nursing practice: An integrative approach (2nd ed., pp.53 73). Philadelphia: W.B. Saunders.

Spross, J.A., Clarke, E.B., & Beauregard, J. (2000). Expert coaching and guidance. In A.B. Hamric, J.A. Spross, & C.M. Hanson (Eds.), Advanced nursing practice: An integrative approach (2nd ed., pp.183-215). Philadelphia: W. B. Saunders.

Sackett, D., Rosenberg, W., Gray, J., Haynes, R., & Richardson, W. (1996). Evidence based medicine: What it is and what it isn’t. British Medical Journal, 312, 71-72.

Milone-Nuzzo, P., & Pike, A. (2001). Advanced practice nurses in home care: Is there a role? Home Health Care Management & Practice, 13(5), 349-355.

Reigle, J., & Boyle, R.J. (2000). Ethical decision-making skills. In A.B. Hamric, J.A. Spross, & C.M. Hanson (Eds.), Advanced nursing practice: An integrative approach (2nd ed., pp.349378). Philadelphia: W.B. Saunders.