The cost-effectiveness of home health: A case presentation: Home health care is a cost-effective alternative to institutionalization

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<ul><li><p>The Cost-effectiveness of Homc Health: A Case Presentation Home health care is a cost-effective alternative to institutionalization. </p><p>BY ANN WALKER </p><p>T he growth of the over 65 population and the in- crease in the cost of institutional long-term care have stimulated interest in home health care. The </p><p>chronic illness and accompanying decreased ability to perform activities of daily living that accompany chronic illness of this population can be treated more cost-effec- tively in the home. </p><p>The case presented is a description of a single unit of study--a person in need of supportive living in the com- munity. Names are changed in this report to ensure fam- ily confidentiality. </p><p>Mary is a 70-year-old black woman with a history of mild dementia and a significant weight loss slowly pro- gressing over a 3-year period. She lives in a poor urban neighborhood in north Philadelphia. </p><p>Her companion and caretaker, Thomas, a 60-year-old black man, is worried about Mary. It is becoming in- creasingly difficult for him to provide the total care that Mary requires. Thomas calls a phone number he sees ad- vertised on television for persons in his situation. He is referred to a social service agency, Counseling for Caregivers, that provides referral and information and education and counseling for families caring for frail, elderly relatives. A social worker confers with Thomas by telephone and determines that medical and nursing ser- vices are needed. The social worker consults with a physician who requests an evaluation from a nurse at our home health agency. </p><p>Initial Assessment </p><p>The nurse visits Mary in her third-floor, two-room, cold, dark apartment. Mary is lying on a cot, totally dependent on </p><p>ANN WALKER, BSN, is director of Home Health Services at Philadelphia Geriatric Center. GERIATR NURS 1996;17:37-40 Copyright 9 1996 by Mosby-Year Book, Inc. 0197-4572/96/$5.00 + 0 34/1/69966 </p><p>Thomas for all daily living activities. She is emaciated and dehydrated and has six pressure ulcers (Table 1). She relies on Thomas to carry her to the bathroom three times daily for bowel and bladder management. There are bowel and bladder incontinence episodes in between these times. Thomas and Mary are not using a bedpan or commode. Mary is alert and oriented, but she refuses to eat and is un- able to ambulate. Thomas reports that Mary was in a nurs- ing home 6 years ago, but he took her home and has been caring for her since. She has not seen a physician in 6 years. Past history reveals short periods of a few days of refusing to eat or walk over the years, but this episode has lasted 2 weeks. Mary is not taking any medication and denies pain. Vital signs are within normal limits. </p><p>The nurse identifies wound care, nutritional status, and mobility as priorities. She reports her assessment and nursing diagnosis to the physician, who concurs with her plan for wound care (Table 1), nutrition instruction, in- struction in the care of the immobile patient, and use of a multivitamin with iron and Ensure supplement. </p><p>Weeks One and Two </p><p>Social support as defined by Kahn ~ is an interpersonal transaction that includes the expression of positive affect of one person toward another, the endorsement of another person's behavior, and the giving of aid to another. Mary's social support network is very limited. Her son lives out of town and is unavailable to assist Thomas in her care. Thomas is a 60-year-old unemployed man who is able and willing to care for Mary. The nurse instructs him in wound care, nutrition, incontinence care, turning, positioning, and exercise. A home health aide is sent to supplement the personal care, provide respite for Thomas, and continue the turning and exercise schedule established by the nurse. Because Mary's social support network is so limited, a social worker is involved to link Mary with community resources that will expand her </p><p>GERIATRIC NURSING Volume 17, Number 1 Walker 37 </p></li><li><p>TABLE 1. DESCRIPTION OF SIX PRESSURE ULCERS, CARE, TREATMENT AND PROGRESS </p><p>Location Admission One week Fifth week Six weeks </p><p>Right shoulder Stage 2 3x5 cm Stage 2 23 cm Healed </p><p>Sacrum Stage 3 69 cm Stage 3 107 cm Stage 2 134 cm </p><p>Right upper hip Stage 2 43 cm Stage 2 5x3 cm Stage 3 46 cm </p><p>Right lower hip Stage 2 85 cm Stage 2 6x6 cm Stage 3 3x6 cm </p><p>Right ankle Stage 2 22 cm Stage 2 22 cm Healed </p><p>Left hip Stage 2 66 cm Stage 2 106 cm Stage 2 46 cm </p><p>Treatment 1) Normal saline wet to 1) Cleanse sacral ulcer Report assessment to dry dressing applied with wound cleanser, physician, request to sacrum daily </p><p>2) Apply hydrocolloid dressing to all others </p><p>Other Instruct Thomas in use of skin cleanser foam and moisture barrier BID and PRN after any incontinence </p><p>apply gel wound dressing, ET to evaluate cover with DSD TID &amp; PRN </p><p>2) Same as sacral for others except cover with transparent adhesive dressing daily </p><p>DSD, Dry, sterile dressing; TiD, three times a day; PRN, as required; ET, enterostomal therapist; BID, two times a day. </p><p>Healed </p><p>Stage 2 (with 5x3 cm undermining) </p><p>Stage 3 4x3 cm </p><p>Stage 3 56 cm </p><p>Healed </p><p>Stage 3 34 cm </p><p>1) Apply enzymatic debriding agent with saline impregnated gauze dressing </p><p>2) Apply skin sealant around all ulcers </p><p>3) Vitamin C 1000 mg daily 4) ET noted air mattress </p><p>not functioning, reported to vendor and fixed </p><p>social support network. The social worker arranges Meals on Wheels, medical assistance coverage, and linkage with a local senior center where a social worker will be assigned to monitor the case on a long-term basis. </p><p>The nurse orders a hospital bed, air mattress, and bedside commode and instructs Thomas and the home health aide in their use. The physician makes a home visit, examines Mary, and concurs with the nursing plan of care. A wheelchair is obtained, and an out-of-bed </p><p>The chronic illness and </p><p>accompanying decreased ability to </p><p>perform activities of daily living </p><p>that accompany chronic illness of </p><p>this population can be treated </p><p>more cost-effectively in the home. </p><p>schedule is initiated. The physical therapist visits twice to establish a safe transfer and exercise program. The physical therapist instructs Thomas, the nurse, and the home health aide in the transfer and exercise program. Thomas is primarily responsible for implementing the program, with assistance and guidance from the nurse and home health aide. </p><p>Week Three </p><p>Mary continues to eat and drink sporadically, and Thomas is instructed to encourage her to eat small amounts throughout the day. There are problems with diarrhea when Ensure intake is increased to greater than four cans, so in- take is limited to four cans, and the diarrhea subsides. </p><p>Week Four </p><p>During the fourth week of home health care, Mary has development of an upper respiratory infection that is treated with antibiotics and cough medicine. During this time her appetite decreases, and she only wants candy and sweets to eat. A 24-hour diet and fluid log and the use of candy as a reward system helps Mary re- turn to compliance with her nutrition program. To mon- itor compliance with the nutrition program, an accurate system for weighing Mary is devised. A sturdy scale is purchased by Thomas, and he is instructed to weigh himself first and record his weight. He then weighs him- self arid Mary together and subtracts his weight from the total. Mary's weight is 53 pounds. The diet and fluid log are continued, and round-the-clock feedings are encour- aged. The upper respiratory infection subsides. </p><p>Week Five </p><p>During the fifth week, Mary is transferring, with a one- person assist, out of bed to a chair for an hour twice daily. </p><p>38 Walker January/February 1996 GERIATRIC NURSING </p></li><li><p>Eleven weeks Fourteen weeks </p><p>Healed Healed </p><p>Stage 2 2xl cm Stage 1 2x3 cm </p><p>Healed Healed </p><p>Stage 2 2x3 cm Stage 1 2x2 cm </p><p>Healed Healed </p><p>Stage 2 2x3 cm Healed </p><p>1) To left hip apply Duoderm 2) Cleanse right hip &amp; sacrum- </p><p>with normal saline solution then apply Transorb every 3 to 5 days </p><p>At 16 weeks all decubitus ulcers were healed, </p><p>treatment was discontinued, </p><p>Pressure mattress was discontinued. </p><p>She is eating an adequate diet and tolerating four cans of Ensure daily. Thomas is providing the wound care and following the turning and exercise schedule. Incontinent episodes have decreased with the use of a bedside com- mode. The nurse is visiting to assess the wounds and con- tinue teaching the care of the immobile patient and monitor the exercise program. Pressure ulcer healing has reached a plateau, and an enterostomal nurse evaluation is requested. Wound care is modified (Table 1). </p><p>Week Eight </p><p>At the end of 8 weeks of treatment, Mary's wounds are healing and her weight is 58 pounds. She is tolerating being out of bed for longer periods of time, and physical therapy reenters the case. </p><p>Months Three and Four </p><p>For the next 2 months, physical therapy works on pro- gressive ambulation training and strengthening exercises. Mary progresses from needing the assistance of two peo- ple to ambulating a few steps to walking independently with a walker for 60 feet. Mary's physical therapy progress would not have been successful without the full participa- tion of Thomas. Mary's judgment and follow-through are poor, and she requires constant reinforcement. </p><p>The nurse continues to visit to assess Mary's nutrition and wound status. The home health aide visits to assist </p><p>TABLE 2. COST COMPARISON OF HOME HEALTH CASE VERSUS SKILLED </p><p>NURSING FACILITY STAY </p><p>1993 Costs </p><p>Skilled nursing $263/day facility charges </p><p>Home health case charges </p><p>182 days $47,866 of care* </p><p>Nurse $66/visit 58 visits $3828 </p><p>Physical therapy $77/visit 22 visits $1694 </p><p>Aide $46/visit 29 visits $1334 </p><p>Social worker $75/visit 2 visits $150 </p><p>Wound care $1082 supplies </p><p>Total 111 visits $8088 * Mary received 111 home health visits over a 182-day period. </p><p>with personal care and reinforce the exercise and ambu- lation regime as instructed by the physical therapist. </p><p>Months Five and Six </p><p>During this time, the nurse decreases her visits to every other week to evaluate reports from Thomas, con- tinue nutrition and skin assessment, and reinforce the prior teaching. The home health aide is discontinued be- cause Thomas demonstrates the ability to manage Mary's personal care and exercise and ambulation pro- gram. Arrangements are made for transportation to the </p><p>Home health care is a humane </p><p>and compassionate way to deliver </p><p>health care and supportive services. </p><p>physician's office for monthly checkups. Mary is linked to a nearby senior center, where the social worker mon- itors her progress. Meals on Wheels, transportation, respite, and homemaker needs can be provided through the senior center. The social worker can refer Mary back to home health services should her condition deterio- rate. </p><p>Follow-up </p><p>Mary keeps her follow-up appointment with the physi- cian a month after her discharge from home health. Her weight is stable at 65 pounds, and she is pressure ulcer free, continent, and ambulatory. This seemed like a hope- less case in the beginning, but with good team work by the home health staff and an "able and willing" caregiver, a satisfying outcome has been achieved. </p><p>GERIATRIC NURSING Volume 17, Number 1 Walker 39 </p></li><li><p>Home health care is a cost-effective alternative to in- stitutionalization. With data from Basic Statistics about Home Care 1993, 2 it is possible to document a savings of $39,778 (Table 2). This assumes that Mary would have spent the 182 days that she received home health care in a skilled nursing facility. Mary's medical problems of malnutrition, dehydration, anemia, pressure ulcers, and her extensive 'rehabilitation needs qualify her for this level of care. Additionally, there is the possibility of a longer stay as a result of nosocomial infections and other institutional-generated impediments to recovery. Cost-ef- fectiveness is not the only rationale for home health care. </p><p>Home health care is a humane and compassionate way to deliver health care and supportive services. Home care reinforces and supplements the care provided by family and friends and maintains the recipient's dignity and in- dependence, qualities that are all too often lost even in the best institutions. 2 </p><p>REFERENCES </p><p>1. Kahn R. Aging and social support. Presented at the Meeting of the American Association for the Advancement of Science, Washington D.C., May 1978. </p><p>2. Halamandaris V. Basic statistics about home care 1993. Washington, D.C.: National Association for Home Care, 1993. </p><p>CALL FOR NGNA SECTION MANUSCRIPTS </p><p>NGNA MEMBERS: Do you want to publish the findings of your research or give an account of a suc- cessful nursing project in GERIATRIC NURSING? The NGNA would like to showcase your efforts! </p><p>We are interested in innovative projects involving gerontological nurses and their clients. Tell us about clinical educational programs you have developed. Describe nursing research you have conducted in gerontology nursing. We want to hear about long-term care issues as well as those in home care and acute care. Have you developed a new NGNA chapter in your region? Share your experiences with your fellow members! </p><p>Query letters are welcome (but not necessary). Send correspondence and manuscripts to: </p><p>Ann Schmidt Luggen, PhD, RN NGNA Editor, Geriatric Nursing Northern Kentucky University Department of Nursing Highland Heights, KY 41099-1202 </p><p>See the "Information for Authors" pages in the front of the journal for editorial policies and guidelines for manuscript preparation. </p><p>Let us hear from you! </p><p>40 Walker January/February 1996 GERIATRIC NURSING </p></li></ul>