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  • The Cost-effectiveness of Homc Health: A Case Presentation Home health care is a cost-effective alternative to institutionalization.

    BY ANN WALKER

    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

    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.

    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.

    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.

    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.

    Initial Assessment

    The nurse visits Mary in her third-floor, two-room, cold, dark apartment. Mary is lying on a cot, totally dependent on

    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

    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.

    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.

    Weeks One and Two

    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

    GERIATRIC NURSING Volume 17, Number 1 Walker 37

  • TABLE 1. DESCRIPTION OF SIX PRESSURE ULCERS, CARE, TREATMENT AND PROGRESS

    Location Admission One week Fifth week Six weeks

    Right shoulder Stage 2 3x5 cm Stage 2 23 cm Healed

    Sacrum Stage 3 69 cm Stage 3 107 cm Stage 2 134 cm

    Right upper hip Stage 2 43 cm Stage 2 5x3 cm Stage 3 46 cm

    Right lower hip Stage 2 85 cm Stage 2 6x6 cm Stage 3 3x6 cm

    Right ankle Stage 2 22 cm Stage 2 22 cm Healed

    Left hip Stage 2 66 cm Stage 2 106 cm Stage 2 46 cm

    Treatment 1) Normal saline wet to 1) Cleanse sacral ulcer Report assessment to dry dressing applied with wound cleanser, physician, request to sacrum daily

    2) Apply hydrocolloid dressing to all others

    Other Instruct Thomas in use of skin cleanser foam and moisture barrier BID and PRN after any incontinence

    apply gel wound dressing, ET to evaluate cover with DSD TID & PRN

    2) Same as sacral for others except cover with transparent adhesive dressing daily

    DSD, Dry, sterile dressing; TiD, three times a day; PRN, as required; ET, enterostomal therapist; BID, two times a day.

    Healed

    Stage 2 (with 5x3 cm undermining)

    Stage 3 4x3 cm

    Stage 3 56 cm

    Healed

    Stage 3 34 cm

    1) Apply enzymatic debriding agent with saline impregnated gauze dressing

    2) Apply skin sealant around all ulcers

    3) Vitamin C 1000 mg daily 4) ET noted air mattress

    not functioning, reported to vendor and fixed

    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.

    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

    The chronic illness and

    accompanying decreased ability to

    perform activities of daily living

    that accompany chronic illness of

    this population can be treated

    more cost-effectively in the home.

    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.

    Week Three

    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.

    Week Four

    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.

    Week Five

    During the fifth week, Mary is transferring, with a one- person assist, out of bed to a chair for an hour twice daily.

    38 Walker January/February 1996 GERIATRIC NURSING

  • Eleven weeks Fourteen weeks

    Healed Healed

    Stage 2 2xl cm Stage 1 2x3 cm

    Healed Healed

    Stage 2 2x3 cm Stage 1 2x2 cm

    Healed Healed

    Stage 2 2x3 cm Healed

    1) To left hip apply Duoderm 2) Cleanse right hip & sacrum-

    with normal saline solution then apply Transorb every 3 to 5 days

    At 16 weeks all decubitus ulcers were healed,

    treatment was discontinued,

    Pressure mattress was discontinued.

    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).

    Week Eight

    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.

    Months Three and Four

    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.

    The nurse continues to visit to assess Mary's nutrition and wound status. The home health aide visits to assist

    TABLE 2. COST COMPARISON OF HOME HEALTH CASE VERSUS SKILLED

    NURSING FACILITY STAY

    1993 Costs

    Skilled nursing $263/day facility charges

    Home health case charges

    182 days $47,866 of ca

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