Chapter 41: Community & Home Nursing

The Home Health Team

-The team varies according to the needs of the client but is usually multidisciplinary -It may include physicians; nurse practitioners; RNs; LPN/LVN's; home health aides; physical, speech, occupational, or respiratory therapists; nutritionists; social workers; pharmacists; podiatrists dentists chaplains; and family members

Safety in the Home

-The two following Joint Commission 2012 home-care safety goals are also important to keep in mind: (1) *Reduce the risk of client harm resulting from falls*: assess the client and the home for risk factors (e.g., dimly lit stairs, clutter on the floors) and teach caregivers falls reduction measures (2) *Identify risks associated with oxygen therapy*: (e.g., fire); be certain the home has working smoke detectors, fire extinguishers, and a fire safety plan; assess the client and family's ability to understand and comply with fire prevention activities, and report any concerns to the physician

Age

-The very young and the very old are less able to adapt to physiological stress and are at increased risk of disease -They are more prone to infection and may not be able to protect themselves environmental hazards, such as cold or heat -These age groups are also more often living in poverty

Classifications of Nursing Interventions

-There are 3 basic levels of care in which nursing interventions can be classified: primary, secondary, and tertiary -*Most community-oriented nursing practices are aimed at the primary (prevention) level*

Occupational Health

-They work primarily in industrial or corporate settings -Traditionally, occupational health nurses provided health teaching for employees and their families in an effort to reduce absentee hours and increase productivity; few industries still use the occupational nurse in this manner -Instead most employ nurses to fulfill union contracts and to complete required medical documentation for disability claims or occupational hazardous events; thus, the responsibilities of the occupational health nurse may be limited to performing new-hire and annual screenings, providing care to injured workers, completing random drug testing, and filing worker's compensation claims -To reduce costs, most large industries hire a staffing agency to provide trained occupational health nurses -Nursing autonomy and responsibility vary with the employer and the negotiated contract

Tertiary Interventions

-Third-level intervention is to halt disease progression and/or restore client functioning to the pre-disease state -The disease process is clinically apparent and client debilitation, including death, is likely without intervention -These interventions are usually the most invasive and require the nurse to collaborate with members of other disciplines to provide treatment -For example, a student may report to a school nurse that she had been involved in unprotected sexual activities; the school nurse may refer the student to the public health clinic for a pelvic exam and lab testing to detect STIs and for hepatitis B, HPV, and HIV screening; the student has an abnormal Pap smear, showing cells suggestive of HPV exposure; the nurse, in collaboration with the provider, provides medical treatment; since there is no cure for HPV, the teen needs to learn how to prevent the spread of the disease to others and obtain regular Pap and pelvic exams to detect cervical cancer and other STIs

Home Health Nurses

-To succeed in home healthcare, you must have the ability to work independently and collaboratively, be flexible and resourceful, and adapt to different home environments and family interactions -*The ANA asserts that because of the level of independence, knowledge, and expertise required to meet the demands of home care, baccalaureate nurses are better prepared for that role*; however, they also say that the necessary knowledge and skills can be developed through formal orientation programs, structured preceptor programs, and guided clinical experiences -The principal roles of a home health nurse (also called visiting nurse) includes: direct care provider, client and family educator, client advocate, and care coordinator

The Omaha Problem Classification System

-Was developed specifically for use in community settings -In addition to nursing diagnoses, it contains standardized terminology for outcomes and interventions -It consists of *diagnostic labels* organized into four *domains* (categories), along with two sets of *modifiers* -Within those domains, the system classifies 42 client problems or areas of concern

Windshield Survey

-What community assessment usually begins with -It is performed by observing the community through your automobile window, on foot, or otherwise being physically present in the area -As you observe, make note of the condition of the buildings and public facilities, residences, religious facilities, streets and sewers, modes of transportation, lighting, outward signs of crime or violence, pollution, waste disposal, and other signs of the well-being of the community

Distinctive Features of Home Healthcare

-When you are in a patient's home, little is in your control -You are the guest in the client's home. The client and family determine whether they are willing to let you enter the home to deliver care -You are responsible for making the assessments and determining whether the primary care provider should be advised of client changes -You must bring all necessary supplies or arrange to have them delivered ahead of time -You must distinguish between skilled services, which are eligible for reimbursement from Medicare, and homemaker services. *Skilled services* are services that must be performed or supervised by a licensed healthcare professional; *Homemaker services* (e.g., cleaning, meal preparation) are available to clients only if the principal reason for home care is skilled service; these services are provided by home health aides -You must be more self-sufficient and function more independently. Often there are no other team members immediately available for support, assistance, or consultation -You must be aware and comfortable with the family relationships and some home environments that are difficult or even dysfunctional -You will need to encourage the family to help in providing care and in taking over care when you leave the home. Over-burdened caregivers may need your help as much as does the client -You must preplan your visit by figuring out the directions to sites in advance and arranging appointments efficiently -Your personal safety is more of a concern when making home visits. You must always be aware of the environment around you and alert to possible dangers -As things do not always go as planned in a less controlled, home environment, you will need to be flexible, and learn to modify your plan

Databases and Public Records

-You can also obtain data from publicly available resources, such as birth records, marriage licenses, newspapers, and community Web sites. -Internet search engines can help you to obtain demographic information, morbidity and mortality data, vital statistics, educational levels, criminal activity, political leadership issues, and/or information about community resources

Client Perceptions

-You will also gather information about how individuals in the community perceive the community and its state of health -Through community gatherings and informal conversations, you can assess a cross section of the population -This is not only an important part of the assessment, but also is an excellent way to establish rapport, convey your concerns, and develop a working relationship with key community members; all of this encourages more members of the community to participate in the resulting plan

Aggregate

-A group of individuals with at least one shared characteristic, either personal or environmental -For example, a community health nurse may work with a class of high school girls to reduce the incidence of adolescent pregnancy -The shared characteristics of this aggregate are that they are female, are of childbearing age, and attend a particular school

Direct Care Provider

-As a direct care provider, you may administer medications, dress wounds, or perform other skilled, complex tasks

Who Pays For Home Healthcare?

-Medicare, Medicaid, private insurance, and individual payments (private pay) help pay for home-care services -*Medicare* is a federally funded healthcare system designed to provide health coverage for persons who are older than 65 years, disabled, or diagnosed with end-stage renal disease

Increased Need For Home Healthcare

-Over the next several decades, the demand for home healthcare is expected to rise sharply -Considering the growing number of older adults in the United States, it is more cost effective to provide healthcare in the home than in an inpatient setting

Structure

-Refers to the general characteristics of a community -These include demographic data, such as gender, age, ethnicity, and educational and income levels, as well as data about healthcare services, such as the number of primary care providers or emergency care facilities in the area

NIC Intervention for Home Health

-The Nursing Interventions Classification (NIC) may also be used in home health nursing -A few of the interventions that pertain to home and families are Caregiver Support, Family Integrity Promotion, Home Maintenance Assistance, and Respite Care

Client Advocate

-You support the client's right to make healthcare decisions yet protect the client from harm if he is unable to make decisions -In the event family members disagree with the client's decisions, remember that as the client's advocate, you must try to see that his wishes are respected and his rights are upheld -You must advocate for the services the clients needs; this may mean trying to secure additional home health support to avoid hospitalization, or it may mean advocating for another level of service, such as referral to hospice or placement in the hospital, based on your assessment of the client and discussion with the client and family

Community nursing care is by nature _____ and it serves a large client population

Holistic

A community can either be a _____ for healthcare delivery or a ______ of healthcare services

Site; recipient

Healthy People 2020 Goals

(1) Increase years of healthy life (2) Eliminate health disparities among different populations, including accessibility of healthcare (3) Create an environment conducive to social and physical health (4) Promote healthy living for people across all life stages -These aggregate goals are to be achieved through promoting health behaviors, increasing access to quality healthcare, and strengthening community health resources

BOX 41-5: Clinical Care Classification: 21 Care Components (Version 2.0) Coded by Alphabetic Classes

*A* Activity Component *B* Bowel Gastric Component *C* Cardiac Component *D* Cognitive Component *E* Coping Component *F* Fluid Volume Component *G* Health Behavior Component *H* Medication Component *I* Metabolic Component *J* Nutritional Component *K* Physical Regulation Component *L* Respiratory Component *M* Role Relationship Component *N* Safety Component *O* Self-Care Component *P* Self-Concept Component *Q* Sensory Component *R* Skin Integrity Component *S* Tissue Perfusion Component *T* Urinary Elimination Component *U* Life Cycle Component

Purpose

-*Direct care agencies* are the most common -They focus on direct client interaction by providing skilled care, associated therapies and health services, home health aides, chore workers, and delivery of *respite care* (relief for family caregivers) -*Indirect service agencies* also play a vital role in home healthcare -Examples include pharmaceutical and infusion companies and suppliers of durable medical equipment -*Durable medical equipment (DME)* is reusable equipment (e.g., walkers, wheelchairs, apnea monitors) -Medicare pays for some, but not all, such devices -It is expensive, so before ordering it, be sure the DME is covered or the client is able to pay for it

BOX 41-1: Omaha System: Domains and Examples of Problem Labels

-*Environmental Domain*: the material resources, physical surroundings, and substances both internal and external to the client, home, neighborhood, and broader community -*Problem (Diagnosis) Labels*: income, sanitation, residence, neighborhood/workplace safety -*Psychosocial Domain*: patterns of behavior, communication, relationships, and development -*Problem (Diagnosis) Labels*: social contact, role change, interpersonal relationships, spirituality, grief, mental health, sexuality, care taking/parenting, neglect, abuse -*Physiological Domain*: functional status of processes that maintain life -*Problem (Diagnosis) Labels*: hearing, vision, oral health, speech and language, pain, respiration, digestion-hydration, communicable/infectious condition -*Health Related Behaviors Domain*: activities that maintain or promote wellness, promote recovery, or maximize rehabilitation potential -*Problem (Diagnosis) Labels*: nutrition, personal hygiene, prescribed medication regimen, sleep and rest patterns, family planning, physical activity -*Problem Modifiers* --Set 1: Health Promotion, Potential Deficit, Deficit --Set 2: Family, Individual, Group

Pioneers of Community Nursing

-*Florence Nightingale*: established the importance of promoting health by manipulating the environment (e.g., light, warmth, sanitation, cleanliness) and nursing the whole person -*Lillian Wald*: known as the first community health nurse; founded the first visiting nurses association in New York -*Clara Barton*: founder of the American Red Cross -*Margaret Sanger*: founded the International Planned Parenthood Federation; pioneered the use of family planning and birth control education

Infection Control in the Home

-*The Joint Commission 2012 safety goals for home care include reducing risk of healthcare-associated infections* -Hand cleaning is one of the most important home interventions to prevent the transmission of infection -You will need to follow Standard Precautions but recognize how to modify infection control techniques for the home environment -Do not assume that a client lives in a clean residence or that running water and electricity are readily available; some people with limited financial resources, especially in urban environments, live in a single-room occupancy hotels (SROs) which includes a small room with shared bath and shower areas; conditions can vary from clean and orderly to unclean and even detrimental to health -To provide optimal care, you need to bring infection control supplies and personal protective equipment to the visit or order them to be delivered to the home

At the Home Care Visit

-*You must remember the home is the client's domain* -Wait to be invited in -Observe common courtesies -The first few minutes of the initial visit set the tone for the relationship among client. family, nurse, and agency; this is your opportunity to develop rapport and trust -Offer your card to identify yourself, and provide contact information for the home health agency -Generally, agencies have information packets that include the client's bill of rights, client responsibilities, billing information, information on the frequency and duration of services, how to reach the agency, and the date and time of visit -You will also gather data: Who answered your questions? What is the relationship between the caregiver and the client? How do they interact? What other people live there? What is the condition of the home? -If this is an initial visit, you may need to verify or complete client data on the referral form -In the hospital, admissions personnel usually gather admitting data and obtain consent for treatment; in home care you need to collect and document this information

Disaster Services Nursing

-A *disaster* is any event inflicting widespread loss of life, health, and destruction of property -Features characterizing a disaster typically involve unpredictability, urgency, threat, speed, and uncertainty -They are typically classified as natural or human-made disasters, and may develop as sudden-onset or slow-onset -*Human-generated disasters* might be the result of activities such as a terrorist attack, war, or use of nuclear energy to cause harm or fear -*Technological disasters* cause damage or disruption on a large scale (e.g., computer systems failure, mass power outage, explosion, or hazardous substance exposure) -Examples of *natural* or *ecological disasters* include hurricanes, earthquakes, tsunamis, and floods, or even environmental degradation, such as deforestation -*Biological disasters* may involve exposure to pathogenic microorganisms, toxin, or other bioactive substance, for instance an outbreak of endemic disease or plant contagion -Community-oriented nursing emphasizes community assessment and education to reduce the number of casualties when disasters occur and to achieve the best possible level of health for the people and community involved in the disaster -*Disasters affect the health status of a community in the following ways: leads to premature death, illness or injury, disrupts healthcare services offered within the community, causes environmental issues, such as outbreaks of communicable disease or food/water-borne illness, causes shortages of safe food and drinking water, and burdens other healthcare systems when displaced populations shift to a host community for basic needs of living* -In large-scale disasters, nurses practicing in special circumstances and disaster conditions are typically needed to do the following: --Rapidly assess the overall situation and that of individual victims --Triage care and initiate life-saving measures first --Adapt nursing skills to the disaster situation, considering available equipment, supplies, and personnel --Evaluate the safety of the environment and remove health hazards --Provide leadership in coordinating care, assigning priorities for care, and transporting victims --Prevent further injury or illness --Provide compassionate support to victims and their families

What Makes a Population Vulnerable?

-A *vulnerable population* is defined as an aggregate that is at increased risk of adverse health outcomes -Members of vulnerable populations have a higher probability of developing illness than do members of the general population -Because of their increased risk of health problems, vulnerable populations are a major focus of community health efforts -Vulnerability involves multiple factors: limited economic resources, limited social resources, age, chronic disease and obesity, and history of abuse or trauma -Other vulnerable populations include people who are poor or homeless, migrant workers, people with disabilities, premature infants, women with high-risk pregnancy and pregnant adolescents, people with communicable disease, people who abuse substances, members of certain ethnic/racial groups, and the untreated mentally ill

Collaborator

-A primary task of a community health nurse is to serve as a collaborator -Partnerships and coalitions can effectively address common concerns among different communities

Medicaid

-A program sponsored jointly by the federal government and the states to provide services to people whose income is below a mandated level -In many states, the criteria for reimbursement are the same as those required by Medicare; however, at present each state determines what services will be part of it medical assistance plan

After a Home Care Visit

-After you leave the home, there is still a lot of work to do, such as documentation for the visit -Home health agencies often use Medicare's Outcome and Assessment Information Set (OASIS) to record initial assessment data -To continue to provide needed services to the client, you must include in your documentation: (1) evidence of homebound status (2) evidence of continued need for skilled care -Other post-visit actives include ordering supplies needed for the next visit, making referrals to additional services (e.g., occupational therapy), coordinating care among the various services, and scheduling the next visit

Funding Source

-Agencies may take on many forms based on funding source, profit or nonprofit status, and relationship with other healthcare organizations -*Public agencies* are official or governmental agencies organized at the city, county, state, or national level -They are usually funded by taxes, along with reimbursement from insurance companies -The local health department is an example of a public agency -Health departments focus chiefly on community needs, although they often also offer some home health services, especially when tracking clients in some of their disease management programs -*Voluntary agencies* are prominent in the delivery of home healthcare -These agencies are normally governed by a board of directors and funded by donations, endowments, and third-party (insurance) reimbursement. -Many *hospice organizations* (groups that provide care for people who are frail, terminally ill, dying or not expected to improve) are voluntary organizations -*Proprietary organizations* are corporate or privately owned businesses that aim to make a profit -These agencies receive payment from insurance companies but also accept private-pay clients -Proprietary organizations may provide traditional home health services as well as private-duty care and other services that assist individuals to remain independent -*Hospital-based agencies* are an extension of the services provided by a hospital -Clients who no longer meet the criteria for continued hospitalization may be transferred to home care for continued services -A benefit of this type of home health agency is in the ease of transition between hospital and home

Parish Nursing

-Also known as faith community nursing -A community-oriented nursing speciality, defined by the ANA and HMA as "the specialized practice of professional nursing that focuses on the intentional care of the spirit as part of the process of promoting holistic health and preventing or minimizing illness in a faith community" -The major accountabilities and job activities of the parish nurse role revolve around integrating faith with health -The parish nurse acts as health educator, and personal health counselor; she develops support groups, trains, volunteers, and provides community referrals as needed

Type of Client Served

-An important specialty home service agency is hospice care -This may be a separate agency or a division of a home health agency -Still other agencies specialize in caring for patients with complex diseases, such as AIDS, or ventilator-dependent clients, or patients of a certain age group (services for older adults or chronically ill children)

Caregiver Role Strain

-Around-the-clock caregiving duties can lead to physical exhaustion, social isolation, resentment, sadness, or depression -This nursing diagnoses identify those whom the burden of delivering care has become--or is at risk for becoming--overwhelming -Common signs include difficulty adjusting to role changes, fatigue, isolation, depression, and difficulty in performing routine care for the client

Educator

-Because community nursing focuses on wellness and disease prevention, much of what the nurse does involves client education--of individuals, aggregates at risk of disease, politicians, or a community at large -However, it is difficult to evaluate the effect of the education because people may not act on the knowledge for months or years after the teaching situation -When planning teaching, you must be aware of the stage of development, educational level, and learning style of the community group you intend to educate

Deficient Knowledge

-Client education is a service that Medicare and other insurers will reimburse -You must be certain to include a Deficient Knowledge diagnosis on the care plan in order to ensure the client's continued eligibility and reimbursement for the service

Community-Orientated Nursing

-Combines components of community and public health -It focuses on health promotion, illness prevention, early detection, and treatment provided within the community setting -The practice is evidence based and collaborative with other community health disciplines -The approach is a comprehensive look at the individual, family, group, and community at large

Geopolitical Community Assessment

-Community assessment is usually ongoing and requires the nurse to collaborate with and compile information from a variety of sources -The assessment approach is based on the type of community, the purpose of the assessment, and personal preference

What Are the Roles of Community Nurses?

-Community health nurses function as client advocates, educators, collaborators, counselors, and case managers

Case Manager

-Community nurses commonly make referrals to or collaborate with other health and social agencies -Be cautious in referring clients to these resources, because agency policies and financing change frequently; also, because community agencies often operate on grants and time-limited funding, a program that is available at one time may be dissolved by another -As a nurse, you will need to remain in contact with agencies to which clients are referred so that you remain aware of the current restrictions and availability of services

Home Health Agencies

-Coordinate the services of various professional and paraprofessionals -The various types of agencies may be categorized by purpose, by type of client served, or by funding source

Nursing in Correctional Facilities

-Corrections nurses deliver patient care within the criminal justice system, for example, in juvenile detention, substance abuse treatment facilities, and prisons -In this environment, the nurse provides primary care services to patients of all ages in an unbiased and nonjudgemental manner -Correctional facilities have a medical team that provides routine examinations and acute and chronic healthcare on a scheduled or as-needed basis -The level of nursing autonomy is high in most correctional or substance rehabilitation facilities -The nurse also commonly performs occupational health duties for facility staff -For personal safety, nurses must meet certain physical requirements and complete special weapons training before working in most correctional facilities

Status

-Describes the biological, emotional, and social outcome components of a community -*Biological* data include morbidity (illness) and mortality (death) rates, life expectancy ratios, and risk factor profiles for the respective age groups within a community -*Emotional* data include general indications of mental health and consumer satisfaction survey results about various aspects of the community as compared to other locales -*Social* data include crime rates, citizenship involvement in community-wide activities, and general functioning levels of the community members

Process

-Describes the overall effectiveness level of the community -For example, do the members of the community perceive that they are part of a group with common purpose, values, or interests? What is the extent of interaction among community members? Does the community have an established forum for conflict resolution?

Supporting Caregivers

-Even when the client is receiving in-home care from an agency, it is not around-the-clock care -If the client cannot perform self-care, most of the duties fall to family members -There is some evidence to indicate that caregiver support and training workshops can relieve depression, reduce the perceived burden of caregiving, and better prepare the caregivers for their role; however, those with more independent lives and social support showed the most improvement

Hospice Nurses

-Focuses on care of patients who are dying or those whose condition is not expected to improve -Hospice nurses are provided in the home, in the hospital, in nursing homes, and in homes specifically designed as hospices -*The goal of hospice care is to promote comfort and quality of life*; for these reasons, most hospice services are provided in the client's home -*The focus of home hospice care is more about providing comfort and managing symptoms because the client is not expected to get better* -As a direct care provider, the hospice nurse assesses the client's condition and monitors responses to interventions aimed at relieving distress -As an educator, the hospice nurse teaches the client and family how to adjust medications and care to control pain and other symptoms -The roles of communicator and client advocate assume prime importance as the client's condition deteriorates -The nurse shares these roles with the family and other home caregivers -There may be greater emphasis on pain management and less coordination of multiple services

Community Health Nursing

-Focuses on how the health of individuals, families, and groups affects the community as a whole -Community health nurses strive to promote, protect, preserve, and maintain the health of the population through the delivery of personal health services to individuals, families, and groups -For example, a community health nurse may work in a prenatal clinic providing free services for low-income women, yet she is doing that to improve the general health of the entire community; by encouraging the mother to eat balanced meals, exercise, and avoid harmful substances, the nurse improves the health of both the mother and baby--who are members of the community--and, therefore, improves the overall health of the community

Public Health Nursing

-Focuses on the community at large and the eventual effect of the community's health status on the health of individuals, families, and groups -The goal of public health is to prevent individual disease and disability, in addition to promoting and protecting the health of the community as a whole -For example, a public health nurse may be employed by a county health department to provide tuberculosis *surveillance services*; the nurse helps to protect the entire community by screening for TB at the local school, by testing high-risk individuals for TB, and by identifying and tracking clients with active disease to ensure that they complete the prescribed 6- to 9-month medication regimen -Because public health focuses on large-scale programs that addresses the entire community, government-based agencies often provide these services -The United States Public Health Service (USPHS) is an example of a public health agency based within the federal government

What Makes a Community Healthy?

-For nurses, it is important to understand what a particular community defines (and values) as health rather than relying on personal definitions -Health is whatever the client community defines it to be -*Healthy People 2020* identifies leading indicators for measuring the health of our nation including: --Physical activity --Overweight and obesity --Tobacco use --Substance abuse --Responsible sexual behavior --Mental health --Injury and violence --Environmental quality --Immunizations --Access to healthcare

Limited Social Resources

-Friends and family are valuable resources to help a person deal with day-to-day stress as well as the demand associated with illness -They often provide feedback, listen to concerns, and offer emotional and physical assistance -Unfortunately, not everyone has social resources -Older adults who live alone and people with mental illness are exampled of groups at increased risk because of social isolation

Clean and Sterile Technique

-Generally, patients have developed some resistance to the microorganisms in their own homes and are less likely to acquire infections there than in the hospital environment -You may find differences in how you handle home infusion therapy, urinary tract care, respiratory care, wound care, and enteral therapy -It is safe in many instances, to replace sterile with clean technique, as in some of the following examples: -*Intravenous therapy*: sterile practices should be the same at home as in the hospital because the associated risk of asepsis is so high -*Insulin injections*: supplies for home use of insulin is expensive and insurance may or may not cover the cost, or the person may not have insurance; therefore, although manufacturers recommend the disposable syringes and needles be used only once, and it is safest to do that, some people find it practical to reuse needles and syringes -*Urinary catheters*: clients and family typically use clean, rather than sterile, gloves to perform catheterization; in the home, clients frequently interrupt the drainage system to empty a leg bag, or to change or disinfect the drainage bag; they may also disinfect and reuse urinary catheters -*Respiratory care*: as an example, tracheostomy care in the home is nearly always performed using clean, not sterile, technique -*Wound care*: procedures for wound care should be based on the potential for contamination and infection; usually clean technique is adequate; if the incision drains or is open, the risk for infection increases, and your wound care procedures must address the risk -*Enteral therapy*: emphasize the need to refrigerate the feedings after opening and store solutions until expiration; teach caregivers to keep the kitchen appliances (e.g., blenders) and tools used in preparation meticulously clean; sterilization of blender parts, measuring cups, and spoons is probably not necessary, but they should be washed in a dishwasher after use

Community

-Historically, it meant a body of like-minded people or the inhabitants of a town -Then and now, the term suggests a general sense of selflessness, sharing, relationship, and doing good that comes from working together -Most members of a community share a common language, certain rituals, and special customs

Care Coordinator

-Home health nurses must manage and coordinate care -As the case manager, you will need to gather data at an initial visit and develop a plan of care that addresses the client's needs -Your plan may require you to make additional visits, as well as delivery of therapies and services by other professionals in the home

Prepare Supplies

-Home health nurses usually carry a nursing bag -The nursing bag is often customized to the needs of the clients in the nurse's case load, and normally contains the following: --Hand washing supplies (e.g., soap or antibacterial hand rub, paper towels) --Stethoscope --Sphygmomanometers (with cuffs in a variety of sizes) --Thermometers (oral and rectal) --Small equipment (scissors, forceps, penlight, staple remover) --Tape measure (with plastic coating that can be cleaned, or several disposable paper ones) --Plastic apron --Gloves, sterile and clean --An assortment of gauze dressings, tape, and cotton balls --Occupational Safety and Health Administration (OSHA) supplies: mask, protective eyewear, disinfectant spray, disposable gowns to protect clothing --A variety of syringes and safety needles (this varies widely among agencies) --Venipuncture supplies --Airway and resuscitation mask --Paper supplies (e.g., agency forms, business cards, local maps) -You may need other supplies, such as medications, a scale, and a transfer belt, depending on the requirements of the clients in your caseload -Note that in some states, nurses are not permitted to carry medications because of safety concerns; check on the rules that apply to your state

Standardized Terminology for Home Health Nursing Diagnoses

-Home-care nurses more commonly use the Clinical Care Classification (CCC) because it is closely related to the OASIS reporting forms required by Medicare -The CCC also contains 182 diagnostic concepts--59 major categories and/or 123 subcategories--that describe nursing diagnoses and patient problems -Common CCC nursing diagnoses used in the home include: --Activities of Daily Living (ADLS) Alteration --Caregiver Role Strain --Family Processes Alteration --Home Maintenance Alteration --Knowledge Deficit --Physical Mobility Impairment --Self-Care Deficit -The CCC system consists of 21 care components to classify diagnoses and interventions -An accompanying coding structure and framework parallels the steps of the nursing process and links the CCC diagnoses to interventions and outcomes

The NANDA-I Taxonomy

-In community practice, you need nursing diagnoses that describe the health status of individuals, families, groups, and entire communities -NANDA-International (NANDA-I) taxonomy of nursing diagnoses can be used in any nursing setting or specialty; you would add the word *community* to other NANDA-I labels when creating a community-based diagnosis -The NANDA-I taxonomy includes three diagnoses that specifically describe the health status of a community: --Deficient Community Health --Ineffective Community Coping --Readiness for Enhanced Community Coping

Limited Economic Resources

-Income is a major predictor of health risk -People with higher incomes typically have greater access to health services and greater selection of providers, treatment options, and location of health services -In contrast, the more limited a person's income, the more limited her healthcare options -Consequently, many persons of low income forgo preventive or health maintenance care and seek healthcare services only when they are quite ill

Client and Family Educator

-Instead of focusing on the procedures, you will be helping the client or family take over the care -You must be able to clearly explain the care required, the rationale for the care, and how to safely perform the care -This requires patience, skill, and repetition

Population

-It can mean a group of people of a particular race or class in a place (e.g., "There are 1,500 Latino people living in Edwards County") -It can also mean any aggregation of people subject to statistical or other study (e.g., all the homeless people in Edwards County, or all the pregnant adolescents living in Edwards County)

Public Health Clinics

-Many community nurses practice within local and state departments of health, including public health clinics -Services offered by health departments can range from basic to comprehensive, based on financial constraints, such as the tax base of the community -Large cities tend to have many nurses who may specialize in an area, such as immunizations, prenatal health, school health, or epidemiological survey -Smaller communities may have only one nurse (or full-time equivalent) providing all services -The autonomy and scope of practice of public health nurses are often limited by the philosophy of the political administration and availability of funding

Goals of Home Healthcare

-Nurses provide care to clients with complex, chronic, or terminal illness in the home -The primary goal in home healthcare is to promote self-care -Nursing activities are also directed at fostering client independence and teaching the caregivers to assist the client with ongoing health needs; this approach may be very different from what you have experienced in other clinical settings

International Nursing

-Nurses that work in an international setting commonly provide relief services after a natural or human-made disaster -They may also offer health or human aid services through a medical clinic, faith-based mission, orphanage, or other international relief program -International nursing requires a high level of autonomy, flexibility, and ingenuity, depending on community needs and available resources -Common problems affecting the health of international communities are related to poor sanitation, contaminated food and water, waste management, limited or dangerous transportation, communicable disease, parasitic infections, cultural practices, and limited education -Nurses working globally commonly treat people with malnutrition, dehydration, mosquito and the insect-related illness, parasitic infestation, and HIV, to name a few -Because of poor access to healthcare and limited or no resources to pay for medication, many people do not receive adequate healthcare

Empowerment

-Nursing intervention that means assisting the client (individual or community) to recognize and use available resources to achieve or maintain the desired level of health, achieve autonomy, and maintain positive self-esteem

School Nursing

-Nursing practice in the school setting began when educators realized that children with health problems had more difficulty learning -School nurses provide direct care for children with chronic health conditions, such as asthma, hyperactivity disorder, and diabetes; they also help children who need routine procedures, such as cauterization, during the school day -They administer prescribed medication and ensure that age-appropriate immunizations are documented -The nurse may also serve as a role model for students who lack parental support or who are struggling with peer pressure

Home Healthcare: Assessment

-On the initial visit, you need to perform an assessment to establish a baseline and determine the type of care required -This assessment includes a health history, review of all medications--prescribed, over-the-counter, and alternative--pertinent family and social history, mental status, functional ability, availability of family and informal support and caregivers, nutritional status, and assessment of the home environment -Often a full assessment requires multiple visits -Medicare requires home health agencies to collect specific information for all Medicare clients they serve using OASIS -The OASIS data must be collected at the start of care, with each recertification (every 60 days), and at the termination of care -Medicare uses these data to determine the effectiveness of care and to monitor client outcomes -In addition to the required OASIS information, many agencies use other assessment tools created specifically for their needs -It is also important to assess the needs of the caregivers--the family members, friends, and support system in the home; take time at each visit to speak with them, making sure to include them in your assessment, plan of care, and teaching

Counselor

-Once you have established rapport with a group, members may consult you about a variety of health and non-health related concerns -You must be careful to offer counsel only in areas within your scope of practice and make recommendations that are practical yet meet the needs of the community -Often, you may need only serve as a witness to the group's concerns -Letting client's debate or work through issues empowers them and fosters self-reliance

Assisting With Medication Management

-One of *The Joint Commission 2012* safety goals for home care is to use medications safely; this involves preventing errors with look-alike and sound-alike medications, educating patients about anticoagulant therapy, and keeping a list and reconciling medications when a client transfers from one agency to another -*The Joint Commission also advises nurses to diligently compare those medications the patient is already taking to new ones to be given in the home; nurses need to make sure patients know about medications they take at home, and that they should bring an updated list every time they visit a healthcare provider* -Some patients, particularly older adults, have visual and motor deficits that limit their ability to read labels and manipulate bottle caps, syringes, and so on -Other reasons for noncompliance include lack of outward symptoms, inability to tolerate side effects, pain, forgetfulness, low motivation, and impaired mental capacity -Alwas investigate the patient's reasons for nonadherence so that you can take appropriate actions -You may need to teach clients and caregivers skills such as measuring dosages, giving injections, and managing intravenous therapy; or they may need tips on how to take oral medications if the client has difficulty swallowing -Older adults and caregivers may have difficulty remembering when to take their pills, remembering which ones to take, and even remembering whether they have already taken them; suggest they use a medication organizer with a compartment for each day of the week

Chronic Disease and Obesity

-People who have chronic diseases are at greater risk for many health problems -For example, people with obesity are at increased risk for heart disease, diabetes, impaired mobility, joint pain, and other complications -People with diabetes are at risk for blindness, impaired wound healing, and other complications

History of Abuse or Trauma

-People who have experienced abuse or traumatic events often feel they have limited control over their health and circumstances -They may experience powerlessness and/or hopelessness and be unable to initiate activities that promote health or lead to early treatment of illness; these circumstances also tax their reserves and place them at risk for mental health problems

Private Insurance and Self-Payment

-Private insurance companies may also offer home health services; the type and extent of covered services are specified in each separate insurance group and plan -Those with limited income may be forced to do without needed services; this disparity may lead to inadequate care and illness, hospitalizations, and even death

BOX 41-7: Ways to Help Caregivers

-Provide a listening ear -Give positive feedback and validate its importance to the client's health -Help the caregiver identify people who may be able to help -Talk with family and friends, if the caregiver wishes -Arrange for a home health aide -Remind family members and significant others to take care of themselves -Encourage the caregiver to maintain spirituality -Communicate medical updates about the client -Help the family understand the goals of care and solve problems when needed -Teach the family what to expect with regard to medications, treatments, and signs of approaching -Follow up with other healthcare team members promptly

Barrier Precautions

-Rationales for using barrier precautions differ from those in hospitals -*As a rule, you will use gowns, gloves, and masks in home care to protect yourself, rather than the patient* -You will need to use standard precautions, but *will usually need a mask only when caring for clients who have pulmonary tuberculosis or multi drug-resistent infections* -These organisms may be transmitted to other home-care patients through inanimate objects or hands, so use appropriate barrier precautions

How Are Clients Referred to Home Healthcare?

-Referrals to home healthcare come from a variety of sources; however, for home care to begin, there must be a medical prescription and a physician-approved treatment plan -Hospital-based agencies have a built-in referral base; if the primary provider or nursing staff determine the client would benefit from home health services, they refer the patient to the agency for evaluation while he is still hospitalized -Many agencies have *intake coordinators* who work in the hospital and review clients for suitability of services, gathering information from the chart, the client, the family, and the hospital team -*Home services are arranged before discharge from an inpatient facility* -Even if the hospital does not have its own home agency, the client may still be referred to home health services during a hospital stay; ideally, a discharge planner gathers information, secured the prescription from the provider, and makes arrangements -Referrals may also come from doctors, nurses, primary care offices and clinics, mental health workers and other healthcare providers in the community, as well as directly from families and clients

Community-Based Care

-Refers to acute care or rehabilitative services performed in clinics, offices, mobile care units, and the facilities in the community--rather than in acute care settings, such as hospitals -For example, many surgeries and diagnostic procedures are now performed in privately owned surgical centers, health clinics, and physicians' offices rather than in hospitals -People also receive mental, physical, cardiac, and pulmonary rehabilitation services in outpatient settings -Includes three approaches: community health nursing, public health nursing, and community-oriented nursing

Continued Research

-Research is needed in the area of strategies to improve the effectiveness of care, identify predictors of need for rehospitilization, and integrate home care into overall community-based services

Before Making a Home Visit

-Review the client's chart and referral form to determine why you are making the visit -Review material about the client's health problem, medications, or treatment plan -Think about what supplies are needed, what teaching materials are needed, what are the goals of the visit, does the agency require additional client information, such as insurance data, to provide care, what forms will the agency have you fill out (e.g., HIPAA privacy forms, billing information) -Before the visit you will need to find the address, get directions to the home, and determine whether there are safety concerns -Contact the client to notify him of the planned date and time of the visit and to determine whether his health status has changed since the referral was made

Careers for Community-Based Nurses

-School nursing -Occupational health -Parish nursing -Nursing in correctional facilities -Public health clinics -Disaster services nursing -International nursing

Secondary Interventions

-Second-level interventions aim to reduce the impact of the disease process by early detection and treatment -For example, a community health nurse may screen a sexually active adolescent girl for hepatitis B and/or HPV; she has known risk factors for sexually transmitted infection but no apparent disease symptoms; the nurse will teach the client how to protect herself from sexually transmitted infections (STIs), hepatitis B, and HIV in the future

What Are the Components of a Community?

-Structure -Status -Process

Increased Use of the Home For Hospice Care

-Technological advances, such as online or telemedicine consultation, make it safer and more affordable to deliver complex care in the home and allow home health nurses to provide a growing array of services -Computerized monitoring and charting allow home health agencies to better coordinate care, receive needed supplies, and closely monitor costs

CCC Nursing Interventions

-The CCC contains 198 nursing interventions organized according to the care concepts -An intervention consists of a label (e.g., Activity Care) and a definition (e.g., Actions performed to carry out physiological or psychological daily activities) -In addition to the label, you must specify the type of intervention action from among four qualifiers: (1) Assess/Monitor/Evaluate/Observe (2) Care/Perform/Provide/Assist (3) Teach/Educate/Instruct/Supervise (4) Manage/Refer/Contact/Notify -The CCC nursing interventions include only skilled services because this type of service is the only type of care reimbursed by Medicare and most insurers in home health

Home Healthcare

-The delivery of health-related services in the client's home -It's appropriate when a client needs ongoing care that exceeds the abilities of friends and family -It may supplement the skills a family member is providing or serve as a backup for safety or additional assessment -Older adults may use home healthcare services when they need ongoing care but want to avoid moving to a skilled nursing facility -People of any age may require home-care service when they are recovering from an illness or surgery or when they are terminally ill -Chronically ill adults and children may receive home healthcare for ongoing care or to avoid hospitalization

Nursing Process in Home Care

-The difference in home care is that you must use forms structured to satisfy Medicare and other insurance requirements -You need to asses the client, the family, the home, and the community in order to *identify* nursing diagnoses and the health problems -You will work from a plan of care prescribed by a medical provider, but individualize it with suitable nursing diagnoses and interventions -Periodically, you must evaluate the client's continued homebound status and ongoing need for medical treatment and skilled nursing care

Client Advocate

-The effective community health nurse consistently supports the identified or expressed concerns of the client and/or community -Advocating for a community often requires political involvement at the local, state, or national levels -The challenge is in knowing whom to approach for political support and how to gain their support

Primary Interventions

-The goal of primary (first-level) interventions is to promote health and prevent disease -Educating susceptible individuals with no known disease process is an example of a routine, primary intervention that community health nurses practice -For example, a nurse may educate 9th grade students about the risk of hepatitis B and HPV, the benefits of vaccinations, and strategies to reduce the likelihood of exposure to contaminated bodies

In the community, nurses' roles vary depending on the _____ and its ______

Community; identified needs

Medicare Reimbursement

Depends on the following: -*The client must need skilled care*; other services may also be provided, but the primary purpose for establishing care must be based on a skilled care need; Medicare will not pay for personal care such as bathing, and dressing when this is the only care the client needs -*The client must be homebound*; this means the client must have a condition that restricts the ability to leave the home and leaving the home requires special assistance, transportation, supportive devices, or an escort -*The client must require nursing care that is part-time and intermittent*; this means Medicare will pay for a limited number of hours per day or days per week that the client can get skilled nursing care or home health aide services -*The plan of care must be authorized by the physician and re-certified every 62 days*; for the client to continue to receive care, there must be evidence of continued need that remains acute -*The care must be medically necessary and reasonable*; the plan of care must address the client's health concerns and have clearly delineated outcome; the expectations of the patient must be reasonable -*Medicare will pay only for interventions identified on the treatment plan*; the payer may periodically request patient records to verify that the care was given -*The home health agency must be approved by Medicare*; an agency must show that it meets the Medicare definitions and requirements in order to become Medicare certified