Chapter 30: Home Health and Hospice

When providing palliative care to a client receiving hospice care, which of the following would be important? Select all that apply. a. Assume nothing about what is wrong b. Use the most complex interventions first c. Believe what the client is reporting d. Be persistent in trying different strategies e. Wait until the symptoms recur to relieve them

a. Assume nothing about what is wrong c. Believe what the client is reporting d. Be persistent in trying different strategies feedback: When providing palliative care, the nurse should make no assumptions about what is wrong; believe the client's report of symptoms; anticipate the symptoms and relieve them before they recur; choose the least complex and most manageable interventions that clients and families can manage themselves at home; and never give up, but persist in trying different palliative strategies.

A home health care nurse reviews the most common conditions managed at home. Which of the following are the most common conditions managed at home? Select all that apply. a. Chronic skin ulcer b. COPD c. Heart failure d. Terminal cancer e. Diabetes

a. Chronic skin ulcer c. Heart failure e. Diabetes feedback: The most common diagnoses managed at home are diabetes, chronic skin ulcer, essential hypertension, heart failure, and osteoarthritis

As part of a group exercise, students are to compare and contrast home care and hospice care. The instructor determines that the activity was successful when the students identify which of the following as reflective of home health care? a. Emphasis on rehabilitation b. Focus on health of the whole family c. Expert use of opioids for suffering d. Management of symptoms

a. Emphasis on rehabilitation feedback: Home health care emphasizes rehabilitation and stabilization of the client whereas hospice emphasizes the quality of life and comfort. Focusing on the whole family, expert use of opioids for suffering and management of symptoms are features associated with hospice care. In contrast, home health care focuses on the health of the client; opioids are used hesitantly to reduce suffering; and symptom management may require hospitalization if unmanageable.

Which of the following Medicare definitions prevent people who could benefit from home care services from receiving those services, even when it would be most cost effective for the client to receive home care rather than more expensive emergent and inpatient interventions? Select all that apply. a. Home-bound status b. Medical necessity c. Prospective payment d. Skilled nursing

a. Home-bound status b. Medical necessity d. Skilled nursing feedback: The entire model for service provision in the home must change to a health care delivery system that continuously serves those living with disabling and terminal illness to maximize well-being at home, anticipate and prevent crises, and minimize emergent and inpatient interventions. The Medicare definitions of homebound, medical necessity and skilled nursing must become extinct.

When developing the plan of care for a client receiving home health care services, which of the following would be the most important goal? a. Promotion of client independence b. Complete resolution of the problem c. Detecting family conflicts d. Ensuring access to resources

a. Promotion of client independence feedback: The most important goal of home health care is to promote independence and self-management. Every effort is made to develop the capacity for self-care so that the home team can safely withdraw. Complete resolution of the problem in many cases is unrealistic. Detecting family conflicts and ensuring access to resources are areas that the nurse addresses and intervenes if necessary to promote the ultimate goal of self-care.

10. When providing home health care, which individual is responsible for coordinating the care? a. Registered nurse b. Social worker c. Physician c. Dietician

a. Registered nurse feedback: The registered nurse is considered the coordinator of care. The social worker is another clinical staff member but is not the coordinator of care. The physician directs the skilled care to clients by agreeing (signing the nurse-generated paperwork) with the plan of care established by the registered nurse who coordinates the care. The dietician is another clinical staff member but is not the coordinator of care.

An instructor is describing the various types of home health care agencies and uses the visiting nurse association as an example of which of the following types? a. Voluntary nonprofit b. Hospital-based c. For-profit proprietary d. Noncertified

a. Voluntary nonprofit feedback: Visiting nurse associations are examples of voluntary nonprofit agencies. Hospital-based agencies are those involving a hospital operating a separate department as a home health agency. It may be nonprofit or generate revenue for the hospital. For-profit proprietary agencies can be governed by individual owners, but many are part of large, regional, or national chains that are administered through corporate headquarters. Many agencies providing services in the home remain outside the federal Medicare system that reimburses skilled nursing. These noncertified agencies are usually private and derive their funding from direct payment by the client or from private insurers.

A home health care nurse performs an initial visit to a client and determines that the client meets the criteria for services with Medicare reimbursement. The nurse understands that this service will be reimbursed for which period? a. 30 days b. 60 days c. 90 days d. 120 days

b. 60 days feedback: The Medicare prospective payment system (PPS) pays an agency for a 60-day "episode of care." All services and many medical supplies must be provided under the payment amount adjusted to geographic location and determined by the client's clinical and functional status at the start of care, as well as the projected need for services over the anticipated 60-day period.

The family of a hospice client is holding a vigil at the client's bedside. During a visit, a hospice nurse participates in this vigil and encourages each of the family members to say their good-byes. The nurse is demonstrating which of the following? a. Palliative care b. Guided letting go c. Connecting d. Responsive use of self

b. Guided letting go feedback: Guiding letting go is a truly unique nursing practice that involves helping the client to let go of former activities and hopes, including life itself. This involves listening to intense emotions and helping the person and family find resolution. Sometimes it involves participating in a vigil at the bedside of the dying person and encouraging loved ones to say their final words of farewell. Palliative care involves the relief of suffering without curing the underlying disease. Connecting refers to the centrality of relationships in providing hospice care as the nurse seeks to understand the emotional and spiritual distress common to the end of life. Responsive use of self is the process expert nurses use to understand the lives of vulnerable clients in the community resulting in stereotypes and assumptions being overturned.

A home health care nurse is assigned to visit a client's home. The nurse identifies the area as a problem neighborhood. Which of the following would be most appropriate for the nurse to do? a. Perform the visit via telephone b. Have another nurse buddy along c. Reschedule the visit for another time d. Leave the cell phone at home

b. Have another nurse buddy along feedback: If there is a question of safety, the nurse should have another nurse accompany him or her on the visit. It would be inappropriate to perform the visit over the telephone. The nurse needs to physically see the client to perform the assessment. The agency typically has policies about how soon after a referral the client must be seen. So, rescheduling the visit may not be an option. In addition, rescheduling the visit does nothing to address the safety issues. The nurse should carry his or her cell phone but leave any valuables, such as cash, wallet, or purse locked in the care.

When describing the role of hospice nurses to a group of students, a hospice nurse identifies which of the following as most important? a. Speaking the truth b. Sustaining oneself c. Encouraging choice d. Strengthening the family

b. Sustaining oneself feedback: Although speaking the truth, encouraging choice and strengthening the family are key interventions of a hospice nurse, sustaining oneself is the priority. Effective hospice nurses understand that to care for others, they must care for themselves because without a healthy nurse, the client cannot thrive.

When evaluating a client's eligibility for Medicare-reimbursed home care, which of the following is crucial? a. The client needs visits by a homemaker. b. The client is homebound. c. The client is a veteran. d. The client is terminally ill.

b. The client is homebound. feedback: Homebound status is a requirement and means the person can only leave the home with difficulty and only for medical appointments or adult day care. Medicare requires that the recipient of reimbursable services need skilled services. The services of a homemaker are not considered a skilled service and are not a requirement for receiving services. There are no requirements that the client be associated with the military, either now or in the past. A client must be considered terminally ill to receive hospice services reimbursed by Medicare but not home health care—the person would just require skilled services.

The nurse educator knows that the nursing student understands the contributions that Lillian Wald made to home care when the nursing student makes which one of the following statements? a. "Lillian Wald made the earliest known effort to care for the sick poor at home." b. "Lillian Wald trained nurses so that wealthy women would hire them as visiting nurses." c. "Lillian Wald began home visiting in New York City and is famed for professionalizing visiting nurses." d. "Lillian Wald approached congress with the idea of Medicare Home Health Benefit."

c. "Lillian Wald began home visiting in New York City and is famed for professionalizing visiting nurses." feedback: Lillian Wald began home visiting in New York City and is famed for professionalizing visiting nurses. It was the Ladies Benevolent Society in Charleston, South Caroline who made the earliest known efforts to care for the sick at home. It was Florence Nightingale who trained nurses so that wealthy women would hire them as visiting nurses. Lillian Wald did establish insurance coverage for home care with the Metropolitan Life Insurance Company but this was in the early 1900s and the Medicare Home Health Benefit did not exist until 1965.

After reviewing the various events associated with the history of home health care, the students demonstrate understanding of the events when they state which of the following as the most significant influence on the growth of home care agencies? a. Creation of the visiting nurse associations b. Era of the Medicare Home Health Benefit c. Enactment of the Balanced Budget Act d. Discharge of nonacute clients

c. Enactment of the Balanced Budget Act feedback: The number of Medicare-certified home care agencies grew rapidly until enactment of the Balanced Budget Act of 1997 that sought explicitly to reduce federal payments for home health care by changing the payment from reimbursement for each visit to the Medicare Prospective Payment System that determined Medicare payment rates based on client characteristics and need for services. Visiting nurse associations, discharging of nonacute clients, and the Era of the Medicare Home Health Benefit had no effect on the growth of agencies.

A home health care nurse is working with informal caregivers. Which of the following is most important? a. Include the client's spouse or significant other in the plan b. Visit frequently to manage and maintain equipment c. Focus on caretaker abilities, not their limitations d. Use nurse's intuition to determine what to teach first

c. Focus on caretaker abilities, not their limitations feedback: Keeping a positive attitude that is focused on abilities, not limitations, of the caregivers is most important. The home health care nurse includes all family members and caregivers in the plan, teaches family members and caregivers how to manage and maintain equipment, and chooses an area to teach first that the client or caretaker is motivated to learn.

When describing the philosophy of hospice care to a group of students, which of the following would the instructor include? a. The right to die and euthanasia b. Working with people in their last year of life c. Holistic and family-centered care to terminally ill clients d. Weaving hospice concepts around curative treatment

c. Holistic and family-centered care to terminally ill clients feedback: The philosophy of hospice care includes holistic and family-centered care to terminally ill clients. Hospice care is delivered to terminally ill people with the recognition that death is a human experience. Euthanasia is not part of the care. Hospice care can be initiated after a physician has declared that a person has 6 months or less to live. Hospice care is initiated in the final phase of a person's illness when he or she is not receiving curative treatment.

After teaching a group of students about hospice and its view of end-of-life care, which statement by the students indicates a need for additional teaching? a. Care should attend to the body, mind, and spirit. b. Death is not considered a taboo topic. c. Medical technology should be used widely. d. Clients have a right to truthful discussion.

c. Medical technology should be used widely. feedback: The hospice movement has emphasized four major changes in end-of-life care: (1) care should attend to body, mind, and spirit; (2) death must not be a taboo topic; (3) medical technology should be used with discretion; and (4) clients have a right to truthful discussion and involvement in treatment decisions.

Assessment of a client in the home reveals that his or her services will be paid by a government source. Which of the following would be a possible source of payment? a. Insurance company b. Health maintenance organization c. Medicare d. Preferred provider organization

c. Medicare feedback: Government payers include Medicare, Medicaid, the military health system (TRICARE), and the Veterans Administration system. Corporate payers include insurance companies, health maintenance organizations (HMOs), preferred provider organizations (PPOs), and case-management programs.

A home health care nurse is invited as a guest speaker to talk to a group of students about challenges of working in the home. As part of the discussion, the nurse describes medication safety. Which of the following would the nurse include as a measure to address this issue? a. Asking the client what he or she takes the drug for b. Throwing out any medications over 1 month old c. Reconciling drugs in the home with those on the discharge sheet d. Setting up medication boxes to organize the medications

c. Reconciling drugs in the home with those on the discharge sheet feedback: It is important for the home health care nurse to reconcile the medications in the client's home with those on the discharge sheet. If there are any discrepancies, then the nurse should contact the client's primary care physician to clarify any differences and confirm the orders. Asking the client what he takes the drug for provides limited information. The nurse needs to know if he or she is taking it currently, and if so, the frequency and dosage. Throwing out any medications that are over 1 month old is inappropriate. A medication may have been ordered previously but was inadvertently missed on the discharge sheet. The nurse must always double check the order and with the physician about any medication. Setting up medication boxes are helpful to organize the medications, but the nurse still needs to verify that the client should be taking the medication.

When visiting a client in the home for the first time, which of the following is absolutely critical to remember? a. There may be dangers lurking around every corner. b. Clients are glad to have the nurse in their home. c. The nurse is a guest in the client's home. d. The nurse knows what is best for the client.

c. The nurse is a guest in the client's home. feedback: Once the nurse arrives at the client's home, there is the challenge of getting through the closed door and making the connection. The nurse must always remember that he or she is a guest in the home. Although there may be dangers, the nurse must focus on the client while maintaining a watchful eye. Clients may be apprehensive or suspicious about a nurse coming to visit, wondering why or what they did. Not all clients are welcoming. The nurse needs to start where the client and family are, not what the nurse thinks is best.

3. Which one of the following statements best describes the family caregiver burdens of providing home care? a. Family members are expected to contribute financially to cover all of the costs of home care. b. Individuals recovering from severe illness or living with debilitating chronic illness rely on family members for unpaid assistance. c. Informal caregivers assume a considerable physical, psychological, and economic burden in the care of their loved one at home. d. Caregivers often describe themselves as emotionally and physically drained.

d. Caregivers often describe themselves as emotionally and physically drained. feedback: The best description of family caregiver burdens is that caregivers have other responsibilities but that their caregiver tasks compete for time, energy, and attention leaving them emotionally and physically drained. Informal caregivers assume a considerable physical, psychological, and economic burden in the care of their loved one at home. Individuals recovering from severe illness or living with debilitating chronic illness rely on family members for unpaid assistance. The other two statements describe the burden in part but the best description is where caregivers often describe themselves as emotionally and physically drained.

Quality measures are being determined for a home health care agency. Which of the following would the agency want to achieve higher percentage rates? a. Hospital admissions b. Urgent unplanned medical care c. Deteriorating wound status d. Decreased pain with movement

d. Decreased pain with movement feedback: A home health care agency would want to achieve higher percentages of the measure involving decreased pain with movement. A higher percentage indicates that the clients are improving with care. The agency would want to achieve decreased or lower percentages for hospital admissions, urgent unplanned medical care, and deteriorating wound status.

A client will receive hospice care under the Medicare Hospice Benefit. The nurse understands that which of the following is true? a. The client denies terminal prognosis. b. The client has a prognosis of at least 6 months of life. c. The client chooses life-extending care. d. The hospice acts as clinical and financial case manager.

d. The hospice acts as clinical and financial case manager. feedback: The Medicare Hospice Benefit requires that a client, who has a prognosis of 6 months or less, must sign up for the comfort-focused hospice benefit and waive the regular hospice benefit. This mandates that the client acknowledge a terminal prognosis and choose comforting care instead of life-extending care. When this choice is made, the hospice coordinates care in all settings, functioning both as clinical and financial case manager.