My view you know is that the ultimate destination of all nursing is the nursing of the sick in their own homes. . . . I look to the abolition of all hospitals and workhouse infirmaries. But no use to talk about the year 2000. - —Florence Nightingale
Figure. Robert Granv...Image Tools
The year 2000 has come and gone, and Florence Nightingale (quoted above in Role Development in Professional Nursing Practice by Kathleen Masters) would be both disappointed and encouraged to see the state of U.S. health care today. Nightingale was a passionate proponent of home-based health care, which has come a long way since 1813, when the women of Charleston, South Carolina, organized the first visiting nurse services under the auspices of the Ladies' Benevolent Society (for more on early home nursing, see "Home Care: A History of Caring, a Future of Challenges," http://bit.ly/91x4kW). But health care is still primarily based in acute and long-term care facilities, and caring for the sick and disabled in a home setting remains one of the more invisible parts of the current U.S. health care system.
Health care itself is in flux right now, and visiting nurses are facing a number of challenges. According to Joan Marren, MEd, RN, chief operating officer of the Visiting Nurse Service of New York (VNSNY), the top issues affecting visiting nurses and home health care are the increasingly complex needs of home care patients and cuts to Medicare and Medicaid reimbursement for home health care services—those already implemented as well as those included in the recently enacted Patient Protection and Affordable Care Act.
"Our nurses are seeing greater numbers of acutely ill patients and those with chronic illnesses requiring ongoing care management," said Marren. "We must develop new care delivery models, improve the quality of our care, and employ new technology—at a time when there's pressure to control costs."
HEALTH CARE REFORM
Health care reform has many in the home health industry feeling unsettled. It's uncertain at this time whether changes will be beneficial or detrimental, said Tina M. Marrelli, MSN, MA, RN, FAAN, editor of Home Healthcare Nurse.
Rose Podany, RN, echoes Marrelli's concerns. "It's all up in the air right now," said Podany, who is evening and weekend supervisor at St. Joseph Health System Home Care Services in Orange, California. "Some say that home health is going to boom because of it, but others say the opposite."
The recently enacted federal health care reform provisions include across-the-board cuts to home health care. This could seriously threaten access to care, especially for vulnerable, high-cost, medically complex patients, according to Marren. However, she believes that the new law includes opportunities for home health agencies to participate and even take the lead in testing new models of care delivery, such as Independence at Home and Community-Based Care Transition programs, which may reduce costs while improving care coordination and quality of services.
Changes in regulatory protocols will also affect home health care and visiting nurses across the country, according to Marrelli.
Perhaps the most taxing regulatory change is the requirement that all home health agencies participating in Medicare use OASIS-C, a form for documenting assessments and outcomes.
"It's a very complex data-driven tool that's been in development for years, and it will affect everyone in our organization. But nurses have to learn to use it right now," she said.
Even though hiring freezes and layoffs have negatively affected health care, staffing shortages persist.
Podany noted that it can be difficult to find good, qualified nurses, and her agency is willing to train those without home health experience. "We had some layoffs a few years ago, and then our census dropped off for a while, so we were able to manage with fewer nurses," she said. "But now we have a lot of new referrals, and we do need more nurses."
Neil Rotter, a board member of the California Association for Health Services at Home (CAHSAH) and vice president of business development at Accredited Nursing, a home health care provider in Southern California, explained that his agency is also in need of more nurses.
"We always need more nurses, so there haven't been cutbacks," he said. "At other agencies that aren't quite as busy, the influx of new nurse applicants—a result of the economy—is taking visits away from some of the existing staff."
According to Marren, although the VNSNY is continuing to hire nursing staff, with the current downturn in the market, turnover in nursing positions is at an all-time low and there are fewer vacant positions to fill.
Another important issue is the continuing shortage of home health aides and assistants, and according to Marrelli, it's only going to get worse. "The population is changing, and the demand for aides and assistants is going to grow." Despite the need, the turnover rate for aides is high. Marrelli pointed out that organizations need to take better care of their aides. "They need to provide continuing education and pay them better, so that they stay on."
As states tighten their belts and slash their budgets, cuts in health and social service programs are inevitable. For example, the Coconino County Health Department in Arizona has announced that the county home health program, which primarily provides assistance to elderly and disabled clients, in the form of visiting nurses, personal care, and respite care, will be discontinued.
According to Jane Miles, MSN, RN, NEA-BC, health care consultant and nursing instructor at East Carolina University in Greenville, North Carolina, funding cuts in her state might force some patients into nursing homes.
New York State, which is facing its most serious budget crisis since the Great Depression, has proposed cuts that would reduce Medicaid funding to most home care agencies by 15% to 25%. When state and federal matching dollars are combined, the total amount of proposed cuts add up to $475 million. If implemented, the cuts would curtail services and put nurses and other staff out of work.
"The big issue in home care is that it's people oriented," said Roger L. Noyes, director of communications at the Home Care Association of New York State (HCA). "There is no infrastructure to cut from, so you have to cut personnel."
Noyes explained that as a result of planned cuts, providers might also have to freeze benefits, consider salary reductions or furloughs, and eliminate some programs.
The HCA has pushed for legislation that offers alternatives to cuts. Called the Home Care Accessibility and Efficiency Improvement Act, it would preserve Medicaid dollars by instituting home care program enhancements, regulatory reform, workforce flexibility, quality and performance standards, and a realignment of financial incentives. "New York is in a hole and we appreciate the need to cut the budget, but there are more constructive ways to do it," said Noyes. "We hope that the governor and the legislature will embrace some of our alternatives."
The reimbursement rate is also a problem, said CAHSAH board member Karrie Decker, who's also director of a hospital-based agency in rural central California.
State reimbursement for home health nursing and therapy is "grossly inadequate," she said. "Every patient seen costs twice as much as what the state reimburses. Consequently, visits are cut back and some patients are simply not seen."
Decker added that Medicare cuts have reduced the profit margin, and all salaries have been frozen for the year. In addition, Medicare has asked that agencies focus on strategies to reduce hospitalizations. "To do this, we need to increase visit frequency and close monitoring is required," she said. "That costs more and reimbursement doesn't go up."
Roxanne Nelson, BSN, RN
© 2010 Lippincott Williams & Wilkins, Inc.