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Home Care Today: Preventing Rehospitalization Through Effective Home Health Nursing Care (Part ll) March 22, 2008

Posted by adimasmw in homecare.

Mr. Smith’s diagnosis is heart failure and diabetes, 2 priority conditions that have available evidence-based practices for nurses to follow in all healthcare settings ( Peterson, 2006 ). Mary Ann’s agency, ABC Home Care, has developed disease management programs for each of Mr. Smith’s disease processes.

Patient/Caregiver Education

Patient and caregiver education is essential to the improvement of outcomes. Mary Ann explains its importance and teaches Mr. Smith and his wife how to monitor his blood sugars, blood pressure, and daily weights, showing them how to log the results each day in a notebook. Mr. Smith has staples to his chest and leg incisions from his coronary bypass surgery. Mary Ann teaches signs and symptoms of infection and how to prevent an infection. She ensures that Mr. Smith keeps his follow-up appointment with his cardiac surgeon, who removes his staples. She also instructs Mr. Smith and his wife about possible abnormal findings and when to call nursing.

Patients who have received a bypass are at risk and need help in managing their disease and its care ( Lord, 2006 ). According to Hollenbeak et al., (2000) , the risk of chest and donor-site infections for patients who receive a bypass range from 0.84% to 17.7%, and approximately 470,000 coronary artery bypass surgeries are performed annually. Patients and their caregivers must be taught what to look for, and the nurse must inspect all incisions for the first few weeks after surgery so nothing is missed.

It is important to note that proper handwashing is vital in the care for any type of wound. Mary Ann stresses the importance of washing hands before and after caring for Mr. Smith’s incisions. She also emphasizes that an elevation in Mr. Smith’s temperature, pulse, blood pressure, weight, or blood sugars may be an indication of an infection and must be reported to her immediately. Mr. Smith is instructed to cover dressings with plastic before bathing to prevent them from getting wet and to redress them if they do get wet.


Telehealth is used by 8% of the top home health agencies, according to the study performed by Briggs Corporation (2006) . Briggs Corporation (2006) defines telehealth as strategy using devices that transmit video images or patient data to the agency from the patient’s home as part of the plan of care in an effort to improve outcomes and potentially reduce unplanned hospitalizations. Mary Ann’s agency does not have the telehealth equipment, but she does help Mr. Smith to obtain a glucometer, a digital blood pressure monitor, and a scale. She calls Mr. Smith several times each week and asks him whether he is taking his medications, what his weight, blood sugar, and blood pressure readings were, and documents results in the medical record. When results are above his normal levels, Mary Ann places a call to his physician and obtains orders to bring these results back to normal levels. These are just a few of the questions she asks him.

This ongoing monitoring is essential, especially for heart failure, because there are approximately 5 million Americans suffering from this disease, and an average of 500,000 new cases are diagnosed each year. Heart failure is one of the most common diagnoses requiring hospitalization for geriatric patients. This diagnosis accounts for 875,000 hospitalizations ( Giacini & Lehmann, 2004 ).

Common Pitfalls

Daily and Newfield (2005) discuss common pitfalls leading to home care risk. Some of these pitfalls are

* unsafe admissions;

* rushed or incomplete assessment;

* incomplete or missing documentation;

* rushed procedures or failure to follow steps laid out in standards.

Unsafe Admissions

It is imperative that home health nurses know how to identify a safe and unsafe admission. A patient who lives alone and cannot ambulate or perform activities of daily living such as meal preparation, bathing, dressing, and the like may be an unsafe admission. The nurse must then decide how to ensure that this patient is safe. An important resource with which nurses should be familiar is Adult Protective Services (APS), which “investigates reports of abuse, neglect, and exploitation of elderly people and people with disabilities … provides or arranges for protective services, including referral to other programs, respite care, guardianship, transportation, counseling, and emergency assistance care with food, shelter, and medical care” ( Texas Department of Family and Protective Services, 2006 ).

Rushed or Incomplete Assessment

When the assessment is rushed or incomplete, the nurse has more room for error, and important findings may be missed. An example of an incomplete assessment would be forgetting to assess Mr. Smith’s incisions. There may be dehiscence of the incision or an infection, which can cause a costly unplanned hospitalization. The home health nurse is the chief component in the monitoring of complications and the communication of findings to physicians. Early interventions can be initiated, and a hospital admission may be avoided.

Incomplete or Missing Documentation

Another important issue that may lead to home care risk is incomplete or missing documentation. It is vital to document all findings and interventions. For example, in documenting calls to physicians, it is important to document the date and time of the call and the name of the person taking the message. Follow-up evaluation also is very important. There are many instances in which the physician had a full caseload and did not get the message on time or, for whatever reason, was unable to return the call. Follow-up interventions also should be well documented.

Rushed Procedures or Failure to Follow Steps Laid Out in Standards

Rushed procedures or failure to follow steps laid out in standards also can lead to risk. Croke (2003) has listed failure to follow standards of care as one of the major categories of negligence resulting in a lawsuit. It is crucial that home health agencies provide updates to staff on new evidence-based practices. Daily & Newfield (2005 , p. 96) plainly state that “education and expertise regarding appropriate documentation, screening for complex case management for high-risk cases, and patient advocacy are keys to success in reducing litigation risk and improving outcomes.”

Mr. Smith’s Outcome

Mr. Smith and his wife Betty were very involved in his care. Both were cooperative and learned important ways to keep him healthy. He kept in touch with his nurse, Mary Ann, throughout his course of care. Mr. Smith maintained a log of his temperatures, blood pressures, blood sugars, and daily weights, taking them with him when he visited his physicians. He kept an updated medication list to show each of his physicians as well. Mr. Smith has regained the strength and endurance he had before his surgery. Mary Ann was able to care for Mr. Smith with the resources she had and to meet his outcomes in a cost-effective manner.


While it must be acknowledged that many patients may need to be hospitalized, it is a universally accepted fact that with the proper interventions, many others could have avoided hospitalizations. It is a reality that has significant implications for patients and their families. It is a reality that causes great stress and frustration to home care agencies and their staff. ( Briggs Corporation, 2006 , p. 1)

Nursing is “based on a systematic body of theory and abstract knowledge”( Ellis & Hartley, 2004 , p. 156). Nursing students spend many years learning the basics of nursing either at a community college or at a university. It is not until after graduation and after accepting a nursing position that the knowledge embedded into a nurse’s brain is put to a test. Something new is learned every day from patients or nursing colleagues or even from the community.

It has been difficult to come up with ways to care for patients under PPS. Just when care finally is becoming more manageable, another new cost control measure is in its early stages of development to be implemented by CMS in the near future ( CMS, 2006 ). This new cost measure is called pay-for-performance, whereby the agencies with better outcomes will receive more reimbursement. This will definitely add to the impact of home healthcare for patients.

The nurse drives the plan of care. Mr. Smith’s case scenario is an ideal case, with outcomes every home health agency would like to achieve. It is important to keep abreast of the many changes in healthcare. Keeping patients out of the hospital is a major focus in home health and will continue to be for years to come.

Taken From Nursingcenter


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