Nursing research in home health care: endangered species?

An information revolution is occurring in home health care documentation processes and systems. The federally mandated Outcomes and Assessment Information Set (OASIS) for patient assessment and the use of electronic patient medical records will significantly affect the conduct of nursing research in home health care. The purposes of this article are to inform potential home care nurse researchers about the standardization of patient information as exemplified by OASIS and electronic patient medical records and recommend strategies to accommodate these changes. The potential for meaningful, scholarly studies in home care has never been greater, but researchers must address new challenges and adapt investigations accordingly.

Doing more with less and less with more.

The "devil is in the details" of any policy response. What forms such changes may take, and what research informs them, are critical to the profession as a whole and to practitioners on a daily basis. Research partnerships between home care agencies and university professors may provide rigorous, systematic, and validated findings necessary for meaningful solutions (Plotkin & Roche, 2000). The evidence of a dialogue between nursing researchers, home healthcare practitioners, and policymakers anticipating impacts on practice of changing fiscal and information-gathering requirements is scant. Such issues are in need a priority discussion by agencies, and collaborative investigative efforts between all involved.

A rural perspective on home care communication about elderly patients after hospital discharge.

Little is known about home health agencies (HHA) and their integration in the continuum of care in rural areas. The aims of this study are to describe the amount and type of patient-related data transferred by discharging hospitals to rural HHAs and to explore the influence of selected organizational factors on that communication process using a previously tested model of interorganizational communication. In this study, 446 closed-case, elderly patient records at three rural HHAs were reviewed using the Referral Data Inventory. Rural HHAs receive about half of the literature-recommended referral data, characterized primarily by background data, some medical data, and almost no psychosocial or nursing-care data. Referrals transmitted by telephone and written data were superior to referrals transferred by a telephone call only. Hospital-affiliated HHAs received significantly greater amounts and richer types of referral data than did free-standing HHAs. Findings suggest that cost-saving measures in the referral process need investigation.

Talking about patients: communication and continuity of care.

Continuity of patient care is a tenet of professional nursing practice regardless of setting. Communication between providers about patients is fundamental to continuity. As the role of hospitals in health care is constrained, care is now commonly delivered to patients during an episode of illness by multiple agencies. Continuity of care now assumes full communication between providers about patients' conditions and needs. Research provides evidence about the dynamics of patient care communication: more lean (background and medical) than rich (nursing care and psychosocial) data are communicated; structured, written formats transmit more information than informal channels of communication; and organizational and patient characteristics would appear to affect communication about patients. Knowledge about the communication dynamics of patient care may assist providers in designing strategies to attain the basic goals of continuity of care.

Unplanned hospital readmissions: a home care perspective.

BACKGROUND: The extensive literature concerning hospital readmissions is grounded in a medical or hospital perspective, and fails to address hospital readmissions during home care. OBJECTIVES: To describe clients who have unplanned returns to an inpatient setting during the first 100 days of home care service delivery. METHOD: Using the Hospital Readmission Inventory (HRI), an audit tool with previously established validity and reliability, 916 medical records for clients from 11 midwestern home care agencies were reviewed retrospectively. RESULTS: Typically, clients were referred for their first home care admission after a 9-day hospital length of stay for a cardiovascular, respiratory, or neoplastic disorder. After an average 18-day length home care stay, clients were readmitted to the hospital, usually due to the development of a new problem, or due to deterioration in health status related to the primary or to a secondary medical diagnosis. Significant respiratory, cardiovascular or GI symptoms were generally present at hospital readmission. Typically, readmitted clients were 75 year old married females, who had been able to care for themselves at home. At hospital readmission, home care nurses judged these clients to be moderately ill, and likely in need of acute care. CONCLUSIONS: Chronic illness appears to be the best indicator for hospital readmission. The crucial time period for hospital readmission during home care is the first 2-3 weeks following hospital discharge. Intensive study of home care service arrangements utilized by readmitted patients, as well as agency variations, are needed. Study findings concerning patients readmitted from home care point to similarities with rehospitalized patients generally. Findings may assist home care clinicians in targeting high risk patients who could benefit from interventions aimed at minimizing unplanned returns to the hospital.

Extended care referral after hospital discharge.

The purpose of this study was to describe the influence of selected organizational and medical factors on communication between hospitals and extended care facilities (ECF) in the referral of elderly clients following discharge from acute care. Using a tool with previously established reliability and validity, 455 closed records of referral were purposively selected and reviewed for the amount and type of information an ECF received upon referral, as well as selected organizational and medical factors. Hospitals transferred approximately three-fourths of the patient care data recommended in the literature. Information contained in an ECF referral consisted primarily of background and medical data, with some nursing care data and limited psychosocial data. More information-rich referrals were generated by very large hospitals and by specialty care units. Similarly, proprietary ECFs received more patient care data than their not-for-profit counterparts. Research concerning patient care communication between provider organizations across the health care delivery system may assist nurses in developing better patient care information-management systems.

Comparison of continuing care communication.

PURPOSE: To describe and compare the patient-care communication exchanged between personnel in hospitals and nursing homes (NHs) and hospitals and home health agencies (HHAs) in referrals of elderly patients using an adaptation of classic communication theory. Little research on patient-care communication across organizational settings has been reported. This study offers baseline information about inter-organizational communication and insight into barriers to patient care communication. DESIGN: A retrospective, descriptive study using a convenience sample of 455 medical records of referrals to NHs and 300 to HHAs. METHODS: Medical records were audited and a Referral Data Inventory (with established reliability and validity) was completed for each of the records reviewed. Data were collected between January and June 1995. FINDINGS: Greater amounts of referral data were transferred to NHs, than to HHAs. Patient information was composed largely of background and medical data, followed by some nursing care data and limited psychosocial data. Hospitals employed more formal channels of communication in referring patients to NHs than to HHAs, and communicated information more promptly. Some organizational factors related to both the referring hospitals and receiving organizations resulted in discrepancies in patient-care communication. CONCLUSIONS: Continuity of patient care involves a series of coordinating linkages across time, settings, providers, and consumers of health care. Communication is a core task in coordinating patient care. Increased and improved inter-organizational communication is needed when patients are discharged to nursing homes or home health agencies.

Home care referral after emergency department discharge.

OBJECTIVE: The purpose of this study was to assess the need for home health care referral screening for elderly patients after ED discharge. The specific research question addressed was: Is there a need for home care referral screenings for elderly patients discharged from the emergency department? DESIGN: A nonexperimental, retrospective, descriptive design was used in this project. METHODS: A convenience sample of 194 closed medical records was obtained from a Midwestern hospital emergency department. The medical records were from patients 65 years of age and older who had visited the emergency department during a 3-month period. One chart audit tool was completed for each medical record. RESULTS: Eighty-eight (45.4%) of the 194 patients in the study could have benefited from a home care referral. CONCLUSION: Elderly patients frequently access the health care delivery system through the emergency department, but little is known about the outcomes of such usage, particularly in the context of continuity of care. If home care referral screenings of elderly ED patients are performed and appropriate referrals are made before ED discharge, a seamless delivery system of health care is provided. A home care visit resulting from a referral may be all that is needed for the maintenance of a patient's condition. To improve the quality and continuity of patient care, home care screening should be integrated into the routine discharge ED activities.

A legal primer on affirmative action in nursing education.

Affirmative action policies are under challenge. To date, judicial concerns must be understood historically. The legal question is to define the conditions under which racial categories may be used for remedial or beneficial purposes to overcome the effects of past discrimination. Beyond exercising strict scrutiny over the use of racial classifications, courts have supported the diversification of academe. For nursing programs, the challenge is to develop policies and procedures to broaden participation without reliance on racial categories. The benefits of diversifying the nursing work force need not be discarded in response to judicial and political reaction to affirmative action.

Home care utilization by congestive heart failure patients: a pilot study.

Home health care costs have increased more than any other health care service covered by Medicare, and new methods of payment by Medicare are being introduced. A prospective payment system would replace the per visit rate now paid to home care agencies by Medicare. In order to remain viable under a new payment system, home health care agencies will need to be efficient in the delivery of home care services and still demonstrate effective patient care. The intent of this descriptive study was to determine norms of resource utilization for the congestive heart failure (CHF) patients admitted and discharged from a not-for-profit home health agency (HHA). Forty agency records were retrospectively reviewed using the Resource Utilization Inventory to collect the characteristics and resource utilization of the sample group. The CHF patients were older than most home care clients and had chronic health problems. Because of these chronic health problems, over half of the study population had caregivers so that the clients could remain in their own homes. Most clients clearly demonstrated the need for skilled nursing or home health aide visits after being hospitalized for an acute CHF episode. Less than half of the study group were discharged form the HHA as improved, and frequently were discharged to another healthcare facility. These results provide a beginning direction for profiling the CHF patient's consumption of resources for setting prospective reimbursement rates.

Affirmative action in medical education: a legal perspective.

The use of affirmative action programs as part of the effort to increase the presence of minorities in medical education and the physician workforce has come under greater legal scrutiny. The authors describe the history of the legal theory behind affirmative action, giving examples from the evolving case law and from Department of Education guidelines. They identify legal pitfalls in the areas of admission and financial aid, including the categorization of students by race, racially disproportionate financial aid awards after accounting for need, racially disproportionate amounts of scholarships as opposed to loans, and, for public medical schools, differential treatment of out-of-state students based on race. Medical schools should be aware of this legal framework so that they can construct affirmative action programs that comply with the law while maintaining momentum toward diversification.

Hospital readmissions during home care: a pilot study.

The health care delivery system has undergone dramatic shifts in care settings during the past decade. More patients are receiving professional home care following discharge from hospitals, skilled-care facilities and rehabilitation centers. Home care is considered to be an integral part of patient recovery. Skilled nursing care delivered in the patient's home may prevent, forestall, or limit costly readmissions to an inpatient setting. Home care professionals have long questioned whether the unplanned returns of their clients to hospitals are preventable. The literature is replete with information from the acute-care and medical or physician's perspective concerning readmission. However, clients' unplanned returns to an inpatient setting while receiving home care services has not received much attention. The purpose of this pilot study is to describe clients who have unplanned returns to an inpatient setting during the first 31 days of home care service delivery. Using the Hospital Readmission Inventory (HRI), an audit tool with established validity and reliability, medical records for 68 clients from 8 midwestern home care agencies were reviewed. Readmitted patients were elderly, married females with cardiovascular or respiratory problems who were not independent in health care decision making or in self-care. Clients were readmitted to the hospital after approximately 2 weeks of home care service. The characterization of home care clients who are readmitted to the hospital may assist in targeting high-risk patients who could benefit from interventions aimed at minimizing unplanned returns to the acute-care setting.

"Doin' politics": linking policy and politics in nursing.

Policies affecting nursing are set within the larger environment of the health policy sector. That sector is characterized by increasing size, complexity, and goal displacement. All three characteristics have served to expand the resource base for this sector despite fiscal constraints on such growth. The environment of policy making shapes both the substance of policy change and the strategies for political adoption. Without understanding the dynamics of the policy environment, efforts by nursing leaders to enhance their growing political sophistication and to articulate nursing interests with maximum effectiveness will be compromised.

Communication between continuing care organizations.

Communication between health care providing organizations is fundamental to discharge planning and continuity of care, but has been reported to be inadequate. Using a classic communication model, the content of communication between hospitals and home health agencies was examined in 300 closed home care records and compared to referral content desired by practitioners. Discharge planners sent about half of the referral information recommended by the literature. Referrals consisted primarily of background data, some medical data, even less nursing care data, and almost no psychosocial data. No referral form was used by the hospital in over one third of the cases. Discrepancies existed between what client care data practitioners identified as important or desirable and the data they actually received. As responsibility for providing health care is decentralized and shared by multiple organizations, communication between providers will play a greater role in ensuring continuity of care. The findings suggest that adoption of standardized, written referral forms might facilitate clear and complete communication.

First-line nurse managers in rural hospitals: perceptions of career success.

First-line nurse managers in small rural hospitals are essential to organizational survival, yet little is known about such individuals. A pilot study comparing demographic characteristics and career success perceptions of first-line nurse managers from rural settings with doctorally prepared nurses found that despite age and educational differences, personal characteristics identified as contributing to career success were remarkably similar in both groups. First-line nurse managers generally credited family members with greater degrees of career influence than did their more educated colleagues. However, both groups saw themselves as primarily responsible for their own career success. This information may assist rural hospitals and nursing personnel to enhance their strategic position in the unstable environment of health care reform.