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Healthcare is evolving, and sometimes more quickly than we like. With the implementation of the complex face-to-face regulation comes the nightmare of operationalizing such seemingly "simple" ideas. And it is not just home care and hospice-I attended the University of Maryland School of Nursing and the Veterans Affairs Maryland Health Care System's 8th Annual Evidence-Based Practice Conference. The Conference was entitled, "Nursing Practice Based on Evidence: Emerging Impact of Health Care Reform." More and more, I think our job is to help ensure that all home care and hospice team members have access to and use evidence-based information. This truly is the core of nursing knowledge and care. Impressive speakers identified numerous pieces of the Affordable Care Act. Dr. Mary Wakefield, the administrator of the Health Resources and Services Administration (HRSA), is the first nurse to hold that position. I usually only think about HRSA related to work force issues, which is in itself a huge purview. I learned that HRSA has 80 different programs, and that there are 8,100 Community Health Center sites that serve 19 million people for their primary care. HRSA is responsible for 50 of the ACA's provisions, and CMS has many more on its list!! Although much of the focus was inpatient care, the trends heard were all-around systems-based concerns including quality, safety, and strategies to build the workforce and educational structure while improving health in people and communities.

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Home care and healthcare at home were very well represented by Carol Raphael, the President and CEO of the Visiting Nurse Service of New York. Carol spoke toward the end of the second day and still energized the group to see and understand the complexity through her clear vision of the healthcare world from a prism of where patients live-in their homes. She made me proud to be in home care!!


Quality and safety discussions oftentimes revolve around medications. A Substance Abuse and Mental Health Services Administration (SAMHSA) report released February 24, 2011 entitled "The Dawn Report: Emergency Department Visits Involving Adverse Reactions to Medications Among Older Adults" identified four bullets "In Brief:"


* "In 2008, an estimated 1,111,686 emergency department (ED) visits were made by adults aged 50 or older for adverse reactions to pharmaceuticals or other types of medications.


* More than half of these visits (61.5 percent) we made by adults aged 65 or older.


* Central nervous system (CNS) drugs (e.g., pain relievers and drugs used to treat anxiety and insomnia) were involved in almost one fourth (24.3 percent) of ED visits for adverse drug reactions among older adults.


* Nearly two thirds of older adults who visited the ED for adverse drug reactions were treated and released (64.2 percent), and nearly one third were admitted to the hospital (32.9 percent)" (SAMHSA, 2011).



The report also displayed an interesting figure that shows the scope of the problem (Figure 1). When you think of our patients at home and how many medications that they take, this is interesting. It appears that one drug/a single pharmaceutical produced the most ED visits. Visit for the entire report.

Figure 1 - Click to enlarge in new windowFigure 1. Number of Pharmaceuticals Involved in Emergency Department Visits for Adverse Reactions among Adults 50 or Older: 2008

And although we in home care are used to "Home Care Compare," in April, the CMS released the "Hospital Compare" Web site, which will offer "new data about hospital-acquired conditions at more than 4,700 hospitals" (CMS, 2011). This information will list "how often hospitals report serious conditions that develop during an inpatient stay and possibly harm patients with new data about the safety of care available."


The Hospital Compare Web site can be accessed at Eight hospital-acquired conditions are listed to be reported. These are as follows:


1. "Blood infections from a catheter placed in the hospital;


2. Urinary tract infections from a catheter placed in the hospital;


3. Falls, burns, electric shock, broken bones, and other injuries during a hospital stay;


4. Blood transfusions with incompatible blood;


5. Pressure ulcers (also known as bed sores) that develop after a patient enters the hospital;


6. Injuries and complications from air or gas bubbles entering a blood vessel;


7. Objects left in patients after surgery (such as sponges or surgical instruments);


8. Poor control of blood sugar for patients with diabetes" (CMS, 2011).



This June issue of Home Healthcare Nurse had the themes of healthcare reform, communications and technology, all important aspects for the primary care-based vision of health and connectivity for the new world view. Sarah Browning and her colleagues address "Telehealth Monitoring," whereas Dianne Hansen et al. address "Cost Factors in Implementing Telemonitoring Programs in Rural Home Health Agencies." One specific technology is discussed in "Webcasting in Home and Hospice Care Services: Virtual Communication in Home Care," authored by Marilyn Smith-Stoner. There is also a hospice and palliative care article in this issue, Jennifer Kennedy's "To Certify or Not to Certify: Why Medicare and Medicaid Hospice Certification and Recertification Are More Challenging Than Ever."


Natural disasters seem to be in the news more, with the earthquake and tsunami (our thoughts and prayers are with the people of Japan) and tornadoes and floods more recently. MaryAnn Duchene authored "Emergency Management in Action: Surviving a Flood" and reminds us that we cannot be too prepared for such events. A more lighthearted look at the tough and snowy winter of 2011 is the Commentary entitled The "Snowtacular" by Ann Mathiews.


I welcome your ideas and letters to the editor. I am seeking papers by nurses, physicians, therapists, dietitians, and respiratory therapists specifically. If you have a team member who wishes to develop a paper, kindly have he or she e-mail me directly at


Tina M. Marrelli

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Centers for Medicare and Medicaid Services (CMS). (2011). New Information to Improve Patient Safety at America's Hospitals. CMS e-mail Press Release, April 6, 2011. [Context Link]


Substance Abuse and Mental Health Services Administration (SAMHSA). (2011). Emergency Department Visits Involving Adverse Reactions to Medications Among Older Adults. The Dawn Report, February 24, 2011. Retrieved from [Context Link]