Medical advancements and reductions in insurance coverage are resulting in patients being sent home "quicker and sicker," with the expectation that they will continue to recover at home. This trend, coupled with the aging of the population, is creating a greater need for competent, experienced home healthcare case managers.
Home healthcare patients are dependent upon case managers to assess their health status and clinical and treatment needs, and to plan, implement, coordinate, monitor, and evaluate a plan of care to meet those needs. These same functions are highly congruent with the "Definition of Case Management" described by the Commission for Case Manager Certification (CCMC): "Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes" (CCMC, 2007).
Providing home healthcare in a managed care-driven environment will create demand, in particular, for nurse case managers, who specialize in delivering quality case management services. According to Medicare's "Conditions of Participation," from the U.S. Department of Health and Human Services, "Patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing, and social needs can be met adequately by the (home health) agency in the patient's place of residence" (Code of Federal Regulations, 2007). Medicare guidelines for home healthcare case management presume that many illnesses and injuries can be treated in a home setting with only part-time or intermittent care.
The Conditions of Participation also stipulates that the initial evaluation visit be conducted by a registered nurse, who also "reevaluates the patient's nursing needs, initiates the plan of care and necessary revisions, furnishes those services requiring substantial and specialized nursing skill, initiates appropriate preventive and rehabilitative nursing procedures, prepares clinical and progress notes, coordinates services, informs the physician and other personnel of changes in the patient's condition and needs, counsels the patient and family in meeting nursing and related needs, participates in in-service programs, and supervises and teaches other nursing personnel" (Code of Federal Regulations, 2007).
The requirement that a registered nurse conduct the assessment and evaluation highlights the opportunity for nurses to provide case management services. Home healthcare requires a comprehensive care plan with emphasis on outcomes, which is also in keeping with the case management process. Therefore, nurses who are also case managers-and who further distinguish themselves by becoming Certified Case Managers-demonstrate that they have the knowledge, expertise, and skills, to competently provide case management services in the home healthcare arena.
Services provided to home healthcare clients begin with an interview to assess the individual's mental and physical state. A face-to-face assessment increases the efficiency and accuracy of the data collected. The case manager collaborates with the client's physician before completing the assessment to verify all findings. The assessment should cover a broad range of conditions, including, but not limited to, medical, nutritional, psychosocial, and functional capabilities, as well as a home-safety assessment.
The nurse case manager determines what clients will require in terms of specific medical needs, such as skilled nursing care, a home health aide, a personal assistant, therapy, medication, and medical supplies, and also coordinates these services. The care plan must be comprehensive and include input from a variety of medical disciplines, as well as incorporate the needs of the client's family.
Key factors in the recovery of the client include the thoroughness of the initial physical assessment conducted by the nurse case manager and how well the implementation of the care plan is proceeding. That initial assessment needs to consider how independent or dependent the client is; what the person is physically capable of doing; whether the person can live alone, and what physical or environmental factors pose a risk of a fall.
Preexisting medical conditions are also taken into account: for example, does the patient has diabetes or a heart condition? The home health nurse case manager will have access to medical records from the hospital or other treating facility upon discharge of the patient, which will specify the medical conditions that need to be monitored as part of the ongoing plan of care. In addition to medical issues, the patient's assessment and ongoing evaluation should focus on behavioral health issues. Poor personal hygiene and/or confusion are signs of concern about a person's mental state.
The ultimate initial goal in home healthcare is to stabilize the client's medical condition, to increase the person's comfort level, and to improve the individual's ability to function. Helping a client to return to a preillness/injury state is a challenge. The client who requires home care is not functioning at his or her usual level of independence, and may require minimal to total assistance in order to recover at home.
This does present unique challenges for the nurse case manager, but the opportunities will grow in the future as the population ages. The older population, in general, is well educated and more interested in healthcare and environmental concerns, as well as the impact on the cost of living. A very important concern of an aging spouse is how to care for a loved one who has become seriously ill and/or physically disabled.
These factors, along with the need to preserve scarce and costly medical resources and the trend toward shorter hospitalizations, will support the home healthcare solution. Nurse case managers operating in the home healthcare arena can contribute positively to the overall goal of providing high-quality care, while assisting and supporting the client's independence.
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