For many patients who might otherwise be in the hospital or in a nursing facility, there's
NO PLACE LIKE HOME
Pulse editor
Sunday, September 21, 2008
With only two nurses on the staff, Visiting Nurse Health System began serving patients in 1948. Today the Norcross-based home health care nonprofit — also known as Visiting Nurse Hospice Atlanta — has more than 300 clinicians who serve about 16,000 patients annually in 26 metro Atlanta counties.
Growth and change have been the two constants in delivering home health care since Mary Zagajeski, RN, MSA, entered the field 20 years ago.
Photos by BARRY WILLIAMS/Special
Bill Traylor, clinical director of Visiting Nurse Hospice Atlanta, watches as patient Dorothy Spears looks at a remote blood pressure monitor in her apartment.
Using a home telemonitoring system, Dorothy Spears sends her vital sign readings to her doctors.
Sheree Burey (left) refers to a map of metro Atlanta as she goes over the work schedule with Sheila Dickerson at Guardian Home Care’s Atlanta office.
‘I’m a hands-on nurse and I love going into a home situation, assessing the patient, and then fighting to help him stay at home and in optimum health. You can make a definite improvement that you can point to, and that’s rewarding.’ - Sheree Burey, Director of clinical services for Guardian Home Care’s Atlanta office
“We’ve seen dramatic changes in home health and, as the demand for our services grows, we’re using every innovation to meet the need. The challenge is always to be creative and do better with what we have,” said Zagajeski, vice president for home health operations at Visiting Nurse Health System (VNHS).
The aging of Americans — who are living longer but with more acute and chronic health problems — has created a rising challenge. According to the Atlanta Regional Commission, 20 percent of metro Atlanta residents will be older than 60 by 2030.
“The longevity of patients today is amazing,” said Lavilla Walker, OTR-L, an occupational therapist who works for various home health agencies through Advanced Rehabilitation Services Inc. “I have one client who is 102 and I’ve seen patients [older than] 90 with hip replacements and bypass surgery. Medical intervention is extending their lives, and our goal is to make sure they get the right care so that they can be as independent as possible.”
Walker believes that most patients make better progress at home, because they are in familiar surroundings. But part of her job is to make sure that patients aren’t sent home from the hospital too soon.
“Our patients are much sicker. Hospitals are charged with discharging sooner [for insurance reimbursement reasons] and our challenge is to provide [them with] almost the same level of care they would get in the hospital at home,” Zagajeski said.
Cost-effective care
People often have misconceptions about what home health care is. They confuse it with unskilled workers (or sitters) helping people with their day-to-day needs as they age, or they think about private-duty nurses taking care of patients, said Bill Traylor, RN, BA, clinical director at VNHS.
“Home health runs the gamut and whole spectrum of clinical care,” Traylor said. “People don’t understand how broad it is and how successful we are at keeping people out of the hospital or a nursing facility. It’s the most cost-effective type of care.”
Home health care allows patients to go home sooner after surgery. Patients can rehab at home with therapists after joint replacements or strokes. With the help of home health technicians, people with chronic obstructive pulmonary disease can learn how to manage high-tech respiratory equipment.
“That’s a savings for the hospital and for the patient’s insurance [company], and it allows patients to have a better quality of life,” Traylor said. “Most patients would prefer to be at home, but it requires a highly trained staff and efficient coordination of services to allow them to age [or heal] in place successfully.”
In 2000, Medicare changed home health reimbursement from a fee-for-service to a pay-per-episode remuneration, Zagajeski said.
The challenge is to be judicious in the use of allowed visits so that patients get the care they need, Traylor said.
It takes a team
Like many home health agencies, Visiting Nurse Hospice Atlanta has refined a team approach to care. A registered nurse makes the initial assessment of a patient and serves as a case manager for a team of nurses, nursing aides, physical, occupational and speech therapists, nutritionists and social workers.
“When I started in home health care 16 years ago, all nurses did the same thing and carried a pager,” Traylor said. “If you got paged, you stopped at a pay phone and called the office.”
Now the organization employs IV, wound care and other specialists to provide care.
Seeing its clinicians faced with 300 to 400 wound patients at any given time, VNHS hired Bianca Woodall-Jones, RN, MS, CWOCN, to develop a wound-care training program for the entire staff, resulting in fewer hospitalizations and better patient outcomes.
“Our rehab department is large and sophisticated,” Zagajeski said. “We hire the best and the brightest, because strength and balance is an important part in being able to stay home.”
High-tech connections
Just because patients aren’t in hospital rooms down the hall doesn’t mean that their caretakers can’t stay in touch.
“Technology allows us to give clinicians the most up-to-date information on their patients,” Zagajeski said.
Pagers have been replaced by laptops, cellphones, wireless cards and text messaging to share patient information between weekly team meetings. In 1995, VNHS was the first Atlanta agency to utilize electronic medical documentation.
“When I first started, documentation was a lot simpler. Now Medicare and commercial insurers are much more exacting and strict in their requirements,” Traylor said.
New home health care nurses spend six to eight weeks in orientation with preceptors to learn the ropes, including the technology system and documentation procedures.
Telemonitoring allows heart and diabetic patients to keep track of their vital signs from home. Clinicians set up blood-glucose machines, blood-pressure cuffs and scales that attach to patients’ home phones and automatically transmit data to agency computers.
“Physicians can monitor patients daily and make subtle changes in care, which can keep them at home safely,” Zagajeski said.
Educating patients
“Home health excels in the use of technology. We have the latest in glucometers, infusion pumps and IV systems, but education is the key to keeping people healthy,” said Sheree Burey, RN, director of clinical services for Guardian Home Care’s Atlanta office. “You make the initial assessment of what patients need and their challenges, and then work with them to set realistic goals.”
Burey likes nuturing relationships with patients.
“When you’re in someone’s home, you get to know them and can see what they are doing,” she said. “You know who is shopping and cooking for a diabetic patient and [you] can make suggestions.
“The hospital is such a rushed environment. I’m a hands-on nurse and I love going into a home situation, assessing the patient, and then fighting to help him stay at home and in optimum health. You can make a definite improvement that you can point to, and that’s rewarding.”
Walker believes that it’s important to a get a patient’s family involved with rehabilitation. “Two visits a week aren’t enough. You teach the patient and the family the exercise program. If the caregiver will follow through, it makes all the difference.”
A different kind of care
Like all areas of care, the nursing shortage has impacted home health.
“It’s hard to recruit into home health,” Traylor said. “You need someone with nursing experience. We used to pay better than hospitals, but now those facilities are offering some pretty incredible compensation packages.”
Flexible schedules appeal to some home health workers; others are drawn to the autonomy of practice.
“It takes a different type of person to practice in the home,” Burey said. “People either like it or hate it, and they usually know quickly.”
Zagajeski looks for nurses with strong assessment and clinical skills; she wants employees who are self-starters, critical thinkers and good decision-makers.
“They need a sense of adventure, because they never know what they will find when they walk into someone’s home,” she said.
Zagajeski strives to create a work environment that sustains long-term employee relationships. It includes flexible schedules, top-notch technology, a tier system for clinical development, ongoing education and focus groups to discuss new initiatives.
“My administration is my practice,” she said. “When you create an environment where clinicians are satisfied, they are better able to care for patients.”
Many nurses — like Traylor — find their niche in home health.
“I loved getting on a more personal level with my patients, seeing them happier at home and being the person to help them progress to wellness,” he said. “There’s a lot of satisfaction in that.”