- Email: [email protected]
Hospital-Based Perinatal Home-Care Program
l0C;SS C L I S I C A L ISSUES
Hospital-Based Perinatal Home-Care Program Nancy L. Friest Dahlberg, MS, RNC, Mary Koloroutis, MS, RN
In recent years, hospitals have established home-care programs to provide care on a continuum,meeting needs in the hospital and home setting, whichever is most appropriate and efficient in response to defined patient needs. Hospital-basedhome-care programs with specialization in perinatal nursing have been established to meet the care needs of patients and their families during antepartum, postpartum, and neonatal periods. One of the greatest advantages of a hospital-basedprogram is the internal availability of highly knowledgeable and skilled nursing staff. Physicians are more likely to refer patients to a program that is staffed with nurses they know and trust from the hospital setting. More cost-effective and coordinated care is achieved through the appropriate use of resources across the continuum.
meet their needs. Home-care programs with specialization in perinatal nursing have been established to meet the needs of antepartum, postpartum, and neonatal patients (Dahlberg, 1988; Dahlberg, Parker, & Knox, 1989; Donlevy, 1993; Evans, 1991).
Organizational Structure
n recent years, hospitals have established home-care programs to provide a continuum of care that meets patients’ needs in the hospital or home; have some internal control over the cost, quality, and access to service; and manage the inpatient stay more effectively. Hospitals also have recognized an opportunity to increase revenue through diversified services and be competitive in contracting to serve patient populations (Lerman, 1987). Traditionally, there are two types of populations served by home care, patients who have been discharged from the hospital and those who are chronically ill (Montgomery, 1993a). Increases in public awareness of the availability of home-care services, along with shorter hospital stays, have increased the demand for such services (Benefield, 1988). Obstetric services are responding to the changing health-care environment, which is seeking alternatives to hospital stays. Home care is an obvious and viable alternative. Some patients may be treated at home and a hospital admission prevented, whereas others may have shorter hospital stays and be discharged to home care for continued nursing services and safe provision of care to
In determining the feasibility of starting a perinatal home-care program, the hospital needs to fully investigate the following issues: areas of competition, market entry, cliept base, referral sources, physician involvement with other existing programs, barriers to success, payer mix, state home-care laws and regulations, and hospital and physician support for a program (Lerman, 1987). A program will be most successful if a market assessment indicates the need for the program; there is physician commitment to and value in the program and services to be offered; and there is hospital commitment to providing the leadership and staff development required for high-quality care and service. Some health-care providers in the perinatal area may have a limited knowledge of home-care services. Many may resist home care because of a lack of understanding regarding the level of skilled nursing care that can be provided in the home. Other health-care providers may have the perception that home care is for maintenance and housekeeping, rather than the high-technology, skilled nursing specialty that has evolved during the last several years (Widmer & Martinson, 1989). Thus, some education and preparation of hospital staff and physicians as a foundation for programming are essential. Once the hospital has decided it is feasible to establish a perinatal home-care program, there are several options for the organizational structure. Generally, they fall into the following three categories: a new service within an existing hospital home-care division, a new program within the hospital perinatal center, or a partnership or subcontracting with an outside agency. If a partnership or subcontracting with an outside agency is considered, the
ha2 J O G F N
Volume 23. Number 8
Home Cure
legal and administrative departments need to be involved in the planning process. They will need to examine the legal implications with this type of structure (O’Niel, 1988). Areas to consider in determining the options of organizational structure would include the following: Administration andphysician commitment: Does the program meet the goals and mission of the hospital? Will there be administrative and physician commitment and support to the success of the program? Is there trust established, which is essential for the program to thrive? Is it financially viable? Nursing care and established relationships:
Does the home-care nursing staff have trusted and respectful relationships with inpatient staff and physicians? Is there competency and depth of experience in perinatal care? Are there skilled and knowledgeable nurses available and interested to staff the program? Availability of technology:
Does the hospital have the technology or resources to invest in the needed technology for the program (i.e., portable fetal monitors, portable ultrasound machines, computer capabilities, infusion pumps, cellular telephones)? If the technology is not available, should it be purchased or should it be obtained from an outside agency through a partnership or subcontracting? Risk management and quality of care
Does the option facilitate consistency in inpatient and home-care standards? Does it support continuity of care between the hospital and the home?
Stafing of the Program One of the greatest advantages of a hospital-based perinatal home-care program is the internal availability of highly knowledgeable and skilled inpatient staff. Interested nursing staff can be cross-trained to the home-care area to provide care to patients referred to the program. Physicians are more likely to refer patients to a program that is staffed with nurses they know and trust from the hospital setting than they would to a program staffed with nurses with whom they are not familiar. Fundamentally, the success or failure of a program is based on the reaction of the hospital medical staff, their support and their perceived value of home care, and their subsequent decisions to refer patients to the program. Marketing a
October 1994
new perinatal program to physicians that know and trust the staff is a great advantage to a program’s success (Louden, 1987; Donlevy, 1993). As the program begins, there may not be enough patient care hours to justify totally dedicated home-care staff, although patient volumes may increase to require permanent staff. It is important to keep creative staffing options and designs open between the hospital units and the home-care program. Nurse managers often are familiar with the concept of multiunit employees-nurses who have a home base on one unit and float hours to another, as needed. This translates comfortably to staffing for home care, if one considers home care as a “unit.” It creates flexibility for staffing and can address a fluctuating hospital census and the need to provide alternative nursing opportunities (Donlevy, 1993; Androwich, 1988). Perinatal home care requires a combination of knowledge bases: perinatal nursing and home-care nursing. The nurses for the inpatient setting have skills that must be expanded into the specialty of home care, and the home-care nurses need to have clinical experience in the hospital to gain the obstetric nursing specialty. A home-care program provides opportunities for professional growth and diversity in practice for inpatient nursing staff. Perinatal home care is not providing inpatient care in the home. Nurses who can expand into perinatal home-care experience practice in the home environment, where they function independently, adjusting to the needs and challenges of each different home and family situation. This is considered a challenging and satisfying area of practice for nurses in the field. Once staff have been identified for the program, it is imperative that they receive comprehensive orientation into home care, which is uniquely different from inpatient care delivery. Perinatal home-care nursing practice requires knowledge and understanding of childbearing/ childrearing, family systems, public health principles, life transitions, health education, and adult learning principles, as well as the expert perinatal nursing skills from the inpatient setting. The nurse functions independently with no direct supervision o r assistance of a team, such as one experiences on an in-patient nursing unit (Benefield, 1988; Dahlberg, 1988). This requires a strong knowledge base and the personal confidence to seek assistance when required. It takes approximately 6 months for an inpatient perinatal nurse with no home-care experience to feel completely competent in the home setting and to meet the productivity standards expected of experienced staff members. The commitment of time and acquisition of knowledge requires thoughtful and intentional recruitment of qualified staff (Montgomery, 1993b). When staff recruitment and retention are issues of concern for a hospital, having home-care opportunities available to nursing staff can aid in the recruitment of talented staff. It provides opportunities for nurses to move into the home-carefield, rather than having to leave a system for new and different career opportunities. With the
J O G N N
683
C L I N I C A L I S S U E S
shifting of health care from the hospital to the home, this is a factor to consider.
Patient Selection Perinatal home care is for antepartum and postpartum obstetric patients. Depending upon the program’s focus, patient selection is determined by the mission of the program and the scope of care and services offered. For current Medicare reimbursement, all services in the home must be under a physician’s direction. The patient must be homebound (considerable difficulty and taxing effort to leave the home) and have a skilled nursing need, as defined by Medicare. The services also must be intermittent (Montgomery, 1993a). It is important for the perinatal program to clearly define its services to assure appropriate types of patients access to care. For example, each agency needs to determine the scope of practice. Some perinatal home-care programs may include services for antepartum, postpartum, and high-risk neonates, whereas another agency may practice exclusively in one area. The agency also may decide not to provide specific services, such as intravenous therapies, home phototherapy, or fetal heart rate monitoring. Written materials describing the services offered will assist physicians and nursing staff in making appropriate referrals. The home-care nursing staff collaborate with the inpatient staff, clinic nursing staff, and physicians to be sure that the patient can be safely cared for at home. Perinatal home visits can enhance recovery and adjustments where patients need it the most, in their homes (Arnold & Bakewell-Sachs, 1991). A current trend is for postpartum hospital stays to be decreased from a 2-day stay to discharge within 24 hours or less after a vaginal birth. Hospitals are looking to home visits as a way to provide postpartum care and meet the needs of these families. At the first postpartum home visit, the nurse completes a maternal and infant assessment and individualizes the care, depending on’the family’s needs and concerns in the home environment. The timing and number of visits are determined by the individual needs of each mother, neonate, and family unit (Evans, 1991; McCarty, 1980;Jansson, 1985). High-risk antepartum home care also is an area of significant home-care needs. Patients experiencing a pregnancy complication and requiring bed rest may be referred to the program. As an alternative to lengthy hospital stays, certain high-risk antepartum women can be safely discharged when a perinatal home-care program can provide home visits and follow-up. Preterm labor, hypertension during pregnancy, or bleeding are some of the most common pregnancy complications women have when referred for home care. There are technologies, such as infusion pumps, remote uterine or blood pressure monitors, and fetal monitors that can assist the woman and health-care team to assure the safety of the woman’s condition at home (Donlevy, 1993; Dahlberg et al., 1989; Dahlberg, 1988).
684 J 0 G N N
The high risk neonate is another patient population that requires significant home follow-up. Nurses specializing in the care of the high-risk neonate are able to assist families in the transition from hospital to home. The care may be short term or long term, depending upon the needs of the infant and family. Ongoing communication within the health-care team (including the home-care agency) is imperative for coordination of care to occur in a seamless fashion. This happens through a written plan of care that is passed from inpatient to home care and from home care to inpatient, depending upon the flow of care. Verbal updates and care planning can occur during rounds or in telephone conversations as patient care continues in the home or hospital setting. An example of such communication is an education flow sheet for postpartum short stay that begins prenatally, continues during the hospital stay, and is completed by the home visiting nurse. Another example would be the long-term antepartum patient or high-risk neonate whose care is anticipated to require hospital stays and home care for an extended period of time. Hospital and home care begin coordinating care and have ongoing communication updates, which will assist care givers and the patient with optimum care.
Reimbursement and Billing Systems As home care has evolved into a major component of the
health-caqe system, many third-party payers reimburse home-care services out of a division separate from their hospital contracting and reimbursement division. Recognizing this, it is important for the hospital to set up the home-care contracting and billing system that is responsive to the payers as a key customer. The hospital contracting department must gain an understanding of the requirements and uniqueness of perinatal home care to negotiate a contract for services with payers. It is essential that a program representative who is knowledgeable about the details of clinical services be present at some of the contract negotiation meetings to assure realistic requirements of the services and to ensure that clinical patient implications are effectively conveyed to the payer. In addition to having contracts in place, home-care payers usually require prior authorization for any home services before they are initiated. This requires a knowledgeable home-care staff person in clinical services to contact the payer, explain services, and obtain approval for the care. Payers usually assign a case manager to the patient’s case, and this case manager, working for the payer, will monitor all of the care provided to the patient. Relationships with these case managers are important to assure appropriate and effective services to patients. Third-party payer policies may require a copay f i r home-care services. The home-care program must explore the insurance benefits the policy has and completely inform the family of their coverage and any fi-
Volume 2.3, Number 8
Home Care
nancial responsibilities they would have if they accepted
to allow the program to function outside of the walls of
home-care services. This is another area in which contracts with the payers are so important for the home-care program. The financial vulnerability of the family often decreases if the program has a contract with the payer and is considered a preferred provider.
the hospital. The community focus, providing quality care to patients referred to the program, is of utmost importance. This equates to the program creating relationships beyond the usual relationships of some hospitals in today’s setting, i.e., physicians who refer patients but who d o not have privileges at the hospital or patients who are never admitted to the hospital but are referred for homecare services.
Use of Resources In a hospital-based program, there are opportunities to use resources within the hospital setting, such as therapists, social workers, dietitians, parent-infant specialists, and other disciplines. The patient experiences increased continuity of care and overall satisfaction with the hospital services because there is not a requirement for an inpatient admission to obtain services (Widmer & Martinson, 1989). This can provide a market advantage for the hospital and strengthen quality through a more comprehensive service. The community also may have resources that are willing and able to come into the hospital to begin establishing a relationship with the family and provide follow up in the home setting (i.e., Early Childhood Family Education, neighborhood support programs, and parent-toparent support programs). It is important for the homecare program and hospital to keep resource information available for the families.
Regulations and Lieensure Issues It is imperative that the perinatal center work with hospital administrators and home-care experts to assist in the development of the home-care program so that in the planning phase, all of the state requirements for home care are understood and considered. There are a number of legislative and regulatory issues that can affect a homecare agency, including licensing laws, wage and hours laws, infection control regulations, equal opportunity, Occupational Safety and Health Administration (OSHA) regulations, and employee health screening (Montgomery, 1993b). The Joint Commission on Accreditation of Healthcare Organizations (‘JCAHO) also has standards for hospital-based home health-care programs. The Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) has standards that address antepartum, postpartum, and neonatal care. It is important to obtain a copy of these standards before writing policies, procedures, and standards of care for the program. Hospital quality activities can be applied to the outcomes of the homecare program and help meet the requirements for regulatory agencies.
Nondirect Care StaJing Hours All home-care nursing staff members reflect the quality
of the program and thus have a great impact on public relations and marketability of services. On some occasions this requires sanctioning time for relationships and connections to occur that assure referrals and satisfaction with services. Controlling costs is important. However, there is a need for home-care staff to connect with inpatient staff and physicians. StaJing Shortage If staffing is tight on the inpatient units, it can be viewed negatively when highly skilled and knowledgeable nursing staff choose to take home-care positions and transfer from a unit to go to a busy home-care area. Contracts Within a large hospital center, a small perinatal homecare program can get lost in the high acuity, big picture. However, once there is a commitment to have such a program, focused attention is needed to ensure the acquisition of payer contracts for the program to be a provider. The worst case scenario would be the program exists, but patients cannot be admitted because the program does not have provider contracts with insurance companies.
Summary Hospital-based home-care programs increase continuity of care through the joint planning and implementation of care. This enhances patients’ and families’ satisfaction with the hospital and home-care experience. Physicians are essential to the program’s success, and their referrals are contingent upon trust and respect for the knowledge and skills of the nursing staff providing the care. Through cross-training experienced perinatal nursing staff, the program will be established from the beginning with efficiency and high quality. The hospital can manage the length of stays more effectively with a known high quality home-care program. Home-careprograms reflect a direct strategy for responding to today’s changing health-care environment and the shift of patients from the inpatient setting to outpatient services and home care.
Some SpeciJic Challenges
References
Beyond the Walls Having a specialized home-care program requires the ability of the manager of the program and administration
Androwich, I. M. (1988). Creative utilization of staff. In L. E. Benefield (Ed.), Home health care managernent(pp. 180199).Englewood Cliffs, NJ: Prentice Hall.
October 1994
JOG”
685
CLINICAL
I S S U E S
Montgomery, P. (19934. Starting a hospital-based home health agency: Part 1. the service and its environment. Nursing Management, 24,39-41. Montgomery, P. (199313). Starting a hospital-based home health agency: Part 11. key success factors. Nursing Management, 24,54-57. O’Niel, E. (1988). Diversification and restructuring. In L. E. Benefield (Ed.), Home health care management ( p p . 127132). Englewood Cliffs, NJ: Prentice Hall. Widmer, A. G . , 8r Martinson, I . (1989) The continuum of care: Partners in acute and chronic care. In A. G . Widmer 8r I . Martinson (Eds.), Home health care nursitzg(pp. 10). Philadelphia: WB Saunders.
Arnold, L., 8r Bakewell-Sachs, S. (1991). Models of perinatal home follow-up. journal of Perinatal atzd Neonatal Nursiizg, 5, 18-26. Benefield, L. E. (1988). Trends in home health care. In L. E. Benefield (Ed.), Home health care management ( p p . 45). Englewood Cliffs, NJ: Prentice Hall. Dahlberg, N . L. F. (1988).Aperinatal center antepartum homecare program. JOGNN, 1730-34. Dahlberg, N . L. F . , Parker, L., 8r Knox, G. E. (1989). A new home care challenge: The high risk antepartum client. Caring, 8, 24-30. Donlevy, J . (1993). Responsive restructuring: Part 1. acute care nursing provide home visits. The New Definition, 8, 1-3. Evans, C. J. (1991). Description of a home follow-up program for childbearing families.JOGNN, 20, 113-1 18. Jansson, P. (1985) Early postpartum discharge. AmericanjournalofNursing, 85, 547-550. Lerman, D. (1987). The home care opportunity. In D. Lerman (Ed.), Home care: Positioning the hospital for the future (pp. 1-16). Chicago: American Hospital Publishing. Louden, T. L. (1987). Astrategic plan. In D. Lerman (Ed.), Home care: Positioning the hospital for the future ( p p . 48-49). Chicago: American Hospital Publishing. McCarty, E. (1980). Early postpartum nursing care of mother and infant in the home care setting. Nursing Clirzics of North America, 15,361-372.
Mary Koloroutis is the Director of Nursing WomenCare and Center for Professional and Clinical Development at Abbott Northwestern Hospital in Minneapolis, MN.
686 J O C N N
Volume 23. Number 8
Addressfor correspondence: Nancy L. Friest Dahlberg, MS, RNC, Minnesota OB Homecare, Abbott Northwestern Hospital, 800 28th Street, Minneapolis, MN 55407. Nancy L. Friest Dahlberg is the Clinical Nurse Manager of Minnesota OB Homecare Program, a hospital-based home care program of Abbott Northwestern HospZtal in Minneapolis, MN.
Hospital-Based Perinatal Home-Care Program Nancy L. Friest Dahlberg, MS, RNC, Mary Koloroutis, MS, RN
In recent years, hospitals have established home-care programs to provide care on a continuum,meeting needs in the hospital and home setting, whichever is most appropriate and efficient in response to defined patient needs. Hospital-basedhome-care programs with specialization in perinatal nursing have been established to meet the care needs of patients and their families during antepartum, postpartum, and neonatal periods. One of the greatest advantages of a hospital-basedprogram is the internal availability of highly knowledgeable and skilled nursing staff. Physicians are more likely to refer patients to a program that is staffed with nurses they know and trust from the hospital setting. More cost-effective and coordinated care is achieved through the appropriate use of resources across the continuum.
meet their needs. Home-care programs with specialization in perinatal nursing have been established to meet the needs of antepartum, postpartum, and neonatal patients (Dahlberg, 1988; Dahlberg, Parker, & Knox, 1989; Donlevy, 1993; Evans, 1991).
Organizational Structure
n recent years, hospitals have established home-care programs to provide a continuum of care that meets patients’ needs in the hospital or home; have some internal control over the cost, quality, and access to service; and manage the inpatient stay more effectively. Hospitals also have recognized an opportunity to increase revenue through diversified services and be competitive in contracting to serve patient populations (Lerman, 1987). Traditionally, there are two types of populations served by home care, patients who have been discharged from the hospital and those who are chronically ill (Montgomery, 1993a). Increases in public awareness of the availability of home-care services, along with shorter hospital stays, have increased the demand for such services (Benefield, 1988). Obstetric services are responding to the changing health-care environment, which is seeking alternatives to hospital stays. Home care is an obvious and viable alternative. Some patients may be treated at home and a hospital admission prevented, whereas others may have shorter hospital stays and be discharged to home care for continued nursing services and safe provision of care to
In determining the feasibility of starting a perinatal home-care program, the hospital needs to fully investigate the following issues: areas of competition, market entry, cliept base, referral sources, physician involvement with other existing programs, barriers to success, payer mix, state home-care laws and regulations, and hospital and physician support for a program (Lerman, 1987). A program will be most successful if a market assessment indicates the need for the program; there is physician commitment to and value in the program and services to be offered; and there is hospital commitment to providing the leadership and staff development required for high-quality care and service. Some health-care providers in the perinatal area may have a limited knowledge of home-care services. Many may resist home care because of a lack of understanding regarding the level of skilled nursing care that can be provided in the home. Other health-care providers may have the perception that home care is for maintenance and housekeeping, rather than the high-technology, skilled nursing specialty that has evolved during the last several years (Widmer & Martinson, 1989). Thus, some education and preparation of hospital staff and physicians as a foundation for programming are essential. Once the hospital has decided it is feasible to establish a perinatal home-care program, there are several options for the organizational structure. Generally, they fall into the following three categories: a new service within an existing hospital home-care division, a new program within the hospital perinatal center, or a partnership or subcontracting with an outside agency. If a partnership or subcontracting with an outside agency is considered, the
ha2 J O G F N
Volume 23. Number 8
Home Cure
legal and administrative departments need to be involved in the planning process. They will need to examine the legal implications with this type of structure (O’Niel, 1988). Areas to consider in determining the options of organizational structure would include the following: Administration andphysician commitment: Does the program meet the goals and mission of the hospital? Will there be administrative and physician commitment and support to the success of the program? Is there trust established, which is essential for the program to thrive? Is it financially viable? Nursing care and established relationships:
Does the home-care nursing staff have trusted and respectful relationships with inpatient staff and physicians? Is there competency and depth of experience in perinatal care? Are there skilled and knowledgeable nurses available and interested to staff the program? Availability of technology:
Does the hospital have the technology or resources to invest in the needed technology for the program (i.e., portable fetal monitors, portable ultrasound machines, computer capabilities, infusion pumps, cellular telephones)? If the technology is not available, should it be purchased or should it be obtained from an outside agency through a partnership or subcontracting? Risk management and quality of care
Does the option facilitate consistency in inpatient and home-care standards? Does it support continuity of care between the hospital and the home?
Stafing of the Program One of the greatest advantages of a hospital-based perinatal home-care program is the internal availability of highly knowledgeable and skilled inpatient staff. Interested nursing staff can be cross-trained to the home-care area to provide care to patients referred to the program. Physicians are more likely to refer patients to a program that is staffed with nurses they know and trust from the hospital setting than they would to a program staffed with nurses with whom they are not familiar. Fundamentally, the success or failure of a program is based on the reaction of the hospital medical staff, their support and their perceived value of home care, and their subsequent decisions to refer patients to the program. Marketing a
October 1994
new perinatal program to physicians that know and trust the staff is a great advantage to a program’s success (Louden, 1987; Donlevy, 1993). As the program begins, there may not be enough patient care hours to justify totally dedicated home-care staff, although patient volumes may increase to require permanent staff. It is important to keep creative staffing options and designs open between the hospital units and the home-care program. Nurse managers often are familiar with the concept of multiunit employees-nurses who have a home base on one unit and float hours to another, as needed. This translates comfortably to staffing for home care, if one considers home care as a “unit.” It creates flexibility for staffing and can address a fluctuating hospital census and the need to provide alternative nursing opportunities (Donlevy, 1993; Androwich, 1988). Perinatal home care requires a combination of knowledge bases: perinatal nursing and home-care nursing. The nurses for the inpatient setting have skills that must be expanded into the specialty of home care, and the home-care nurses need to have clinical experience in the hospital to gain the obstetric nursing specialty. A home-care program provides opportunities for professional growth and diversity in practice for inpatient nursing staff. Perinatal home care is not providing inpatient care in the home. Nurses who can expand into perinatal home-care experience practice in the home environment, where they function independently, adjusting to the needs and challenges of each different home and family situation. This is considered a challenging and satisfying area of practice for nurses in the field. Once staff have been identified for the program, it is imperative that they receive comprehensive orientation into home care, which is uniquely different from inpatient care delivery. Perinatal home-care nursing practice requires knowledge and understanding of childbearing/ childrearing, family systems, public health principles, life transitions, health education, and adult learning principles, as well as the expert perinatal nursing skills from the inpatient setting. The nurse functions independently with no direct supervision o r assistance of a team, such as one experiences on an in-patient nursing unit (Benefield, 1988; Dahlberg, 1988). This requires a strong knowledge base and the personal confidence to seek assistance when required. It takes approximately 6 months for an inpatient perinatal nurse with no home-care experience to feel completely competent in the home setting and to meet the productivity standards expected of experienced staff members. The commitment of time and acquisition of knowledge requires thoughtful and intentional recruitment of qualified staff (Montgomery, 1993b). When staff recruitment and retention are issues of concern for a hospital, having home-care opportunities available to nursing staff can aid in the recruitment of talented staff. It provides opportunities for nurses to move into the home-carefield, rather than having to leave a system for new and different career opportunities. With the
J O G N N
683
C L I N I C A L I S S U E S
shifting of health care from the hospital to the home, this is a factor to consider.
Patient Selection Perinatal home care is for antepartum and postpartum obstetric patients. Depending upon the program’s focus, patient selection is determined by the mission of the program and the scope of care and services offered. For current Medicare reimbursement, all services in the home must be under a physician’s direction. The patient must be homebound (considerable difficulty and taxing effort to leave the home) and have a skilled nursing need, as defined by Medicare. The services also must be intermittent (Montgomery, 1993a). It is important for the perinatal program to clearly define its services to assure appropriate types of patients access to care. For example, each agency needs to determine the scope of practice. Some perinatal home-care programs may include services for antepartum, postpartum, and high-risk neonates, whereas another agency may practice exclusively in one area. The agency also may decide not to provide specific services, such as intravenous therapies, home phototherapy, or fetal heart rate monitoring. Written materials describing the services offered will assist physicians and nursing staff in making appropriate referrals. The home-care nursing staff collaborate with the inpatient staff, clinic nursing staff, and physicians to be sure that the patient can be safely cared for at home. Perinatal home visits can enhance recovery and adjustments where patients need it the most, in their homes (Arnold & Bakewell-Sachs, 1991). A current trend is for postpartum hospital stays to be decreased from a 2-day stay to discharge within 24 hours or less after a vaginal birth. Hospitals are looking to home visits as a way to provide postpartum care and meet the needs of these families. At the first postpartum home visit, the nurse completes a maternal and infant assessment and individualizes the care, depending on’the family’s needs and concerns in the home environment. The timing and number of visits are determined by the individual needs of each mother, neonate, and family unit (Evans, 1991; McCarty, 1980;Jansson, 1985). High-risk antepartum home care also is an area of significant home-care needs. Patients experiencing a pregnancy complication and requiring bed rest may be referred to the program. As an alternative to lengthy hospital stays, certain high-risk antepartum women can be safely discharged when a perinatal home-care program can provide home visits and follow-up. Preterm labor, hypertension during pregnancy, or bleeding are some of the most common pregnancy complications women have when referred for home care. There are technologies, such as infusion pumps, remote uterine or blood pressure monitors, and fetal monitors that can assist the woman and health-care team to assure the safety of the woman’s condition at home (Donlevy, 1993; Dahlberg et al., 1989; Dahlberg, 1988).
684 J 0 G N N
The high risk neonate is another patient population that requires significant home follow-up. Nurses specializing in the care of the high-risk neonate are able to assist families in the transition from hospital to home. The care may be short term or long term, depending upon the needs of the infant and family. Ongoing communication within the health-care team (including the home-care agency) is imperative for coordination of care to occur in a seamless fashion. This happens through a written plan of care that is passed from inpatient to home care and from home care to inpatient, depending upon the flow of care. Verbal updates and care planning can occur during rounds or in telephone conversations as patient care continues in the home or hospital setting. An example of such communication is an education flow sheet for postpartum short stay that begins prenatally, continues during the hospital stay, and is completed by the home visiting nurse. Another example would be the long-term antepartum patient or high-risk neonate whose care is anticipated to require hospital stays and home care for an extended period of time. Hospital and home care begin coordinating care and have ongoing communication updates, which will assist care givers and the patient with optimum care.
Reimbursement and Billing Systems As home care has evolved into a major component of the
health-caqe system, many third-party payers reimburse home-care services out of a division separate from their hospital contracting and reimbursement division. Recognizing this, it is important for the hospital to set up the home-care contracting and billing system that is responsive to the payers as a key customer. The hospital contracting department must gain an understanding of the requirements and uniqueness of perinatal home care to negotiate a contract for services with payers. It is essential that a program representative who is knowledgeable about the details of clinical services be present at some of the contract negotiation meetings to assure realistic requirements of the services and to ensure that clinical patient implications are effectively conveyed to the payer. In addition to having contracts in place, home-care payers usually require prior authorization for any home services before they are initiated. This requires a knowledgeable home-care staff person in clinical services to contact the payer, explain services, and obtain approval for the care. Payers usually assign a case manager to the patient’s case, and this case manager, working for the payer, will monitor all of the care provided to the patient. Relationships with these case managers are important to assure appropriate and effective services to patients. Third-party payer policies may require a copay f i r home-care services. The home-care program must explore the insurance benefits the policy has and completely inform the family of their coverage and any fi-
Volume 2.3, Number 8
Home Care
nancial responsibilities they would have if they accepted
to allow the program to function outside of the walls of
home-care services. This is another area in which contracts with the payers are so important for the home-care program. The financial vulnerability of the family often decreases if the program has a contract with the payer and is considered a preferred provider.
the hospital. The community focus, providing quality care to patients referred to the program, is of utmost importance. This equates to the program creating relationships beyond the usual relationships of some hospitals in today’s setting, i.e., physicians who refer patients but who d o not have privileges at the hospital or patients who are never admitted to the hospital but are referred for homecare services.
Use of Resources In a hospital-based program, there are opportunities to use resources within the hospital setting, such as therapists, social workers, dietitians, parent-infant specialists, and other disciplines. The patient experiences increased continuity of care and overall satisfaction with the hospital services because there is not a requirement for an inpatient admission to obtain services (Widmer & Martinson, 1989). This can provide a market advantage for the hospital and strengthen quality through a more comprehensive service. The community also may have resources that are willing and able to come into the hospital to begin establishing a relationship with the family and provide follow up in the home setting (i.e., Early Childhood Family Education, neighborhood support programs, and parent-toparent support programs). It is important for the homecare program and hospital to keep resource information available for the families.
Regulations and Lieensure Issues It is imperative that the perinatal center work with hospital administrators and home-care experts to assist in the development of the home-care program so that in the planning phase, all of the state requirements for home care are understood and considered. There are a number of legislative and regulatory issues that can affect a homecare agency, including licensing laws, wage and hours laws, infection control regulations, equal opportunity, Occupational Safety and Health Administration (OSHA) regulations, and employee health screening (Montgomery, 1993b). The Joint Commission on Accreditation of Healthcare Organizations (‘JCAHO) also has standards for hospital-based home health-care programs. The Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) has standards that address antepartum, postpartum, and neonatal care. It is important to obtain a copy of these standards before writing policies, procedures, and standards of care for the program. Hospital quality activities can be applied to the outcomes of the homecare program and help meet the requirements for regulatory agencies.
Nondirect Care StaJing Hours All home-care nursing staff members reflect the quality
of the program and thus have a great impact on public relations and marketability of services. On some occasions this requires sanctioning time for relationships and connections to occur that assure referrals and satisfaction with services. Controlling costs is important. However, there is a need for home-care staff to connect with inpatient staff and physicians. StaJing Shortage If staffing is tight on the inpatient units, it can be viewed negatively when highly skilled and knowledgeable nursing staff choose to take home-care positions and transfer from a unit to go to a busy home-care area. Contracts Within a large hospital center, a small perinatal homecare program can get lost in the high acuity, big picture. However, once there is a commitment to have such a program, focused attention is needed to ensure the acquisition of payer contracts for the program to be a provider. The worst case scenario would be the program exists, but patients cannot be admitted because the program does not have provider contracts with insurance companies.
Summary Hospital-based home-care programs increase continuity of care through the joint planning and implementation of care. This enhances patients’ and families’ satisfaction with the hospital and home-care experience. Physicians are essential to the program’s success, and their referrals are contingent upon trust and respect for the knowledge and skills of the nursing staff providing the care. Through cross-training experienced perinatal nursing staff, the program will be established from the beginning with efficiency and high quality. The hospital can manage the length of stays more effectively with a known high quality home-care program. Home-careprograms reflect a direct strategy for responding to today’s changing health-care environment and the shift of patients from the inpatient setting to outpatient services and home care.
Some SpeciJic Challenges
References
Beyond the Walls Having a specialized home-care program requires the ability of the manager of the program and administration
Androwich, I. M. (1988). Creative utilization of staff. In L. E. Benefield (Ed.), Home health care managernent(pp. 180199).Englewood Cliffs, NJ: Prentice Hall.
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Montgomery, P. (19934. Starting a hospital-based home health agency: Part 1. the service and its environment. Nursing Management, 24,39-41. Montgomery, P. (199313). Starting a hospital-based home health agency: Part 11. key success factors. Nursing Management, 24,54-57. O’Niel, E. (1988). Diversification and restructuring. In L. E. Benefield (Ed.), Home health care management ( p p . 127132). Englewood Cliffs, NJ: Prentice Hall. Widmer, A. G . , 8r Martinson, I . (1989) The continuum of care: Partners in acute and chronic care. In A. G . Widmer 8r I . Martinson (Eds.), Home health care nursitzg(pp. 10). Philadelphia: WB Saunders.
Arnold, L., 8r Bakewell-Sachs, S. (1991). Models of perinatal home follow-up. journal of Perinatal atzd Neonatal Nursiizg, 5, 18-26. Benefield, L. E. (1988). Trends in home health care. In L. E. Benefield (Ed.), Home health care management ( p p . 45). Englewood Cliffs, NJ: Prentice Hall. Dahlberg, N . L. F. (1988).Aperinatal center antepartum homecare program. JOGNN, 1730-34. Dahlberg, N . L. F . , Parker, L., 8r Knox, G. E. (1989). A new home care challenge: The high risk antepartum client. Caring, 8, 24-30. Donlevy, J . (1993). Responsive restructuring: Part 1. acute care nursing provide home visits. The New Definition, 8, 1-3. Evans, C. J. (1991). Description of a home follow-up program for childbearing families.JOGNN, 20, 113-1 18. Jansson, P. (1985) Early postpartum discharge. AmericanjournalofNursing, 85, 547-550. Lerman, D. (1987). The home care opportunity. In D. Lerman (Ed.), Home care: Positioning the hospital for the future (pp. 1-16). Chicago: American Hospital Publishing. Louden, T. L. (1987). Astrategic plan. In D. Lerman (Ed.), Home care: Positioning the hospital for the future ( p p . 48-49). Chicago: American Hospital Publishing. McCarty, E. (1980). Early postpartum nursing care of mother and infant in the home care setting. Nursing Clirzics of North America, 15,361-372.
Mary Koloroutis is the Director of Nursing WomenCare and Center for Professional and Clinical Development at Abbott Northwestern Hospital in Minneapolis, MN.
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Addressfor correspondence: Nancy L. Friest Dahlberg, MS, RNC, Minnesota OB Homecare, Abbott Northwestern Hospital, 800 28th Street, Minneapolis, MN 55407. Nancy L. Friest Dahlberg is the Clinical Nurse Manager of Minnesota OB Homecare Program, a hospital-based home care program of Abbott Northwestern HospZtal in Minneapolis, MN.