History: At one time, the poor were sent to the hospital while the wealthy received health care services in the comfort of their homes. Physicians made house calls and nurses made home visits. Both provided health care services and education. These nurses became known as public health or visiting nurses. In the twenty-first century, home health services are still provided in the patient’s residence, but the technology, costs, and scope of services have changed.
Coming home: Cancer patients are often discharged from hospitals while still recovering from illness or surgery. Supportive skilled services and treatments by the home health care team make it possible for cancer patients to heal in the comfort of their homes. Home health care agencies provide intermittent skilled and nonskilled home care services as indicated by the patient’s diagnosis, medical orders, and insurance reimbursement.
The home care team usually includes a multidisciplinary group of professionals such as registered nurses, nursing assistants/home health aides, physical therapists, respiratory therapists, occupational therapists, speech therapists, and medical social workers. Sometimes agencies also include chaplains and volunteers. Staff members work together to provide holistic health services in the home, with the physician providing oversight through the medical care plan.
Most home care agencies provide home health services for Medicare patients as well as private insurance and self-pay patients. To qualify for home health care services under Medicare, the patient must meet the following criteria:
- Require a skilled service by a registered nurse, physical therapist, or occupational therapist.
- Meet guidelines as a homebound patient due to illness or injury. The patient does not have to be bed-bound but must require considerable assistance or use a supportive device, such as a wheelchair or walker, to get around. The patient is able to leave the home only on a limited basis, usually for doctor office visits.
- Be under the care of a qualified physician who provides written medical orders to the home care agency for skilled care services and treatments.
- Receive home health services from a certified home care agency, subject to state and federal requirements and inspection.
Types of home health services: The interdisciplinary team of professionals coordinates the skills and knowledge needed to provide a comprehensive approach to home health services. Services may vary based on the needs of the cancer patient and the reimbursement. Services are provided on an intermittent basis (usually several times a week) so the caregiver remains the person responsible for daily continuous care. Home health services are not meant to be custodial or long term.
Skilled nursing services are provided by a registered nurse (R.N.). The nurse usually coordinates care and develops the patient’s plan of care. Nurses provide infusion therapy in the home for intravenous antibiotics, chemotherapy, or home parenteral nutrition (HPN). They support the patient and caregiver with teaching. They provide pain management and medication information. The R.N. supervises the home health aide who gives personal care to the patient in the home. Also, the nurse assesses ongoing problems and addresses these promptly. Home safety is important for effective home health services.
Physical therapists provide physical therapy to homebound patients with the goal of restoring function, encouraging independence, and minimizing decline. Physical therapists teach patients and caregivers how to maintain gains in function and prevent further injury.
Occupational therapists are key to enabling homebound patients to perform activities of daily living, such as bathing, dressing, feeding, or toileting. They may help redesign the placement of kitchen dishes and utensils to allow the patient with decreased functional ability to carry on daily chores. These professionals teach the patient how to use adaptive equipment such as a prosthesis. The goal is for the patient to attain the highest level of functioning possible.
Speech therapists work with patients who have suffered strokes, are neurologically compromised, or are having trouble swallowing or communicating, as is common among patients with cancers of the lips, mouth, or throat. Again, the goal is optimal function of the patient in normal routines.
Home health aides can make all the difference in the success of home health services. These caregivers are supervised and directed by the R.N. while providing personal hygiene care such as bathing, dressing, feeding, washing hair, or helping the patient walk. Sometimes they provide light housekeeping or a simple meal if these tasks are covered by the insurance provider. Many patients and caregivers report that the home health aide is the most helpful of all home health service providers.
Medical social workers assist cancer patients and caregivers to assess resources available in the community. Their skills are valuable as they facilitate referrals to other services, provide counseling and support, and act as patient advocates.
Registered dietitians and nutritionists may provide education for the patient and caregiver. These professionals are especially important if the patient is receiving an infusion of home parenteral nutrition (nutrition introduced nonintestinally, such as intravenously). They also can teach patients and caregivers critical aspects of diet and nutrition related to their cancer.
An infusion therapy company may provide infusion therapy products and equipment, becoming an important part of the home health care team. Once infusion therapy was provided only in a hospital setting, but now it is a part of home care services. Intravenous antibiotics, chemotherapy, or home parenteral nutrition is delivered through an infusion pump within the residence.
Specimens for tests ordered by the physician can be collected in the home. Samples can be taken by a registered nurse or phlebotomist. Lab tests can vary from routine blood counts to monitoring of medication/drug levels needed for the treatment plan.
Home medical equipment providers play a critical role in home health services. Specialized equipment provided in the home can make care of the patient more efficient and ease the physical stress on the caregiver. Typical equipment needs in the home include special beds designed for home use, walkers, wheelchairs, wound and ostomy supplies, catheters, bed pads for incontinence, and oxygen therapy and supplies.
Volunteers may be a part of the home health care service. They can provide a range of services such as cooking, cleaning, emotional support, providing transportation, making phone calls, or providing respite care while the caregiver rests or runs errands. These services are needed in the home but rarely are covered under the reimbursement insurance.
Chaplains are sometimes a part of the home care team, especially in a specialized home health service called hospice for terminally ill patients. These professionals provide spiritual support to the patient, caregiver, and home care staff.
Skilled vs. custodial health care services: Some cancer patients may not need a skilled service provided by professionals but may require support services to continue to stay in their homes. These services are considered custodial services and are usually not covered by Medicare or private insurance. Community or private agencies may provide support services such as private duty nurses or sitters to stay with the patient for shifts of eight to twelve hours, live-in companions, or home-delivered meals. Some pharmacies provide delivery services for medications. Groceries can be delivered to the home. These types of services are generally considered out-of-pocket expenses and are paid for by the patient, caregiver, or both. These services, however, can help the patient stay in the home environment. Medical social workers from a home health care agency are available to assess patient needs and make necessary referrals to community agencies.
Nontraditional therapy at home: Cancer patients may choose to pay for nontraditional care services delivered in their homes. Therapies and services that may be available to homebound patients include massage therapy, podiatrist services, and acupuncture services. Engaging in relaxation therapies such as yoga, meditation, tai chi, or guided imagery may be useful to reduce stress. Patients may choose to investigate or use herbal or vitamin supplements, but they should discuss any supplement with their health care provider before adding these to the mediations already prescribed; certain medication interactions can occur when supplements are taken with prescribed drugs. For their safety and optimal health outcome, patients are advised to discuss alternative therapies with their health care provider.
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Meyer, Marie M., and Paula Derr. The Comfort of Home: A Complete Guide for Caregivers. Portland, Oreg.: CareTrust Publications, 2007.
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