Lifestyle and Behavior

Home Health Care and Diabetes Assessment, Care, and

As hospitals, cognizant of the can cause poor sleep, nocturnal falls, measurement may not even be includ-
Diagnostic Related Groupings re- incontinence, dehydration, impaired ed in initial or ongoing patient assess-
imbursement criteria, continue to mobility, falls, and visual disturbances ments. Again, most home health care
shorten patients’ lengths of stay, home that interfere with self administration patients in the United States are
health care is increasingly relied upon of insulin.4 Yet diabetes is often put referred by hospitals to home health
to holistically address the needs of on the back burner of elderly patient care for whatever comorbid condition
patients at home. From a more posi- care. led to their hospitalization; they are
tive standpoint, health care in the Experts estimate that, in caring for rarely referred for diabetes care itself.
home environment is more comfort- the aging population, home health
able for patients, offers less risk of care providers are an increasingly Home Health Care: A Definition13
infection, saves health care dollars, essential segment of the health care The term “home health care” encom-
and lends itself to the promotion of system, especially in the United passes a wide range of health and
ongoing strategies to improve States.5–7 social services that are usually avail-
patients’ quality of life. able 24 hours a day. Home health
Diabetes mellitus, whether type 1 Diabetes as a Home Health Care care is indicated when an individual
or type 2, offers special challenges to Concern needs post-hospitalization care or
home health care providers world- The U.K. Prospective Diabetes Study prefers to stay at home but needs
wide. (UKPDS)8 and the Diabetes Control ongoing care that cannot easily or
A study funded by the American and Complications Trial (DCCT)9 effectively be provided by family and
Diabetes Association (ADA) found have shown that optimal control of friends. Increasingly, older people are
that “diabetes is rarely a focus of care blood glucose can make a difference choosing to live independent, non-
for patients with diabetes when they in preventing diabetes-related com- institutionalized lives. They are receiv-
require hospitalization for other con- plications. The question now is how ing home health care services as their
ditions.”1 The diagnosis of diabetes health care providers can under- physical capabilities decline or as
may not even be included in the hos- stand and use the UKPDS and there is a need for high-tech medical
pital records of people who have dia- DCCT to enhance diabetes manage- treatment (e.g., dialysis) to be carried
betes. According to Jeffrey B. Halter, ment and health status. Rappaport out in their home environments. In
MD, a professor of internal medicine et al.10 expressed the hope that these the United States, home health care
and director of the Geriatric Center at studies might encourage patients organizations include:
the University of Michigan in Ann and providers to take glycemic con- 1. Home health care agencies. These
Arbor, “Treatment of high blood glu- trol seriously “by creating plans to organizations are Medicare-certi-
cose levels is often ignored in older aggressively treat hyperglycemia and fied and meet minimum federal
people or relegated to secondary other risk factors and recognizing standards for patient care and
importance because of perceived bar- that at any point throughout the life management. The services they
riers that often do not exist.”2 A span, patients can alter the appear- provide are highly regulated.
recent epidemiological study found ance or progression of diabetes Home health agencies organize and
that 42% of the diabetic population complications.” coordinate the activities of care-
in the United States is 65 years or Many home health care patients giving teams that may include a
older. This proportion is projected to have never achieved glycemic control nurse (the primary provider), a
increase to 53% by 2025 and to 58% and are found on admission to home physical therapist, an occupational
by 2050.3 That is of concern because care to have blood glucose levels well therapist, a social worker, a regis-
people with diabetes and hyper- over 200 mg/dl, a level considered tered dietitian (RD), a homemaker
glycemia face a greater risk of major toxic11 that impairs leukocyte func- (an agency-provided individual
cognitive decline or physical disability tion,12 resulting in predisposition to who assists with cooking and
than do those without diabetes. In infection. If diabetes is not identified housekeeping), and home care
addition, hyperglycemia in the elderly as a home care concern, blood glucose aides. Home health agencies also
217
Diabetes Spectrum Volume 16, Number 4, 2003
 Lifestyle and Behavior

arrange for their clients to obtain sibilities for diabetes management care agencies on October 1, 2000,
the durable medical equipment and tasks. Patients and their caregivers was the greatest change in the
supplies needed for their care at need to understand and accept their Medicare home health care benefit
home. roles in the self-management of dia- since Medicare was originally enacted
2. Homemaker and home care aide betes. Buse15 has proposed that “the in 1965. Its single greatest goal is to
agencies. These organizations are selection of initial therapy should be maximize effective patient outcomes
usually licensed by the state. They based on mutually (patient and while minimizing costs and continuing
recruit, train, and supervise person- provider) recognized priorities.” He to deliver high-quality patient care.
nel who serve as homemakers, offers seven options to guide goal-set- Before the PPS, home care agencies
home care aides, and companions ting with diabetic patients: 1) minimal were paid for each patient visit, and
and assist patients with meal cost strategy, 2) minimal weight gain supplies needed to care for the patient
preparation, bathing, dressing, and strategy, 3) minimal injection strategy, were reimbursed separately. Now,
housekeeping. 4) minimal circulating insulin strate- under the PPS, Medicare gives home
3. Staffing and private-duty agencies. gy, 5) minimal patient effort strategy, health care agencies a standard flat fee
These groups provide nurses, 6) hypoglycemia avoidance strategy, to care for and provide necessary sup-
homemakers, home care aides, and and 7) postprandial targeting strategy. plies for each patient for a 60-day
companions. They are not required Home health care nurses can assist in period.
to be licensed or to meet any regu- realistic goal selection through inter- Home care is covered under
latory requirements. They recruit action with patients and caregivers in Medicare Part A. The national stan-
their own personnel and are their home setting, thereby providing dard payment rate for a 60-day
responsible for the care rendered. yet another means of stress relief. episode of home health care is
4. Registries. These are employment approximately $2,274 and includes
agencies for nurses and aides. They Home Health Care: Who Pays? services of all disciplines, all nonrou-
are usually not licensed or regulat- In the United States, Medicare pays tine medical supplies the patient may
ed. They are not required to screen for a limited amount of home health need during the episode, and any
or do background checks on care- care for Medicare recipients who are Medicare Part B outpatient therapy
givers they hire and send into homebound, under a physician’s care, costs the patient may incur during
patients’ homes. and in need of medically necessary that time. For clients with diabetes,
5. Independent providers. This skilled nursing services or therapy home health care agencies must
includes nurses, therapists, RDs, programs. Medicaid covers almost absorb the cost of insulin needles and
aides, homemakers, and compan- unlimited home health care for indi- syringes and blood testing supplies if
ions whom patients hire privately. viduals receiving federally assisted clinicians are administering or teach-
income maintenance payments (e.g., ing the administration of insulin or
Additional information about home Aid to Families With Dependent performing or teaching blood glucose
health care can be obtained at the Children, Social Security disability testing.
NAHC website: www.nahc.org. income, or the “categorically needy,” The case mix-adjusted rate is calcu-
such as aged, blind, or disabled indi- lated using the Home Health
Home Health Care: The Stress viduals). Several “Medigap” insurance Resource Group (HHRG). The
Reliever plans as well as some long-term care HHRG is a point system that com-
Home health care organizations pro- insurance plans also cover home care. bines assigned points for clinical,
vide mental and physical stress relief In countries with cradle-to-grave functional, and service utilization to
for patients at home. This is particu- health care systems, home health care reflect the intensity and cost of care
larly important for people who have agencies are often able to give free required by a typical patient with a
diabetes. Most stressors can cause care when there is an assessed and given group of diagnoses with nursing
increases in counter-regulatory hor- documented need. Individuals without assessment scores on the 23-item
mones. This can exacerbate insulin insurance coverage for home care Home Health Care Outcome and
resistance and lead to release of glu- must pay for these services out of Assessment Information Set (OASIS)
cose from the liver, resulting in ele- pocket. Questionnaire, which determines
vated blood glucose levels.14 The ther- In the United States, the Center for resource utilization for different types
apeutic presence and care of home Medicare and Medicaid Services of patients and measures the intensity
health care nurses can help reduce (CMS, formerly the Health Care of care and services required for each
these stress responses. They can also Financing Administration) implement- patient. The HHRG score for an indi-
help reduce external environmental ed in 2000 a new Prospective Payment vidual client is then multiplied by the
stressors by arranging for other need- System (PPS) and new conditions of standardized payment rate for the 60-
ed service, such as those provided by participation for home health agencies day episode of home health care
a home health aide, physical thera- that have forced home health care (approximately $2,274) to determine
pist, social worker, or community agencies to focus on cost containment the agency’s rate of payment for the
program (e.g., Meals on Wheels) and quality improvement. Many agen- 60-day episode. Nearly half of all
when indicated. cies have had to redesign their meth- HHRG scores are less than 1, result-
Patients and their caregivers often ods of care delivery to remain viable.16 ing in payments less than the stan-
also feel stress related to their respon- The PPS, implemented in all home Continued on p. 220
218
Diabetes Spectrum Volume 16, Number 4, 2003
 Lifestyle and Behavior

Continued from p. 218 2. Many physicians of home health these patients should be expected.
care patients are not concerned Therefore, there should be a mandate
dardized flat rate.17 Although CMS about hyperglycemia. In fact, many from CMS to support the direction
recognized that patients/clients with prefer to have patients’ blood glu- for this type of care. Without some
diabetes require greater resource uti- cose levels high rather than risk regulatory mandate, however, it is
lization, and therefore a higher re- them running serious low blood unlikely that most U.S. home health
imbursement rate for Home Health glucose, because hypoglycemia is care agencies will provide state-of-the-
Care, there is no question in the regarded as a significant change in art diabetes assessment, care, and edu-
OASIS that evaluates the quality of condition (SCIC) and is implicated cation—and especially adequate self-
diabetes intervention. The author has in mental status changes. A SCIC management education—for this
published a diabetes assessment tool must be reported to CMS. greatly at-risk population of patients.
that CMS could add to the OASIS.18 3. Physicians may not routinely order
hemoglobin A1c or fructosamine
Diabetes-Related Problems for Home tests or follow any ADA standards References
Care19 of care20 with their home care 1
Roman SH, Chassin MR: Windows of opportu-
In the current health care environ- patients with diabetes. Home nity to improve diabetes care when patients with
ment, there will be no administrative health care nurses have the poten- diabetes are hospitalized for other conditions.
movement toward improving quality tial to assist physicians to comply Diabetes Care 24:1371–1386, 2001
of diabetes care unless there is a relat- with such standards if their agen- 2
Halter JB: Diabetes mellitus in older adults:
ed profit incentive or a care deficit- cies consider such goals a priority. underdiagnosis and undertreatment. J Am
related penalty. Evidence-based It is clear, however, that elderly Geriatr Soc 48:340–341, 2000
improved methods and tools for patients (the largest percentage of 3
Boyle JP, Honeycutt AA, Narayan KMV,
achieving optimal glycemic control home health care clients) with dia- Hoerger TJ, Geiss LS, Chen H, Thompson TJ:
are now available. It is ironic that bar- betes do not appear to be receiving Impact of changing demography and disease
prevalence in the U.S. Diabetes Care
riers exist simultaneously to prevent optimal diabetes care.21 24:1936–1940, 2001
the delivery of state-of-the-art diabetes 4
assessment, care, and self-manage- The Future Fonseca V: Rationale for good glycemic control
in the elderly. Presentation at an Institute for
ment education to this population of The role of registered nurses (RNs) is Postgraduate Medicine seminar conducted in
patients in the most cost-effective of primary importance in home health conjunction with the American Association of
care-delivery setting: the home. An care. RNs formulate patients’ plans of Diabetes Educators Annual Meeting in Louisville
analysis of the current dilemma fol- care and coordinate the implementa- Ky., August 2001
lows: tion of those plans with all health care 5
Bauerhaus P, Staiger D: Future of the nurse
1. There is, at present, no regulatory team members. Home care agencies labor market according to health executives in
or accreditation mandate, and thus should have a clinical nurse specialist high managed care areas of the United States.
Image 29:313–319, 1997
no incentive, to provide state-of- (CNS) or nurse practitioner who is
6
the-art diabetes care and educa- also a certified diabetes educator Mitchell P: Protests force U.S. government to
tion. Although the diagnosis of dia- (CDE) available as a resource to help postpone home-care surveillance scheme. Lancet
353:1423, 1999
betes results in a higher reimburse- staff nurses keep their diabetes knowl-
7
ment for home health care, there is edge updated and to assist in assess- Schoen M, Koenig R: Home healthcare nursing:
past and present. Med Surg Nurs 6:230–233,
no regulatory agency that evaluates ment, care, and teaching22 of home 1997
the quality of home health inter- health care patients with diabetes to 8
ventions for patients with diabetes. meet the care standards of ADA and U.K. Prospective Diabetes Study (UKPDS)
Group: Intensive blood glucose control with sul-
If diabetes is not the primary diag- the American Association of Diabetes fonylureas or insulin compared with convention-
nosis, documentation of patients’ Educators. Home care agencies should al treatment and risk of complications in patients
blood glucose level is not required also develop updated patient and pro- with type 2 diabetes. Lancet 352:837–853, 1998
by CMS or any other agency that fessional diabetes teaching materials 9
The Diabetes Control and Complications Trial
reviews home care standards. and policies specific to the needs of Research Group: The effect of intensive treat-
Many home care agencies do their patient population. ment of diabetes on the development and pro-
not permit nurses to carry blood The Visiting Nurse Service of New gression of long-term complications in insulin-
dependent diabetes mellitus. N Engl J Med
glucose meters. If patients do not York (VNSNY) has taken the lead in 329:977–986, 1993
have a blood glucose meter and providing innovative home health ser-
10
test strips that are quality con- vices to people with diabetes. VNSNY Rappaport WS, Cohen RT, Riddle MC:
Diabetes through the lifespan: psychological
trolled with glucose control solu- employs three diabetes CNSs who are ramifications for patients and professionals.
tion, there is no valid way to assess CDEs in a model diabetes program Diabetes Spectrum 13:201–208, 2000
their glycemic control. Blood glu- that is part of the Diabetes Manage- 11
DeFronzo RA, Bonadonna RC, Ferrani E:
cose testing for patients with dia- ment Center of Excellence. The Pathogenesis of NIDDM: a balanced overview.
betes is as important a component VNSNY website is www.vnsny.org. Diabetes Care 15:318–368, 1992
of home health care nursing visits Because home care agencies receive 12
Pozilli P, Leslie R: Infections and diabetes:
as assessment of blood pressure, a higher level of reimbursement from mechanisms and prospects for prevention.
temperature, weight, heart sounds, CMS for patients with diabetes, the Diabet Med 11:935–941, 1994
and lung sounds. highest quality of intervention for Continued on p. 222
220
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Continued from p. 220 Healthcare Nurse 20:308–318, 2002 Standards of Diabetes Nursing Practice. 2nd
18
edit. Washington, D.C., American Nurses
13
Retrieved from the National Association of Linekin PL: How the OASIS could include dia- Publishing, 2003
Homecare website, www.nahc.org betes. Home Healthcare Nurse 19: 659, 2001
19
14
Illness and surgery. In A Core Curriculum for Linekin PL: The challenge of diabetes as a sec-
Diabetes Education: Diabetes Management
ondary diagnosis. Home Healthcare Nurse Patricia Landi Linekin, RN, MSN,
19:712–719, 2001 CNS, CDE, was chairperson of the
Therapies 4th edit. Franz MJ, Kulkarni K,
Polonsky W, Yarborough P, Zamudio V, eds. 20
American Diabetes Association: Standards of Home Healthcare Specialty Practice
Chicago, American Association of Diabetes medical care for patients with diabetes mellitus
Educators, 2001, p. 261–279 (Position Statement). Diabetes Care 26 (Suppl. Group of the American Association of
15
1):S33–S50, 2003 Diabetes Educators from 2001 to
Buse J: Progressive use of medical therapies in
type 2 diabetes. Diabetes Spectrum 13:211–220,
21
Weiner JP, Parente ST, Garnick DW, Fowles J, 2002. She is in private practice as a
2000 Lawthers AG, Palmer RH: Variation in office- home health care nurse, lecturer, and
based quality: a claims-based profile of care pro-
16
St Pierre M: Home care in the new millennium: vided to Medicare patients with diabetes. JAMA
diabetes consultant to home health
major home health regulatory changes in 2000. 273:1503–1508, 1995 care agencies in New York City,
Home Healthcare Nurse 18:27–31, 2000 22 Nassau County, and Suffolk County
American Nurses Association and American
17
Sienkiewicz J: Have you mastered PPS? Home Association of Diabetes Educators: Scope and in New York.

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