Home Health Nursing Uploaded by Nursing Organizations

Background

Home health care is a arrangement of care provided by skilled practitioners to patients in their homes nether the management of a physician. Abode wellness care services include nursing intendance; physical, occupational, and speech-language therapy; and medical social services.¹ The goals of dwelling health care services are to help individuals to meliorate function and live with greater independence; to promote the client'due south optimal level of well-beingness; and to aid the patient to remain at dwelling house, avoiding hospitalization or admission to long-term care institutions.^ii–4 Physicians may refer patients for home health care services, or the services may be requested by family members or patients.

The Centers for Medicare and Medicaid Services (CMS) estimates that 8,090 abode health care agencies in the The states provide care for more than 2.four million elderly and disabled people annually.^v To exist eligible for Medicare reimbursement, home health intendance services must exist deemed medically necessary by a medico and provided to a home-jump patient. In addition, the care must exist provided on an intermittent and noncontinuous basis.⁵ Medicare beneficiaries who are in poor health, accept low incomes, and are 85 years of age or older take relatively high rates of home health intendance use.^{half dozen} Common diagnoses amidst home health care patients include circulatory affliction (31 percentage of patients), heart disease (16 pct), injury and poisoning (fifteen.9 percent), musculoskeletal and connective tissue disease (14.1 percent), and respiratory disease (11.6 percent).⁷

Delivering Health Care in the Home

The abode wellness intendance environment differs from hospitals and other institutional environments where nurses work. For example, home health care nurses work alone in the field with support resources available from a cardinal part. The nurse-md work relationship involves less direct physician contact, and the physician relies to a greater degree on the nurse to make assessments and communicate findings. Habitation health care nurses spend more time on paperwork than hospital nurses and more than time dealing with reimbursement bug.^{eight , 9} Certain distinctive characteristics of the home health intendance environment influence patient safety and quality of outcomes: the high degree of patient autonomy in the dwelling house setting, limited oversight of informal caregivers past professional clinicians, and situational variables unique to each domicile.

Respect for patient autonomy is valued in hospital-based intendance. Nonetheless, many decisions are made by clinicians on behalf of hospitalized patients. In home health care, clinicians recognize that the care setting—the domicile—is the inviolable domain of the patient. Therefore, compared to the hospitalized patient, the abode health care patient often has a greater role in determining how and even if certain interventions will be implemented. For case, in a infirmary, nurses, physicians, and pharmacists may all play a part in ensuring that the patient receives antibiotics at therapeutically appropriate intervals. At dwelling house, nonetheless, the patient may cull to take the medication at irregular times, despite advice about the importance of a regular medication schedule. Thus, interventions to promote patient safety and quality care must business relationship for the fact that patients volition sometimes cull to act in means that are inconsistent with the relevant prove, and the clinician'southward best efforts may not consequence in desired outcomes.

In improver to deliberate choices made by informed and capable patients regarding their care, individual patient variables may also influence home-based outcomes in ways that are unlike from those patients who are hospitalized. Ellenbecker and colleagues^{10 , 11} reported that reading skill, cognitive ability, and financial resources all affect the power of home health care patients to safely manage their medication regimens. Yet, none of these variables may play a meaningful role in the prophylactic administration of medications to hospitalized patients.

In addition to cocky-care, some home-bound patients receive assistance from family members or other informal caregivers. Professional clinicians take no authority over these caregivers. Further, the home environment and the intermittent nature of professional dwelling house health care services may limit the clinician's power to observe the quality of care that informal caregivers deliver—unlike in the infirmary, where care given by back up staff may more easily be observed and evaluated. For example, considering of express access to transportation, a husband may decide not to purchase diabetic supplies for his dependent wife. This behavior may not come up to the clinician's attention until an adverse effect has occurred. Evidence-based interventions are predicated on conscientious cess. However, limited opportunity to direct notice the patient and informal caregivers may hinder efforts to quickly determine the etiology of an adverse event. If a dwelling house health care patient is constitute with bruises that the patient can't explain, is the cause a autumn, physical abuse, or a blood dyscrasia? In both self-care by patients and care by informal caregivers, safety and quality standards may not exist understood or achieved.

Another distinctive feature of habitation health care is that clinicians provide intendance to each patient in a unique setting. At that place may be situational variables that present risks to patients that may be difficult or incommunicable for the clinician to eliminate. Hospitals may have environmental safety departments to monitor air quality and designers/engineers to ensure that the height of stair risers is safety. Habitation health care clinicians are not likely to take the training or resource to appraise and better such risks to patient safety in the patient'due south home.

Finally, given the large number of elderly persons who receive care from Medicare-certified home health care agencies, it is reasonable to conceptualize that some patients will be in a trajectory of reject. Due to both normal aging and pathological processes that occur more frequently with advancing age, some elderly persons will feel decreasing ability to carry out activities of daily living (ADLs), even when high-quality home health care is provided. Thus, an implicit goal of domicile health care is to facilitate a supported refuse. That is, patients who do not testify clinical signs of comeback may yet receive quality care that results in a decelerated decline or increased quality of life. This is consequent with the American Nurses Association's assertion that promoting the patient's optimal level of well-existence is a legitimate goal of abode wellness care.^three

Assessing Quality of Care in the Home

The goals and multidisciplinary nature of dwelling health intendance services nowadays challenges to quality measurement that differ from those found in a more traditional hospital setting. The CMS mandates reporting of home wellness care effect measures. The Outcome-Based Quality Monitoring (OBQM) programme monitors, reports, and benchmarks agin events such as emergent care for injury caused past fall or blow, increased number of pressure ulcers, and substantial pass up in three or more ADLs.⁵

Pay for performance, a mechanism that ties a portion of an agency's reimbursement to the delivery of intendance, is another CMS quality initiative anticipated in the near future.¹² In preparation, quality-improvement organizations and providers are working to identify and develop a set of performance measures proven constructive in home care. A 2006 Medicare Payment Informational Committee report to Congress identified patient safety as an important component of quality and the demand to expand quality measures to include procedure and structural measures. An expanded approach to quality measurement should accomplish the post-obit goals: augment the patient population being evaluated, expand the types of quality measures, capture aspects of care directly under providers' command, reduce variations in practise, and meliorate information technology.¹³

In January 2007, the home health community, health care leaders, and quality-improvement organizations launched the Home Health Quality Improvement National Campaign 2007. The entrada focuses on improving the quality of patient care in the abode health care setting by providing agencies with monthly best practice intervention tools. The goal is to prevent avoidable hospitalizations for home health care patients. The Habitation Health Quality Comeback National Entrada uses a multidisciplinary approach to quality improvement that includes central dwelling house health, hospital, and doctor stakeholders.¹⁴

Research Show

In many respects, home wellness care clinicians and clinicians working in other settings have similar concerns well-nigh patient condom and intendance quality. For instance, patient falls occur both in homes and in hospitals, and some measures aimed at preventing falls are equally applicable to both settings. However, the significant differences between home health care and other types of health care frequently crave interventions tailored to the home health care setting.

This chapter includes an analysis of the evidence on promoting patient safety and health care quality in relation to bug frequently seen in habitation health care. The following six areas were selected for review:

• Medication management

• Fall prevention

• Unplanned infirmary admissions

• Nurse work environment

• Functional outcomes and quality of life

• Wound and pressure ulcer direction

Adverse events in these areas could jeopardize achievement of one or more than home wellness care goals.

Medication Management

Nearly one-3rd of older home health care patients have a potential medication problem or are taking a drug considered inappropriate for older people.¹⁵ Elderly dwelling house health care patients are especially vulnerable to adverse events from medication errors; they frequently take multiple medications for a variety of comorbidities that accept been prescribed by more than 1 provider. The majority of older domicile wellness care patients routinely take more than 5 prescription drugs, and many patients deviate from their prescribed medication government.^xi The potential of medication errors among the abode health care population is greater than in other wellness care settings because of the unstructured environment and unique communication challenges in the habitation wellness care organization.¹¹

A search of the literature identified only three studies testing interventions to improve medication management and adherence in home health intendance patients.^16–xviii The studies are summarized in Table i. All three studies used a controlled experimental pattern, with random assignment of patients to one or ii handling groups and a control group of usual care. The populations studied were elderly Medicare patients receiving home health care, ranging from 41 to 259 patients.

Table i

Summary of Evidence Related to Medication Direction

The interventions tested were patient instruction delivered by telephone or videophone with nurse followup, pedagogy tailored to individual patients, and medication review and collaboration amidst providers (e.yard., nurse, pharmacist, physician) and patient. Specific outcomes included identifying unnecessary and duplicate medication, improving the use of specific categories of medication such every bit cardiovascular or psychotropic drugs, and identifying the extent of use of nonsteroidal anti-inflammatory drugs (NSAIDs). The effectiveness of the interventions was measured past improved medication management and adherence to drug protocols. Adherence was estimated considerately from medication refill history and medication effect monitoring, and subjectively from patient self-report scores on pre- and postintervention questionnaires testing knowledge, understanding of disease, and adherence.

Prove from these studies suggests that all of the interventions tested were at least somewhat constructive. Medication use improved for patients receiving the intervention, while control groups had a significant reject in adherence to drug protocols. The educational interventions were most successful when individually tailored to patients' learning abilities. The interventions were near effective in preventing therapeutic duplication and improving the use of cardiovascular medications, less effective for patients taking psychotropic medication or NSAIDs. Generally, as knowledge scores improved, adherence improved. When more than 1 intervention was tested, there was mostly no difference between the two intervention groups.

Evidence-Based Practice Implications

Nurses must be vigilant for the possibility of medication errors in the abode wellness care setting, recognizing the associated risk factors. Technology provides many opportunities to improve communication with patients, to provide patients with accurate information, to educate them about their medications, and to monitor medication regimes. Paying shut attention to at-take a chance patients is virtually effective; therefore, authentic documentation and review of medications during each patient meet is important. The show suggests that frequent medication reviews and collaboration with other members of the health care team, especially pharmacists, will assist to prevent adverse events associated with poor medication management.

Research Implications

More than constructive methods are needed to improve medication use in the abode wellness care population. Research should go along to aggrandize the knowledge of factors that contribute to medication errors in home health care and make up one's mind what interventions are the near effective in improving medication direction in the home.

Fall Prevention

Emergent treat injury caused past falls or accidents at abode is one of the almost ofttimes occurring agin events reported for patients receiving skilled home wellness care services.¹⁹ Thirty percent of people age 65 and older living in the community fall each year. One in v of these autumn incidents requires medical attention.^twenty Falls are the leading cause of injury-related death for this population.²¹ Amongst the elderly, Stevens²² reported direct medical costs in 2000 totaled $179 million for fatal fall-related injuries and $nineteen billion for nonfatal injuries due to falls.

Although at that place is stiff testify of constructive autumn-prevention interventions for the general over-65 population,^{20 , 23 , 24} knowledge of fall prevention in domicile health care is limited. For the general older population living in the community, bear witness suggests that individualized habitation programs of muscle strengthening and residue retraining; complex multidisciplinary, multifactorial, health/environmental risk gene screening and intervention; home hazard assessment and modification; and medication review and aligning tin all reduce the incidence of falls.^xx However, patients in habitation health intendance are often older, sicker, and frailer than the boilerplate customs-residing older adult, and it is not known if knowledge from other settings is transferable to habitation health care.

Research studies specific to dwelling house health intendance are predominantly retrospective, descriptive, correlational designs in single agencies, using matched control or randomized command groups to explore patient characteristics and other factors contributing to patient falls.^25–27 Findings suggest that factors related to falls for home health care patients are previous falls, primary diagnosis of low or anhedonia, employ of antipsychotic phenothiazines and tricyclic antidepressants, secondary diagnoses of neurological or cardiovascular disorders, residue bug, frailty, and absence of handrails.^25–27

A literature review located only three studies testing interventions to prevent falls.^28–xxx The studies are summarized in Table 2. All three interventions were quality-improvement programs in single agencies. The findings suggest that run a risk factor screening and intervention using a valid and reliable instrument and physical therapy aimed at comeback in gait and balance may reduce injury and emergent care for falls. Unfortunately, there is no bear witness that the number of falls incurred past the home wellness intendance population can be reduced. Information technology may be that improved provider assessments increased the number of falls reported and documented.

Tabular array two

Summary of Evidence Related to Autumn Prevention

Show-Based Practice Implications

Home health care providers demand to know the risk factors for falls and demonstrate constructive assessment and interventions for fall and injury prevention. Falls are more often than not the upshot of a complex fix of intrinsic patient and extrinsic environmental factors. Utilize of a fall-prevention plan, standardized tools, and an interdisciplinary approach may be effective for reducing fall-related injuries.

Research Implications

There are several limitations in the current prove on falls in abode wellness care. Most of the research is descriptive, and there are no randomized controlled studies. Findings from small, single-agency quality-comeback projects cannot be generalized. Information technology is non known if predictors for falls in domicile health intendance patients are the same as those for other customs dwellers over age 65. Research is needed to expand the knowledge of factors that contribute to falls in this population and to develop constructive interventions. Research is too needed to explore factors to prevent injury from falls, as information technology is likely that the incidence of falls in this population cannot be completely eliminated.

Unplanned Hospital Admissions

A primary goal of dwelling house health care is to discharge the patient to cocky or family care and avert subsequent hospitalizations. Unplanned access to the hospital is an undesirable outcome of domicile health care that causes bug for patients, caregivers, providers, and payers. Unplanned hospital admissions are associated with complications, morbidity, patient and family stress, and increased costs.³¹ An estimated 1,034,034 dwelling health care patients were hospitalized in 2004. The national rate of unplanned hospital admissions for home health intendance patients has gradually increased from 27 percentage in 2000 to 28 pct in 2006,³² and it is the only publicly reported home health intendance patient outcome that has never improved at the national level.³³

Several researchers have explored the characteristics of abode health care patients and other factors associated with hospitalization.^{31 , 34–39} The studies accept been predominantly retrospective, descriptive, and correlation designs examining home care populations from single or multiple agencies.^{31 , 35–38} One written report is a prospective study of a random sample of agencies.³⁹ Bear witness suggests that unplanned hospital admissions are due mostly to an acute exacerbation of chronic disease—exacerbations that could exist prevented through knowledge of risk factors, provider communication, and careful monitoring.³⁹ Risk factors associated with unplanned hospital admissions are polypharmacy,^{31 , 35} length of home health intendance episode,^{34 , 36} development of a new problem or worsening principal or secondary diagnosis,³⁶ wound deterioration and falling accidents,³¹ and age.^{31 , 37} Based on this bear witness most experts^{31 , 37} conclude that 20 to 25 pct of unplanned hospital admissions are preventable. For example, Shaughnessey and colleagues^two found that agencies actively involved in Outcomes-Based Quality Comeback (OBQI) monitoring reduced their rate of patient hospitalizations when compared to non-OBQI agencies.

The Briggs National Quality Improvement and Hospitalization Reduction Study³³ convened a console of experts to identity best exercise strategies that agencies should implement to prevent unplanned hospitalizations. Recommended all-time practices included implementing a fall prevention program, front end loading visits, direction support, 24-hr on-call nursing coverage, medication management, case management, patient/caregiver education, special support services, disease management, positive physician and hospital relationships, data-driven services, safety and risk assessment, and telehealth. These recommendations were not empirically tested, however.

Only eight studies have tested the effectiveness of interventions to prevent unplanned hospital admissions for home wellness care patients. V of these studies employed a randomized controlled trial blueprint, and three used a nonrandomized control or comparison group design. The tested interventions consisted primarily of increasing the intensity of intendance provided through a disease management program, a team direction domicile-based primary intendance program, a multidisciplinary specialty team intervention, advanced practice nurse (APN) transitional care, telehealth services, and intensive rehabilitative care prior to hospital discharge.^40–43 Nigh of these interventions were effective or somewhat effective in preventing or delaying hospitalization. Additionally, four of the studies reported lower mean costs or charges for the intervention groups related to lower hospital costs,^{40 , 42–44} and ane study⁴⁵ reported higher costs for the intervention group based on the costs of the team-managed primary care intervention.

In these studies, patients with congestive heart failure (CHF) had fewer unplanned hospital admissions and longer survival times prior to get-go admission^39–42 if they received APNtransitional care, squad-managed home-based master care, or a multidisciplinary specialty team intervention.^40–43 Patients with CHF who received telecare and telephone interventions besides had significantly fewer emergency room visits, but no alter in hospital admissions.⁴² Squad-managed habitation-based master care has been plant to exist about effective for people who are severely disabled.⁴⁵ Daly and colleagues ⁴⁴ reported that long-term mechanically ventilated patients who received a disease management program intervention involving APN services and interdisciplinary coordination had significantly fewer mean days of hospitalization.

Results from one nonrandomized controlled report suggest that patients with chronic obstructive pulmonary disease (COPD) who received APN transitional care besides experienced fewer unplanned infirmary admissions.⁴⁶ Intrator and Berg⁴⁷ reported that patients hospitalized with hip fractures had fewer unplanned hospital admissions when they received dwelling house health care services following inpatient rehabilitation compared with those patients who received inpatient services but. Findings are summarized in Tabular array 3.

Tabular array 3

Summary of Evidence Related to Unplanned Hospital Admission

Evidence-Based Practise Implications

Evidence suggests that specialized, coordinated, interdisciplinary care has a positive touch on on unplanned hospital admissions in select habitation health care populations. Agencies tin identify patient characteristics associated with hospitalization unique to their patient population. High-take a chance patients may require specialized interventions beyond the traditional scope of home health intendance services. Targeted interventions using procedure-of-care analysis and data bachelor from the Issue and Assessment Information Set up (Haven), within the framework of OBQI, may issue in fewer unplanned hospital admissions for home health intendance patients.

Research Implications

The bachelor testify suggests that in addition to the apply of APNs for care of circuitous cases, traditional home health care professionals, individually or through interdisciplinary practice, may be effective in preventing unplanned hospital admissions with targeted interventions. Although numerous strategies have been recommended by researchers and other home care experts, nigh interventions accept not been empirically tested. Costs and benefits of the various interventions likewise need further exploration. The measurement of intervention costs and cost savings from prevented hospitalizations are not well understood. Some patient populations, due to the nature and complexity of advanced disease process, may require more intense and specialized home health care services that will not result in toll savings. On the other hand, utilize of seemingly more expensive transitional resources, such as APNs, have been proven price effective, although adoption of such research-based best practices may be impeded past lack of reimbursement and incentives.⁴⁸ Research is needed to empathise the bear on of shifting care and cost to home health care on patient outcomes and habitation health care manufacture fiscal status.

Nurse Work Environment

Show from the astute care setting suggests a human relationship between nurses' piece of work surround, patient condom, and quality of patient care.^49–51 A positive work environment is one that supports nurse autonomy and control over the piece of work surround, including shared governance or decisionmaking.^52–55 It is an environment with strong and visible nursing leadership, organizational support, peer back up, and positive medico collaboration.^53–55

Inquiry exploring the relationship of the work environment, patient safety, and quality in home wellness care is in early stages of evolution. There have been no randomized controlled studies to appointment. Feldman and colleagues⁵⁶ examined the human relationship of patient agin events with characteristics of the nurses' piece of work environment at one very large urban home health care agency. Characteristics of 86 home health intendance teams within the agency were examined. Researchers reported that adverse events were lower for teams with higher patient volume and visits, fewer weekend admissions, more than equitably distributed incentives, and more teamwork. Rates were higher when teams perceived supervisor support for agin effect reporting. This is the first rigorous written report to identify organizational factors associated with potential agin events, and in that location were limitations. It was a descriptive, correlational study, and the agency involved in the report is not typical of most agencies in the United States as it serves a unduly diverse urban population. Several of the findings approached significance only at a probability level (alpha) of 0.ten.

Kroposki and Alexander⁵⁷ explored the relationships amid patient satisfaction, nurse perception of patient outcomes, and organizational construction in a descriptive study. They reported that college patient satisfaction scores were more likely in home wellness intendance agencies where nurses and supervisors had expert working relationships, opportunity for shared decisionmaking was present, and formalization of organizational and professional guidelines existed. Limitations of this study included its descriptive, nonrandomized design of multiple agencies from 1 State and the lack of a reliable and validated tool to measure nurse perception of patient outcomes. Findings are summarized in Table 4.

Table 4

Summary of Show Related to Nurse Work Surroundings

Evidence-Based Practise Implications

Agencies should consider how characteristics of the work environment may be influencing patient safety and quality outcomes. It is necessary to explore the context of the surroundings when examining clinicians' practices in an effort to place necessary system changes.

Research Implications

It is non known what characteristics of the dwelling house health care nursing work environs are related to patient condom and quality. Home health care research is needed to investigate the relationship of work surround characteristics, nurse satisfaction, and patient outcomes.

Functional Outcomes and Quality of Life

The goal of care provided in the home is to restore or maintain patient physical and mental functioning and quality of life, or to slow the charge per unit of decline to allow the patient to remain at dwelling and avoid institutionalization. Most patients and family members prefer the home surroundings, when it is feasible. A patient's and family'southward ability to office independently and safely in the abode increases the possibility of the patient remaining in that location.

Improving patient prophylactic and quality of care by educating and assisting caregivers (families and providers) is an approach tested in several randomized controlled trials. The findings are summarized in Table 5. Archbold and colleagues⁵⁸ pilot tested preparedness, enrichment, and predictability (PREP), a formal nursing intervention designed to prepare family caregivers to provide intendance. While the study had many limitations, preliminary bear witness on the effectiveness of the intervention suggests that families benefit from beingness informed and prepared.

Table 5

Summary of Evidence Related to Functional Outcomes and Quality of Life

Other researchers have tested interventions to improve nurse providers' noesis and awareness.^59–61 Intervention studies to educate and inform nurse providers have been conducted in small-scale and large urban and rural home wellness care settings, with nurses randomly assigned to an intervention grouping or a command grouping. The interventions generally provided nurses with additional education, extra resources for patients, and specialized patient information. In ane frequently reported report, evidence-based care with specific disease-related information was sent to nurses past "but-in-time" due east-mail reminders.^{59 , lx}

In all cases the interventions improved nurses' functioning, which resulted in amend patient outcomes. Patients of nurses in these studies showed significant improvement in hurting direction, quality of life, satisfaction with care, and other variables associated with improved quality of care, including amend advice with providers, better medication management, and improved illness symptoms. Nurses' improved performance included increased documentation of critical patient assessments. In the example of "just-in-fourth dimension" e-mail reminders, the intervention group that had additional clinical and patient resource had better patient outcomes, suggesting that the multifaceted arroyo or stronger dose of the intervention was more effective.

A number of randomized controlled trials have tested the effectiveness of specific interventions to amend patient safety and quality in disease management,^{62 , 63} urinary incontinence,^{64 , 65} level of ADL functioning,^{44 , 46 , 66–68} quality of life, general wellness outcomes, and patient satisfaction.^{44 , 46 , 59 , 62 , 66–70} Corbett⁶³ demonstrated that individualized patient teaching in human foot care for diabetics was effective in improving patients' cocky-care. Scott and colleagues⁶² demonstrated an comeback in quality of life in patients with CHF though a programme of patient pedagogy and mutual goal setting. Dougherty and colleagues⁶⁴ and McDowell and colleagues⁶⁵ tested behavioral direction interventions to treat urinary incontinence in the elderly and reported positive results based on behavior direction interventions of self-monitoring and float training. Mann and colleagues⁶⁷ tested the introduction of assistive technology (canes, walkers, and bath benches) and changes made to the home environment (adding ramps, lowering cabinets, and removing throw rugs) with populations of frail elderly. These interventions were successful in slowing functional decline in the study patients.

Some of the research show suggests more efficient mechanisms for providing care. In exploring the corporeality of care that is constructive, Weaver and colleagues⁷¹ decreased (compared with usual care) the number of post-hospitalization visits by patients with knee and hip replacements and added one preoperative abode visit. No differences in functional ability, quality of life, or level of satisfaction between those patients receiving usual intendance (more visits) and those receiving the intervention (fewer postoperative visits and one preoperative visit) were found. Several studies have examined the use of technology in patient functioning and independence. Johnston and colleagues⁶⁹ tested existent-fourth dimension video nursing visits and establish no divergence in patient outcomes or level of satisfaction with usual care or care enhanced by video engineering.

A number of randomized controlled trials have tested the outcomes of interventions based on the specialty of the provider combined with dissimilar models of care management, or interventions based solely on dissimilar models of care management.^{44 , 46 , 65 , 70 , 71} Research examining the effect of APN providers on the quality of patient care suggests they have a positive issue. In two studies testing the transitional care model, APN-directed teams delivered care to patients with COPD⁴⁶ and CHF^lxx and found improvements in the group in the transitional care model. Patients experienced fewer depressive symptoms and an increase in functional abilities when compared with patients receiving usual care.^{46 , 70} Patients in these studies as well needed fewer nursing visits, had fewer unplanned hospital admissions, and had fewer acute intendance visits. A nurse practitioner'south urinary incontinence behavioral therapy was effective in decreasing the number of patients' urinary incontinence accidents.⁶⁵ The Veterans Affairs Squad-Managed Home-Based Primary Care was an add-on to intendance routinely provided in the Veterans Affairs Home-Based Primary Intendance programme.⁴⁴ The added component emphasized continuity of care and team management with a chief care manager, 24-hour on-call nursing availability for patients, prior approval of hospital admissions, and squad participation in discharge planning. The investigators found meaning improvements in quality of life, operation, pain management, and full general health outcomes for terminally ill patients in this study, and an increment in satisfaction for nonterminally ill patients and family caregivers.

Still, mixed results take been obtained from the research to appointment on the effectiveness of models of care management.^{66 , 68} Some intervention models take been less effective than others. The interventions are ordinarily an addition to routine intendance, and their effectiveness has been determined past a comparing to a control group of usual or routine abode wellness care. An intervention model that does non appear to be effective is the Health Outcomes Management and Evaluation model tested past Feldman and colleagues⁶⁶ This model adds a consumer-oriented patient self-care guide and training to improve nurses' educational activity and support skills. Study results showed no departure in patient quality of life or satisfaction. Tinetti and colleagues⁶⁸ compared the outcomes of a systematic, multicomponent rehabilitation program, including therapies for physical and functional impairments, to the outcomes from usual home-based rehabilitation intendance. No differences were institute between the two groups.

Bear witness-Based Practice Implications

The preceding word suggests that working closely with and supporting family caregivers is, and will continue to be, an important attribute of helping patients to remain in their homes. Information technology besides suggests that nurses' effectiveness in working with patients can be enhanced if nurses are supported in their work. Support can exist provided past electronic communication, reminders of protocols, disease-specific educational materials for patients, and working with APN colleagues to serve as clinical experts for staff. Home health care nurses are relatively isolated in the field, and any machinery to better advice with supervisors in the office and with other providers will assist nurses in their practice. Incorporating the use of remote technology to substitute for some in-person visits can improve access to domicile health care staff for patients and caregivers.⁶⁹

Specific patient interventions tin be helpful in improving patient health and quality of life. Interventions of individualized education and affliction-specific programs, such every bit a behavioral management program for urinary incontinence or educational programs for human foot intendance, should be incorporated into practice. The charge per unit of a patient's functional decline can exist slowed and costs reduced through a systematic approach to providing assistive technology and environmental interventions to frail elderly patients in their homes. A patient's need for these interventions can be determined with a comprehensive assessment and continued monitoring.

Enquiry Implications

Testify of the outcomes of health care provided in the home is limited; there are very few controlled experiments on which providers can base their practise. Inquiry is express in the areas of composition, duration, and amount of home health care services needed to ensure patient safe and quality. Enquiry is needed to decide effective interventions to amend, maintain, or slow the refuse of performance in the abode wellness care population. More research is also needed to decide mechanisms to continue nurses informed and supported. Providing communication and support is a challenge when providers are geographically dispersed and spend near of their fourth dimension in the field. Remote engineering science has the potential to reduce costs: it can substitute for some in-person visits, and it can improve admission to habitation health intendance staff for patients and caregivers.

Wound and Pressure Ulcer Management

Adverse wound events are monitored under the OBQM program. Emergent intendance for wound infections, deteriorating wound status, and increase in the number of pressure ulcers are monitored and reported equally adverse events.^seventy The information are used to reflect a change in a patient's health status at two or more than times, unremarkably betwixt home health care access and transfer to a infirmary or other health care setting. Data for these outcomes are collected using Oasis-designated intervals. Patient outcome measures related to surgical wounds that are monitored under the OBQI include improvement in the number of surgical wounds and improvement in the status of surgical wounds.¹⁸

Wound Management

Over a third of habitation health care patients crave treatment for wounds, and near 42 percent of those with wounds have multiple wounds. Over 60 pct of wounds seen in dwelling wellness intendance are surgical, while just under i-quarter are vascular leg ulcers and another one-quarter are pressure ulcers.⁷¹ Near domicile wellness intendance nurses tin can accurately identify wound bed and periwound characteristics; the majority (88 pct) of wound treatments have been constitute to be appropriate.⁷² The appropriateness of wound treatments in home health care is significantly related to wound healing. Patients with healing wounds had shorter dwelling house health care visits and shorter dwelling house health care lengths of stay.⁷¹

A literature review identified seven studies that tested interventions to better wound care management in home health care.^73–79 Findings are summarized in Table 6. Three compared effectiveness of various wound treatments. Capasso and Munro⁷⁴ plant no significant difference in wound closure between amorphous hydrogel dressings and moisture-to-dry out saline dressings, but costs were establish to be significantly higher for the saline dressings due to the need for more than nursing visits. Kerstein and Gahtan⁷⁶ found the percentage of venous leg ulcers healed using hydrocolloidal dressings was half-dozen times college than with saline gauze dressings and nearly four times greater using an Unna boot; the hydrocolloidal dressings were well-nigh cost-effective. Employ of negative pressure level wound therapy resulted in successful closure of 43 percent of wounds that failed to respond to previous treatment.⁷⁸

Table half-dozen

Summary of Evidence Related to Wound Management

Four studies reported positive outcomes from interventions to ameliorate and support home health care nurse practise.^{73 , 75 , 77 , 79} Use of telemedicine to provide consultation with wound management experts resulted in improved healing rates, decreased healing time, and decreased home visits and hospitalizations related to wounds.^{73 , 77} Fellows and Crestodina⁷⁵ studied the rate of bacterial contagion of normal saline solutions prepared from distilled h2o and table common salt, a practise common for wound care in the home, and found refrigerated solutions essentially growth-free at iv weeks. A quality improvement project reported a reduction in adverse events through structured nurse education, introduction of protocols, and competency review.⁷⁹

Pressure Ulcer Direction

Rodriques and Megie⁸⁰ found that 37 percent of wounds in dwelling wellness care patients were pressure level ulcers, with a hateful wound duration of almost 27 months. About one in 10 patients admitted to home wellness care had force per unit area ulcers and approximately one-tertiary were at risk of developing new ulcers; still according to one study, but 27 percent of patients with existing ulcers and fourteen pct of those at adventure were receiving appropriate pressure-reducing treatment.⁸¹ Incontinence, limitations in ADLs, mobility damage, skin drainage, recent fractures, anemia, use of oxygen, and recent institutional discharge were associated with pressure ulcer development.^{81 , 82} Guidelines from the Wound, Ostomy and Continence Nurses Society⁸³ call for an initial risk assessment for force per unit area ulcers of all patients on access to home health care, and reassessment every visit thereafter, using a validated hazard assessment tool. Still, one study found that only 21 percentage of agencies used a validated tool such as the Braden Scale⁸⁴ to place patients at run a risk, near 8 percent performed no assessments on admission, and merely 33 per centum used risk prediction or pressure ulcer prevention protocols.⁸⁵ Just over half of agencies reported routine skin inspections by nurses of at-risk patients.

A literature review resulted in identification of five studies relating to pressure ulcer management in home health care. The findings are summarized in Table 7. 3 studies were randomized controlled trials testing interventions to improve pressure ulcer healing.^86–88 I intervention tested the use of air-fluidized bed therapy with services of a nurse specialist;⁸⁷ a second intervention used noncontact normothermic wound therapy.⁸⁸ Both resulted in significant improvement in wound healing compared to conventional moist dressings. Overall healing rates were similar for polymer hydrogel and hydrocolloidal dressings, although debridement functioning of the hydrogel dressing resulted in more favorable clinical evaluation.⁸⁶

Tabular array 7

Summary of Prove Related to Pressure Ulcer Management

The remaining two studies evaluated the use of the Braden Scale for prediction of pressure ulcer risk in home health care patients, with mixed results. Ramundo⁸⁹ reported that the Braden Calibration had validity in identifying at-risk patients, but limited predictive ability, while Bergquist⁸² plant that the summative score of the scale was significantly associated with pressure ulcer evolution. All subscale scores except nutrition were significantly and negatively associated with pressure ulcer development.

Testify-Based Practice Implications

When compared with wet-to-dry or moist saline dressings, most wound treatments tested showed greater effectiveness or lower cost. Home health care nurses should exist knowledgeable in the utilise of the full range of existing and emerging wound products, practices, and treatments and demonstrate skill in authentic wound assessment and staging. Provision of structured resources, expert consultation, and competency testing for abode health care nurses can improve domicile wellness care wound management. Nurses must be knowledgeable in risk factors for pressure level ulcer development and relevant preventive measures; they must assess every patient using a valid and reliable instrument, such as the Braden Scale, on admission to abode wellness care and regularly thereafter.

Research Implications

Relatively little is known nigh the most effective practices for wound care in the habitation health care setting. Although studies take compared different treatments for wounds, the nigh efficacious treatments for unlike wounds are unknown in the presence of diverse risk factors found in the home health intendance setting. Randomized controlled clinical trials exist comparing unlike pressure ulcer treatments in the habitation, with the exception of intendance of other types of wounds. Promising findings from studies with small sample sizes should exist replicated with larger samples and diverse populations.

Determination

Dwelling wellness care clinicians seek to provide high quality, condom intendance in ways that award patient autonomy and accommodate the individual characteristics of each patient'due south abode and family. Falls, declining functional abilities, pressure ulcers and nonhealing wounds, and adverse events related to medication administration all have the potential to upshot in unplanned hospital admissions. Such hospitalizations undermine the achievement of important dwelling house health care goals: keeping patients at dwelling and promoting optimal well-beingness. Nevertheless, the unique characteristics of dwelling health care may brand information technology difficult to use—or necessary to change—interventions that have been shown to be effective in other settings. Therefore, inquiry on effective practices, conducted in dwelling house health intendance settings, is necessary to support splendid and evidence-based care.

In reviewing the extant studies, the authors of this chapter found useful evidence in all selected areas. However, the number of studies was few and many questions remain. Replications of investigations originally conducted in health care settings other than the abode, and studies considering home health care-specific issues are needed to support evidence-based clinical decisions. The available prove suggests that the work environment in which home health care nurses do may indirectly influence patient outcomes in many areas, and that engineering can be used to support positive patient outcomes. Thus, studies that link nurse-related variables to improved intendance safety and quality are needed, as well as studies that focus directly on patients. The demographics of an aging club will sustain the trend toward home-based intendance. Abode wellness care practices grounded in conscientious inquiry will sustain the patients and the clinicians who serve them. Given the focused review of evidence-based studies comprising this affiliate, many informative sources of use to the practicing dwelling health care nurse are omitted. Table 8 lists additional key resources.

Search Strategy

The literature review for this chapter focused on identifying prove-based practices that supported the goals of home health care: to promote independent operation; to remain at home, avoiding hospital or nursing home admission; and to attain optimal well-beingness. The search was conducted using multiple variations of fundamental terms informed by the characteristics of domicile wellness care described at the beginning of this affiliate, adverse events used in the OBQM,^v goals of the Dwelling Health Quality Comeback National Campaign 2007,^xiv and the nurse-sensitive quality indicators developed by the American Nurses Association.¹⁵ The Cumulative Index to Nursing & Allied Wellness, Cochrane Library, Medline, and ProQuest Nursing & Allied Health databases were searched, as well as the grey literature and government Spider web sites, including the CMS and Bureau for Healthcare Research and Quality. Hand searches were conducted of the reference lists of retrieved manufactures. Search limitations were English language language, Us or Canada, peer-reviewed journals or scholarly literature, published between 1990 and the first quarter of 2007. Studies cited in the prove table were accepted for review using the following inclusion criteria:

• The study was published betwixt 1990 and the showtime quarter of 2007, inclusive.

• The research was conducted in the United States or Canada.

• The study included an intervention that straight or indirectly influenced a patient effect.

• The intervention took place under the auspices of a home health care agency.

• Subjects in the written report had to be home health intendance patients (not community-residing or outpatient ambulatory) and eighteen years of age or greater.

References

1.

2.

Shaughnessy PW, Hittle DF, Crisler KS, et al. Improving patient outcomes of home health care: findings from two demonstration trials of result-based quality improvement. J Am Geriatr Soc. 2002;fifty(8):1354–64. [PubMed: 12164991]

3.

American Nurses Clan. Scope and standards of home health nursing exercise. Washington, DC: ANA; 1999.

4.

five.

6.

7.

eight.

National Clan for Dwelling Health Care & Hospice. Basic statistics about dwelling health care. [Accessed February 23, 2006]. http://world wide web​.nahc.org/04HC_Stats.pdf.

nine.

Anthony A, Milone-Nuzzo P. Factors attracting and keeping nurses in domicile health care. Home Healthc Nurse. 2005;23(6):372–7. [PubMed: 15956856]

x.

Ellenbecker CH, Samia Fifty, Neal 50. What nurses are maxim about staying and leaving. Habitation Healthc Nurse. 2006 In press.

eleven.

Ellenbecker CH, Frazier SC, Verney Due south. Nurses' observations and experiences of problems and adverse effects of medication management in domicile wellness care. Geriatr Nurs. 2004;25(iii):164–70. [PubMed: 15197376]

12.

13.

14.

fifteen.

American Nurses Clan. Nursing-sensitive indicators for community-based non-acute care settings and ANA's rubber and quality initiative. [Accessed Feb 11, 2006]. http://nursingworld​.org​/readroom/nurssens.htm.

16.

Meredith Due south, Feldman P, Frey D, et al. Improving medication use in newly admitted dwelling house health care patients: a randomized controlled trial. J Am Geriatr Soc. 2002;50(9):1484–91. [PubMed: 12383144]

17.

Gates BJ, Setter SM, Corbett CF, et al. A comparison of educational methods to ameliorate NSAID knowledge and use of a medication list in an elderly population. Home Health Intendance Direction & Practice. 2005;17(v):403–10.

xviii.

Fulmer TT, Feldman PH, Kim TS, et al. An intervention report to enhance medication compliance in community-dwelling elderly individuals. J Gerontol Nurs. 1999;25(8):6–xiv. [PubMed: 10711101]

19.

xx.

Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev . 2003(iv):CD000340. [PubMed: 14583918]

21.

22.

Stevens JA. Falls amidst older adults–take a chance factors and prevention strategies. J Safety Res. 2005;36(4):409–11. [PubMed: 16242155]

23.

Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the hazard of falling among elderly people living in the community. N Engl J Med. 1994;331(13):821–7. [PubMed: 8078528]

24.

Hogan DB, MacDonald FA, Betts J, et al. A randomized controlled trial of a community-based consultation service to forbid falls. CMAJ. 2001;165(five):537–43. [PMC costless article: PMC81411] [PubMed: 11563205]

25.

Isberner F, Ritzel D, Sarvela P, et al. Falls of elderly rural domicile wellness clients. Home Health Intendance Serv Q. 1998;17(two):41–51. [PubMed: 10186165]

26.

Lewis CL, Moutoux Thousand, Slaughter M, et al. Characteristics of individuals who fell while receiving home health services. Phys Ther. 2004;84(ane):23–32. [PubMed: 14992674]

27.

Sheeran T, Brown EL, Nassisi P, Bruce ML. Does depression predict falls amongst domicile wellness patients? Using a clinical-research partnership to ameliorate the quality of geriatric care. Home Healthc Nurse. 2004;22(vi):384–9. [PubMed: 15184780]

28.

Bright Fifty. Strategies to ameliorate the patient condom effect indicator: preventing or reducing falls. Home Healthc Nurse. 2005;23(i):29–36. [PubMed: 15632504]

29.

Yuan JR, Kelly J. Falls prevention, or "I recollect I tin, I think I can": An ensemble approach to falls direction. Home Healthc Nurse. 2006;24:103–11. [PubMed: 16474247]

30.

Sperling South, Neal K, Hales M, et al. A quality improvement project to reduce falls and improve medication direction. Home Wellness Intendance Serv Q. 2005;24(ane–2):13–28. [PubMed: 16236656]

31.

Taft SH, Pierce CA, Gallo CL. From hospital to home and back again: a study in infirmary admissions and deaths for homecare patients. Home Wellness Care Management and Do. 2005;17:467–80.

32.

33.

34.

Alexy B, Benjamin-Coleman R, Brown S. Domicile health care and customer outcomes. Dwelling house Healthc Nurse. 2001;19:233–9. [PubMed: 11985255]

35.

Flaherty JH, Perry HM 3rd, Lynchard GS, et al. Polypharmacy and hospitalization among older home wellness care patients. J Gerontol A Biol Sci Med Sci. 2000;55:M554–9. [PubMed: 11034227]

36.

Hoskins LM, Walton-Moss B, Clark HM, et al. Predictors of infirmary readmission among the elderly with congestive heart failure. Home Healthc Nurse. 1999;17(half-dozen):373–81. [PubMed: 10562014]

37.

Madigan EA, Tullai-McGuinness S. An examination of the most frequent adverse events in home health care agencies. Dwelling Healthc Nurse. 2004;22(4):256–62. [PubMed: 15073556]

38.

Rosati RJ, Huang L, Navaie-Waliser M, et al. Risk factors for repeated hospitalizations among home health care recipients. J Healthc Qual. 2003;25(2):4–10. [PubMed: 12659074]

39.

Fortinsky RH, Madigan EA, Sheehan TJ, et al. Take chances factors for hospitalization among Medicare abode care patients. West J Nurs Res. 2006 Dec;28:902–17. [PubMed: 17099104]

forty.

Naylor MD, Brooten DA, Campbell RL, et al. Transitional care of older adults hospitalized with eye failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(v):675–84. [PubMed: 15086645]

41.

Hughes LC, Robinson LA, Cooley ME, et al. Describing an episode of dwelling house nursing intendance for elderly postsurgical cancer patients. Nurs Res. 2002;51(2):110–8. [PubMed: 11984381]

42.

Jerant AF, Azari R, Martinez C. A randomized trial of telenursing to reduce hospitalization for eye failure: patient-centered outcomes and nursing indicators. Home Health Intendance Serv Q. 2003;22(1):one–20. [PubMed: 12749524]

43.

Rich MW, Beckham 5, Wittenberg C, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive center failure. Due north Engl J Med. 1995;333(eighteen):1190–5. [PubMed: 7565975]

44.

Daly BJ, Douglas SL, Kelley CG, et al. Trial of a disease direction programme to reduce hospital readmissions of the chronically critically ill. Chest. 2005;128:507–17. [PubMed: 16100132]

45.

Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284:2877–85. [PubMed: 11147984]

46.

Neff DF, Madigan E, Narsavage G. APN-directed transitional home wellness care model: achieving positive outcomes for patients with COPD. Home Healthc Nurse. 2003;21:543–50. [PubMed: 12917525]

47.

Intrator O, Berg Thou. Benefits of abode health care afterward inpatient rehabilitation for hip fracture: health service utilize past Medicare beneficiaries, 1987–1992. Arch Phys Med Rehabil. 1998;79:1195–9. [PubMed: 9779670]

48.

Naylor MD. Transitional care: a critical dimension of the habitation health care quality agenda. J Healthc Qual. 2006 Jan-February;28(one):48–54. [PubMed: 16681300]

49.

Aiken LH, Clarke SP, Sloane DM. Hospital staffing, arrangement, and quality of intendance: cantankerous-national findings. Nurs Outlook. 2002;50(5):187–94. [PubMed: 12386653]

50.

Aiken LH, Sloane DM, Lake ET, et al. Arrangement and outcomes of inpatient AIDS care. Med Intendance. 1999;37:760–72. [PubMed: 10448719]

51.

Aiken LH, Smith HL, Lake ET. Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care. 1994;32:771–87. [PubMed: 8057694]

52.

Tullai-McGuinness S, Madigan EA, Anthony MK. Practise of autonomous domicile wellness care practice: the relationship with nurse characteristics. Home Healthc Nurse. 2005;23:378–84. [PubMed: 15956857]

53.

Kramer M, Schmalenberg C, Maguire P. Essentials of a Magnetic work environs: office 4. Nursing. 2004;34(9):44–8. [PubMed: 15382382]

54.

Kramer 1000, Schmalenberg C, Maguire P. Essentials of a Magnetic work surround: role three. Nursing. 2004;34(8):44–7. [PubMed: 15346593]

55.

Kramer M, Schmalenberg C. Essentials of a Magnetic work environs: part 2. Nursing. 2004;34(vii):44–7. [PubMed: 15270042]

56.

Feldman P, Bridges J, Peng TR, et al. Working conditions and adverse events in home health care. Rockville Physician: Agency for Healthcare Inquiry and Quality; 2001–2005. RO1 HS11962.

57.

Kroposki M, Alexander JW. Correlation among client satisfaction, nursing perception of outcomes, and organizational variables. Home Healthc Nurse. 2006;24(2):87–94. [PubMed: 16474244]

58.

Archbold PG, Stewart BJ, Miller LL, et al. The PREP organization of nursing interventions: a airplane pilot test with families caring for older members. Preparedness (PR), enrichment (Eastward) and predictability (P). Res Nurs Health. 1995;eighteen(i):three–16. [PubMed: 7831493]

59.

McDonald MV, Pezzin LE, Feldman PH, et al. Tin just-in-time, testify-based "reminders" improve pain direction amongst home wellness intendance nurses and their patients? J Pain Symptom Manage. 2005;29(5):474–88. [PubMed: 15904750]

lx.

Feldman PH, Murtaugh CM, Pezzin LE, et al. Just-in-time bear witness-based email "reminders" in dwelling health care: impact on patient outcomes. Health Serv Res. 2005;40:865–85. [PMC free article: PMC1361172] [PubMed: 15960695]

61.

Vallerand AH, Riley-Doucet C, Hasenau SM, et al. Improving cancer hurting direction by homecare nurses. Oncol Nurs Forum. 2004;31:809–16. [PubMed: 15252435]

62.

Scott LD, Setter-Kline Chiliad, Britton Equally. The effects of nursing interventions to raise mental health and quality of life among individuals with heart failure. Applied Nurs Res. 2004;17(iv):248–56. [PubMed: 15573333]

63.

Corbett CF. A randomized pilot study of improving foot intendance in home wellness patients with diabetes. Diabetes Educ. 2003;29:273–82. [PubMed: 12728754]

64.

Dougherty MC, Dwyer JW, Pendergast JF, et al. A randomized trial of behavioral management for continence with older rural women. Res Nurs Health. 2002;25(1):3–13. [PubMed: 11807915]

65.

McDowell BJ, Engberg Due south, Sereika Southward, et al. Effectiveness of behavioral therapy to treat incontinence in homebound older adults. J Am Geriatr Soc. 1999;47:309–eighteen. [PubMed: 10078893]

66.

Feldman PH, Peng TR, Murtaugh CM, et al. A randomized intervention to meliorate middle failure outcomes in community-based domicile health care. Home Health Care Serv Q. 2004;23(one):1–23. [PubMed: 15160686]

67.

Mann WC, Ottenbacher KJ, Fraas L, et al. Effectiveness of assistive engineering and ecology interventions in maintaining independence and reducing home wellness care costs for the fragile elderly. A randomized controlled trial. Arch Fam Med. 1999;8:210–vii. [PubMed: 10333815]

68.

Tinetti ME, Baker DI, Gottschalk M, et al. Home-based multicomponent rehabilitation program for older persons after hip fracture: a randomized trial. Curvation Phys Med Rehabil. 1999;80:916–22. [PubMed: 10453768]

69.

Johnston B, Wheeler L, Deuser J, et al. Outcomes of the Kaiser Permanente tele-home wellness inquiry project. Arch Fam Med. 2000;9(ane):40–5. [PubMed: 10664641]

70.

Naylor Dr.. A decade of transitional intendance research with vulnerable elders. J Cardiovas Nurs. 2000;14(iii):1–14. [PubMed: 10756470]

71.

Weaver FM, Hughes SL, Almagor O, et al. Comparison of 2 abode health intendance protocols for full joint replacement. J Am Geriatr Soc. 2003;51(iv):523–8. [PubMed: 12657073]

72.

73.

Bolton L, McNees P, van Rijswijk 50, et al. Wound-healing outcomes using standardized assessment and care in clinical practice. J Wound Ostomy Continence Nurs. 2004;31(2):65–71. [PubMed: 15209428]

74.

Capasso VA, Munro BH. The cost and efficacy of 2 wound treatments. AORN J. 2003;77(5):984–92. [PubMed: 12769329]

75.

Fellows J, Crestodina Fifty. Home-prepared saline: a safe, cost-effective alternative for wound cleansing in abode care. J Wound Ostomy Continence Nurs. 2006;33:606–9. [PubMed: 17108769]

76.

Kerstein Medico, Gahtan V. Outcomes of venous ulcer care: results of a longitudinal report. Ostomy Wound Manage. 2000;46(6):22–6. [PubMed: 11029932]

77.

Kobza 50, Scheurich A. The impact of telemedicine on outcomes of chronic wounds in the home wellness care setting. Ostomy Wound Manage. 2000;46(10):48–53. [PubMed: 11889733]

78.

Philbeck TE Jr, Whittington KT, Millsap MH, et al. The clinical and cost effectiveness of externally applied negative pressure wound therapy in the handling of wounds in home health care Medicare patients. Ostomy Wound Manage. 1999;45(11):41–50. [PubMed: 10687657]

79.

Sturkey EN, Linker S, Keith DD, et al. Improving wound intendance outcomes in the abode setting. J Nurs Care Qual. 2005;20(4):349–55. [PubMed: 16177587]

80.

Rodrigues I, Megie MF. Prevalence of chronic wounds in Quebec home care: an exploratory study. Ostomy Wound Manage . 2006 May;52(five):46–8. l, 52–seven. [PubMed: 16687769]

81.

Ferrell BA, Josephson K, Norvid P, et al. Force per unit area ulcers among patients admitted to home health care. J Am Geriatr Soc. 2000;48(9):1042–7. [PubMed: 10983902]

82.

Bergquist S. Subscales, subscores, or summative score: evaluating the contribution of Braden Scale items for predicting pressure ulcer take a chance in older adults receiving home wellness intendance. J Wound Ostomy Continence Nurs. 2001;28(6):279–89. [PubMed: 11707760]

83.

84.

Bergstrom N, Braden BJ. Predictive validity of the Braden Calibration among Black and White subjects. Nurs Res. 2002;51(half-dozen):398–403. [PubMed: 12464760]

85.

Bergquist S. The quality of pressure ulcer prediction and prevention in home wellness care. Applied Nurs Res. 2005;18(3):148–54. [PubMed: 16106332]

86.

Motta G, Dunham Fifty, Dye T, et al. Clinical efficacy and cost-effectiveness of a new constructed polymer sheet wound dressing. Ostomy Wound Manage. 1999;45(10):41, 44–6. [PubMed: 10687651]

87.

Strauss MJ, Gong J, Gary BD, et al. The cost of home air-fluidized therapy for pressure sores. A randomized controlled trial. J Fam Pract. 1991;33(one):52–nine. [PubMed: 2056290]

88.

Whitney JD, Salvadalena G, Higa L, et al. Handling of pressure ulcers with noncontact normothermic wound therapy: healing and warming effects. J Wound Ostomy Continence Nurs. 2001;28(5):244–52. [PubMed: 11557928]

89.

Ramundo JM. Reliability and validity of the Braden Scale in the home wellness care setting. J Wound Ostomy Continence Nurs. 1995;22(3):128–34. [PubMed: 7599722]

mckayence1973.blogspot.com

Source: https://www.ncbi.nlm.nih.gov/books/NBK2631/

Share this post