This course describes the history of home health in the context of evolving nursing practice; provides examples of the significant clinical, societal, and economic features of the industry; and relates the practice of home care nursing to health care in the larger community. The nurse taking this course will learn how case management is used in home care, other disciplines with which the nurse associates, and the expectations that home health agency administrators and state and federal regulators have of the home care nurse.

Key concepts covered in this course include the structure of the interdisciplinary home care team, the plan of care, home health eligibility, similarities and differences between generalist and specialist nurses in home care, the environment of care, coordination of care, reimbursement of services and the relationship of nursing practice to payment of services, documentation requirements, and recent developments in outcomes management. Resources related to key concepts are included, along with information about home health certification. Key concepts and relevant information are layered throughout the chapters.

Chapter One - Development of an Industry

Care in the home is as old as the concept of home itself, but not until the mid-1800s did formal programs exist to provide professional home care services. In 1859, a Quaker businessman named William Rathbone encouraged the development of the first training program for visiting nurses. Impressed by the care his own wife had received in their home during her terminal illness, Rathbone wanted to make the same level of care available to others in his community of Liverpool, England. Rathbone was particularly interested in meeting the needs of the poor, who were unlikely to have the resources necessary for hospital care, and his work eventually led to the development of districts in Liverpool to which “friendly visitors” were assigned to deliver health services.¹

In response to Rathbone’s published accounts of his efforts, Florence Nightingale wrote a pamphlet, Suggestions for Improving Nursing Service, that outlined nursing care specific to the home environment. With the encouragement and support of Rathbone, Nightingale, and other like-minded philanthropists, home nursing programs proliferated in England and, ultimately, spread to the United States.

Programs in New York, Philadelphia, and Boston were among the first in America to promote home care services. The industrialization of the country promoted immigration to cities; burgeoning populations frequently led to crowding, poverty, poor health, and other social problems. In response, charitable organizations began to fund training for visiting nurses and for programs to support nursing staff as well as the working poor, whom the nurses served.^{1, 2} For example, in 1877 Frances Root, a graduate of Bellevue Hospital’s first nursing class, was employed to visit patients at home, where she was expected to supply both nursing care and religious instruction. Similarly, nurses in Philadelphia cared for patients at home, discovering early on that success would depend on the nurses’ ability to instruct family members in furnishing aspects of care between professional visits.

District, public health, and frontier nursing services

Philanthropic groups in Boston banded together to start a visiting nurses program, whose staff worked to improve hygiene, teach nutritional requirements, and act on medical orders. Out of this effort in 1888 was established a voluntary agency, the Instructive District Nursing Association, committed to serving the poor in their homes.¹

Along with visiting nurses organizations, public health programs developed to meet the needs of increasingly complex populations, primarily in cities. Early public health efforts drew on the initial findings of community activists who opened the first programs to offer care in the home. In 1893, Lillian Wald and Mary Brewster, both trained nurses with considerable financial and social clout, established the Henry Street Settlement House, which provided neighborhood nursing for the poor.¹ Wald, who coined the term “public health nursing” and founded the National Organization for Public Health Nursing in 1888, also wrote about Henry Street, thus documenting the experience so that it could be shared and duplicated. Soon thereafter the concept of serving the community through thoughtful management of at-risk populations had spread across the country. By 1898, the dedicated work of Wald and others like her was evident when the Los Angeles City Council allocated its first public funds to pay for nursing care.^{1, 3}

Care in the home developed in tandem with other medical and ancillary services, services that frequently required cooperation between professional groups and disciplines. The child welfare movement, for instance, focused its early efforts on hygiene and nutrition, which eventually led to a better understanding of how to prevent infant deaths at home. As part of its infant mortality prevention efforts, in the late 1880s the New York City Health Department assigned community health nurses to make home visits to newly delivered infants and their mothers. A comparison of death rates between infants who had received visits versus those who had not showed a marked reduction in mortality.¹

In a similar vein, Wald was able to show the Metropolitan Life Insurance Company (MLI) that offering home visits to beneficiaries would reduce the number of death benefits the company paid. As a result, MLI policy holders received 100 million home nursing visits between 1900 and 1952.⁴

The Frontier Nursing Service (FNS) provides an example of how care developed in the homes of rural families. Mary Breckenridge, a trained nurse from the South, created the FNS in order to bring midwifery to the Appalachian mountains of Kentucky.^{1, 3} The FNS began serving families in 1925 and continues to do so now, with the focus of attention having broadened to include the needs of entire families. One image from the work of the FNS is that of a nurse on a horse; so many families in the early days of the FNS lived so remotely that nurses routinely made their home visits on horseback.

Inception of Medicare

Until the early part of the 20th century, charitable organizations or individuals paid for health care. Partly as a result of increasingly accessible care and the recognition that a profit might be made, the insurance industry evolved, assuming the risk of payment for care that individuals once had taken on themselves. True to expectations, the insurance business was relatively lucrative and remained so until advanced technology both increased the cost of care and extended lives that would have otherwise been cut short.

By the end of World War II, the lifespan of the average American had reached beyond 60 years. In addition, more widely available antibiotic therapy, along with other drug therapies, decreased the inevitability of death in circumstances that had until then been fatal. But longevity came at a price: Older citizens were sometimes without the resources to pay for drugs and treatments. All these factors eventually combined in 1965 to lead to the enactment of Titles XVIII and XIX, Medicare and Medicaid (or Medi-Cal) respectively, as part of the Social Security benefit. Since then, the federal government has assumed the financial risks for the care of older and disabled citizens, which charities or individuals and, thereafter, insurance companies had generally shouldered before.¹

Contemporary home care

The development of the modern home health industry relied in large measure on the enactment of Medicare. The two basic features of Medicare are the Part A benefit, which insures recipients (beneficiaries) against hospitalization; and the Part B benefit, a supplemental insurance policy. Along with other things, parts A and B of Medicare cover home health care, depending on the patient’s situation and his or her needs.

Medicare benefits have changed over the past four decades to reflect the federal government’s understanding of trends in the population of Medicare recipients—or potential recipients. For example, it was clear to the government that people receiving Social Security as the result of a disability would also benefit from the health care coverage available through Medicare benefits. Consequently, when Social Security was amended in 1972, Medicare was extended to people with disabilities. Similarly, in the 1990s when experts began to treat AIDS as a chronic illness rather than a terminal disease, medical experts advised legislators about criteria for benefits for people with AIDS, and soon thereafter Medicare became available under specific circumstances.

Chiefly associated with elders and people with disabilities through most of the 1990s, for 45 years Medicare has set the standard for home care coverage and practice. In order to receive reimbursement for services, home care agencies have had to work within Medicare’s guidelines.

Other third-party payers that eventually entered the home health arena generally followed Medicare’s example regarding coverage issues. With the advent of managed care, however, Medicare’s primacy has been challenged as entities such as the health maintenance organization (HMO) and the primary provider organization (PPO) have developed somewhat different models of care delivery, jockeying for position in the health services marketplace at the same time.

In addition to the development of Medicare, several signal events deserve attention. First, in 1980 the government abolished the following Medicare requirements:⁵

• A limit on the number of home care visits allowed
  
  
• A deductible on Medicare coverage
  
  
• At minimum, a three-day hospitalization prior to establishing services
  
  
• Restrictions in the certification of for-profit, or proprietary, agencies
  
  

These regulatory changes encouraged the growth of the industry. Periodically during the ensuing 20 years, the government wavered in its liberalized approach to management of home health. Nonetheless, agencies in every region of the country, whether affiliated with a large corporate entity or not, whether non-profit or for-profit, opened their doors for business.

Second, in the early 1980s, a reimbursement model based on diagnosis-related groups (DRGs) referred to as a prospective payment system (PPS) was mandated for hospital services. Suppliers of the most expensive health care available, hospitals all over the country looked for ways to reduce financial risks both by diversifying services and by offering care as efficiently as possible. Along with other strategies to manage costs, many hospitals purchased or affiliated with home health agencies.⁶

Third, in 1987 the Omnibus Budget Reconciliation Act (OBRA) was passed, heralding an era of unannounced home health surveys; a focus on the rights of patients; training on a regular basis, as well as competency evaluations for home health aides; and the use of a functional assessment tool to evaluate patients and the delivery of care.⁵ These changes added government-imposed structure to the entrepreneurial spirit that pervaded this period of growth.

A decade later, the 1997 Balanced Budget Act (BBA’97) ushered in yet another singular event for the home health industry. The BBA’97 introduced reimbursement for home health similar to the reimbursement hospitals have received since the early 1980s. As is true under the hospital DRG system, home care has now begun to receive payment according to fixed criteria. Phased in over several months, the fully developed PPS Model became effective in October 2000.⁷

Finally, Operation Restore Trust (ORT) began its work under the auspices of the Office of the Inspector General (OIG) in Washington, launching a program in the mid-1990s to combat fraud and abuse throughout the home health industry.⁸ According to the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA), the number of home health agencies (HHAs) grew from 5,730 in 1990 to 10,518 in 1997, and expenditures rose from $3.1 billion in 1990 to $16.7 billion in 1996. Furthermore, the average number of visits more than tripled, from 23 to 73 visits per patient, during the 10 years between 1987 and 1997.⁹

Many people in the home health industry argue that under ORT many honest agencies were punished for the misdeeds of an unscrupulous few. Regardless, the preliminary results of ORT along with its ongoing investigations of fraud and abuse have reduced home care costs, at least partly by reducing the number of agencies doing business since 1997.

Despite periods of growth and decline, home care is still an important part of health services in this country. HHAs in every region continue to try to attract nurses, and nurses who know about the industry before making the commitment to work in it generally make the most satisfying transition from one part of the health continuum to home care.

Chapter Two - Case Management in Home Health

Coordinating care between members of a community and the individuals in it who are responsible for care delivery has been part of public health nursing since the start of this nursing specialty in the late 1880s. Public health nurses have led the way in negotiating the needs of patients, while at the same time safeguarding the goals of neighborhoods, villages, townships, cities, and nations.

By the middle of the 1900s, developing technology had improved communication and made advances in medical research more widely available. With the end of World War II and the return of injured soldiers, this progress was put to good use almost immediately. Physicians and other health care providers had better tools to apply to the rehabilitation of the wounded. Success was predicated in some measure on ensuring continuity of care, the foundation of what we now call case management.¹

As a term used to define and guide practice, “case management” appeared in the social welfare literature in the 1970s. Recognizing that nurses in specific service areas had long employed case management, some nursing leaders and pioneers of case management models began to use the term as well. An early form of nursing case management was established at the New England Medical Center in Boston in 1980. The program has evolved but remains available today.¹

By the mid-1980s, the usefulness of case management had become apparent to other sectors of health care. As a result, insurance companies, workers compensation programs, and HMOs and PPOs incorporated the principles and practices of case management in their service profiles. By the 1990s, the Case Management Society of America had been established, and the membership of CMSA began to add standards of practice to the philosophical infrastructure of the organization.²

Case management in home health developed as the industry grew; the practice of case management was a primary feature of the service in home care from the beginning. A comparison of the perception of case management from the perspectives of general case management and home health may be instructive.

Approved by the CMSA, the following definition of case management also encompasses many aspects of the nursing process:

“. . . a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s needs through communication and available resources to promote quality and cost-effective outcomes.” ^{(2, p.5)} This definition is meant to cross service lines, since it applies to all types of case management.

In home health, case management is usually defined on the basis of its function; in other words, case management is achieved by way of care coordination, and care coordination is the centerpiece of the concept. For example, one expert defines case management in the following way: “. . . [a] method of delivering client care based on client outcomes and cost containment. Components of case management include a case manager for complex cases and the use of clinical paths.” ^{(3, p.426)}

Although the definition of case management in home health does not explicitly include issues of quality, the management of outcomes is linked with quality throughout health care. Both the CMSA and the home health definitions emphasize cost-effective service, a hallmark of case management, regardless of setting.

Another home health expert has defined case management as “ . . . the supervision of the care given to a specific patient or caseload population. In home health care, this is often a care model with the RN case manager rendering the skilled care, supervising, or collaborating with other ordered professional services.” ^{(4, p.626)} This definition points out one of the chief distinctions between home care case management and case management in most settings: In home health, the case manager not only coordinates the care of others, but also delivers direct care.

The case management team

Regulation is a driving force in home care, more about which will be covered in future chapters. But you need to know that the expectations Medicare developed in determining reimbursement guidelines have dictated the leadership of the home health clinical team. First and foremost, Medicare stipulates that a physician, as the patient’s medical doctor (MD), is responsible for ordering services for a patient in the home and is, therefore, in charge of the case.⁵ Thereafter, a registered nurse (RN) or, in some circumstances, a physical therapist (PT) or speech therapist (ST) activates home care services and coordinates the plan of care for the home health agency. Other major home care disciplines include the occupational therapist (OT), social worker (SW), licensed vocational nurse (LVN), and certified home health aide (CHHA), all of whom work with the RN, PT, or ST in planning, implementing, and evaluating the plan of care. Many agencies have found that the RN has the best skill set for case management in home health. On the other hand, agencies that specialize in rehabilitative services may prefer to use the PT in the case manager role.

Often referred to as “providers” in the industry, each member of the team has a crucial role to play in realizing the goals of the plan of care (POC). In addition to the RN, PT, OT, ST, SW, LVN, and CHHA, the dietitian is at times part of the team. Under the Medicare benefit, nutritional support is a covered service; thus, agencies that are certified to work with the Medicare program must employ, either contractually, per diem, part time, or full time, a dietitian for consultative purposes. Each agency organizes and deploys staff according to its own understanding of the needs of the community. Medicare has a few rules regarding staff but generally does not dictate the configuration of teams. A discussion of each major discipline in home health will help you understand the function of the team and the responsibility of the case manager.

Nursing: Nursing services are provided by a registered nurse or a licensed vocational nurse under the RN’s supervision. Most agencies expect that the RN will have either a public health nurse (PHN) certificate or one year of nursing experience, while the LVN needs one year of experience.

Along with delivering direct care, home care nurses act as teachers, counselors, case managers, and advocates for patients and their families. Only the RN can perform the initial assessment for nursing care, establish a plan of care based on the assessment, and, in consultation with the patient’s physician, prepare a care plan that includes the services, treatments, and medications to be provided. Nursing services include 1) observation and assessment; 2) management and evaluation of a patient care plan; 3) teaching and training; 4) the administration of medication; 5) treatments, such as catheterization, wound care, and intravenous therapy; and 6) the supervision of other home care providers.

The RN usually supervises the CHHA, who gives personal care and other services to support the patient and the family. The RN is responsible for assessing the patient’s need for other skilled services, such as rehabilitation therapy or social work.

Advanced practice and specialty nurses have a place on the home care team as well. Nurse practitioners, nurses with special certificates—such as the certified enterostomal therapy nurse (CETN) or the certified diabetes educator (CDE)—and the clinical nurse specialist (CNS) may be employed by or work within the HHA. Specialists supply respiratory care, psychiatric consultation, maternal/child health expertise, pediatric services, IV therapy, geriatric and oncology care, and restorative nursing evaluations and assessments.

Coordinating the plan of care means working with other providers inside and outside of the agency. The RN case manager can make referrals to other community agencies but is also free to rely on social work staff for advice whenever needed.

Physical therapy: As a rule, the physical therapist has one year of experience before home health employment. Medicare considers physical therapy, like nursing, a primary or qualifying service, which accounts for the PT case manager role.

The PT’s goal is to promote optimal health and function. The PT visits at first to determine the patient’s condition and rehabilitative potential. At the same time, the PT evaluates the home in order to advise how to eliminate structural barriers to health and safety. The PT may help to obtain adaptive equipment, oversee the construction of ramps, and locate referrals to outpatient therapy sources once home care goals have been met. PT services range from therapeutic exercises to the education of other caregivers, who can include other members of the home care circle, a family member or friend, or an unskilled worker in the home.

Speech therapy: The ST is a primary discipline and may initiate home care services. Care is directed at rehabilitation for speech, language, cognitive and perceptual problems, and swallowing disorders.

The ST may help access communication equipment and area day services, among other resources. An evaluation should be considered in the case of any voice or speech impairment, as well as loss of attention, memory, or problem-solving abilities.

Occupational therapy: Working under the treatment plan, the OT provides therapy services with the goal of increasing independence, especially in activities of daily living (ADLs). If the other case manager disciplines—nursing, physical therapy, speech therapy—have completed their work with the case, the OT may be called upon to serve as the case manager. However, the OT may not initiate case management of a home health patient.

During initial assessment, the OT reviews physical and psychological circumstances, as well as home safety and accessibility. OT services range from training in the use of adaptive equipment to cognitive skill development. The OT instructs about specialized medical devices and ways of using household items as tools for rehabilitation. Because of the connection between PT and OT disciplines, careful coordination between the two will prevent duplication of service. For example, while the PT and the OT are each qualified to perform a safety evaluation of the home, Medicare would deem it a duplication of service were both disciplines making visits in order to complete the home evaluation.

Social work: Social work services are available to a patient whose condition shows a specific link between the problem/diagnosis and potential for recovery. (An example could be a patient with diabetes whose condition becomes unstable because he or she is unable for some reason to get adequate nutrition. The SW could arrange for Meals on Wheels, thereby facilitating and influencing the potential for recovery.) Services are delivered or supervised by a qualified medical or psychiatric social worker.

The SW influences decisions about care alternatives, including in-home support (IHS), long-term placement, and institutionalization. Addressing high-risk behaviors, circumstances that endanger mental and physical health, and ways to cope with terminal illnesses are some of the skills of social work staff.

Certified home health aide: The CHHA works under the direction and supervision of a nurse, PT, or ST. The CHHA provides direct personal care and related services to maintain health or complement treatment. Because the CHHA must be strictly supervised, the plan of care should specify each CHHA activity. The case manager or one of the other professional disciplines performs a supervision visit every other week.

Personal care includes all aspects of bathing, dressing, and grooming. Otherwise, the CHHA changes linens; helps with feeding, elimination, and ambulation; and completes light housekeeping, meal preparation, and laundry in the home. Without fail, the CHHA must provide a personal service during each visit.

The CHHA is often the first team member to know the patient’s and family’s needs. The intimacy between the CHHA and the patient or family often creates a deep relationship and can result in the CHHA being the team member most fondly remembered at the end of care.

Case managers and the plan of care

The case manager (CM) is responsible for coordinating total care among the home health disciplines from the patient’s admission through to discharge. The CM works closely with the patient and the primary caregiver (CGR), the person who spends the most time with the patient and who also delivers the bulk of care: a spouse or significant other, paid caregiver, or agency staff member. The CM works with the patient and CGR in developing the POC; getting physician orders and other referrals; talking to insurance staff; delivering discipline-specific services; monitoring patient progress, discipline by discipline; managing intra- and interdisciplinary team meetings; and completing documentation of coordinating efforts. Documentation of case coordination must be completed whenever the patient’s status, interventions, or prognosis change.⁷ (See table below for a summary list of CM responsibilities in home care.)

The well-written plan of care and each thorough evaluation of it emphasize the frequency and duration of visits, as well as a visit schedule. During evaluation, the POC may need to be revised to reflect changes in the patient’s condition observed by members of the team. Critical to both the observation and documentation duties of the CM is noting how the patient responds to the home care plan.⁸

Finally, the CM prepares for discharge of the patient who has met the goals of the plan of care. The goals as written in the POC are important language in relation to Medicare guidelines, for Medicare stresses the need to evaluate goals and monitor outcomes.

Such efforts amount to a continuous improvement process, one that can occur at team meetings, during special case conferences, and when agency committees, some required by regulation and others a matter of agency discretion, work on projects. To keep all clinical staff informed of changes in regulations, most agencies offer in-services that cover clinical, administrative, and regulatory issues.

Case management varies across settings. To learn more about case management and the standards of the Case Management Society of America, see the “for more information” box.

Eligibility for services: the first regulation

Medicare coverage is available to people 65 and older; those who have had a disabling condition for two years or more, with a physician’s certification; and people with end-stage renal disease (ESRD).³ The patient with Medicaid or other third-party insurance, such as Blue Cross or Kaiser, may also receive home health services, provided that both the HHA and the patient meet specific criteria. (The limitations and regulations related to insurance coverage are discussed in upcoming chapters.) Because Medicare reimbursement helped establish the standard in home health, the programs of other payers generally follow federal regulations. But exceptions abound, requiring almost constant vigilance.

In addition to age and health condition requirements, Medicare has several unequivocal expectations, all of which fall to agency staff to verify. See the table for Medicare home health criteria. In total, these criteria make up Medicare eligibility for home health services.

Chapter Three - Clinical Expectations

Nurses enter home care in a number of ways, but rarely without first having gained experience in at least one specialty or subspecialty of nursing. Some home care providers minimize the differences between settings; others believe that the nurse’s response to the change in setting determines whether she or he will adapt to home care practice.

The home care generalist

Entry into home care practice is an opportunity for the nurse to use experience as a bridge, with the understanding that he or she must also learn new skills. Home care has a variety of nursing specialties.

At the same time, many nurses function as generalists, never limiting themselves to a particular type of patient with specific problems. These nurses like the variability in their schedules: Their caseloads may include frail elders as well as new mothers and infants; pediatric patients; and middle-aged men and women with wounds, injuries, or exacerbating illnesses who need the attention of the home care nurse.

The home health nurse generalist has a strong background in medical/surgical nursing, usually as a result of first-hand experience on a medical/surgical hospital floor. From here, the nurse accrues skills transferable to home health, skills such as basic health assessment; respiratory treatment; intravenous line insertion and management; blood withdrawal; nasogastric, gastrostomy, and other abdominal/digestive tube procedures; male and female catheterization; wound care; organization and instruction of the medication regimen, disease processes, and nutritional requirements; infection control and safety management; mobility-related therapies; and proficiency in written and oral communication.^{1, 2} Thus the home health nurse generalist might be assigned to see a patient with any of the above requirements.

In addition, she or he might be expected to manage the patient with any number of neurological conditions; the patient with postsurgical needs, such as oversight and education regarding short- or long-term therapies; or the patient newly diagnosed with a life-altering illness, such as lupus, multiple sclerosis, or rheumatoid arthritis.

The expertise that the medical/surgical hospital nurse brings to the home health nurse generalist role eases the intellectual, physical, and psychological transition to home health.³

The home care bag

Something that every nurse in home health becomes familiar with is the home care bag. Each agency develops both policy and procedure for managing the bag. Some agencies distribute the bag with all of its contents and even supply lab coats. Other agencies expect the nurse to buy a bag and to care for it according to agency guidelines; the agency supplies the contents. The primary requirement for the agency is simply to support practice through consistent, logical policy and procedure, ensuring that all staff have an orientation to both.

In other books or articles you may find variations on the following information, but the principles will remain constant.^{1, 4}

The purpose in using the bag is to give the nurse an area in the patient’s house (a place normally outside of the nurse’s control) to prevent contamination of patient care equipment. The bag both is and contains a clean work area.

The bag includes discipline-specific items that the nurse might use daily. In addition, the bag contains items chargeable to the patient, such as catheter and irrigation supplies, as well as those that the agency is responsible for providing as part of its service, such as antiseptic wipes for blood drawing and cleaning equipment. Part of the nurse’s duty is to maintain the supplies in quantities consistent with the agency’s policy. After a day’s visits, the nurse adds equipment to the bag for visits the next day. Equipment is obtained through a central supply area, such as a locked and monitored supply room at the agency or the central supply department of a hospital if the HHA and the hospital are affiliated.

The following supplies are basic to the nursing bag, and some are useful to other members of the home care team:

• Handwashing equipment (soap and paper towels, antiseptic waterless gel)
  
  
• Assessment equipment (thermometers, stethoscope, measuring tools, sphygmomanometer)
  
  
• Disposable supplies: plastic aprons, sterile and non-sterile gloves, dressings, tape, alcohol swabs, tongue blades, applicators, lubricant jelly, scissors, Band-Aids
  
  

Bag technique
The bag is managed by way of something called “bag technique,” a method to ensure asepsis. Bag technique is usually described in a simple, procedure-oriented manner. In reading the following description of bag technique, imagine that you are a new home care nurse embarking on your first visit during orientation.

• Place the bag in a clean area on a newspaper or paper towel to avoid contaminating the outside of the bag. Avoid placing the bag on overstuffed furniture or at a level where a child or pet might disturb it.
  
  
• Prepare a separate bag or newspaper for disposal of contaminated or soiled materials.
  
  
• Wash your hands, using agency soap and towels.
  
  
• Remove equipment needed for the visit and place it on a paper towel.
  
  
• Use universal standard precautions throughout the visit. Instruct the patient, family, and caregiver about the need to wash hands in order to prevent contamination and infection and to dispose of equipment and supplies safely.
  
  
• At the end of the visit, clean used equipment and wash your hands before returning equipment to the bag. Close the bag, leaving it in a clean area until you leave the home.
  
  

Other nursing responsibilities related to the bag include cleaning it monthly, or when soiled. A recommended cleaning solution is one part bleach to 10 parts water. When an infectious disease is present in the home, leave the bag in the car, taking in only items that can be discarded after use.

Ergonomics is another important consideration related to the nursing bag. One recent study showed that more than 60 percent of respondents reported discomfort associated with their bags. Factors included the weight of the bag and the number of stairs respondents climbed daily. In the same study, nurses who carried bags weighing 20 pounds or less experienced much less discomfort.⁵

Lab coat etiquette

Whether the nurse, often referred to along with other home care providers as “field staff,” wears a lab coat is a matter of agency policy. Few agencies require a uniform, which is one reason that agencies usually do expect professional attire, such as a coat. Most field staff launder lab coats at least once a week.

Home health nursing specialties

Before discussing the options for specialty nurses in home health, it is worth noting that home health nursing is a specialty unto itself. Administrators and academics have come to recognize that the nursing skills needed to serve the home care patient, although grounded in fundamentals of practice, are not merely medical/surgical skills dressed in a lab coat rather than scrubs.⁶ The body of knowledge required to comfortably and competently care for a patient in the home is both discrete and complex, so much so that even the generalist in home health may elect to take a certifying exam, as described later in this chapter.

Home health agencies are under no regulatory obligation to maintain a staff of specialist nurses. Instead, after conducting a needs assessment in the community as part of its original, annual, and perhaps ongoing planning activity, each agency decides which specialty nurses the community requires and the agency can support.^{7, 8} Then the agency develops a plan for recruiting and grooming specialists. Otherwise, a nurse specialist may work most of the time as a generalist, using specialty experience when a patient or a group of patients can benefit from it, in accordance with the policy of the agency. The nurse specialist may be certified, as is the certified enterostomal therapy nurse (CETN); or the nurse specialist may possess highly developed skills, according to the standards and regulations of a particular agency, as is true for many IV nurses at work in home health. The requirements are based on the needs of the community, the availability of staff in a given region, and the amount of risk both the agency and the nurse specialist choose to shoulder.

Some agencies have teams of specialists, teams that might also work in larger geographical teams; other agencies with fewer specialists and a different set of community needs might simply assign expert staff to case manage or consult on the patient whose needs the specialist can best meet. The following discussion of specialist nurses is meant to provide examples without excluding any specialist whose expertise may be pertinent to home health practice. As with all home health staff, the role of the nurse specialist is to serve patients in the community in a cost-effective and culturally sensitive manner.

The certified diabetes educator
A core component of specialty nursing along with the CETN, the certified diabetes educator (CDE) can also case manage or provide consulting services. The CDE is an ideal home health case manager in the following circumstances:

• When diabetes is listed as the primary diagnosis
  
  
• When a patient is newly diagnosed with diabetes
  
  
• When diabetes is considered “out of control”
  
  
• For any patient with diabetes, newly on insulin
  
  
• The first time the patient with diabetes requires oral hypoglycemia agents
  
  
• When the patient has complex teaching needs
  
  

Many home health professionals think that the best use of CDE resources is to ask for a CDE consult whenever the MD, patient, family, or a team member identify a need. Another situation to be aware of is the potential of overlooking, neglecting, or forgetting the patient with diabetes who does not comply for some reason with the plan of care, risking as a result additional complications secondary to poor management.

Certified enterostomal therapy
The CETN is often called the ET nurse and in some parts of the country is referred to as a certified wound, ostomy, and continence nurse (CWOCN). He or she helps other team members to safely maintain the patient with wounds at home. One of the most important roles of the CETN is to educate the patient and other staff members about the principles and practice of wound healing and management. The CETN usually consults when the following conditions exist:

• Multiple wounds
  
  
• Fistulas
  
  
• Drains
  
  
• Tubes
  
  
• An old ostomy—not primary diagnosis for the current admission
  
  
• Daily or more frequent wound care
  
  
• Rash or skin problems
  
  
• Infected wounds
  
  
• Newly acquired or history of incontinence
  
  

Managing most of these conditions is costly, both in terms of human and fiscal resources. The agency uses the CETN’s expertise to minimize wasted supplies and inappropriate therapeutic modalities. For example, whether the patient with an ostomy has a new or an established stoma, a great deal of care and education is often needed to maintain that patient safely at home. When the CETN consults or case manages such a patient, the agency can hope to efficiently use its resources, at the same time reducing the uncertainty and dependence that the patient might be prone to experience.

The psychiatric nurse specialist
The mainstreaming of people with psychiatric disorders has increased the need for psychiatric nurse specialists in the home setting. Medicare has strict guidelines about what constitutes a psychiatric need, along with the extent to which the patient is eligible to receive services at home. At the same time, Medicare has stipulated that the psychiatric nurse be a specialist with skills and experience related to mental illness beyond those of other nurses; the nurse must meet these requirements in order for the agency to receive Medicare reimbursement for services for patients with psychiatric conditions.

The specialist is often asked to consult when the patient has a new psychiatric diagnosis, when a new psychotropic medication has been added to the regimen, when the patient’s mental status exacerbates or causes deterioration in his or her medical condition, and when the patient is suspected of abusing alcohol or drugs. The psychiatric nurse specialist can also be helpful with the patient who admits to wanting to die, one who quits taking psychotropic medication, or one who develops a fundamental change in mood or a thought disorder.

Other nursing specialties in home health include cardiovascular, gerontology, rehabilitation, terminal care, infection control, intravenous therapy, maternal-child health, and women’s health, to name a few. Each agency is free to recognize specialties according to agency-specific criteria. As long as the agency honestly represents its staff, it may use staff credentials as part of its corporate profile.

Advanced practice in home health
The clinical nurse specialist (CNS) prepared at the postgraduate level has had a place in home care for many years. Used as an expert consultant, an exemplar, or a mentor, the CNS typically manages a practice, perhaps as a collaborative party with a physician or physician group that either sees a number of senior patients or sees patients who for some reason other than age may need home health services. Another role that the CNS is well-suited to is that of the educator. Highly visible and, ideally, respected for his or her ability, the CNS has the influence required to handle a classroom of professional staff. During the development of disease state management programs, which have at the same time developed in acute and ambulatory settings, the CNS has made a major contribution in writing program guidelines and in preparing staff to visit patients under a sometimes unfamiliar model of care. In addition, management and other staff often view the CNS in home health as a change agent, one whose sophistication in practice foreshadows a deep understanding of the patient’s health needs as well as health-related issues in the community.⁹ While Medicare and other third-party payers do not reimburse CNS services at a higher rate than RN services, agencies frequently offer the CNS compensation above that of the generalist and the specialist nurse.

A place in home health may soon open up to the nurse practitioner (NP). Because Medicare guidelines specify that a physician oversee the plan of care in home health, the NP has been unable to assume this primary care role. On the other hand, research has shown the NP to be useful and cost-effective in a primary clinical role, and challenges to the Medicare regulations from NP groups seeking reimbursement have begun to develop. Such groups interested in the development of the role have tracked whether and where reimbursement is available to the NP in the wider field of health care. In Hawaii, for example, the Hawaii Medical Services Association, part of Blue Cross/Blue Shield, reimburses for the care of the NP, CNS, certified registered nurse anesthetist (CRNA), and certified nurse midwife (CNM), whereas Blue Cross/Blue Shield of Delaware reimburses CRNA, NP, and CNM services only.¹⁰

Opportunities for certification

The home health RN who has or would like to have certification in a specialty may be able to achieve on-the-job recognition in the form of increased pay for the extra work certification demands. Each certifying body has developed standards for testing and certification, based on standards in the body’s own professional community as well as input from its membership.

Some agencies acknowledge all certifications, whether specific to home health or not. Other agencies offer economic incentives to the nurse with a public health certificate or hospice and palliative care certification. Jointly supported by the American Nurses Association (ANA) and the Home Healthcare Nurses Association (HHNA), certification is also available in community and home health nursing; such certification is highly regarded in the industry.

Chapter Four - Coordination of Care

Regulatory considerations

Almost without exception, the case conference is part of case management across all health settings. During the home care case conference, members of each of the clinical disciplines meet to discuss specific patients and their care plans. Team members help one another to identify and resolve problems, to find resources that match individual needs, and to share ideas regarding the agency’s environment, the state of the industry, and other work-related issues.

Although organizational templates exist, each agency has the choice of assigning teams according to its own goals. One typical configuration is that of several small multidisciplinary teams arranged according to ZIP codes or regional designations. The ZIP code method of team organization is patterned after the arrangement of teams in many U.S. public health departments—not hard to understand when one knows that there’s a history of public health and home health professionals, especially among social work and nursing staff, moving between community and home care practice.

Home care is a highly regulated industry. The state and federal governments have separate laws and regulations pertaining to home health. Moreover, each agency in a given state must abide by both. State home care associations make working at state and federal levels somewhat easier by offering regular in-services and publishing guides that review, compare, and analyze requirements. In California, for example, the California Association of Health Services at Home publishes a side-by-side comparison of state regulations (the regulations under Title 22) and federal regulations (the Medicare conditions of participation, COPs). In Title 22 and the Medicare COPs, home care agencies are required to coordinate patient services through activities that include holding case conferences with each of the clinical disciplines, developing policies that influence care, and issuing written and verbal communications. Home care agencies then are required to record the immediate results of coordinating efforts, communicate conference findings to the patient’s MD when indicated, and reconvene team members to discuss the patient and the patient’s care plan at intervals. Regulations specify that meeting intervals are to be determined by the patient’s condition and that a summary of findings be made available to the patient’s physician. As the regulations, particularly the COPs, evolve in accordance with ongoing efforts to create efficiencies and standardize practice, CMS has proposed that demonstrated coordination of care occur no less often then once during each period of home health certification.^{1, 2}

Standards in the community

Coordination of care is the signature of case management in home health. Effective care coordination is demonstrated when the patient and primary CGR achieve independence (the ability to care for the patient without home health services) while learning to manage the patient’s disease process. Coordination is a multidisciplinary opportunity, one that relies on participation from every team member in order to achieve outcomes and receive reimbursement.³ In fact, clinical goals are met through a team approach, a team whose skills are based on scientific knowledge coupled with a sensitivity to social and spiritual needs.

Consistent and clear communication facilitates coordination of care and the purpose of case management. An account of the patient’s response to treatment and progress toward the goals of the POC, as well as the impressions from among the disciplines that have contributed to the plan, must be included in case conference notes and individual patient records. The failure to meet these expectations can result in the patient’s exacerbated illness and a loss of trust and revenue for the agency.³

Physicians who refer to home health depend on agency staff to carry out orders, manage the patient in the community, and update the plan of care as goals are met. Physicians also depend on agency staff to guide them and their staff in meeting Medicare guidelines. One challenge in working with physicians is that home health activities, such as patient education, must also be physician-approved in order for the agency to receive reimbursement for teaching services. Under Medicare home health benefit regulations, even services within the realm of the nurse’s scope of practice need authorization, something neither the physician nor the new home care nurse typically realize.⁴ Thus cultivating a good relationship characterized by clear communication with the physician is both efficient and useful.

Since home care practice occurs in the community and in behalf of a community member, it stands to reason that the patient may have received services from other health care providers before accepting the services of the HHA. Home care team members outside of the agency can be comprised of staff from HHAs that once served the patient; public health nursing, social work, or community health professionals in the public health system; staff from any local or state health care agency, including the Department of Health Services, where Child or Adult Protective Services are based; employees from child care or senior centers; and students from local schools who may interact with a patient during a rotation through home health. To prevent duplication of services, which Medicare will not tolerate, health care personnel must coordinate their efforts, sometimes requiring, for example, that staff members from public health and home health, or elder day care and home health, or physician office and home health staff confer about the history, progress, and prospects of a particular patient. An example is the patient with a leg ulcer following hospitalization for placement of a shunt and subsequent dialysis treatments. Care of the wound and the shunt should be orchestrated to prevent duplication of services, as well as conserving the patient’s energy as much as possible. In such a situation, the home health CM might take leadership in coordinating, documenting, and following through with the dialysis clinic staff. If possible, wound care—usually the responsibility of the home health staff—might be completed during the dialysis treatment. As you can see, intra- and interagency communication may become a part of the job.⁵

Tools for care coordination

In home health, technologies including accounting, patient documentation, and quality improvement software have been developed over the years, much as similar tools have been developed for other segments of health care. HHAs in some parts of the country began to include technological approaches to managing services as soon as those technologies were available. But technology is expensive, and HHAs without endowments, other funding sources, or grant monies have been slow to invest in such resources. The past 10 years have been a time of huge advances in technology, but also a constricted time in home health, if not throughout the whole of health care.

Nonetheless, tools are available, and recent regulatory requirements make them more necessary, if not more attractive, than ever before. Software written specifically for field staff, who can enter patient-related data directly from a patient’s home, is available from a number of vendors.

Ultimately, software is chosen according to the agency’s goals. Management’s ability to integrate technology with patient care has depended partly on the products available and partly on pressures from public and private payers to include information that justifies charges by demonstrating interventions and outcomes. (See the “for more information” box for Internet sites where you can learn more about software for home health billing, patient care documentation, managing quality projects, and human resources activities, among other related products.)

Less technical but highly evolved documentation tools exist to enhance care coordination. Individual agencies have developed and piloted documentation, sometimes sharing the results with other agencies at conferences or through journals articles.

Apart from a clear interpretation of the regulations regarding care coordination, rules about how to achieve it are at the discretion of each agency. Some agencies require staff to complete a conference sheet on each patient whenever the CM or others meet to discuss the patient. Other agencies prefer that staff complete a progress note or a multipurpose form in the event of a patient-related meeting. As is true in other health settings where coordination is routine and at the same time essential, the documentation of the service helps to define the care process. (See the figures below for sample care coordination documents.)

Finally, the home health industry began using other communication tools as soon as the financial resources became available. The following resources are now commonplace in the home care industry; agencies across the country have benefited from all or most of them for a decade or more: agency reception staff, answering services, voice mail, pagers, fax machines, desktop and laptop computers, the Internet, cellular phones, field charts and other paper records, and interpretation services.

Case Management Tool

Sample Care Coordination Patient Card

Chapter Five - The Home Health Benefit

Medicare

The development of Medicare spawned the modern home health industry. Medicare Part A was designed to provide the hospital benefit while Part B covered outpatient services. Until BBA’97, both Parts A and B paid for home care, but the majority of home care was covered under Part A. You may have heard that Medicare is under revision: One result has been to shift more of the responsibility for reimbursing home health to Part B benefits so that a solvent program for Part A can be ensured in the future.^{1, 2}

Medicare has strict criteria for home health services, which are described in detail here. CMS continuously re-examines these guidelines to be sure that they meet the goals of the Medicare program. Along with reallocating reimbursements under Parts A and B, for example, legislators and federal administrators have found ways for providers and beneficiaries to share in the responsibility of specific aspects of the program by monitoring their respective interventions and other practices that relate to the criteria. This has resulted in more regulator-initiated surveys and mandates about giving home health information to all Medicare beneficiaries.³

The first criterion for coverage is that the patient be eligible for Medicare benefits. In other words, the patient must be a) a U.S. citizen, 65 years or older, who has worked for at least 10 years, otherwise counted as 40 consecutive work quarters; b) a person who, based on a disability of at least 24 months, qualifies under the Social Security Disability Act for payments; or c) a person with irreversible kidney failure who must undergo dialysis.¹

The second criterion is that Medicare be the right payer. For instance, as a rule Medicare will not pay for care related to an automobile accident since auto insurance is expected to cover services; in cases of liability or workers compensation; for the patient with Veterans Administration (VA) coverage; in the case of black lung disease, which is covered under a separate program; or for anyone with other federal coverage.

To be sure that Medicare and no other insurer is responsible for the services, the admitting home health provider looks at the Medicare card, either taking a copy of it or copying the information from it, usually in a manner consistent with the agency’s policies. The next criterion for Medicare coverage is that the services be covered under the terms of the Medicare program. The services should relate back to the POC, for Medicare will not reimburse for care unless it has been stipulated in the plan. In the federal guidelines and the home health industry this requirement is called “medical necessity.”

The patient must also have a need for intermittent skilled nursing care or a need for physical therapy, speech therapy, or a continuing need for occupational therapy.⁴ (See the table for a discussion of intermittent care.) One way to look at this federal requirement is to understand that nursing and therapy services qualify the patient for the Medicare home health benefit. As a result, in the industry people call nursing and physical or speech therapy “qualifying services.” Occupational therapy is also a qualifying service after the case has been established through nursing, PT, or ST and only after these disciplines have finished their work. When occupational therapy is the final professional discipline in the home, the OT can manage the patient and complete related responsibilities. Naturally, all disciplines in home health that contribute to a specific POC must furnish services recognized to be consistent with legitimate home care. Medicare fully reimburses all treatments that it authorizes.

Next, the agency must be a participant in the Medicare program. Unless the HHA has been certified to work with Medicare, services will not be reimbursed. An agency earns certification through an application and survey process. Most HHAs, whether profit or non-profit, opt for Medicare certification. Another related requirement is that the agency make available, at a minimum, skilled nursing services and at least one of the therapy services.⁴ Additional Medicare regulations relate directly to the patient. He or she must be homebound, meaning that to leave home requires effort and has significant consequences. The patient may reasonably leave home for services, such as pastoral care, hair care services, or adult day care, which are ordinarily received at a place other than the home. Of course, the expectation is that the patient will also leave home to see the physician.⁴

Finally, the patient’s MD must have established and approved the POC for home health, just as the physician must continue to authorize the plan through ongoing supervision of and participation in the patient’s care.⁴ When it established the home health program, the government envisioned that the MD would provide home care team leadership, although the physician rarely knows the team and typically communicates with an agency by telephone and through orders.

Medicaid/Medi-Cal

The Medicaid program (known as Medi-Cal in California) provides health services to the poor and disabled. Guidelines have been established for assessing both economic status and physical or psychosocial standing. The program is mandated by the federal government but administered by each state according to its guidelines. Inpatient (including hospital, skilled nursing facility [SNF], and sub-acute settings) and outpatient, home health, and hospice settings are covered under Medicaid/Medi-Cal. Hospice coverage through Medicaid/Medi-Cal is optional and, as a consequence, not all states have elected to offer it.⁵

Medicaid/Medi-Cal’s patient-care regulations are similar to Medicare’s: a) services are provided on an intermittent basis; b) staff must be licensed and certified according to standards in the state; and c) the patient must have an up-to-date POC, as well as physician approval and participation.⁶ Care is reimbursed on a fixed fee-for-service basis at the same level of payment throughout each state. However, reimbursement for services does vary state-to-state. For example, medications, supplies, and equipment are reimbursed selectively.

Third-party payers

Third-party payers are represented by a variety of insurance programs, including traditional indemnity programs, like Blue Cross; managed care programs, such as Prudential and the Medicare HMOs; and capitated programs, for example Aetna and Signa Health. The home care patient may have third-party insurance as well as Medicare. At times a couple may each share in the other’s insurance benefit. When the patient has additional coverage, the private or third-party insurance provides primary coverage, while Medicare is the secondary payer. In each patient’s admission documentation packet, the HHA includes a form, typically called a “Medicare payer form,” that helps the CM and the agency to determine both primary and secondary responsibility for payment.

Here is a brief explanation of the features of the types of third-party payers:

• Indemnity programs pay 80 percent of what is known as the usual-and-customary rate for a service, and the patient contributes 20 percent.
  
  
• Managed care establishes fixed rates of reimbursement, and services are contracted according to a set fee. The terms of the contract frequently restrict the patient in his or her choice of provider. A co-payment for office visits, medications, supplies, and home medical equipment (durable medical equipment or DME) becomes the patient's responsibility. Under most managed care plans, home care does not include a co-pay.
  
  
• Capitated contracts are organized around groups of patients or “risk pools,” each with a fee per member, and the fee is paid monthly. The provider is responsible for service at the pre-determined fee regardless of the health conditions that occur in that group.

Medicare hospice benefit

When possible, care of the terminally ill patient at home is delivered through a hospice program. Medicaid/Medi-Cal managed care and third-party payers have followed many of the same guidelines adopted by HCFA when it established the COPs for the Medicare program, in which hospice is included. Differences between hospice and home care coverage do exist: All of the same disciplines may visit the patient, but the RN is almost always the CM. In addition to nursing, PT, ST, OT, SW, and CHHA, hospice includes the care of a chaplain, respite care, extensive volunteer services, and bereavement services.^{7, 8} Core services, or those required from every Medicare-certified hospice program, include nursing; social work; medical direction, usually from the hospice medical director; volunteer services; bereavement services; and inpatient care when needed. Other services, supplies, and equipment must at a minimum be available by contract organizations and suppliers.⁶

Clinical care in hospice is organized around the concept of an interdisciplinary group (IDG), providers who collaborate in the coordination of care. The IDG is formal and highly structured. Members meet as often as needed, at least every one to two weeks. Benefits are provided over two 90-day periods, followed by an unlimited number of 60-day certification terms.

It has been said that hospice is an early example of managed care because Medicare has for years reimbursed hospice on a per-diem basis. All disciplines, supplies, equipment and medications are paid for out of the per-diem rate; therefore, the risk of fiscal management falls to the administrators and clinicians of the hospice organization.

Chapter Six - The Environment of Care

Influence of setting on practice

In some respects, the health setting defines practice. For example, care in a trauma hospital is usually more highly technological than care in an outpatient surgery center, even though in both cases defibrillators, surgical equipment, and pharmaceuticals are available.

Another way of evaluating care delivery, and thus practice, is with the environment at the center. To do so requires well-grounded and imaginative assessment skills, particularly because some environments undergo change every day. In home care, the environment of care is like a blanket we spread over the patient: Without the patient, the blanket is just so much fabric, but with the patient, the blanket assumes any number of shapes, shapes to which you and the patient may respond by reorganizing and reshaping the material.

Getting into the community

An initial consideration in home care practice is whether the patient and provider have access to each other. The bulk of home health is governed by Medicare regulations or regulations that mirror the intent of Medicare. Regulations require that the patient be homebound; therefore, service necessarily occurs in the patient’s home.

The home care provider generally drives to the patient’s home. In urban and inner-city settings, however, it is sometimes possible to take a bus, to bicycle, or walk to the patient’s home. Automotive transportation is a matter or productivity: The provider can travel greater distances and see more patients if he or she has a car. With other means of transportation, mobility must be evaluated from the standpoint of the layout of the city and the proximity of the patient caseload. Urban or inner-city home health often entails a nurse’s visiting several patients in the same building, for example.

A nurse must evaluate the transportation available as well as issues of safety while traveling in unfamiliar neighborhoods before committing to home health practice. Although safety is difficult to control, organizations like CMS, state regulatory bodies, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Community Health Accreditation Program, and the Occupational Safety and Health Administration (OSHA) expect that home care administrators will do as much as possible to ensure the safety of patients and field staff alike. JCAHO and OSHA regulations also address specific considerations involving transportation safety and, in response, home health providers receive in-services on assessing the neighborhoods in which they work for parking safety, safe access to and from apartments and other residential buildings, times during the day and night that might be less safe than others, and the presence of people who might impede transportation or, worse, pose a danger to staff.^{1, 2} (See link below for information about assessing and developing a safe community.)

Parking and the neighborhood

Field staff are encouraged to evaluate and re-evaluate the patient’s neighborhood. Each provider conducts what is sometimes called a “windshield survey,” assessing the overall cleanliness of the neighborhood, the kinds of residences and how each is constructed, the presence of shops and other businesses, the demeanor of people on the street, and the racial and ethnic mix of community members. Although field staff must be careful to avoid making hurried or biased judgments, this information can be helpful in assessing the safety of the provider and the patient and in evaluating the patient’s ability to access community resources.

Additional considerations include whether green space (such as a park) is available; the potential for ground or area pollutants (oil or other noxious substances); and the condition of streets, walkways, and other walking or standing surfaces, such as the concrete spaces in parks and schools.³ This environmental information contributes to the picture the provider develops of the patient and is one important facet of understanding the rehabilitation potential a patient has.

Parking must be considered from the perspective of both the provider and the patient. Can the provider park conveniently without creating a problem for the patient’s family members or the neighbors? Are points of parking etiquette in the neighborhood readily understood? Are parking signs visible?

Patient access and safety

The home care case manager or other clinical provider also evaluates whether safety issues prevent access to the patient. In arranging the visit, the patient or caregiver should supply the field staff with complete directions to the neighborhood, as well as how and where to enter the patient’s residence. As a rule, HHAs have large wall maps in the office for reference or make printed guides and maps of the community available to their staff. The provider who makes late visits is advised to park in a well-lighted area, preferably one that is heavily traveled.⁴

On the initial visit, the admitting discipline observes for any environmental dangers, such as loose external stairs or cluttered passageways, that can pose a danger to other personnel and are potential barriers to the care of the patient. Other considerations include whether the patient has unfriendly pets or weapons on the grounds and whether there are people in the house who create a threatening atmosphere. Although providers try to give service to all patients in need, staff are not expected to jeopardize their personal safety on the job.