GLORIA BUTLER BALDWIN

Home healthcare isn’t just one option out of many for a lot of people; it’s a necessary service.

Even if patients or their families are reluctant to use home healthcare, insurance companies are increasing pressure for people to take care of their own medical needs at home. As baby boomers reach their senior years and hospitals become more crowded, the need for home healthcare will increase dramatically. Family members are being trained to do some of the tasks typically done in hospitals, sometimes with disastrous results.

A study by numerous departments at the Vanderbilt School of Medicine in Nashville of two of the largest urban home healthcare agencies in the United States — The Visiting Nurse Service of New York and The Visiting Nurse Association Foundation in Los Angeles — found a startlingly high number of medication errors in home healthcare patients, although the study did not look at who or what caused the errors.

According to the study, which was conducted between 1996 and 1998 using The Home Health criteria and The Beers criteria, nearly one-third of the home healthcare patients surveyed had evidence of potential medication problems or were taking a drug considered inappropriate for older people. Although the study is 10 years old, problems still exist. The Journal of the American Geriatrics Society, June 2001, indicated that more effective methods are needed to improve medication use in this vulnerable population.

Medicare is paying an enormous amount toward home healthcare each year and, although there are exceptions, most patients only see their home health nurse once or twice a week. Between nurse visits, families are trained to dispense medication, treat wounds and keep IV medication going. Lawsuits are filed frequently against home healthcare providers, although there’s often a blur between who’s really at fault: the doctor, the home health agency or the family.

The question is raised: Who’s to blame for errors? The home healthcare nurse who is being forced to train families who are sometimes incapable of understanding? Families who are being forced to add more to their already very busy lives? Or, the numerous caregivers who don’t communicate with each other?

Jennifer Hall, director of nursing for HomeChoice Health Services, said she has five full-time nurses in Memphis who often run into problems with caregivers.

“We teach IVs and wound care — pretty much anything that needs to be done for a patient,” Hall said. “We’re teaching them a skill, because insurance won’t pay for every visit. They usually give you three visits to go out and teach and once a week to monitor. There’s some situations where there’s no caregiver or a where we feel where the caregiver isn’t capable. Some of those we just can’t admit. If patient or caregiver isn’t competent, it’s a liability for us to take that patient on.” Hall said the problems are becoming more and more frequent.

“Patients are discharged very quickly because of their family situation,” she said. “They may say they have a caregiver and then get home and it’s a different story. Or the caregiver they’re counting on isn’t there. Some patients that really should be in a skilled facility or nursing home refuse to go there. In those cases, we really should be there. And, we can’t because of insurance. A lot of times, we have to make other referrals.”

Visiting Angels director and owner Mike Terry said at issue is the state license that does not let anybody but family members do some of the vital things that are needed. Visiting Angels is a national franchised, private, non-medical home care agency that is allowed to assist in bathing, errands and changing diapers, but does not handle anything related to medical care or medication administration. “We can’t administer medication or injections even though we’ve got qualified CNAs that are trained to do it,” Terry said. “It forces the home health people to train a family member to do it and some can’t. It’s an error in the ways the laws are written right now. I was involved in the committee that wrote the rules for licensure for non-medical home care that came into effect a couple of years ago, but it got edited and changed by the state. It’s really a mess. We may have a patient that has a feeding tube and medications going through, but our license won’t allow us to do it and the home health people won’t do it unless you pay them $200 to come out there four times a day to do it. They’re not structured to do it and Medicare won’t pay them. It leaves the family in a vulnerable position. They have to do some things that require them to take off work, get a neighbor to come in to do it. It forces the carelessness that goes on.”

Terry said the law ties their hands even from opening a medicine bottle for the patients.

“We’re able to do medicine reminders, but we’re not able to give injections or even take pills out of the bottle for them,” Terry said. “We’re only able to hand them the bottle and sometimes they can’t even open it. We have to refuse to do some things the family needs do. Now we get a family to provide us medicine planners- the pillboxes, but some can’t read the boxes to know what day it is. Some have Alzheimer’s and can’t remember if they took it or not and double up or some don’t want to take it at all and hide it under the bed. We see that a lot. We work with home health agencies and they refer us to their clients that need somebody there. But, with the law the way it is written, we can’t do that much to help them with these things. The law has some kinks in it we need to work out.”



November 2007