Elizabeth Hogue on the Fundamental Difference Between Home Care and Institutional Care

Discharge planners/case managers who work in institution such as acute hospitals, skilled nursing facilities, etc; may not have thought of a fundamental difference between home care and care provided in the institutions in which they work. The difference is that discharge planners/case managers and other staff at institutions have at least fundamental control over the environment in which they provide services. Home care providers, including home health agencies, hospices, HME (home medical equipment) companies and private duty agencies, work in an environment that is completely controlled by patients and their families. They have little or no control over the environment in which they render care to patients.

Consequently, home care providers, are, for example, vulnerable to physical violence and even death. Several home care nurses have been fatally shot within the past several years. The murder of a home care nurse, along with the patient and the patient’s mother, in Maryland received national attention from the media several years ago. Some agency staff members make visits to patients’ homes accompanied by armed guards because visiting staff are vulnerable to patients, their families, anyone who enters the patients’ homes, and going to and from patients’ homes.

Home care staff are also subject to attack from various sorts of animals. Dogs are the most obvious offenders. Imagine being attacked by a flock of pecking geese as you attempt to enter a patient’s home or coming eye to eye with a pet alligator named Bubba in a mobile home in Louisiana. True stories! There are no fellow staff members to call for help under these circumstances. There is no security force to call for assistance. Home care staff members are on their own and extremely vulnerable to attack by humans and animals.

Home care providers are also vulnerable to injury because of the physical surroundings in which they work. A manager at a home health agency related a sad story about a nurse on the staff who made a routine visit to a patient who lives alone in her home. The physical condition of the patient’s home was compromised. As the nurse was making her way to the patient’s bedside, she fell through the floor of the patient’s home! Unfortunately, she suffered severe injuries and required back surgery.

Agencies owe their employees a duty of reasonable care. That is, they are responsible to take reasonable precautions to protect their employees from harm. The Occupational Health and Safety Administration (OHSA) has affirmed this obligation on the part of home health agencies. This obligation is becoming far easier to talk about than to fulfill in increasingly threatening environments for home care personnel.

Of course, a key question regarding this obligation on the part of agencies is: What is reasonable? Providers are clearly obligated to make reasonable efforts to identify situations in which their workers are likely to be injured. This means that they must gather as much information about patients, their primary caregivers and their home environments as possible prior to admission.

In order to help ensure that they have as much information as possible, providers may want to review patients’ charts, talk to patients and/or their families while they are still in the hospital or SNF, etc. It is not always necessary to decline to accept referrals of patients based on the information obtained. If advance information is available, home care providers can act to protect staff and help patients. Put Bubba in a cage!

Case managers/discharge planners who impede efforts of home care providers in their efforts may enhance the likelihood that patients will go without needed services and home care providers will be injured.

Providers that fail to meet their obligations in this regard may be the target of suits for negligence by employees and/or workers’ compensation claims. Since occupational health and safety requirements include a general mandate to employers to provide a safe working environment for their employees, as described above, agencies may also face OSHA violations when workers allege that conditions are unsafe.

It may be helpful for case managers/discharge planners to imagine being all alone in an urban area that has a reputation for being unsafe or in an isolated rural area knocking on the door of a patient’s home for the first time not knowing what is on the other side of the door. If case managers/discharge planners think carefully about this scenario that is enacted by home care providers hundreds of times a day, they are likely to better understand why agency staff members want as much information about patients prior to admission as possible.

© 2012 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.

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