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

Discharge planners/case managers who work in institutions such as acute hospitals, skilled nursing facilities, etc. may not have thought about a fundamental difference between home care and care provided in the institutions in which they work. The difference is that patients receive continuous care in institutional settings, but receive only intermittent care from home care providers, including home health agencies, hospices, HME (home medical equipment) companies and private duty agencies, unless they choose to receive and pay for 24-hour care seven days per week of private duty care. Few patients choose the latter, if for no other reason than because it is extremely expensive. Most home care patients, therefore, receive only intermittent care.

Patients must continuously meet the following criteria, regardless of payor source, in order to be generally appropriate for home care services:

  • The patient’s clinical needs can be met at home.
  • The patient can either self-care, or there is a paid or voluntary reliable primary caregiver to meet the needs of the patient in between home care visits.
  • The patient’s home environment supports home care services.

All three of these criteria must be met on a continuous basis in order for patients to safely receive home care services of any kind.

The second criterion listed above is absolutely crucial for the safety of patients following discharge to their homes. Home care staff may encounter very significant difficulties with this criterion as follows:

  • When staff evaluate patients for admission, they will certainly identify a potential primary caregiver. Realistically speaking, however, all they can tell about potential primary caregivers during the admission visit is that they are vertical and breathing. The competence and reliability of primary caregivers can only be assessed over time. To the extent possible prior to patient discharge, case managers/discharge planners in institutional settings should identify possible primary caregivers and assess their willingness and ability to act as primary caregivers after patients are discharged.
  • Home care staff members are also often working uphill against the expectations of patients and their families. Specifically, case managers/discharge planners in institutional settings are under so much pressure to move patients out of the institution that it is difficult to find the time to explain to patients and their families what must be their role in home care. Consequently, patients often are referred to home care with the expectation that nurses will take care of everything, just like they did in the institution. This expectation is further enhanced by the general lack of understanding by many patients and their families about home care. In addition, in the face of illness, it is only human for vulnerable patients and families to want agencies to simply step in and take care of everything.
  • In addition, some of the tasks that primary caregivers may be expected to perform are repugnant to them. The “big three” such tasks are: wound care, changing diapers, and giving injections. When these tasks are involved, the reliability of primary caregivers may be sorely tested. Case managers/discharge planners and agency staff members should be specific about the tasks primary caregivers will be required to perform, especially the three mentioned above.

Reliable primary caregivers are crucial to the safety of patients after discharge. Although it will never be foolproof, case managers/discharge planners can help ensure patients’ safety by assessing the reliability of primary caregivers prior to discharge. Post-acute providers are well-advised to educate case managers/discharge planners regarding this fundamental difference.

Contact Elizabeth E. Hogue, Esq. at (877) 871-4062 or via email by clicking here. Click here to follow Elizabeth Hogue on Twitter!

© 2013 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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