System joins community nursing and home health

Coordinate intake and resources for success

Although Valley Health System in Winchester, VA, originally set up the community nurse case management program as a separate department that operated independently of home health, people soon realized that the two areas needed to coordinate their activities, says Lisa M. Zerull, RN, MS, program director of the community nurse case management program.

"Physicians were confused with two departments offering care in the homes, and we would accept patients who would have qualified for home health and vice versa," she says.

"We also found that physicians would refer their patients to community nurse management because there are fewer requirements in terms of written orders, signatures, and oversight," says Patricia Klinefelter, RNC, BSN, home health director for Valley Health.

To address these problems, home health’s intake department now screens all patients referred for home care and determines which level of care is best for the patient, she explains.

Basically, a home health admission is a patient who has experienced an acute episode, is coming out of a hospital admission, and needs skilled nursing services such as wound care, Foley catheter care, or intravenous medications, Klinefelter says.

Community nurse management patients are chronic patients, often with congestive heart failure, diabetes, chronic obstructive pulmonary disease, behavioral health, or other heart conditions, she adds.

Other differences in the two programs are that home health requires a physician order, provides medical care, and can provide visits multiple times during a day, week, or month, says Zerull.

"Community nursing does not require a physician order, unless we are asked to fill medication boxes or take pulse oximetry readings. We focus on nursing care, patient education, and assessment of the patients’ understanding of their condition and their responsibilities," she adds.

"We also visit the patients only once per week," she says.

Because there only are three nurses in the community nursing program, Zerull has chosen to hire only RNs. "We want to make sure the nurse is able to assess the physical and medical condition of the patients to make sure they are stable and not in need of other medical care," she explains.

Although physician orders are not necessary for community nursing, Zerull says that they do contact the patient’s physician with a letter that lets the physician know a nurse is seeing the patient, and periodic reports are faxed to the physician.

With the nursing shortage making it difficult for home health agencies to find qualified nurses, Zerull was careful not to "raid" the home health agency.

"My three nurses were all employed in the hospital in the rehabilitation, pulmonary, and emergency departments. They required some training and attend inservices with the home health staff, but they made the transition to community nursing very easily," she explains.

The community nurse’s main responsibility is to enhance patient education and help patients comply with the activities they need in order to stay stable or improve their condition, explains Zerull.

"The nurses develop a close, long-term relationship that is more like a friendship with the patients because they see them for almost three months in most cases," she says.

"We’ve had many patients who want to please their nurse, so they make sure they check and log their blood sugar levels or whatever task the nurse will check," Zerull adds.

Patients are discharged from community nursing when they:

  • meet intake criteria for home health, hospice, or other community agency;
  • are able to manage self-care with little or no support;
  • move out of the region or receive health care from another hospital or health system;
  • choose not to work toward improved self-care;
  • are not at home three times for scheduled visits;
  • engage in drinking, drug abuse, or other activity that makes the environment unsafe for the nurse;

The key to a successful community-nursing program is to coordinate care between home health and community nursing, Klinefelter points out.

"We want to make sure that no nurse is asked to perform a duty outside the scope of his or her service," she says. "We also wanted to streamline the process so referral sources or patients could make one phone call and be admitted to the best service for their needs."

Another reason to have the two programs work closely together is accreditation, Zerull adds. "Community nursing is surveyed under the same standards as home health, so we did borrow the home health policies and procedures to set up our own.

"We recently underwent an accreditation survey by the Joint Commission on the Accreditation of Healthcare Organizations and received a score of 99 for home health and community nursing," she says. "Surveyors commented on how the coordination of the programs reduced duplication of services and assured good patient care.