GLORIA BUTLER BALDWIN

It’s no secret that Florida is one of the fastest growing states around with much of that growth due to retiree relocation. With so many retirees moving in, health care is in huge demand. Likewise, the need for home health will continue to grow as more hospitals are filled and independent minded baby boomers stay home to avoid a nursing or assisted living facility. In addition, insurance companies are increasing pressure for people to take care of their own medical needs at home. The results are that family members are being trained to do some of the tasks typically done in hospitals and nursing homes, and concern over the number of medical errors is increasing.

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.

Although usually unintentional, non-compliance by family members is the number one problem nurses see daily in home health and hospice situations.

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 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.

Scott Clark, administrator for the Orlando Regional Visiting Nurse Association, said he sees the biggest challenge and cause for error as communication failure between physicians, families or patient and health care providers, such as home health workers. His own father, who had always been organized and regimented about his medications, had started falling in the mornings and his home health agency couldn’t understand why - until he remembered he had forgotten one very important thing - he was also taking a sleeping pill at night. “Many times there will be multiple medications and multiple physicians and specialists,” Clark said. “Dr. A doesn’t communicate with Dr. B. So, so no one has a complete picture of all the medications that patient is currently taking or has been on historically. An advantage of home health is that you’re physically in the home. We typically ask the patient to bring out all meds they’re taking including vitamins and supplements so we can evaluate them all. They don’t know that supplements or vitamins or something as simple as taking an aspirin because they have a headache can compound the problem.”

Clark said they are currently developing a house call program to bridge the gap among the hospitals, physicians and patients when they are discharged from the hospital.

“This can add a tremendous improvement in the medical interaction between clinicians and physicians. Almost like a bridge,” Clark said. “Doctors in the hospital may not communicate with primary care physicians outside the hospital. That interaction between what happens in the hospital and what happens when you’re discharged is very murky sometimes. We will offer to send a doctor or advanced registered nurse practitioner in between and in conjunction with nurse visits. They would become the primary care physician for the home health visits, but the ultimate goal is to get them back to their own primary care physician. This would improve their overall care and diminish the chance of errors. It all comes down to communication. Any break down at any point and there are problems.”

Absolute Home Health Care Administrator, Therese Kirlew-Holston, said non-compliance is always an issue, but there are contributing factors such as social and economic factors and fragmentation of the family structure that can hinder compliance.

“Lots of times you don’t have extended family to help them, so many elderly live by themselves,” Holston said. “Sometimes they can’t get to their medication or pour the bottle or read the pill containers. Even if nursing would go in and pre-pour and prepare it for them, many can’t read how to take it or open it. Many have poor eyesight and short-term memory. They’ll act like they understand when you’re there, but the next day they can’t remember how. They have to be reminded home health care is not long term care, but rather acute, intermittent care and they’ll have to learn how or find someone that can help care for them after home health leaves.”

Holston said it’s easy for patients to fall through the cracks unless home health workers help locate a skilled facility that can assist the patient once home healthcare ends.

“A plan has to be put into place to teach the family or help them locate a skilled service to help them after home health ends,” Holston said. “There have been Medicare cuts across the board in home health. As a result there continues to be even more of a gap and they fall through the cracks. It’s not because we’re not doing our job. A lot of medication errors shouldn’t be happening at the level of assessment. The medication errors that typically are happening are that patients have been instructed, but can’t understand, or have dementia or the caregivers aren’t doing it correctly. The only thing you can really attribute errors to is failure of home health agencies to monitor medications and get re-demonstrations done. You can’t just instruct someone and not follow up because there are many factors why a person may not be compliant. Evaluating compliance is as important as instruction.”



November 2007