National trend pushes more pulmonary disease patients into home care
It's time to hold an inservice on COPD
At least one major trend is expected to push more pulmonary disease patients into the home care setting within the next few years, experts say: Increasing numbers of health systems and organizations owned by physicians and hospitals are expected to contract directly with Medicare to provide all health care services to Medicare beneficiaries. As that happens, health systems often will choose to put chronically ill patients into home health care to prevent their more costly use of hospital inpatient beds and emergency department visits.
Increasing numbers of hospitals, physician groups, and even managed care companies are forming integrated delivery systems (IDS). The number of the most highly integrated delivery systems rose by nearly 19% from 1995 to 1996, and about 79% of these systems have home health agencies, according to the Managed Care Digest Series of 1997, published by Hoechst Marion Roussel in Kansas City, MO. Many integrated systems also have health maintenance organizations (HMOs), the Hoechst Marion Roussel report shows. And those systems are on the forefront of contracting with Medicare to serve Medicare beneficiaries on a capitated basis.
That means the IDS will receive from Medicare a set fee per month for each covered life and will not be paid on a fee-for-service basis. Once that happens, a health care system will look for the least expensive ways to keep patients healthy, and for many patients who have chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and diabetes, that means home care is the best answer.
The future has arrived in Puget Sound, WA, where one IDS - Group Health Cooperative of Puget Sound - has witnessed an increase in COPD patient referrals to home health care. The same is true of diabetic patients and people with CHF, says Pat Philbin, assistant administrator for Home and Community Services, a division of the IDS, which has its own hospitals, clinics, home care, and managed care organization.
"We have done some preliminary work in the area of a protocol for COPD, an actual protocol of what home care staff do on each visit to prevent rehospitalization," Philbin says. "Home care actually reduces costs in the long run, and we've been able to substantiate that and prove it time and time again."
Group Health Cooperative has a capitated contract with the Health Care Financing Administra tion (HCFA) to serve Medicare clients in the community. The company receives a set amount of money for each Medicare beneficiary who contracts with Group Health, whether or not that beneficiary is hospitalized, treated at home, or is healthy and only makes annual visits to an outpatient clinic, Philbin says. "In that light, we can choose to spend that money in any way we choose to spend that money."
That means the company can put patients in to home care even if they don't meet Medicare's strict homebound requirements because the same rules don't apply when payers have risk arrangements with HCFA. Since HCFA doesn't pay home care agencies on a fee-for-service basis under those types of arrangements, the federal government doesn't have to set limits on visits and services.
Death rates on the rise
Home care agencies also might start to see more COPD patients simply because the rate of people being hospitalized for the disease is on the rise, according to statistics from the American Lung Association (ALA) in New York City. The death rate from chronic bronchitis and emphysema, two of the biggest diseases grouped under the COPD heading, also is on the rise, ALA statistics show.
COPD is a grab-bag term that includes emphysema, asthma, bronchitis, and other diseases, says Stephen Rennard, MD, a professor of medicine at the University of Nebraska Medical Center in Omaha. "The most common cause is cigarette smoking, and it accounts for about 80% of COPD cases," he says.
COPD has no cure at present, but if patients quit smoking, their quality of life and life span likely will improve. Treatments include respiratory therapy, medicine, surgery, and oxygen therapy. Many of the standard treatments can be done in the home care setting.
"I think the restrictions on hospitalization are such that there's a lot more effort now to take care of patients at home, including getting them on oxygen therapy and antibiotics," Rennard says.
An extensive COPD education program
A Texas home care agency already is seeing an increase in patients who have COPD or some other form of respiratory disorder. Those patients might have other diagnoses as well, but the lung disease greatly affects their quality of life, says Shonna DeFoy, RN, assistant director of nurses and education director for Cozby-Germany Home Health in Grand Saline, TX. The small, hospital-based agency provides a continuity of care with skilled nursing and aide services. It serves a rural area in Eastern Texas.
"What I noticed in home care was that eight times out of 10 - or at least a high percentage of patients - have some form of respiratory disorder, whether it's COPD or an exacerbation of the disease," she says.
With a goal of improving the lives of those patients, DeFoy developed an extensive COPD education program that can be used to teach aides, patients, and other staff. (See story on creating a COPD inservice, p. 91.)
At a recent conference of the American Thoracic Society of New York City, COPD experts discussed how the health care community should start rehabilitation of COPD patients before they spin out of control in the disease's downward spiral, says Kathryn L. Anderson, PhD, RN, an associate professor at the Seattle University School of Nursing in Washington.
"The symposium was on pulmonary rehabilitation, and one of the most important things we can do is improve people's endurance and exercise tolerance," Anderson says. "This allows them to do the things they need to do and the things they want to do."
If those patients are given rehabilitation in earlier stages of their disease, such as before they are confined to a recliner, then they'll retain their strength and endurance longer, Anderson says. "That's a hard sell to people who pay for rehabilitation, but it makes perfect sense."
Some health systems also are trying to develop home care rehabilitation for COPD patients, says Suzanne C. Lareau, RN, MS, a pulmonary clinical nurse specialist at the VA Medical Center in Loma Linda, CA. Although it's too soon to call home care COPD rehabilitation a trend in the United States, Lareau says it's becoming pretty big in Europe. "In Europe, physiotherapists go into the home twice a week. They have a very active exercise physiology or physiotherapy program."
Home care nurses can help COPD patients deal with their shortness of breath and improve their exercise endurance, which will make them stronger and help them recover better, Lareau says. "The home care nurse can go over inhaler techniques, for example," she adds. Also, COPD patients often end up in hospice care because their health steadily decreases with the disease, and eventually they need palliative care more than rehabilitative treatment.
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