Nurses to rein in CHF home care
July 1, 1999 5 minutes read
Nurses to rein in CHF home care
Move continues to define their role
Ann Frantz, BSN, RN, says just 10 years ago, getting help with CHF at home meant being part of a grassroots home care program. Nurses affiliated with hospitals and other care agencies developed their own methods of educating patients and making sure they were following the care strategy their doctors prescribed.
Patients who had this assistance at their personal bedside, she recounts, had better outcomes than those discharged to fend for themselves. Doctors learned about getting their patients into such programs, and soon word spread. Facilities developed their own cardiac-specific systems and began to compete for patients.
Today, Frantz says the appeal of controlling a patient’s CHF is as strong as ever. But after a decade of being sold on disease management, there is no clear-cut definition of the product being delivered to the patient and what it takes to make sure the nurse will be able to deliver what is needed.
"Anyone can claim they have a special program and offer this, that, and the other," says Frantz, a CHF nurse in Pontiac, MI. But that doesn’t mean the care focuses on the best patient outcome. To do that, she says, the Home Health Nurses Association has prepared a consensus statement to define what nurses should know and be able to do at the patient’s home.
In May, Frantz presented the guidelines, which she helped write, to members of the American Association of Critical Care Nurses in New Orleans. She also announced a competency exam should become available "to complement the guidelines."
"I believe this is groundbreaking," she says, noting the guidelines are based on the nurse possessing these qualifications:
• experience in cardiac care;
• ability to provide cardiac assistance;
• understanding drug therapies and treatments;
• ability to be an integral member of the health care team.
To help disease management evolve, she says, the nurses working with patients need to have certain skills. "At least a first step is to recognize certain competencies," she says. "Home care will have a select group of cardiac home care nurses; you have to have the skill set if you’re going to care for cardiac patients in the home."
The team member at home
Frantz says the move to standardize the role of the home care CHF nurse is tied to the team care approach. A nurse who knows only the practical bedside skills risks becoming isolated from the rest of the care team and, eventually, being squeezed out of CHF treatment.
"Nurses need to know what the collaboration is doing," she says. Besides the doctor, there often are pharmacists, occupational therapists, exercise physiologists, and social workers on the case. So nurses need to know how to work with each one.
The goal of this nurse, Frantz says, is to work with the patient one-on-one, training the patient on the details of CHF itself, what the medications do, how to take them, and understanding the weighing schedule, until patients can provide most of the care themselves. From that point, the nurse can step back a bit from the everyday routine and become more of a consultant to both patient and the rest of the team. But until now, Frantz says there wasn’t a list of what nurses should have in their arsenal.
Frantz says nurses can get the complete 57-page set of guidelines through the Home Health Nurses Association. (See note at the end of this story.) The journal Home Healthcare Nurse featured a summary of the guidelines in its November 1998 issue.
The value of the guidelines
The summary includes an overview of CHF management and caring for a patient recovering from heart failure exacerbation. Guidelines include:
• How many home visits are usually needed for a patient each year, depending on his or her NYHA Class.
• What the nurse should assess in each encounter, such as compliance, physical and psychosocial status, response to treatment, and functional status.
• What patients should be taught about the disease — medication, urgent and emergency plans, nutrition and hydration, activity, stress of chronic disease, and community resources.
In other sections of the summary, guidelines include histories and assessments, care for patients recovering from myocardial infarction, home single-lead ECG monitoring, and caring for bypass patients.
"The CHF specialist has to have a comprehensive understanding of disease pathophysiology and current treatment modalities in order to facilitate patient plan integration," says guidelines co-author Cynthia Bolin, RN.
Making sure nurses have this clinical expertise is important, she continues, because it can support a collaborative effort between doctor and nurse.
A nurse who continues to call the physician because a patient’s systolic blood pressure falls below 100 may not understand the effects of CHF treatment, she says.
In the same way, the nurse needs to know the medications by name and group, so when a doctor asks what dose of ACE inhibitor or beta-blocker the patient is on, the nurse will not have to ask which is which. That level of expertise has to be there, or the doctor may think the nurse taking care of the patient isn’t up to speed, Bolin adds.
Finding incentives for patient compliance
Getting the whole picture of CHF home care also means nurses can help patients set goals for themselves.
Frantz notes one of her patients in NYHA class IV CHF wanted to dance at her daughter’s wedding. "Everything revolved around that," she says. The care team had seven months to get her in condition, and she was able to do it.
Another patient wanted to be able to attend a golf tournament and watch Lee Trevino play.
When the goals are set, Frantz and Bolin say it’s up to the nurse to determine how the patient is going to be able to follow the treatment plan. Frantz says when nurses have the right cardiac skills, they can become "nurse-artists" who know where to tweak the routines so patients follow them and still accomplish goals.
[For the complete set of guidelines, contact the Home Health Nurses Association at (800) 558-HHNA. The cost is $19.95 for members and $34.95 for nonmembers.]
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