Second International Home Care Nurses Organization Conference:

Person-Centred Care in Home-Based Nursing – Service Models, Nursing

Roles and Competencies

Singapore 23-26 September 2014

Overview of the State of Home-Based Care and the

Leadership Role of Nurses: Impact and Challenges in

Health Care and Implications for Nursing Education,

Research and Practice

Carol O. Long, PhD, RN, FPCN

Contents

Learning Objectives

Current State

Integration

Innovation

Interprofessional

Inspiration

The Future

Summary

References

Learning Objectives

Overview of the State of Home-Based Care

Provide an international context and mandates

that are driving new models of home-based

care

Outline a Vision for the Future with education,

research and practice underpinnings and

overview of exemplars

Identify ways to survive and thrive in home care

Increasing life expectancy:

73 for women, 68 for men;

6 years longer than 1990

Low income countries in

Asia and Africa with

greatest progress

High income countries:

attacking non-

communicable diseases

(e.g., hypertension)

Fewer children are dying

before their fifth birthday (WHO, 2014)

WHO: State of the World

1

Aging in the 21st Century

The numbers:

2012: 10 million

2020: 1 billion

2050: 2 billion

Two people turn age 60

every second

More than 50,000 adults

over 100 in Japan (HelpAge International,

2014)

2

International Trends: Life Expectancy and Aging

International Trends: Life Expectancy Across Countries

3

WHO, 2014

International Trends: Causes of Death

4

WHO, 2014

Not listed as WHO leading cause of death

#6 cause of death in the US (Alzheimer’s Association,

2013)

#3 cause of death in Australia (ABS, 2013)

Not well-known in Asia (Access Economics PTY Ltd, 2006;

Chan et al., 2013)

Global burden of dementia (Prince et al., 2013)

5-7% worldwide; higher in Latin America (8.5%)

and lower in sub-Sahara (2-4%)

Tremendous burden: healthcare system, families

and the community (ADI, 2013)

Home-based care: need for knowledge and resources

International Trends: Dementia as Cause of Death

5

Only 1 in 10 people who need

palliative care get it

20 million people need palliative

care every year; 6% are

children

1/3 are people with cancer; 2/3

with noncommunicable

diseases, HIV and MDR-TB

3 million receiving palliative

care; mostly at end of life

80% of need is low-to middle

income countries

Only 20 countries have

palliative care well-integrated

into their healthcare system

(WPCA, 2014)

6

http://www.who.int/cancer/publications/palliative-care-atlas/en/

International Trends: Palliative Care

At-risk population:

mothers and babies

Home-based care:

Prenatal visits and

postpartum care

Country mandates have

led to: safer deliveries,

increased LOS,

improved life

expectancy for

newborns (WHO, 2012)

International Trends: Vulnerable Groups

7

Increasing morbidity and mortality: non-communicable

diseases

Care for vulnerable populations: unborn, mothers and

children, older adults

Issues affecting home care:

Access to health care

Quality healthcare and health disparities within and across

nations

Capacity-building: workforce and systems of care and need

for community workers (Marren, n.d.; Stone et al., 2013)

Costly care and health care reform

Little research in home-based care

In Summary… Global Complexity and Home Care Needs

8

The Iceberg Metaphor

9

What we know:

• Value of home care

• Continuum of care

• Serve: vulnerable

populations with at-

risk or medical needs ____________________

What we need to know:

• Better care, better

value, better cost

4 key components driving the future of

home-based care:

1. Integration

2. Innovation

3. Interprofessional

4. Inspiration

A Vision for the Future

10

PREMISE: Home-based care is morphing into new

models of care! Need to thrive!

INTEGRATION

Need: Address at-risk young and fragile families –

educate and monitor (e.g., nutrition, parenting,

readiness to learn)

Solution: Maternal, Infant, and Early Childhood Home

Visiting Program (DHHS, 2014)

Impact: 500 nurses + team executing home-based

preventive care; improved outcomes in 7 domains

(e.g., child health, maternal health, parenting and

more) (Avellar et al., 2014)

1

Integration Solution (1)

1

homvee.acf.hhs.gov/

Need: 1/5 of Medicare patients readmitted to hospital

within 30 days (Jencks, 2009); support safe and effective

transitions to reduce fragmentation and readmission

Solution: Centers for Medicaid and Medicare (CMS)

initiative: Care Transitions Program (CTP)®

Impact: Averted 5,872 readmissions; 19% reduction

over 18 months http://www.noplacelikehomeaz.com/

How? transition coaches, telehealth, dismantle silos

and build relationships, patient education (Romagnoli et

al., 2013)

Integration Solution (2)

2

Need: Improve access and reduce costs through

person-centered and consumer-directed care models

Solutions:

Program of All-Inclusive Care for the Elderly

(PACE®) - US and Singapore npaonline.org

Interventions to Reduce Acute Care Transfers

(INTERACT) and keep people at home (Ouslander

et al., 2014) interact2.net/home_health.aspx

Home and Community Care Packages – Australia agedcareguide.com.au/

Impact:

Reduce admissions/readmissions, improve

consumer choice and keep people home!

Integration Solutions (3)

3

Need: holistic and home-based care nursing across

settings

Solutions: education of nurses / patients

End of Life Nursing Education (ELNEC) Consortium

Pediatric, Geriatric, Core http://www.aacn.nche.edu/elnec

Impact: 18,300 RNs: all of USA + 79 countries; numerous

home-based efforts

Chronic Disease Self-Management Program (CDSMP)

Numerous topics – empowerment; workbook, CD

http://patienteducation.stanford.edu/

Impact: cost savings, patient outcomes (Ory et al, 2013)

Integration Solutions (4)

4

INNOVATION

Need: Infusion of evidence-based practice (EBP) in

home care nursing settings

Solutions: Use EBP protocols, clinical practice

guidelines

Hartford Institute for Geriatric Nursing (HIGH) www.consultgeri.org

National Consensus Project for Quality Palliative

Care (2013) www.hpna.org

Numerous collaboratives

Solution: Professional association leadership –

Visiting Nurse Associations of America

http://vnaa.org/vnaa-blueprint

Innovation Solution (1)

1

Innovation Solution (1) cont.

2

With Permission, M Terry 2014

http://www.vnaablueprint.org/main-

menu.html

Need: Education and training of students and RNs

using home care principles

Solution: Create new models of undergraduate and

continuing education: competencies and simulation

Marquette University College of Nursing http://www.marquette.edu/nursing/index.shtml

Impact:

learn novice to complex skills, home care education of

mother-baby, older adults

2012-2104: 970 students; 214 individual simulations with

external partners

Innovation Solution (2)

3

Need: Geriatric care competency of nurses working in

community-based settings

Solution: Tsao Foundation: Hua Mei Training Academy

Certificate in Community Gerontological Nursing: 280

hours didactic/skills

Impact: 2 cohorts - 35 RNs from community-based

settings – primary care, home health, nursing home,

community care, hospice and day care

Innovation Solution (3)

4

http://tsaofoundation.org/doc/HMTA_CGN_Brochure.pdf

Needs: specific product lines; creative strategies

Solution: Palliative Care for Dementia in the home http://www.hov.org/caregiver-support-dementia

Impact estimated: reduced cost of care, keep people

at home

Innovation Solution (4)

5

“Mabel Sawyer gives her husband Bob eight hugs six times a

day. It’s the best medicine a wife could offer – particularly to a

husband with Alzheimer’s disease.”

Need: Cost-effective use of technology for patient care

and efficiency

Solutions: Create innovative models for aged care

Dementia care telephonic ecosystem to support

caregivers and the person with dementia at home www.healthcare-informatics.com/news-item/dementia-care-ecosystem-bring-

online-respite-caregivers

CareSmarts: daily text messages to patients with

diabetes http://www.innovations.ahrq.gov/content.aspx?id=4174

Solutions: Point of care technologies: billing, EMR,

scheduling, laboratory (Fazzi, 2014); handheld

technologies for nurses

Innovation Solution (5)

6

As of 9/9/2104; Agency for Healthcare Research and

Quality Innovation Exchange (AHRQ)

Home Care

Home care (non-health) - 17

Home health care - 42

Home Hospice care - 2

Patient self-management - 25

Age - 677

Chronic conditions….many!

Innovation Solutions (6)

7

http://www.innovations.ahrq.gov

INTERPROFESSIONAL

Need: efficient teams; communication

Solutions: Interprofessional team-based care through

education (IOM, 2013; WHO, 2010)

Geriatric Interdisciplinary Team (GITT) http://hartfordign.org/education/gitt/

TeamSTEPPS

http://teamstepps.ahrq.gov/

University of Louisville, Kentucky USA:

Oncology Palliative Education

(iCOPE) interdisciplinary case management

experiences (ICME) (Head et al., 2104)

http://louisville.edu/nursing/news-archive/palliative-care-curriculum

Interprofessional Solutions (1)

1

Need: Collaborative efforts and opportunities in

palliative care across disciplines and countries

(Silbermann, 2014)

50% incidence of cancer in people < 65

99% untreated and painful deaths

Solutions: Middle East Cancer Consortium (MECC) -

Israel, PA, Cyprus, Turkey, Egypt, Jordan www.mecc.cancer.gov

Partner with Oncology Nursing Society: Increase

capacity-building; interprofessional care

Emerging need for home care as preferred

place of care (Silbermann et al., 2012)

Interprofessional Solution (2)

2

INSPIRATION

Need: Leadership skills

Solutions: skill building!

Agile decision-making

Mentoring, coaching

Navigating change; transformation

Build and sustain collaborative relationships

Project management

Translational care; using research and evidence

Day-to day-management: budget

Better leaders, better agencies, lead to better

outcomes for staff and patients (Parker et al., 2014)

Inspiration Solutions (1)

1

Need: staff and management burn-out/stress

or compassion fatigue

Solutions:

Take care of staff: nurture and care for (Fox & Fox,

2014)

Reflective practice, self-care, mindfulness

Adopt new communication skills:

Health coaching (Miller, 2014)

Motivational interviewing (Purath et al., 2014)

Teach-back, medication reconciliation, timely

communication support safe transitions of care (Dreyer, 2014)

Inspiration Solutions (2)

2

Need: Moral imperative…address loss of hope,

isolation, loneliness, abandonment, pain, suffering for

the patients/families we serve

Solutions: Incorporate spiritual assessment and care

is part of home care practice; add humor to the lives of

others!

Inspiration Solutions (3)

3

Many issues to tackle: access, disparities in

quality care, capacity-building, reform and cost-

effective care

4 vision elements in futuristic thinking and doing

to thrive!

Summary

Vision of the Future…

Thank you! Carol O. Long, PhD, RN, FPCN

Principal, Capstone Healthcare

Adjunct Faculty, Arizona State University

Phoenix, Arizona USA

E-mail: carollongphd@gmail.com

www.linkedin.com/pub/carol-o-long-phd-rn-fpcn/6/b3/279/

• 2

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