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Home Care of Patients with Chronically Ill in the World and Turkey Prof. Dr. Güler Cimete Marmara University,School of Nursing President of Home Care Association
Home care • HC is provision of protective, therapeutic, rehabilitative services in the place of residence of individuals and families who have needs resulting from acute illness, long-term health conditions, permanent disability or terminal illness.
home care services are based on holistic and multidisciplinary health team approach
Development of home care services • Home care began in the US around the 1800s. Care was given to sick person by sisters/ladys • First home care organization is Boston Dyspensary, (1796) • Visitor nurses began to care giving for patients at their home, at 1880s. • In 1898, home care services began to payed by national budget.
In 1909, the Metropolitan life insurance company began offering home nursing services to policy holders. • In 1966, Medicare and Medicaid began to reimbursement of home care services • In 1990s, home care continues to be a diverse and rapidly growing service industry. • Development of home care services in many European countaries is similar with US.
Home care team: physician, nurse, physical therapist, social worker, home care aid, occupational therapist, language therapist, dietitian, patient, family members, ect ……
Who need home care • People who have; • Acute illness • Newborns • Chronic illness/ disability pysical, mental, physicological Terminal stage illness Olders
Conditions requiring home health care most frequently include diabetes, heart failure, chronic ulcer of the skin, osteoarthritis, hypertension. In our country; cancer, SVO, heart failure, trauma
Providers and users of home care services in USA • 20 000 providers deliver home care to 7.6 million individuals • Almost two-thirds (62.3 percent) of home health care recipients are women. • More than two-thirds (68.6 percent) of home health care recipients are over age 65.
health care trend from institualized care to.home care • Causes of that 1- Demographic changes. Contuniusly increase the life expectancy at birt, older population and chronic illness 2- Medical knowledge and technology continue to advance in home care Ventilators are manufactured solely for home use.
3- Home care is cost effective* 4- Other adventages. Most patients and families prefer to home care,** *Nicholson et.al. (2001), Aust. Health Review, 24(4): 181-87 *Tuggey,Plant,Elliot. (2003) Thorax, 58(10); 867-71. ** Elgen, Zander (1990) www.thracic.org/adobe/statement/home1-2 pdf
1- Demographic changes • Globally, at the begining of the 21st century, 1 in every 10 persons was 60 years or over by 2020 the figure will be about 1 of every 8. by 2050 %20 of the population will be 60 years age and older More than 80% of individuals older than 65 have at least one chronically illness.
2- Thecnologic developments Home care therapies • oxygen therapy, inhalation (nebulizer) therapy, • tracheostomy care, • home apnea monitoring, • intravenous medications, • mechanical ventilation. • Woun care • Tube feeding, TPN • IV infusion • Others………………
Ventilator • Tecnology allows, encourages and supports chronic ventilator users to live at home. • Ventilator market growed to more than 40% in 2006. (USA) *The number of ventilator-dependent patients doubled from 1980 to 1990, -with about 20% of the estimated 11,419 patients being cared for at home- *…….Chest 1998. 113, 289-344
2003 *6% of patients with cystic fibrosis received home oxygen therapy, 8.9% used supplemental tube feedings at home *Cystic Fibroses Foundation, Annual Report. http://www.cff.org/uploadedFiles/publications/files/2003%20patient%20registryreport.pdf
3- Payment system and Cost-Effectiveness • Home care services can be paid by the patient/ family public and private sources. Public payors (USA): Medicare, Medicaid, the Older Americans Act, the Veterans Administration, and Social Services block grant programs.
In the USA, the federal government reimburses home health care through the Medicare program (usually 60 days) • 65 years and older people are included by Medicare
Respiratory care equipment and home oxygen therapy may be reimbursed under Medicare, Medicaid, or private insurance. • Medicare does not reimburse for the in-home services of respiratory therapists (RTs),
HOME CARE EXPENDİTURE (USA) In 2003 Total expenditure for health care ; $ 1.673.6 billion Home care expenditure; $ 38.3 billion
Medicare home health utilization by principal diagnosis, 1999. Total all diagnosis %100 Diseases of the respratory 11.6 system Pneumonia 3.7
Sullivan et.al. noted that nearly 50% of Medicare costs are incurred by about 10% of patients with COPD (not only home care, hospital and emergency expenditure more…. . ) Sullivan. Et.al. Chest 2000;117(Suppl 2):5-9
Home care is less costly than hospital care for patients with chronic respiratory conditions, especially for home care of patients receiving long-term intravenous therapy or chronic ventilator care (1, 2, 3). • 1-Williams DN. Am J Med 1994;97:50–552-Fields AI.et.al. Am J Dis Child 1991;145:729–733. • 3- Pond MN.et.al. Eur Respir J 1994;7:1640–1644.
Bergner, et.al. attempted cost comparisons of specialize respiratory home care with standard home care. It was found that both interventions were expensive, and that home health care delivered by specially trained respiratory nurses was more expensive than standard home health care while producing similar health-related quality of life outcomes. Bergner, et.al. Med Care. 1988;26:566–579
4- Other adventages • Home care services; increase the functioning and health-related quality of life of patients (5b) increase the satisfaction of patient and caregiver from home care reduce emergency room use (1, 2, 3), not reduce (4,5a) 1-Farrero. et.al.Chest 2001;119:364–369, 2-Bourbeau. et.al. Arch Intern Med 2003;163:585–591. 3- Haggerty. et.al. Chest 1991;100:607–612 4-Smith. et.al. Aust N Z J Med 1999;29:718–725. 5a-Dranove. Inq 1985;22:59–66.5b-Winkler MF. Et.al. Nutr Clin Prac. 2006 Dec. 21(6);544-56
Home care services; reduce clinic visits (6, 7), no make difference (8,9) reduce the number of hospitalization (10), not reduce (11, 12, 13, 14, 15) reduce unsheduled physician visits (16) 6-Dranove D. Inq 1985;22:59–66. 7- Neff DF. et.al. Home Health Nurse 2003;21:543–549. 8- Littlejohns P, et.al. Thorax 1991;46:559–564. 9- Smith BJ. et.al. Aust N Z J Med 1999;29:718–725. 10-Barnett M. Prof Nurse 2003;19:93–96, 11- Davies L.et.al. BMJ 2000;321:1265–1268 12- Sala E.et.alEur Respir J 2001;17:1138–1142. 13-Shepperd S.et.alBMJ 1998;316:1786–1791 14- Hernandez C.et.al. Eur Respir J 2003;21:58–67 15- Cotton MM. et.alThorax 2000;55:902–906. 16- Bourbeau J.et.al. Arch Intern Med 2003;163:585–591
There is no difference in mortality between patients treated for acute COPD exacerbation in hospital and those treated at home (17, 18). • 17-Davies L. et.al. BMJ 2000;321:1265–126818-Hernandez C.et.al. Eur Respir J 2003;21:58–67
Future home care goals may include • patient and family satisfaction, • reduction of complications resulting from hospitalization, • maintaining an acceptable quality of life, • enabling a comfortable and dignified death. • Cost reduction could become a collateral benefit, instead of a primary goal, for home health care.
Respite Care • Formal respite care allows family care givers time away from caregiving activities
Needs and problems related to home care in Turkey • All factors which increased to needs for home care at another countries are true for Turkey, too. • Older population is increasing • There is a growing the number of chronically-ill patient • Caregivers from family members are decreasing • Discharge services are not sufficient
additionally • Home care law is not contain all aspects of home care services. • There is not public home care system • Public insurance system is not including to home care services, • Private home care services are reimbursed by private insurange agencies or by pocket of the patients or families
Providers of home care services • Private home care agencies • Private hospitals • Some public hospitals (generally voluntary and limited service) • Municipalities
Home care team in private agencies Generally, composed from • Nurse • Home care aide • Physician
Services of private home care agencies • Patient care; wound care, respratory therapy, oxygen therapy, phsical therapy, IV infusion, enteral feedings, TPN, health education, ventilation support, etc. ... • Dignostic studies; x-ray, lab…. • Supplies of medical equipment for patients • Transportation of patients
Diagnosis of patients • End stage cancer/terminal patients • Heart disease with COPD or without any lung disease • SVO • Post operative period for serious illness • Others
Home care services of Municipalities • Home care for older, poor, chronic patients • Services are not paid but limited
Home Care Association It was establised in 2005 Aim of the Association; prepare a home care law which is include all aspects of home care services and work together with Ministry of Health for legislated it.