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An integrated approach to home health care.

Pediatric patients with chronic respiratory conditions requiring prolonged mechanical ventilation represent complex case-examples for home care discharge planning and management. In order to accomplish a successful transition from hospital to home, it is necessary to recognize requirements in six major areas:

* Medical: Pathophysiology represents the most essential consideration for diagnosis, treatment, prognosis, and organization of respiratory home care. The ventilator-assisted child must be medically stable on optimal support. Goals include reducing risk of acute decompensation, augmenting functional reserve, and creating optimal conditions for growth and development.

* Psychosocial: Each child's full potential for health must be considered by an interdisciplinary professional team focusing on child development, rehabilitation, and education. Family-centered care is key to success. Families must be informed and accept all that is involved; they must be prepared and capable of doing all that is required. Professionals, in collaboration with self-help groups, can provide support needed by families at home.

* Environmental: The hospital setting during preparation for home care, the home environment, and the community must be supportive. Considerations include building accessibility, transportation adaptability, communication access, utilities' capacity, and emergency service availability. The home must have sufficient space for family members, equipment and supplies, and supplemental caregivers. The house must be evaluated for sanitary conditions, building safety, and electrical power.

* Technical: Each respiratory home care program needs flexibility. A written prescription should detail required equipment, supplies, and techniques adapted to individual needs. Supplemental monitoring should be considered, but alarms can never replace a prepared, qualified, alert person. Techniques and devices used in the home should be easy to learn and use by the family. Technology performance must be tracked with mechanisms for routine maintenance and emergency repair.

* Organizational: The home care prescription should be designed by an interdisciplinary team including all involved primary care professionals, home care experts, community home care providers, and the family. Each case requires a written operational plan and an educational program. The plan must define roles, responsibilities, and relationships; determine means to coordinate care and manage services; and describe mechanisms for quality and risk management.

* Financial: All essential reimbursement should be provided and guaranteed. This requires justification of medical necessity and interactive dialogue among responsible parties. The family-centered approach values the family role in managed care.

Case Scenario

The following case scenario summarizes an innovative, collaborative experience featuring physician involvement in home care and family participation in creative home care management and financing.

The favorable outcome in this case would not have been possible without innovative case management. Success was due to a team effort featuring physician-family collaboration and integrated management by a home care physician and a physician manager responsible for funding approval. The care, delivered in a cost-effective manner, fulfilled the definition of quality.

The total cost of providing care over a 40-month period was $780,000. Had care been rendered throughout this period in the tertiary-level children's hospital or in a transitional site (which would have been required), the cost, including applicable discounts, would have been $1,650,000 to $2,175,000. By utilizing the home care, the total savings ranged from $870,000 to $1,395,000. 11

In this new column, Physician Executive presents abstracts of successful approaches in the management of home health care services. The abstracts are written by members of the College's Society on Home Health Care Management and/or have been presented at one of the major meetings of the College. Allen I. Goldberg, MD, chair of the Society, serves as editor for the column. If you have a home health care experience to share with physician executives, please send it to Dr. Goldberg in care of the College.


The patient, a Hispanic-American female, was born after a 24-week gestation at a birth weight of 690 grams (1 lb. 8.5 oz). She was placed on a ventilator from birth; a tracheotomy was performed early in the hospital course. A primary diagnosis of bronchopulmonary dysplasia was established. There were multiple acute medical problems related to severe prematurity. The infant spent the first year of life hospitalized in an intensive care unit. When it became clear that weaning from the ventilator was going to be difficult and a long-term enterprise, alternative care plans were reviewed, and she was transferred to a transitional care site.

Several factors pointed to home care as a realistic possibility. The parents were devoted and responsive to their infant's needs; professionals were available with expertise in providing home ventilator care, and there was an adequate and flexible payment resource. A plan was formulated to continue the infant's care at home that required the cooperation of the parents, physicians, respiratory therapists, home health nursing personnel, and equipment suppliers.

Many case management decisions were made by physicians during the course of meeting the patient's needs at home. Arrangements were made to provide full-time nursing care to be supervised by a registered respiratory therapist, who consulted with a physician specialist in home respiratory care. The patient's primary care physician, a community-based pediatrician, was integrated into the care chain and was involved in all aspects of care and decisions. The HMO medical director participated collaboratively in all case management with the home care physician.

During the course of providing home health nursing care, several problems arose that required immediate resolution so as not to disrupt the care plan. The patient's mother became so adept at using the ventilatory equipment that she rejected home health personnel who were, in her opinion, hesitant or uncertain. It was necessary to employ several agencies to locate personnel who were able to perform their duties and enjoy the confidence of the mother. Also, the patient's 16-year-old sister was discovered to be providing respite care on occasions. She satisfactorily demonstrated the ability to respond appropriately to her sister's needs. As 24-hour nursing became less medically necessary, the decision was made to pay members of the family to serve as caretakers. This permitted coverage for a longer period and respite for the parents. Other decisions allowed certain disposable items as a benefit so that home care could continue.

Over the course of two years at home, the patient required only one readmission for pneumonitis and a one-day stay for bronchoscopy. As she matured and developed, weaning from nasogastric to oral feedings occurred, withdrawal from ventilation was accomplished, and supportive home physical therapy was provided. By her third birthday, the patient was well on the road to achieving growth and development goals for a three-year-old child. Her tracheostomy was closed, and she was freed of all respiratory problems and support.

Allen I. Goldberg, MD, MM, FAAP, FCCP, is Professor of Pediatrics, Loyola Stritch School of Medicine, and Director, Pediatric Home Health, Loyola University Medical Center, Maywood, Ill. Mitchell J. Trubitt, MD, is Vice President, Medical Affairs, Chicago HMO Ltd., Chicago, Ill.
COPYRIGHT 1994 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1994, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

Article Details
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Author:Trubitt, Mitchell J.
Publication:Physician Executive
Date:Jan 1, 1994
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