Dottie Heerema, on home health nursing

By Bree LeMaire, MS, RN
April 26, 2004

How did you get into nursing?

How did you get into nursing? Home health nursing?

My brother and I were a year apart in age. He was ill throughout most of his life with a liver-related disease and lived to be 13. We spent those first 12 years going back and forth to Columbia-Presbyterian Hospital. My first [memory] of those nurses was that I wanted to be just like them.

Home health was a baptism by fire at the Columbia-Presbyterian nursing program. We took the subways in New York to the downtown Lower East Side to teach the principles of home health to new moms and their babies. Those were the first tenements I had ever entered. We had to climb many stairs to get to their apartments. I saw rats that had literally chewed and nibbled at the babies’ faces where the mothers had left food on the infants’ faces.

I remember distinctly that rats were part of that environment. I was horrified, but thrilled at the prospect of teaching those mothers in their own environment. It was exciting to actually get through to those mothers and see that I could bring about change.

What do you do?

My title is vice president and director of marketing/case management. This includes marketing for HHS and intake case management of newly referred patients. We have grown from one to seven branches recently with plans to expand further.

There is a lot of competition in home health and we focus on customer service, provided through our on-site case management department. Patients are often bewildered and frightened about going home. We find that physicians and discharge planners appreciate the attention to their patients that we provide.

From an intake/case management perspective, we accept the home health patient into our agency 24 hours a day. We do an initial evaluation before they are ready to go home. The department is composed of RNs, medical social workers, and others with discharge planning experience. We gather all the information to help organize care for each patient.

How has home health changed recently and how have you been affected?

Medicare, before 2000, reimbursed on a paid-per-visit scale. This, unfortunately, created an incentive to increase the number of visits and some unscrupulous agencies made the most of that system.

After 2000, the Centers for Medicare & Medicaid Services introduced a prospective payment system similar to the shift from fee-for-service to diagnosis-related groups of the 1980s. Today, home health receives a fixed lump sum determined by the severity of the patient’s status. Basically, the new system requires lower utilization with high efficiency.

Tell me about decreasing visits and getting better outcomes.
Under the Medicare payment system, an agency is given an incentive to achieve the desired outcomes, such as being able to get around the house better or remembering to take medications. We have to have a plan that produces the best-known care techniques for patient diagnoses.

Alzheimer’s, for instance, has clinical guides that ensure success regardless of the clinician’s personal level of expertise with the patient. They are going to have the best-practice techniques such as hanging a picture of a bed on the bedroom door or a toilet on the bathroom door. Wandering can be curtailed with a big, red stop sign on the exterior of the door or putting a shoebox over the doorknob.

Tell me about HIV and home health.

Our goal is to keep our HIV patients at home as opposed to hospitalization. This is done by establishing a good patient-nurse relationship and working with medication compliance. Many of our patients are on medication cocktails and taking 40 to 50 pills a day. They need a lot of encouragement. We also keep close tabs on weight and immune status, concentrating on prevention.

Most of our clients are referred from the county hospital. Ryan White funding is available for those with AIDS who do not qualify for Medicare or Medicaid.

What challenges are you facing?

As a nurse executive, I am faced daily with cost structures that must accommodate reimbursements based on previous years. In October 2002, CMS imposed another 15% cut in home health reimbursement. We are always streamlining care and making comprehensive clinical guides or care pathways more important.

This work has a concentration on details as well as customer service. We want the patients and their referring medical professionals to be happy. It is difficult to find medical clinicians well-versed in the discharge planning process.