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Caregivers also are aging. "Now we find a 65-year-old
taking care of her 95-year-old mother or father,"
Suther said. Or people taking care of children, parents
and grandchildren at the same time. "We used to
have what they called the sandwich generation,"
she said, referring to people who care for both their
parents and their children. "Now, we have the club-sandwich
generation."
At the other end of the spectrum, improvements in technology
allow infants with serious conditions who never would
have survived in the past to go straight home from intensive
care units, where they are monitored and cared for by
their families and pediatric home health nurses.
"It's very much a specialty," said Louisa
Wolter, RN, executive director of new business development
for Melmedica Children's Healthcare Inc., a children's
home care agency in the Chicago area. "We can do
everything at home-medication, feeding, ventilation."
Her agency has treated shaken babies, accident victims
and babies with genetic illnesses, all with conditions
that require 24-hour care. The nurses, who mostly work
one-on-one with their patients, must deal not only with
the extensive technology needed to keep the patient
alive, but with families reeling from the emotional
effects of having a child who requires constant monitoring
and care.
Unlike hospital nurses, who rarely have to touch a
ventilator, home care nurses need to know how to set
it up, take it apart, clean it and teach family members
to do the same, Wolter said. Because they have no backup,
home care nurses need to be especially alert for any
equipment problems.
"In home care, you are keyed into every sound
around you because you have to be," she said. "All
your senses are working all the time."
In 1967, 1,753 Medicare-certified home health agencies
were in operation in the country, most of them community-based,
nonprofit organizations. By 1997, home health agencies
had increased to more than 10,000, with more than half
of them freestanding for-profit organizations, according
to statistics from the National Association for Home
Care.
Fearing fraud and overbilling-which those in the home
care industry deny-the federal government cut Medicare
spending. The number of home care agencies dropped to
about 7,000 by 2000, which the National Association
for Home Care attributes directly to the Medicare cuts
enacted in the Balanced Budget Act of 1997.
About the same time, the government demanded increased
documentation from home health agencies, including a
14-page, 90-item assessment form with questions on everything
from the payment source for home care to safety hazards
in the home to the patient's ability to bathe, get to
the bathroom and use the telephone.
In 2000, the government changed the system of reimbursement
for Medicare-the primary insurer for home care. Instead
of paying for every visit and every service, Medicare
allots patients a lump sum, depending on their condition,
over a 60-day period.
"Reimbursement and managed care have been the
biggest changes in home care throughout the '90s,"
said Monica Seay, RN, administrator of the Visiting
Nurses and Hospice of San Francisco. "It decreased
the number of visits we could do."
Previously, nurses might visit a patient five times
a week, she said. Now, they might make two visits a
week.
But in those visits, they must spend time teaching
patients and families how to become more involved in
their own health care, she added. "They put us
in the position of being the risk managers. Nurses now
have to be a lot better organized. They have to focus
on time management and they need critical thinking skills."
Both managed care and the new reimbursement system-called
the prospective payment system, or PPS-have shifted
the focus of home care to making patients more independent
and responsible for their own care, said Carolyn Humphrey,
MS, RN, editor of Home Healthcare Nurse, the only monthly
national peer-reviewed home care journal in the country.
"The patient needs to become independent as fast
as possible, which is good for them as well as saving
resources," she said. "The nurse has to give
the appropriate amount and type of service, watching
the cost at all times."
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