New Programs Aim to Improve Home Care Services

SAN FRANCISCO--For both nurses and their patients, home care is becoming an increasingly cost-effective and satisfactory alternative to longer hospital stays. At the Oncology Nursing Society Annual Congress, several speakers discussed methods used at their institutions to improve home health services.

Mills-Peninsula Hospitals, Burlingame, California, started a program in 1994 to increase home care and community support for cancer patients who need intensive case management. "It became apparent to us that we were getting to patients too late. Many admissions could have been avoided, or discharges made more timely, if oncology nursing were available in the community," said study co-author Marie Rinaldi, RN, MS, OCN, cancer care clinical nurse specialist with Mills-Peninsula Health Services.

Ms. Rinaldi along with Jennifer Vickerman, RN, MS, OCN, took on an expanded role, following 15 high-risk cancer patients each, as well as performing their other duties. High-risk cancer patients were defined as those with complex symptom management or educational needs, concurrent treatment with radiation and chemotherapy, poor caregiver support, three or more emergency department visits each month, and frequent or lengthy acute admissions. A comprehensive plan for each patient was drawn up, and each patient was followed at regular intervals.

Results revealed that patients’ symptoms decreased--they experienced less pain, nausea and vomiting, and weight loss--and in the first year of the program, the nurses were able to save the hospital at least $35,000.

Response Teams

Another innovative plan was created at the University of Kentucky Hospital to help ease problems caused by lack of communication in outpatient care. The hospital formed joint nurse/physician/clerk response teams that met before each clinic to go over each patient’s record and plan of care. Each member of the team entered information into "The Book," which contained records of each patient’s history, treatment, and other vital information.

As a result, communication was enhanced, and both patients and health care professionals experienced increased satisfaction with their roles and the care provided. "It really enhanced trusting relationships," said study author Mary Ryles, clinical nurse manager, University of Kentucky, Lexington.

In an era of shorter hospital stays, nurses also face another challenge: to meet patient and family expectations of care in a much shorter time. Breast cancer patients undergoing segmental or modified radical mastectomy with axillary dissection, for example, are typically released the same day as the operation or one day after. This can lead to fewer educational opportunities, less psychosocial support, added caregiver burden, and undetected complications.

To help avoid these problems without increasing the hospital stay, Methodist Hospital, HealthSystem Minnesota, is providing home care nurse visits for these patients 24 to 48 hours preoperatively and 24 hours postoperatively.

After being surveyed, 15 (94%) of 16 patients undergoing treatment felt that the education and emotional support received at home was helpful, and 88% were "satisfied or very satisfied" with their care, said study author Karen Swenson, RN, MS, OCN, oncology research manager with HealthSystem Minnesota.

Six surgical nurses who were surveyed reported that patients who received preoperative home visits were more prepared for surgery and easier to educate.

However, even with the program, one-half of the patients were uncomfortable about going home after the first day. Thus, while home care may be helpful for many patients, it is not a solution for everyone, Ms. Swenson said. "Some patients may need hospitalization for symptom control and emotional support," she commented.

Take-Home Book

A study at the University of Western Ontario, London, Ontario, explored the use of a take-home book about chemotherapy as a replacement for a 45-minute education session with a nurse in the hospital. The take-home book, written by one of the hospital’s oncologists, was presented to 103 patients in a 15-minute session with a nurse educator. The control group of 102 patients received the 45-minute hospital session.

Three months later, there was little difference between the two groups in the patients’ knowledge of chemotherapy or their satisfaction with treatment. The group that had received the book found the side effects they experienced more upsetting--probably because these patients tended to have more aggressive cancers than the control group, said study author Heather Porter, RN, PhD, a consultant for H.B. Porter & Associates, Kitchener, Ontario.

The group with the self-care book tended to ask for more home care visits and, probably as a consequence, experienced fewer hospital stays, Dr. Porter said. "Many patients took their books with them everywhere," she noted.