Practice report of The American Dietetic Association: Home care--an emerging practice area for dietetics.

As long as the field of dietetics has been in existence, the scope of dietetics practice has expanded to fill needs for nutrition services wherever they arose. In the 1980s, dietetics practice expanded to nontraditional areas such as private practice, sports nutrition, and business and industry [1]. Today, home care is a new frontier for dietetics practice. Of the 7.5 million new jobs created in the United States during the first half of the 1990s, jobs in home care were among the top 10 [2].

The aging of the American population, the growth of managed care, and the increasing availability of sophisticated technologies are important factors favoring the growth of home care [3,4]. The need for nutrition services in home care is also expected to grow. In part, this growth is expected because the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) 1999-2000 standards for home care require a home care provider to perform nutrition screening of all home care patients at moderate to high risk [5].

The growth of managed health care also encourages attention to provision of nutrition services in home care. In the capitated home care environment, the struggle to control costs and maintain quality of care increases the appeal of providing proactive nutrition services to reduce or prevent nutrition related complications and costs.

A number of dietitians are already practicing in home care today. The American Dietetic Association (ADA) 1997 Membership Database Update showed that 1.4% of respondents (n=399) listed home care as their primary employment setting [6]. A 1992 survey of home care dietitians found that 70% worked for home infusion companies, 12% worked for home health agencies, 8% were self-employed, 7% were employed by private physicians or outpatient clinics, and 3% were employed by hospitals [7].

Because home care is a burgeoning addition to the scope of dietetics practice, a panel of 6 dietitians currently practicing in the field was convened to create this resource for other dietetics professionals who are interested in home care. This article uses available information from the literature and the home care experience and knowledge of the panelists to accomplish the following objectives:

* to describe home care organizations and related reimbursement factors;

* to describe opportunities for dietetics professionals in home care along with suggested skills and characteristics that are likely to contribute to success in this emerging practice area; and

* to recommend actions that individual dietetics professionals can take, individually and collectively, to improve the quantity, quality, and access to nutrition services in home care.

ASPECTS OF HOME CARE

The home care industry provides a diverse array of temporary and ongoing services to frail or disabled people of all ages, ranging from premature infants to pediatric clients to young adults to the elderly. An important goal of home care is to enable these people to remain in their own homes instead of in health care institutions. Experts say that home care has a number of other advantages as well. First, there may be financial benefits, especially if home care prevents or delays a patient's transfer to a nursing home or hospital. A home care visit can cost as little as 19% of the cost of a day of care in a nursing home and about 4% of the cost of a day of hospitalization [8]. Home care may also be preferred because it may reinforce and supplement care provided by family and friends and, therefore, help maintain the recipient's dignity and independence. Quality of life may be better for people when they are cared for in their usual environment where they can maintain their usual lifestyle surrounded by loved ones and familiar foods and other things [9].

TYPES OF HOME CARE ORGANIZATIONS

The home care industry is a dynamic one, and is composed of a variety of entities known collectively as home care organizations. Broadly speaking, home care organizations are defined as an operational unit that provides one or more home care program to individuals in their residence. Following is a list of typical categories of home care programs. The most common, home health agencies and hospices, will be discussed in greater detail in the next section.

* Home health care Professional services provided in a patient's place of residence on either a part-time, intermittent, hourly, or shift basis.

* Hospice An organized program of interdisciplinary services for terminally ill patients and their families to provide palliative medical care and supportive social, emotional, and spiritual services.

* Support care Supportive services related to assistance with the instrumental activities of daily living provided on a part-time, intermittent, shift, or hourly basis.

* Personal care Personal care related to assistance with activities of daily living provided on a part-time, intermittent, hourly, or shift basis.

* Home infusion therapy Provision of both pharmaceuticals and skilled nursing services.

* Home medical equipment/durable medical equipment Companies that provide equipment in the home care setting.

Home Health Agencies and Hospices

The number of agencies providing home health and hospice services rose from 8,000 in 1992 to 13,500 in 1996 [10]. Home care agencies and hospices are differentiated by the types of services they provide. Home care agencies provide services to individuals and families in their homes for the purpose of promoting, maintaining, or restoring health or for the purpose of maximizing independence while minimizing the effects of disability and illness. Home care agencies that provide skilled services (eg, nursing services) make up the largest segment of the home care industry. Some agencies providing skilled services have specialty areas such as pediatrics, rehabilitation medicine, high-risk pregnancy, oncology, or maternal and child health. They may also provide personal care services to assist clients with the activities of daily living, such as meal preparation, bathing, dressing, and housekeeping.

By comparison, hospices provide palliative and supportive services for people in their final stages of disease ([less than or equal to]6 months of life expected), their families, and other loved ones. Hospices provide organized, interdisciplinary programs to provide physical, psychological, social, and spiritual care [10]. Aggressive therapies such as chemotherapy and parenteral and enteral nutrition are generally not considered consistent with the hospice philosophy as nutrition care is considered to be palliative. In this environment, dietetics professionals play important roles as information resources and educators.

Medicare added hospice benefits in October 1983. Hospices certified by Medicare must meet specific participation requirements [11]. Some hospice services, however, can be provided by home care agencies.

Infusion Therapy

Organizations designed to deliver infusion therapy represent another type of home care structure. These organizations specialize in the delivery of intravenous drugs, blood and blood products, other intravenous solutions, equipment, and professional services for people receiving intravenous medications, nutrition support, or other systemic therapies.

Some of these …