FCRP Policy Statement

Hospitals are spending increasing amounts of health care dollars and staff time on discharge planning and referrals for skilled home care services. Referrals for Skilled Nursing (SN) and Home Health Aides (HHA) are ordered by physicians and based on Medicare guidelines that requires patients be homebound. Criteria do not include family situations or patient needs not related to homebound status. For instance, a frail, elderly spouse, or an adult daughter who is working and caring for the patient may not qualify to receive SN or HHA services.

The Family Caregiver Research Group at Michigan State University interviewed 628 first time caregivers three weeks following the discharge of their elderly family member from a hospital in Michigan and asked whether or not they received SN or HHA services since their patient had returned home. Referral of these 2 services was assessed at patient discharge from the hospital and actual use was assessed 3 months later.

Findings:

• 68% of the sample were referred for Skilled Nursing Services
• 33% of those receiving SN services also were referred for assistance by Home Health Aides.
• Of those referred, 83% used SN service while only 51% used HHA.
• Almost half of those who could benefit from HHA did not use the service.
• Non-spouse caregivers (e.g. daughters) were more likely to be referred for both SN and HHA than spouses. Perhaps this is because it is seen as part of a spouses "duty". This creates problems when the spouse is elderly or in poor health. Older patients were more likely to be referred for both services and were more likely to use SN.
• Male patients were more likely to be referred for SN services.
• Employed caregivers were more likely to use HHA than those not employed.
• Situations with more dependencies were more likely to use HHA.
• Of those families referred for HHA and NOT using the services, up to half were caring for patients with numerous disabilities.

Policy Implications:

1. Family members as well as patient needs should be considered in the discharge planning and the referral process e.g. caregiver's health, caregiver's employment status, gender, or age). Altering criteria for home care may actually help some families to remain out of institutions and provide more appropriate care to other patients.
2. One home or nursing home visit, post hospitalization to assess needs for community services may help determine not only who needs services but also facilitate the elderly accessing services available to them.
3. Families should be informed and counseled on the nature and availability of services and assist them in accessing these services. This would be useful to those who did not utilize HHA when it was appropriate.
4. Health care professionals should monitor need for service throughout the illness to note changes.
5. Eligibility criteria may need to be changed so that the referral is not based solely on patient dependence especially when patients live alone.
6. Elderly caregiver spouses should be specifically targeted for more active referral services.
7. Hospital discharge planners should be educated as to the dynamics involved in needs of patients and families for skilled home care services.

This research supported by grant #2 ROI AGO6584, "Caregivers Responses to Managing Elderly patients at Home," funded by the National Institute on Aging. C.W. Given and B.A. Given, Principal Investigators. Correspondence should be addressed to Dr. C.W. Given, B- 100 Clinical Center, Department of Family Practice, Michigan State University, East Lansing, MI 48824-1313 (1-800-654-8219 or 5 17-353-3843).