Why Is Home Health Not Home Hospice?

by Nancy Reynolds, RN

"Why can't I keep my home health nurse?" It's a question frequently asked by patients referred to hospices for terminal care. It's difficult for patients, who have given up so much already, to give up nurses, nursing assistants, and other caregivers whom they have come to know through their home health agencies. However, there are several very good reasons why home health is not home hospice. Since this column seeks to educate the public about the services hospice provides, let's take a look at why it benefits dying patients and their families to release their attachments to their home health caregivers and forge new relationships with hospice workers.

The first very big difference between home health and home hospice is focus. For home health agencies, time is money, and their goal is to get in, get the patient well, and get out. Home health nurses and other caregivers are expected to complete their work with each patient in as timely a manner as is prudent. They frequently have six or more patients to see each day, and are expected to average about 30 minutes per patient. They do not have the luxury of time to provide proper counseling and emotional support to grieving patients and families, no matter how much they would like to.

Hospices do not have a focus on time. They are usually paid a flat fee for providing hospice care and are expected to take their time with their patients. Hospice nurses, nursing assistants, social workers, and chaplains are expected to include counseling and emotional support in their routine patient care. Their case loads are three to four patients a day, and they are expected to spend an hour or more with their patients and families.

Home health nurses are usually very skilled in their areas. However, their focus is in restoring patients to health. They generally do not have training in handling patients who are terminally ill and require aggressive pain and symptom management farther than curative treatment. Hospice nursing is very specialized. Pain control measures in hospice are not practiced in the general patient population. Hospice nurses are educated about common and uncommon combinations of medications, common and uncommon routes of delivery for these medications, and amounts of pain medication that are much greater than those given to the general public. Nurses who are not specially trained in these techniques could unwittingly allow their patients to suffer pain and other distressing symptoms that trained hospice nurses could alleviate.

Medicare regulations (and therefore all insurance industry regulations) governing home health are very different for those governing home hospice. Home health agencies are limited in the amount of times nurses, home health aids, and social workers can see their patients. They're limited as to the amount of medical equipment they can provide, and they're even limited as to the amount of comfort measures, such as oxygen, they can provide. On the other hand, they are expected to carry out aggressive medical treatment for their patients, and to send them to the hospital for even more aggressive treatment should their conditions deteriorate.

Hospice, on the other hand, is empowered to provide patients with as much nursing care as the hospice nurse feels is appropriate. They can provide any necessary medical equipment. They have unlimited access to comfort measures, such as oxygen, without having to meet arbitrary Medicare criteria guidelines. In hospice, a patient's worsening condition or even eminent death is not an emergency, and the patient will not be submitted to a useless hospital admission unless it is the express wish of the patient or family. Most hospices have their own inpatient hospice units and can admit a patient for ongoing hospice care if their treatment is too complicated to handle at home.

Finally. hospice provides holistic care for dying patients and their families. In addition to the nurses and nursing assistants, hospice offers patient care that is not provided by any other institution. Hospice social workers are trained in a myriad of areas. They help patients and families connect with community resources, make financial plans and final arrangements, but they are also clinicians. This means that hospice social workers are trained in providing psychological counseling to patients and their families, which will help them through family problems as well as the grief process. Hospices are also mandated to have on their staffs chaplains who are trained in the special needs of dying patients, grief and aftercare counselors who work with grieving families after their loved ones have died, and volunteers who provide companionship to patients and respite for family members.

I hope this review of home health services and hospice services has answered the question of why home health and home hospice are not the same. It is important that we educate the general public on these matters, because there are still many physicians and nurses who do not understand the differences in care. The better educated the general public is about the expertise provided by hospice, the better quality of care dying patients will receive. 

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