Background: Palliative care is based on a holistic approach to maintain quality of life and alleviate suffering. The increased life expectancy where more people are living with chronic diseases means that the need for palliative care is increasing. Palliative home care is conducted through a team-based approach where the person and the relative are seen as a part of the care team. The nurses primary work is caring which includes giving support and alleviating suffering. The work also includes administrative tasks such as documentation and coordination. More knowledge about nurses experiences of working with palliative home care is required to increase understanding. Aim: Describe nurses experiences of providing palliative homecare. Method: Literature review with a thematic analysis including 10 articles. Results: Four themes were identified, collaboration between the professions, emotional challenges, time consuming work and cooperation with relatives. Conclusion: Palliative home care yields nurses many advantages in their caring role but requires competence and well-structured organisations. Nurses must advocate for all parties involved, including themself to be able to provide quality care. Present study identifies that nurses finds themself emotionally engaged in their work which is both an asset and a vulnerability. / Bakgrund: Den palliativa vården utgår från en helhetssyn på människan för att bibehålla livskvalité och lindra lidande. Den ökade medellivslängden där allt fler lever med kroniska sjukdomar medför att behovet av palliativ vård ökar. Den palliativa hemsjukvården bedrivs genom ett teambaserat tillvägagångssätt där personen och anhöriga ses som en del av vårdteamet. Sjuksköterskans primära arbete är omvårdnad vilket innefattar stöd och lindra lidande. Arbetet inkluderar även administrativa uppgifter såsom dokumentation och koordination. Det krävs mer kunskap om sjuksköterskors upplevelse av att arbete med palliativ vård i hemmet för att öka förståelsen. Syfte: Var att beskriva sjuksköterskors erfarenhet av palliativ vård i hemmet. Metod: Litteraturöversikt med tematisk analys inkluderande 10 artiklar. Resultat: Fyra teman identifierades, samarbete mellan professionerna, emotionella utmaningar, tidskrävande arbete och samverkan med anhöriga. Slutsatser: Palliativ vård i hemmet ger sjuksköterskor många fördelar i sitt utövande men ställer krav på kompetens och välstrukturerade organisationer. Sjuksköterskor behöver representera och advocera för alla parter, inklusive sig själv för att tillgodose god vård. I föreliggande studie framkommer att sjuksköterskor finner sig själva emotionellt engagerade iarbetet vilket är både en tillgång och en utsatthet.

Sammanfattning   Titel: Sjuksköterskors erfarenheter av palliativ vård i hemmet.    Bakgrund: Palliativ vård handlar om att lindra ett lidande, främja patientens livskvalitet samt att beakta patientens behov vid ett obotligt sjukdomstillstånd. Många patienter som vårdas inom palliativ vård önskar att få somna in i sitt eget hem. Sjuksköterskan behöver då ha kunskap, kompetens och erfarenhet för att vårda patienten på bästa sätt.    Syfte: Att beskriva sjuksköterskors erfarenheter av att vårda vuxna patienter som erhåller palliativ vård i hemmet.   Metod: En kvalitativ litteraturöversikt som baserades på elva vårdvetenskapliga artiklar. Databaserna som användes var CINAHL och PsycINFO samt en manuell sökning. Analysen gjordes enligt Fribergs analysstruktur. Från analysen framträdde två huvudteman och sex subteman.   Resultat: Resultatet presenteras i två huvudteman: Att samarbeta i team, Att möta utmaningar vid palliativ vård i hemmet. Vidare presenterades sex subteman: Att samarbeta interprofessionellt, Att samarbeta med patienter, Att samarbeta med närstående, Att anpassa vården i hemmiljön och att känna osäkerhet, Att uppleva att personcentrerad vård inte prioriteras.   Slutsats: God kommunikation och samarbete underlättar en säker och personcentrerad vård. Sjuksköterskans arbetsmiljö brister på flera plan, vilket ger risk för skador och stressrelaterade symtom. Hierarkin påverkar vården negativt och leder i många fall till avsaknad av personcentrering.   Nyckelord: Hemsjukvård, Palliativ vård, Sjuksköterskor, erfarenhet. / Summary   Titel: Nurses´experiences of palliative care in home health care.     Background: Palliative care is about alleviating suffering, promoting the patient's quality of life, and considering the patient's needs in the event of an incurable disease. Many patients who are cared for in palliative care wish to die in their own home. The nurse needs to have knowledge, competence, and experience to care for the patient in the best way possible.   Aim: To describe nurses experiences of caring for adult patients who are receiving palliative care in their home.   Method:  A qualitative literature review based on eleven nursing scientific articles. The databases used were CINAHL, PsycINFO and a manual search. The analysis was performed according to Friberg's analysis structure. From the analysis, two main themes and six sub-themes emerged.   Results: The results were presented in two main themes: Collaborating in teams and Meeting challenges in palliative care at home. Furthermore, six sub-themes were presented: Collaborating interprofessionally, collaborating with patients, collaborating with relatives, Adapting care in the home environment, Feeling insecure and To experience that person-centered care is not a priority   Conclusion: Good communication and cooperation facilitates safe and person-centered care. The nurse's work environment is inadequate on several levels, which gives rise to the risk of injuries and stress-related symptoms. The hierarchy has a negative effect on care and in many cases leads to a lack of person-centered care.   Keywords: Home health care, Nurses’ experience, palliative care

Background: Pressure ulcers are a problem that can lead to psychological, economical and physical issues for patients in a community. Pressure ulcers can occur in different settings and home healthcare is one of them. Pressure ulcers can emerge fast on pressure exposed areas of the body and can take a long time to heal. The registered nurses’s nursing work includes preventing and treating pressure ulcers. Aim: The aim of the study was to describe registered nurses preventive nursing care for pressure ulcers in home health care. Method: A literature review with 10 original articles which was analysed with a manifest content analysis. Result: The analysis resulted in twomain categories and five subcategories. One of the main categories was Nursing based on the profession as an expert with educating the team and team cooperation as subcategories. The other main categories was Nursing with an evidence based practice with skin assessment, risk assessment, repositioning and pressure reliving devices as subcategories. Conclusion: To prevent pressure ulcers in patients in home healthcare registered nurses must work with an academic basis where the team gets educated and cooperated. They should also work with an evidenced based practice where skin assessment, risk assessment, repositioning and pressure reliving devices are used. / Bakgrund: Trycksår är ett problem som kan leda till en psykisk, ekonomisk och fysisk skada för patienter i samhället. Trycksår kan uppstå i olika sammanhang där hemsjukvård är en av dem. Trycksår kan uppstå fort på tryckutsatta kroppsdelar och kan ta lång tid att behandla. I sjuksköterskans omvårdnadsarbete ingår det att förebygga och behandla trycksår. Syfte: Syftet med studien var att beskriva hur sjuksköterskors omvårdnadsarbete kan förebygga trycksår. Metod: En litteraturöversikt med 10 originalartiklar och data analyserades med en manifest innehållsanalys. Resultat: Analysen resulterade i två huvudkategorier samt fem subkategorier. Huvudkategori var omvårdnad utifrån professionen som expert med subkategorierna utbilda teamet och samverka i team samt omvårdnad utifrån evidens med subkategorier hudbedömning, riskbedömning och lägesändring och tryckavlastande hjälpmedel. Slutsats: För att förebygga trycksår hos patienter inom hemsjukvården bör sjuksköterskor arbeta med omvårdnad utifrån professionen som expert där teamet utbildas och samverkar. Det bör även arbeta utifrån evidensbaserade åtgärder med hjälp av hudbedömningar, riskbedömningar och lägesändringar samt tryckavlastande hjälpmedel.

Heart failure (HF) affects 6 million Americans, has an expected increasing prevalence in the next 20 years, and has a 5-year mortality rate of 50%. It represents the number one reason for hospitalization in patients older than 65 years. Recent legislation has increased the accountability of care of patients with HF, specifically readmission rates for HF in less than 30 days. This increased focus on HF readmission rates has led many health care organizations to reassess transition-of-care issues (i.e., from home to hospital, from hospital to home) and possible interventions to positively impact these readmission rates. During this process, home health care providers play an integral role and should be aware of possible issues to ensure optimum care for patients.

The primary clinical characteristics of cystic fibrosis (CF) are malnutrition caused by malabsorption secondary to pancreatic insufficiency, chronic pulmonary infections, and male infertility. The major cause of morbidity and mortality are bronchiectasis and obstructive pulmonary disease. Lung disease in CF is manifested by this chronic lung disease progression, with intermittent episodes of acute worsening of symptoms called pulmonary exacerbations. Once the patient has stabilized, and if suitable care can be arranged, these interventions are often transitioned to the home. This review summarizes important points pertinent to the use of intravenous and inhaled antimicrobials that may be encountered by prescribers, nurses, technicians, and case managers in the home health setting. Appropriate dosing, indications, adverse drug reactions, monitoring parameters, and practicality of both intravenous and inhaled antimicrobials are discussed.

Diabetes mellitus, whether type 1 or type 2, offers special challenges to home health care providers. Treatment of diabetes can become increasing complex. While insulin remains the cornerstone of treatment in patients with type 1 diabetes (T1DM), the utilization of insulin to safely control blood glucose is also necessary for many patients with type 2 diabetes (T2DM). Many different insulin products are available, with each product possessing different characteristics and adverse effect potential. Balancing glycemic control with patient safety is paramount. The individualization of insulin therapy can be challenging for both patients and health care professionals. Regular evaluation of blood glucose monitoring is vital for patient assessment. This article provides a review of insulin for providers caring for patients in the home health care setting.

Home health clinicians are uniquely qualified to fully evaluate patient falls risk and carry out clinical interventions to reduce risk. The objectives of this article are to give home health providers an update on the risk factors for falling, review the current guideline recommendations for prevention of falls, and provide a stepwise approach to evaluate patients and apply the clinical literature to decrease falls in older patients living at home. Many falls may be prevented with patient screening, assessment of risk, and modification of risk factors. Since the risk of falling is an interaction between three groupings of patient-specific factors, namely, environmental factors, diseases/disorders, and medication use, a multifactorial fall risk assessment can help identify the factors to consider modifying in an individual patient.

Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services.

Background: Home health is the fastest-growing healthcare setting in the country. Through Home Health Value-Based Purchasing (HHVBP), the Center for Medicare and Medicaid Services (CMS) provides incentives or penalties to HHAs based on outcomes. Hospitalization and emergency department use are weighted heaviest as poor outcomes. HHVBP requires HHAs to report on whether they are engaging in advance care planning (ACP) conversations. For this study, ACP was defined as a conversation held in advance of a medical crisis with a loved one and/or a health care provider about goals; values; preferences for future medical treatments; and choice of a surrogate decision-maker. Purpose: to determine whether the proportion of Black patients was correlated with robustness of HHAs’ ACP protocols and levels of acute care services use. Methods: A cross-sectional, quasi-interventional design was used. The sample size was n = 89. Electronic surveys about ACP protocols were distributed to HHAs. Existing data about demographics and acute care services use were accessed via CMS websites. Spearman’s correlation coefficient was used. Results: No relationship was found between robustness of ACP protocols and the proportion of Black population per agency. No relationship was found between overall acute care services use rates proportion of Black patients. However, a trend was found: The greater proportion of Black patients, the greater the tendency for an agency to have a higher hospitalization rate. Discussion: Results are compared to current literature and to a CMS-commissioned study’s discussion about the potential for value-based purchasing programs to exacerbate health disparities in vulnerable populations.

Although guidelines and minimal standards for the care and documentation of wounds in home health care settings in the United States are available, there is a lack of compliance among many home health care agencies (HHAs) with regard to the accuracy of wound documentation and care of wounds. Failure to follow guidelines for wound care according to Centers for Medicare and Medicaid Services and Home Health Outcome and Assessment Information System standards could result in loss of revenue for HHAs, improper treatment of wounds, and legal ramifications. The purpose of this doctoral project was to develop and validate a staff educational module on wounds and wound documentation for an HHA. Benner's from-novice-to-expert model was the conceptual framework for understanding nurses' matriculation. The practice-focused question focused on whether a wound staff educational module increased the home health care nurse's knowledge about wounds and wound documentation. A 5-level Likert scale was used by an expert panel to validate the staff educational module. Descriptive analysis was used to evaluate the data. The results of the survey supported implementing the educational module with recommendations (overall percentage 93% [4.4]). The findings of this project contribute to social change by increasing nurses' knowledge of wound care, improving the quality of wound care, increasing reimbursement and revenue, and decreasing the cost of care for wounds.