Public Health Nursing Vol. 7 No. 2, pp. 118-126 0737- I209/90/$2.00 0 1990 Blackwell Scientific Publications, Inc.
The Albrecht Nursing Model for Home Health Care: Implications for Research, Practice, and Education Mary Nies Albrecht, Ph.D., R.N.
and restorative care have been rediscovered and pressures are mounting to increase the quantity, maintain quality within cost restraints, and broaden the diversity of the services that are available (De Crosta, 1980; Shaw, 1985). Home health care is a subsystem of the health service delivery system that will continue to expand (Braden & Herban, 1976). Even now it is growing by providing high-technology services in the home (Auerbach, 1985). Such care is receiving increased attention in government, as reflected in the recent changes in Medicare and Medicaid regulations. These changes are beginning to BACKGROUND eliminate past barriers to home health care and are enHome care is preferred by the American public over couraging more flexibility in providing services to elinursing homes (De Crosta, 1980; Hammond, 1979; gible beneficiaries. Home health care also is an alternative to institutionMundinger, 1983). The need for such services will quadalization. A major goal is to provide care that will facilruple in volume in the next 15 to 20 years (Auerbach, itate the client’s independence in a cost-effective man1985; Shaw, 1985). “The 85 and over population is exner. The nurse working in this setting is the key person pected to reach 5.4 million by the year 2000 and 7.5 milwho can identify available resources and assist clients lion by the year 2020” (Auerbach, 1985, p. 291). The and families to maneuver through a complex maze of home care industry is currently meeting only 25% of services. To achieve this, the nurse must be skilled in market needs, however (Spiegel, 1983). The health care coordinating a broad range of services in addition to system’s incentives for efficiency and the decreasing deproviding direct care. At the present time, no scientifimand for inpatient hospital services will be the forces cally valid model exists to increase quality of practice driving health care toward a competitive marketplace and to identify content for teaching in home health care. (Stuart-Siddall, 1986). The many benefits of home- and Therefore, one must be developed that initially will be neighborhood-based services that combine preventive descriptive and eventually explanatory and predictive (Adams, 1985; Stevens, 1984).
Abstract Home health care has become increasingly popular with consumers. Despite this movement of care away from the hospital, the literature does not contain a comprehensive nursing model of home health care. The need for a model to guide nursing research and ultimately, nursing practice and education is apparent. Four health service delivery models are available to be applied to home health care nursing; however, analysis of all four demonstrates a need for one specific to home care nursing.
Mary Nies Albrechr, Ph.D., R . N . is Assistant Professor of Nursing, Deicke Center for Nursing Education, Elmhursi College. Elmhurst. Illinois Address correspondence 10 Mary Nips .Albrechr, p h . D . , R . N . , 5504 Groveside Lane, Rolling Meadows, IL 60008.
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DEFINITION OF HOME HEALTH CARE Home health care cannot simply be defined as care at home, as it includes a Variety Of Services. A more Comprehensive definition was prepared by a Department of
Albrecht: Model for Home Care
Health and Human Services interdepartmental work group with the assistance of materials provided by the Assembly of Ambulatory and Home Care Service of the American Hospital Association, the National Association of Home Health Agencies and Community Health Services of the National League for Nursing (NLN), the American Nurses’ Association (ANA), the National Health Council, and the American Medical Association: Home health care is that component of a continuum of comprehensive health care whereby health services are provided to individuals and families in their home for the purpose of promoting or restoring health, while minimizing the effects of disability and illness, including terminal illness. Services appropriate to the needs of the individual patient and family are planned, coordinated, and made available by providers organized for the delivery of home health care through the use of employed staff, contractual arrangements, or a combination of the two patterns. (Warhola, 1980)
This definition integrates the components of home health care, client, family, health care professionals (multidisciplinary), and goals to assist the client to return to an optimum level of health and independence. The types of services provided will vary according to the client needs, the home care provider, and the reimburser.
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home health care agency; (4) graduate experience in a veterans administration hospital-based home health care agency, a voluntary home care agency, and a proprietary home care agency; ( 5 ) experience teaching undergraduate nursing students community health nursing; and (6) critique and synthesis of four models related to home health care (Coombs, 1984; Dreher, 1984; Landau, 1981; Shortell et al., 1977). MODELS RELATED TO HOME HEALTH CARE
The rationale for selecting these four models was as follows. First, Dreher’s (1984) is the only one found to deliver public health nursing service of which home care is a component. Coombs’s (1984) is the only one derived from a review of the literature that specifically identified itself as a conceptual framework for home nursing. Landau (1981) provided a method for analyzing a health care delivery system. Finally, Shortell et al. (1977) examined the relationship between the patient and provider variables in a health service delivery model. Each of these models includes some of the important variables to be considered in home health care nursing. None, however, is complete in that factors are missing that are important to this area of nursing practice. The Dreher Model
DEVELOPMENT OF THE MODEL FOR HOME HEALTH CARE
Conceptual models deal with concepts that are assembled by virtue of their relevance to a common theme (Fawcett, 1984). They can be useful in clarifying the association between concepts and guiding research when formal theories are not relevant for a specific research problem (Fawcett, 1984, p. 2). Therefore, the components of a model for any discipline are the concepts and the statements that integrate them into a valid configuration (Stevens, 1984). Such concepts and propositions are abstract and general, and thus are not amenable to empirical testing (Stevens, 1984). The descriptive model proposed here contains concepts that the author considers relevant to understanding and carrying out nursing practices in home health care. Such a model must incorporate concepts of health service delivery, home care, and nursing on which to focus practice, research, and education. The approaches used to develop and select variables for this model were (1) review of literature on home health care (Auerbach, 1985; De Crosta, 1980; Mundinger, 1983; Shaw, 1985; Spiegel, 1983; Stuart-Siddall, 1986); (2) experience as a site visitor for the NLN Community Health Home Care Accreditation Program (NLN, 1987); (3) professional experience in an official agency providing home health care and a hospital-based
Dreher (1984) presented a model of population-based nursing. It assumes that a focus of public health nursing is chronic illness and care of the elderly in the home. It includes both well and sick care across the life span. This model, which appeared in the 1920s, may hold great possibilities for addressing the nation’s current and future health problems. The three main components of the district nurse’s role are school nursing, health promotion and prevention, and home care (Dreher, 1984). These services are provided regardless of ability to pay or meeting reimbursement criteria. The concepts that are identified in the Dreher model are availability, accessibility, accountability, comprehensiveness, coordination, cost-effectiveness, and quality care. The major factors missing or not made explicit are the relationships among the concepts, uniqueness of the client and family, client outcome, and definition of the concepts. The Coombs Model
The major concepts in the Coombs (1984) framework are nurse, intervention, client, and community. They are not defined. In this framework, it is postulated that home nursing is dynamic, complex, and challenging. Another assumption is that the nurse plays a central role in a client’s response to an illness. Of primary importance, it depicts the factors (such as bedroom on up-
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stairs level) that exist in the home but not in the hospital that affect the nursing intervention. Thus nursing care is primarily the result of the interaction of the client and the nurse in the home. The family is not mentioned as part of the interaction. This model is based on an inductive study done in Australia. The major factors missing or not made explicit are structural elements such as the number of staff available to provide care, accessibility of home care to the client, outcomes other than those specific to the client, and the fact that the major focus is restricted to the interpersonal relationship between the nurse and the client.
the process of care; importance of the home setting in the nursing process; the nature of the types of care that can be provided in the home; and outcomes other than client satisfaction. Summary of Models Related to Home Health Care
Table 1 compares the concepts contained in each model and shows which ones they have in common. As the table shows, none of the models contain all of the 18 concepts which the author feels are important for home health care based on review of literature, experience in home care, and synthesis of the four models pertinent to home care. This points to the need for a model that The Landau Model combines concepts of health service delivery, home The Landau (1981) model presents a method for the health care, and nursing. Models that are developed in analysis of rural primary health care delivery systems, isolation from home care nursing practice have little the dynamics of which are viewed as an interaction be- utility for clinicians who are seeking appropriate intertween the consumer and the provider. Overall, it sug- ventions for their practice (Table 2). A nursing model will clearly indicate the importance gests that alternative health care systems must be of the nurse in this realm of practice. As the coordinator evaluated as to their effectiveness, efficiency, and acof care, the nurse uses other disciplines as necessary. cessibility criteria. An assumption is that accessibility The need for a model to guide nursing research and ulaffects efficiency through the process of mediating retimately, nursing practice and education is apparent: it source use. must ( I ) recognize the aspects of care at home for both Efficiency, accessibility, quality of care, client outthe nurse and the client in attaining positive outcomes; come, cost, productivity, and demand and use are all (2) acknowledge the importance of the family or loved defined. To obtain a complete understanding of the efones and friends as factors in client outcomes; (3) adfectiveness and efficiency of health care delivery sysdress the elements of structure for both the consumer tems, the consumer and provider must be considered and the provider and their role in determining the protogether. The former is made up of client needs and use cess at home; (4) recognize that the nursing care proof services. The latter consists of quality of care and vided in the home affects elements of structure and of productivity of the health care providers. outcome; ( 5 ) guide the development of nursing intervenThe major factors missing or not made explicit in the Landau model are the importance of social and psycho- tions that are efficient and effective in our costlogic variables and the family of the consumer (which conscious society; and (6) combine the concepts of would affect provider productivity and client outcome), home health care nursing and health service delivery. impact of the education, philosophy, and number of ALBRECHT NURSING MODEL FOR staff on the process of care, the importance of the home HOME HEALTH CARE setting on the nursing process, the nature of the various types of care provided in the home, and provider Assumptions and Definitions outcomes. Intrinsic to the proposed model are the assumptions that clients and their families are capable of making indepenThe Shortell Model dent decisions about the setting of their health care; The Shortell (1977) model of health services delivery is clients are active and mutual participants in their care; based on the interrelationships among patient and pro- they prefer home care to institutionalization; and they vider variables and access, use, continuity, quality, and and their family must accept responsibility for this care satisfaction with medical services. It is more global than (Table 3). The model reflects a beginning attempt to the previous three in that it deals with health service as identify the complex nature of home health care as well a subsystem of society. Its variables are “structural, as the dynamic relationship among the structure, proprocess, and outcome” (Shortell et al., 1977, p. 140). cess, and outcome. The major factors missing or not made explicit in the The model proposed here is based on the interrelamodel are the importance of psychologic and social tionships among variables identified by the author as variables of the consumer; effect of the philosophy, important for home health care. It subsumes many of number of staff, standards, and costs of the provider on the concepts and variables generated by the four previ-
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TABLE 1 . Concepts Included in the Models Models Dreher
Concepts
Accessibility Accountability Availability Comprehensiveness Continuity Coordination Cost-effectiveness Clientkonsumer Demand Efficiency Intervention Nurse Client classification Productivity Provider Quality of care Satisfaction Use of home care Totals 18
Coombs
X X X X
Landau
Shortell et al.
X
X
X X X X
X X X X
X
X
X X X X
X X
X X X X
8
7
X 8
4
TABLE 2. Assessment of Selected Models
Model
Concepts Defined
Nursing
Focus
Dreher
Coombs Landau
Shortell et al.
ously assessed models, but with greater emphasis on home health care nursing. A major factor is the availability of services. For example, if the structural elements are present (family/ loved one(s)) but the availability of home care in the health service delivery system is absent, the type of care needed and self-care capability are decreased. If the suprasystem does not provide the necessary payment sources, home care may not be an option. Thus the suprasystem affects the health service delivery system, which in turn affects care in the home. The model in Figure 1 identifies and shows the relationship among variables necessary to care for clients and families in the home. It attempts to link in a single model structure, process, and outcome. The assumption is that the arrows in the figure indicate the variables that affect other variables, either directly or indirectly. With research, the model could be used for explanatory
Home Setting
Links Between
Concepts
Important Concepts
-
+ + +
and predictive purposes. The goal is to identify and suggest relationships among the home subsystem, structural elements, process elements, outcomes, the health service delivery system, and the suprasystem.
Structural Elements
Structural elements include the client, family, provider agency, health team, and professional nurse. The family can be present or absent, or vary with respect to participation and quality of relationship. The client includes demographic, economic, social, and psychologic variables. The provider agency consists of philosophy, organizational structure, standards, funding, technology, and travel time. The health team variables are the disciplines, technical nurses, and home health aides available to provide services in &hehome. The nurse vari-
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TABLE 3. ConceDts and Definitions of Home Health Care Model Structural
Modifying
Process
Outcome
Client: rational, biologic, emotional, social being desiring the use of home care services
Client classification: complexity or difficulty of nursing care required
Type of care: focus and intensity of care given by nurselothers in the home
Costs: charges or fees per visit or for agency operation
Coordination of care: case management by professional nurse for continuity and comprehensive services in the home according to professional, agency, and federal guidelines, and use of other community re sources
Satisfaction: verbal or written expression of positive statements toward care given andor received Quality of care: care meets ANA standards for home health care practice/ certificatiodNLN accreditation standards
Intervention: actions taken by professional nurse, health team members, client, or family to promote or enhance selfcare capabilities
Cost effective: costs of delivering a set of services while maintaining ANA/ NLN quality standards
Family, loved one(s): any other individuals present in the home and willing to participate in care as needed by the client to maintain self-care at home Provider agency: any official, voluntary, private, hospital-based, nonprofit, or proprietary agency providing health care services at home Professional nurse: individual with license to practice professional nursing in state Health team: members coordinated by the professional nurse; any LPN. ADN. or professional in speech, social work, home health aid, physical therapy, occupational therapy, nutrition, dental hygiene, respiratory therapy; physician; durable medical equipment; home meals, homemaker, transportation, or volunteers available to provide care or service at home
Demand: number of client or families requesting home care services Availability: number of home care agencies available for clientlfamily use, or availability of health team and nurse to accept new cases Productivity: number of clients nurses can visit in one day or number staff can visit in month or year Accountability: of health team and nurse for own actions, agency to standards, and consumer to participation in care Accessibility: ease at which one can enter home health care system Efficiency: high ratio of output to input in system, minimum wasted effort
ables are education and experience. The outcomes of home health care can be affected by the way these multiple variables interact with one another. The model purports that the structural elements may be modified by client classification, demand, accessibility, efficiency, availability, accountability, and productivity factors. For example, classification may be increased or decreased depending on the availability of family members. In addition, all the structural elements interact simultaneously with each other to address a specific need. For example, a client’s economic status, combined with
Health status: cured; self-care; self-care with assistance; dependent on others; alternative care (nursing home. hospital, clinic, hospice); death Self-care capability: ability to perform activities 0 1 daily living that permit the individual to live independently at home
family status, and the provider’s financial resources for health care will be more likely to predict a certain outcome than will examination of any of the variables in isolation from the others. Process Elements The structural and process elements affect the response to care. As a result, outcomes are more fully explained by these combined effects on care. This model explicitly addresses the provision of care to the client at home and identifies this as an influence
Albrecht: Model for Home Care 123
-*
Structural elements
Process elements
Client
Demographic, psychologic, social, and economic variables $ Family, loved one
Present, absent, participation in care $ Provider agency
Funding source, organizational structure, standards, philosophy, technology, travel time $ Professional nurse
Education, experience Health team Other disciplines
available, technical nurses, home health aide
Type of care
Modified by I I I I I I I I I I
+ I I I I I I I I I I I I I
Client classification costs Demand Availability
+
Productivity Accountability Accessibility Efficiency
I
I I I I I I I I I I I I I
I I I I I I I I I I
I I I I I
I I I I I I I I I I I I I
Preventive, education, supportive, therapeutic, high tech
t Coordination of care
Continuity, comprehensive, federal legislation $ Intervention
Nursing process, client involvement, family involvement, legal constraints, ethical constraints, other disciplines
I
I I I
I I
Home health subsystem I
-
Outcome elements
-
Satisfaction with care
I I I I I I I I I I
+ I I I I I I I I I I I I I I I I I I I I I I I I I I I
Client, family, professional caregiver Quality of care Cost effectiveness Health status Self-care capability Use of home care
Figure 1. The Albrecht nursing model for home health care.
on outcome. The process elements have three compo- gest a deficit in one or more of these elements and nents, the relevance of which varies according to the necessitates feedback to either or both for further proclient’s health care needs. The relationship between the cessing, modification, and intervention (Braden & structural elements and the process elements directs Herban, 1976). intervention approaches. Depending on the structural The link between the structural elements and the proelements and mediating factors, a client may require ed- cess elements is affected by the modifying factors, as ucation, or preventive, supportive, therapeutic, or high- well as by the health service delivery system and the tech care that is delivered based on the nursing process; suprasystem. Self-care capability is one of the outcomes the nurse is responsible for executing the nursing pro- of the interplay between the structural and process elecess, which includes assessment, nursing diagnosis, ments. The bidirectional paths of the arrows in the planning, intervention, and evaluation. The professional model reflect the idea that these processes are transacnurse should be responsible for coordinating other dis- tional and that reciprocal feedback can occur at each ciplines and for ensuring continuity of care. The inter- stage. As noted in Figure 1, provider agency, client classification, and coordination of care ultimately affect actions of the process elements affect outcome. the quality of care and health status. Thus the structural and process elements greatly influence outcomes, Outcome Elements which in turn affect structural and process elements. The model allows for identification of relevant variThe outcome elements consist of satisfaction with care, quality of care, cost-effectiveness of care, health status, ables, use of each one, and the determination of the proand self-care capability. Positive outcomes refer to ad- posed interaction among them. It also provides for equacy of structural elements and effective implemen- many interactive predictors, nursing care, and a variety tation of the process elements. Negative outcomes sug- of outcome criteria. One may tap into the model at var-
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ious stages depending on the purpose of the study and the problems under investigation. Both cross-sectional and longitudinal research designs are possible in this model. Analyzing the interfaces among client demographic variables and client classification over time would help evaluate the effects of structural elements on satisfaction with and costeffectiveness of care. A cross-sectional study would show the association between provider agency and coordination of care. APPLICATION OF THE ALBRECHT MODEL TO HOME HEALTH CARE Research This model can be used as the framework for research. An example would be investigation of the amount of time the nurse spends in the home with the use of more technology. A relationship exists among the nurse, productivity, technology, type of care, and cost-effectiveness. If staff have to spend more time in the client’s home due to increased technology (process), this affects cost-effectiveness and possibly, quality of and satisfaction with care (outcome). Increased time in the home (process) also determines availability of the staff to other consumers who require services (structure). Other examples of research studies testing this model are evaluating the specific type of care required by the consumer and carried out by the nurse, and nurse satisfaction with care, staff accountability for their responsibilities, and the effect this has on client use of home care. The model can guide nursing research to answer several questions. (1) Is the client’s satisfaction with care based on the type of care required? (2) Does preventive care lead to greater client satisfaction than high-tech care? (3) Should a family member or loved one be required to be present for home services to be provided? (4) Should type of care provided focus on the most costeffective in contrast to the highest quality available and what will most improve the client’s health status? ( 5 ) To what extent can the structural elements predict self-care outcomes in the home? (6) Will client classification predict structural and process elements necessary to provide quality care? (7) What is the relationship among the types of care provided by the nurse, and professional and consumer satisfaction? (8)What effect does the provider agency have on costs, coordination of care, and health status? (9) What is the cost of home care based on consumer variables, type of care needed, and quality of care? (10) What combination of variables provides the best self-care capability in the home? (1 1) What combination of nurse education and experience pro-
vides the best process and outcomes for the client? (12) Does client classification predict type of care needed? Nursing Practice The ANA (1986) developed standards of nursing for home health care practice. The first states that. all such services will be directed by a master’s-prepared professional nurse with experience in community health and administration. Although standards are included in the structural elements of the model, if this one is lacking it will affect the process and outcome of care. A negative outcome may necessitate a change in practice. Standard 5 states that the nurse continually evaluates the client’s and family’s response to care to determine goal attainment, and to revise the plan of care. Again, this is congruent with the proposed model, and the model could facilitate improvement in clinical practice. The nurse using the model would recognize that assessing consumer variables, family, and health team availability are all important for determining the type of care required. The nurse working in home health care knows nursing interventions depend on client and family involvement in addition to legal and ethical constraints present in the health service delivery system. Skills of the nurse and family, client classification, philosophy of the agency, number of health team members available all provide insight into type of care needed. For example, it might be more helpful, and therefore produce the desired outcome, to provide a client who has had a cerebrovascular accident with a home health aide to assist with self-care activities than a professional nurse, if this is what the family desires. The client and family are likely to have greater satisfaction with care, continue to use home care and thus avoid rehospitalization, and improve client and family self-care capability. An advantage of the model for nursing practice is the linking of the professional nurse, client, client classification, and type of care to evaluation of outcomes. Interventions are specifically focused on the interrelationships of structural and process elements. Prior to implementing the nursing process in the home, the nurses would have to (1) assess consumer variables, family ability to participate in care, standards for providing care, health team disciplines available, and the nurse’s own experience and travel time to the home; (2) consider the client classification, the payment source of family, and their desire for service; and (3) assess the type of care needed and how services will be coordinated. Based on these considerations the nursing process can be carried out appropriately. Outcomes of care can be measured by any of the elements identified in the model. Client and family out-
Albrecht: Model for Home Care
comes are satisfaction with care, use of home care, health status, and self-care capability. Professional or agency evaluation measures are satisfaction with, and quality and cost of care. Based on measures used, the findings would either support or suggest changes in the nursing process. Another use in the clinical setting would be as a guide for appropriate assignment of staff to meet client needs. Based on type of care needed, client classification, organizational structure, health team disciplines available, and desired outcome, the nursing manager could select the appropriate care provider in the home. Staff may place greater emphasis on education and preventive care and less on high-tech care. Performance evaluation might indicate that a nurse feels a deficit or lack of skill in providing high-tech care. As a result, these clients may be receiving inadequate care. The nursing manager now has a responsibility to provide staff-development programs in this area or hire people who can provide it. Such intervention should increase productivity and professional satisfaction with care and ultimately, client self-care capability. Education
Finally, the model clearly defines important education content areas for nursing students at the undergraduate level and those at the master’s level who are specializing in home health care. Professional satisfaction and quality of care, and therefore effective outcomes, depend on education and experience of the nurse. Also, education and experience affect productivity and accountability levels. Several implications become apparent. First, nursing programs at the undergraduate and graduate levels must prepare competent providers of home health care. Curricula have to include concepts related to the suprasystem, health service delivery system, and home subsystem, which includes structural, process, and outcome elements. At the undergraduate level, it is important that students have at least one clinical observation or experience in a home health care agency. This will facilitate understanding of the elements important to home care. It will also facilitate transition from student to professional in an area in which many nursing graduates will be working in the near future, given the advent of diagnosis-related groups and consumer preference (Auerbach, 1985; Shaw, 1985). At the graduate level, programs specializing in home health care will have to include specific courses covering the identified concepts in the model. General areas include knowledge on education, preventive, supportive, therapeutic, and high-technology nursing interventions for home health care; a multidisciplinary approach to home health care; health law and ethics; systems the-
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ory; economics covering supply, demand, and productivity; and, finally, case management and coordination, finances, and organizational structure. At the graduate level, it would be mandatory to have a clinical practicum in a home health care agency to observe, apply, and analyze the model in action. CONCLUSIONS AND RECOMMENDATIONS
The proposed model was developed to reflect the complex nature of home health care as well as the dynamic relationship among the structural, process, and outcome elements. The use of a conceptual model is important in designing research since it facilitates the identification of pertinent variables and a definition of the relationships among variables (Fawcett, 1984). Many of the variables are incorporated from models of health service delivery; however, this model is significantly different from earlier ones in that it incorporates both nursing and home health variables. In sum, it includes those crucial to the definition of home health care and identifies sources of variance in outcome of care. The purpose of home health care nursing is to promote self-care capability in the client at home. In doing this, the family can maintain their status within the social, political, and economic suprasystem. This model facilitates predicting those variables that contribute to care at home. Nursing practice needs, as well as needs for in-service programs, are readily identifiable. The model is a synthesis of important variables necessary for home care and is congruent with consumers’ demand for accessible, available, and affordable care. It also appears congruent with consumers’ demand for a voice in provision of care (Auerbach, 1985; Institute of Medicine, 1979; Jahiel, 1982). Finally, it affords a degree of prescription for research agendas in home health care and for educational content in nursing programs, and suggests ideas for improving nursing practice in the home. Additional work must be done to move this model from a descriptive, conceptual stage to an explanatory prescriptive, theoretical one. Testing of hypothesized relationships between variables with reliable and valid measures will increase the ability to confirm the structure-process-outcome relationships between nursing interventions and changes in self-care capabilities of clients. Once these relationships are tested, they can be either supported or not supported. Regardless of status, with the right combination of structural and process variables, the client can have an outcome of self-care capability. Research on the model would provide data on the combinations of structural and process variables that provide for the most desirable outcomes.
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Institute of Medicine. (1979). Health services research. Washington, DC: National Academy of Science. The author wishes to acknowledge the assistance Jahiel, R. (1982). Health services research in the health serof Drs. Judith Sullivan, Pamela Kulbok, and Judith vices system. Annals of the New York Academy of SciStorfjell for their review and critique on this manuences, 387, 5747. script. Landau, T. (1981). A methodology for the analysis of rural primary health care delivery systems. Computers in Biology and Medicine, 11(92), 51-72. REFERENCES Mundinger, M. (1983). Home care controversy. Kockville, Adams, E. (1985). Toward more clarity in terminology: MD: Aspen. Frameworks, theories, and models. Journal of Nursing Ed- National League for Nursing. (1987). Accreditation division ucation, 24(4), 151-155. for home care and community health: Accreditation, criAmerican Nurses’ Association. (1986). Standards of home teria, standards, and substantiating evidences. Publ. No. health nursing practice, Kansas City, MO: Author. 21-1306.New York: Author. Auerbach, M. (1985). Changes in home health care delivery. Shaw. S. (1985). A home care technology. Caring, 4, 21-25. Nursing Outlook, 33(6), 29&291. Shortell, S., Richardson, W., Logerfo, J., Diehr, P., Weaver, Braden, C., & Herban, N . (1976). Community health: A sysB., Green, K. (1977). The relationship among dimensions tems approach. New York: Appleton-Century-Crofts. of health services in two provider systems: A causal model Coombs, E. M. (1984). A conceptual framework for home approach. Journal of Health and Social Behavior, 18(2), nursing. Journal of Advanced Nursing, 9, 157-163. 139-159. De Crosta, T. (1981). Home health care is red hot right now. Spiegel. A. (1983). Home health care: Home birthing to hosNursing Life, I , 54-60. pice care. Owing Mills, MD: National Health Publishing. Dreher, M. (1984). District nursing: The cost benefits of test- Stevens, B. (1984). Nursing theory: Analysis, application, ing of a population-based practice. American Journal of evaluation. Boston: Little, Brown. Public Health, 74, I 107-1 1 1 I . Stuart-Siddall, S. (1986). Home health care nursing: AdminFawcett. J. ( 1984). Analysis and evaluation of conceptual istrative and clinical perspectives. Chico, CA: Aspen. models of nursing. Philadelphia: F. A. Davis. Warhola, C. (1980). Planning for home health services: A reHammond, J. (1979). Home health care costs effectiveness: source handbook. DHSS Publ. No. (HRA) 80-14017. An overview of the literature. Public Health Reports, Washington, DC: Public Health Service, Department of 94(5), 305-3 1 I . Health and Human Services.
ACKNOWLEDGMENTS
The Albrecht Nursing Model for Home Health Care: Implications for Research, Practice, and Education Mary Nies Albrecht, Ph.D., R.N.
and restorative care have been rediscovered and pressures are mounting to increase the quantity, maintain quality within cost restraints, and broaden the diversity of the services that are available (De Crosta, 1980; Shaw, 1985). Home health care is a subsystem of the health service delivery system that will continue to expand (Braden & Herban, 1976). Even now it is growing by providing high-technology services in the home (Auerbach, 1985). Such care is receiving increased attention in government, as reflected in the recent changes in Medicare and Medicaid regulations. These changes are beginning to BACKGROUND eliminate past barriers to home health care and are enHome care is preferred by the American public over couraging more flexibility in providing services to elinursing homes (De Crosta, 1980; Hammond, 1979; gible beneficiaries. Home health care also is an alternative to institutionMundinger, 1983). The need for such services will quadalization. A major goal is to provide care that will facilruple in volume in the next 15 to 20 years (Auerbach, itate the client’s independence in a cost-effective man1985; Shaw, 1985). “The 85 and over population is exner. The nurse working in this setting is the key person pected to reach 5.4 million by the year 2000 and 7.5 milwho can identify available resources and assist clients lion by the year 2020” (Auerbach, 1985, p. 291). The and families to maneuver through a complex maze of home care industry is currently meeting only 25% of services. To achieve this, the nurse must be skilled in market needs, however (Spiegel, 1983). The health care coordinating a broad range of services in addition to system’s incentives for efficiency and the decreasing deproviding direct care. At the present time, no scientifimand for inpatient hospital services will be the forces cally valid model exists to increase quality of practice driving health care toward a competitive marketplace and to identify content for teaching in home health care. (Stuart-Siddall, 1986). The many benefits of home- and Therefore, one must be developed that initially will be neighborhood-based services that combine preventive descriptive and eventually explanatory and predictive (Adams, 1985; Stevens, 1984).
Abstract Home health care has become increasingly popular with consumers. Despite this movement of care away from the hospital, the literature does not contain a comprehensive nursing model of home health care. The need for a model to guide nursing research and ultimately, nursing practice and education is apparent. Four health service delivery models are available to be applied to home health care nursing; however, analysis of all four demonstrates a need for one specific to home care nursing.
Mary Nies Albrechr, Ph.D., R . N . is Assistant Professor of Nursing, Deicke Center for Nursing Education, Elmhursi College. Elmhurst. Illinois Address correspondence 10 Mary Nips .Albrechr, p h . D . , R . N . , 5504 Groveside Lane, Rolling Meadows, IL 60008.
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DEFINITION OF HOME HEALTH CARE Home health care cannot simply be defined as care at home, as it includes a Variety Of Services. A more Comprehensive definition was prepared by a Department of
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Health and Human Services interdepartmental work group with the assistance of materials provided by the Assembly of Ambulatory and Home Care Service of the American Hospital Association, the National Association of Home Health Agencies and Community Health Services of the National League for Nursing (NLN), the American Nurses’ Association (ANA), the National Health Council, and the American Medical Association: Home health care is that component of a continuum of comprehensive health care whereby health services are provided to individuals and families in their home for the purpose of promoting or restoring health, while minimizing the effects of disability and illness, including terminal illness. Services appropriate to the needs of the individual patient and family are planned, coordinated, and made available by providers organized for the delivery of home health care through the use of employed staff, contractual arrangements, or a combination of the two patterns. (Warhola, 1980)
This definition integrates the components of home health care, client, family, health care professionals (multidisciplinary), and goals to assist the client to return to an optimum level of health and independence. The types of services provided will vary according to the client needs, the home care provider, and the reimburser.
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home health care agency; (4) graduate experience in a veterans administration hospital-based home health care agency, a voluntary home care agency, and a proprietary home care agency; ( 5 ) experience teaching undergraduate nursing students community health nursing; and (6) critique and synthesis of four models related to home health care (Coombs, 1984; Dreher, 1984; Landau, 1981; Shortell et al., 1977). MODELS RELATED TO HOME HEALTH CARE
The rationale for selecting these four models was as follows. First, Dreher’s (1984) is the only one found to deliver public health nursing service of which home care is a component. Coombs’s (1984) is the only one derived from a review of the literature that specifically identified itself as a conceptual framework for home nursing. Landau (1981) provided a method for analyzing a health care delivery system. Finally, Shortell et al. (1977) examined the relationship between the patient and provider variables in a health service delivery model. Each of these models includes some of the important variables to be considered in home health care nursing. None, however, is complete in that factors are missing that are important to this area of nursing practice. The Dreher Model
DEVELOPMENT OF THE MODEL FOR HOME HEALTH CARE
Conceptual models deal with concepts that are assembled by virtue of their relevance to a common theme (Fawcett, 1984). They can be useful in clarifying the association between concepts and guiding research when formal theories are not relevant for a specific research problem (Fawcett, 1984, p. 2). Therefore, the components of a model for any discipline are the concepts and the statements that integrate them into a valid configuration (Stevens, 1984). Such concepts and propositions are abstract and general, and thus are not amenable to empirical testing (Stevens, 1984). The descriptive model proposed here contains concepts that the author considers relevant to understanding and carrying out nursing practices in home health care. Such a model must incorporate concepts of health service delivery, home care, and nursing on which to focus practice, research, and education. The approaches used to develop and select variables for this model were (1) review of literature on home health care (Auerbach, 1985; De Crosta, 1980; Mundinger, 1983; Shaw, 1985; Spiegel, 1983; Stuart-Siddall, 1986); (2) experience as a site visitor for the NLN Community Health Home Care Accreditation Program (NLN, 1987); (3) professional experience in an official agency providing home health care and a hospital-based
Dreher (1984) presented a model of population-based nursing. It assumes that a focus of public health nursing is chronic illness and care of the elderly in the home. It includes both well and sick care across the life span. This model, which appeared in the 1920s, may hold great possibilities for addressing the nation’s current and future health problems. The three main components of the district nurse’s role are school nursing, health promotion and prevention, and home care (Dreher, 1984). These services are provided regardless of ability to pay or meeting reimbursement criteria. The concepts that are identified in the Dreher model are availability, accessibility, accountability, comprehensiveness, coordination, cost-effectiveness, and quality care. The major factors missing or not made explicit are the relationships among the concepts, uniqueness of the client and family, client outcome, and definition of the concepts. The Coombs Model
The major concepts in the Coombs (1984) framework are nurse, intervention, client, and community. They are not defined. In this framework, it is postulated that home nursing is dynamic, complex, and challenging. Another assumption is that the nurse plays a central role in a client’s response to an illness. Of primary importance, it depicts the factors (such as bedroom on up-
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stairs level) that exist in the home but not in the hospital that affect the nursing intervention. Thus nursing care is primarily the result of the interaction of the client and the nurse in the home. The family is not mentioned as part of the interaction. This model is based on an inductive study done in Australia. The major factors missing or not made explicit are structural elements such as the number of staff available to provide care, accessibility of home care to the client, outcomes other than those specific to the client, and the fact that the major focus is restricted to the interpersonal relationship between the nurse and the client.
the process of care; importance of the home setting in the nursing process; the nature of the types of care that can be provided in the home; and outcomes other than client satisfaction. Summary of Models Related to Home Health Care
Table 1 compares the concepts contained in each model and shows which ones they have in common. As the table shows, none of the models contain all of the 18 concepts which the author feels are important for home health care based on review of literature, experience in home care, and synthesis of the four models pertinent to home care. This points to the need for a model that The Landau Model combines concepts of health service delivery, home The Landau (1981) model presents a method for the health care, and nursing. Models that are developed in analysis of rural primary health care delivery systems, isolation from home care nursing practice have little the dynamics of which are viewed as an interaction be- utility for clinicians who are seeking appropriate intertween the consumer and the provider. Overall, it sug- ventions for their practice (Table 2). A nursing model will clearly indicate the importance gests that alternative health care systems must be of the nurse in this realm of practice. As the coordinator evaluated as to their effectiveness, efficiency, and acof care, the nurse uses other disciplines as necessary. cessibility criteria. An assumption is that accessibility The need for a model to guide nursing research and ulaffects efficiency through the process of mediating retimately, nursing practice and education is apparent: it source use. must ( I ) recognize the aspects of care at home for both Efficiency, accessibility, quality of care, client outthe nurse and the client in attaining positive outcomes; come, cost, productivity, and demand and use are all (2) acknowledge the importance of the family or loved defined. To obtain a complete understanding of the efones and friends as factors in client outcomes; (3) adfectiveness and efficiency of health care delivery sysdress the elements of structure for both the consumer tems, the consumer and provider must be considered and the provider and their role in determining the protogether. The former is made up of client needs and use cess at home; (4) recognize that the nursing care proof services. The latter consists of quality of care and vided in the home affects elements of structure and of productivity of the health care providers. outcome; ( 5 ) guide the development of nursing intervenThe major factors missing or not made explicit in the Landau model are the importance of social and psycho- tions that are efficient and effective in our costlogic variables and the family of the consumer (which conscious society; and (6) combine the concepts of would affect provider productivity and client outcome), home health care nursing and health service delivery. impact of the education, philosophy, and number of ALBRECHT NURSING MODEL FOR staff on the process of care, the importance of the home HOME HEALTH CARE setting on the nursing process, the nature of the various types of care provided in the home, and provider Assumptions and Definitions outcomes. Intrinsic to the proposed model are the assumptions that clients and their families are capable of making indepenThe Shortell Model dent decisions about the setting of their health care; The Shortell (1977) model of health services delivery is clients are active and mutual participants in their care; based on the interrelationships among patient and pro- they prefer home care to institutionalization; and they vider variables and access, use, continuity, quality, and and their family must accept responsibility for this care satisfaction with medical services. It is more global than (Table 3). The model reflects a beginning attempt to the previous three in that it deals with health service as identify the complex nature of home health care as well a subsystem of society. Its variables are “structural, as the dynamic relationship among the structure, proprocess, and outcome” (Shortell et al., 1977, p. 140). cess, and outcome. The major factors missing or not made explicit in the The model proposed here is based on the interrelamodel are the importance of psychologic and social tionships among variables identified by the author as variables of the consumer; effect of the philosophy, important for home health care. It subsumes many of number of staff, standards, and costs of the provider on the concepts and variables generated by the four previ-
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TABLE 1 . Concepts Included in the Models Models Dreher
Concepts
Accessibility Accountability Availability Comprehensiveness Continuity Coordination Cost-effectiveness Clientkonsumer Demand Efficiency Intervention Nurse Client classification Productivity Provider Quality of care Satisfaction Use of home care Totals 18
Coombs
X X X X
Landau
Shortell et al.
X
X
X X X X
X X X X
X
X
X X X X
X X
X X X X
8
7
X 8
4
TABLE 2. Assessment of Selected Models
Model
Concepts Defined
Nursing
Focus
Dreher
Coombs Landau
Shortell et al.
ously assessed models, but with greater emphasis on home health care nursing. A major factor is the availability of services. For example, if the structural elements are present (family/ loved one(s)) but the availability of home care in the health service delivery system is absent, the type of care needed and self-care capability are decreased. If the suprasystem does not provide the necessary payment sources, home care may not be an option. Thus the suprasystem affects the health service delivery system, which in turn affects care in the home. The model in Figure 1 identifies and shows the relationship among variables necessary to care for clients and families in the home. It attempts to link in a single model structure, process, and outcome. The assumption is that the arrows in the figure indicate the variables that affect other variables, either directly or indirectly. With research, the model could be used for explanatory
Home Setting
Links Between
Concepts
Important Concepts
-
+ + +
and predictive purposes. The goal is to identify and suggest relationships among the home subsystem, structural elements, process elements, outcomes, the health service delivery system, and the suprasystem.
Structural Elements
Structural elements include the client, family, provider agency, health team, and professional nurse. The family can be present or absent, or vary with respect to participation and quality of relationship. The client includes demographic, economic, social, and psychologic variables. The provider agency consists of philosophy, organizational structure, standards, funding, technology, and travel time. The health team variables are the disciplines, technical nurses, and home health aides available to provide services in &hehome. The nurse vari-
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TABLE 3. ConceDts and Definitions of Home Health Care Model Structural
Modifying
Process
Outcome
Client: rational, biologic, emotional, social being desiring the use of home care services
Client classification: complexity or difficulty of nursing care required
Type of care: focus and intensity of care given by nurselothers in the home
Costs: charges or fees per visit or for agency operation
Coordination of care: case management by professional nurse for continuity and comprehensive services in the home according to professional, agency, and federal guidelines, and use of other community re sources
Satisfaction: verbal or written expression of positive statements toward care given andor received Quality of care: care meets ANA standards for home health care practice/ certificatiodNLN accreditation standards
Intervention: actions taken by professional nurse, health team members, client, or family to promote or enhance selfcare capabilities
Cost effective: costs of delivering a set of services while maintaining ANA/ NLN quality standards
Family, loved one(s): any other individuals present in the home and willing to participate in care as needed by the client to maintain self-care at home Provider agency: any official, voluntary, private, hospital-based, nonprofit, or proprietary agency providing health care services at home Professional nurse: individual with license to practice professional nursing in state Health team: members coordinated by the professional nurse; any LPN. ADN. or professional in speech, social work, home health aid, physical therapy, occupational therapy, nutrition, dental hygiene, respiratory therapy; physician; durable medical equipment; home meals, homemaker, transportation, or volunteers available to provide care or service at home
Demand: number of client or families requesting home care services Availability: number of home care agencies available for clientlfamily use, or availability of health team and nurse to accept new cases Productivity: number of clients nurses can visit in one day or number staff can visit in month or year Accountability: of health team and nurse for own actions, agency to standards, and consumer to participation in care Accessibility: ease at which one can enter home health care system Efficiency: high ratio of output to input in system, minimum wasted effort
ables are education and experience. The outcomes of home health care can be affected by the way these multiple variables interact with one another. The model purports that the structural elements may be modified by client classification, demand, accessibility, efficiency, availability, accountability, and productivity factors. For example, classification may be increased or decreased depending on the availability of family members. In addition, all the structural elements interact simultaneously with each other to address a specific need. For example, a client’s economic status, combined with
Health status: cured; self-care; self-care with assistance; dependent on others; alternative care (nursing home. hospital, clinic, hospice); death Self-care capability: ability to perform activities 0 1 daily living that permit the individual to live independently at home
family status, and the provider’s financial resources for health care will be more likely to predict a certain outcome than will examination of any of the variables in isolation from the others. Process Elements The structural and process elements affect the response to care. As a result, outcomes are more fully explained by these combined effects on care. This model explicitly addresses the provision of care to the client at home and identifies this as an influence
Albrecht: Model for Home Care 123
-*
Structural elements
Process elements
Client
Demographic, psychologic, social, and economic variables $ Family, loved one
Present, absent, participation in care $ Provider agency
Funding source, organizational structure, standards, philosophy, technology, travel time $ Professional nurse
Education, experience Health team Other disciplines
available, technical nurses, home health aide
Type of care
Modified by I I I I I I I I I I
+ I I I I I I I I I I I I I
Client classification costs Demand Availability
+
Productivity Accountability Accessibility Efficiency
I
I I I I I I I I I I I I I
I I I I I I I I I I
I I I I I
I I I I I I I I I I I I I
Preventive, education, supportive, therapeutic, high tech
t Coordination of care
Continuity, comprehensive, federal legislation $ Intervention
Nursing process, client involvement, family involvement, legal constraints, ethical constraints, other disciplines
I
I I I
I I
Home health subsystem I
-
Outcome elements
-
Satisfaction with care
I I I I I I I I I I
+ I I I I I I I I I I I I I I I I I I I I I I I I I I I
Client, family, professional caregiver Quality of care Cost effectiveness Health status Self-care capability Use of home care
Figure 1. The Albrecht nursing model for home health care.
on outcome. The process elements have three compo- gest a deficit in one or more of these elements and nents, the relevance of which varies according to the necessitates feedback to either or both for further proclient’s health care needs. The relationship between the cessing, modification, and intervention (Braden & structural elements and the process elements directs Herban, 1976). intervention approaches. Depending on the structural The link between the structural elements and the proelements and mediating factors, a client may require ed- cess elements is affected by the modifying factors, as ucation, or preventive, supportive, therapeutic, or high- well as by the health service delivery system and the tech care that is delivered based on the nursing process; suprasystem. Self-care capability is one of the outcomes the nurse is responsible for executing the nursing pro- of the interplay between the structural and process elecess, which includes assessment, nursing diagnosis, ments. The bidirectional paths of the arrows in the planning, intervention, and evaluation. The professional model reflect the idea that these processes are transacnurse should be responsible for coordinating other dis- tional and that reciprocal feedback can occur at each ciplines and for ensuring continuity of care. The inter- stage. As noted in Figure 1, provider agency, client classification, and coordination of care ultimately affect actions of the process elements affect outcome. the quality of care and health status. Thus the structural and process elements greatly influence outcomes, Outcome Elements which in turn affect structural and process elements. The model allows for identification of relevant variThe outcome elements consist of satisfaction with care, quality of care, cost-effectiveness of care, health status, ables, use of each one, and the determination of the proand self-care capability. Positive outcomes refer to ad- posed interaction among them. It also provides for equacy of structural elements and effective implemen- many interactive predictors, nursing care, and a variety tation of the process elements. Negative outcomes sug- of outcome criteria. One may tap into the model at var-
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ious stages depending on the purpose of the study and the problems under investigation. Both cross-sectional and longitudinal research designs are possible in this model. Analyzing the interfaces among client demographic variables and client classification over time would help evaluate the effects of structural elements on satisfaction with and costeffectiveness of care. A cross-sectional study would show the association between provider agency and coordination of care. APPLICATION OF THE ALBRECHT MODEL TO HOME HEALTH CARE Research This model can be used as the framework for research. An example would be investigation of the amount of time the nurse spends in the home with the use of more technology. A relationship exists among the nurse, productivity, technology, type of care, and cost-effectiveness. If staff have to spend more time in the client’s home due to increased technology (process), this affects cost-effectiveness and possibly, quality of and satisfaction with care (outcome). Increased time in the home (process) also determines availability of the staff to other consumers who require services (structure). Other examples of research studies testing this model are evaluating the specific type of care required by the consumer and carried out by the nurse, and nurse satisfaction with care, staff accountability for their responsibilities, and the effect this has on client use of home care. The model can guide nursing research to answer several questions. (1) Is the client’s satisfaction with care based on the type of care required? (2) Does preventive care lead to greater client satisfaction than high-tech care? (3) Should a family member or loved one be required to be present for home services to be provided? (4) Should type of care provided focus on the most costeffective in contrast to the highest quality available and what will most improve the client’s health status? ( 5 ) To what extent can the structural elements predict self-care outcomes in the home? (6) Will client classification predict structural and process elements necessary to provide quality care? (7) What is the relationship among the types of care provided by the nurse, and professional and consumer satisfaction? (8)What effect does the provider agency have on costs, coordination of care, and health status? (9) What is the cost of home care based on consumer variables, type of care needed, and quality of care? (10) What combination of variables provides the best self-care capability in the home? (1 1) What combination of nurse education and experience pro-
vides the best process and outcomes for the client? (12) Does client classification predict type of care needed? Nursing Practice The ANA (1986) developed standards of nursing for home health care practice. The first states that. all such services will be directed by a master’s-prepared professional nurse with experience in community health and administration. Although standards are included in the structural elements of the model, if this one is lacking it will affect the process and outcome of care. A negative outcome may necessitate a change in practice. Standard 5 states that the nurse continually evaluates the client’s and family’s response to care to determine goal attainment, and to revise the plan of care. Again, this is congruent with the proposed model, and the model could facilitate improvement in clinical practice. The nurse using the model would recognize that assessing consumer variables, family, and health team availability are all important for determining the type of care required. The nurse working in home health care knows nursing interventions depend on client and family involvement in addition to legal and ethical constraints present in the health service delivery system. Skills of the nurse and family, client classification, philosophy of the agency, number of health team members available all provide insight into type of care needed. For example, it might be more helpful, and therefore produce the desired outcome, to provide a client who has had a cerebrovascular accident with a home health aide to assist with self-care activities than a professional nurse, if this is what the family desires. The client and family are likely to have greater satisfaction with care, continue to use home care and thus avoid rehospitalization, and improve client and family self-care capability. An advantage of the model for nursing practice is the linking of the professional nurse, client, client classification, and type of care to evaluation of outcomes. Interventions are specifically focused on the interrelationships of structural and process elements. Prior to implementing the nursing process in the home, the nurses would have to (1) assess consumer variables, family ability to participate in care, standards for providing care, health team disciplines available, and the nurse’s own experience and travel time to the home; (2) consider the client classification, the payment source of family, and their desire for service; and (3) assess the type of care needed and how services will be coordinated. Based on these considerations the nursing process can be carried out appropriately. Outcomes of care can be measured by any of the elements identified in the model. Client and family out-
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comes are satisfaction with care, use of home care, health status, and self-care capability. Professional or agency evaluation measures are satisfaction with, and quality and cost of care. Based on measures used, the findings would either support or suggest changes in the nursing process. Another use in the clinical setting would be as a guide for appropriate assignment of staff to meet client needs. Based on type of care needed, client classification, organizational structure, health team disciplines available, and desired outcome, the nursing manager could select the appropriate care provider in the home. Staff may place greater emphasis on education and preventive care and less on high-tech care. Performance evaluation might indicate that a nurse feels a deficit or lack of skill in providing high-tech care. As a result, these clients may be receiving inadequate care. The nursing manager now has a responsibility to provide staff-development programs in this area or hire people who can provide it. Such intervention should increase productivity and professional satisfaction with care and ultimately, client self-care capability. Education
Finally, the model clearly defines important education content areas for nursing students at the undergraduate level and those at the master’s level who are specializing in home health care. Professional satisfaction and quality of care, and therefore effective outcomes, depend on education and experience of the nurse. Also, education and experience affect productivity and accountability levels. Several implications become apparent. First, nursing programs at the undergraduate and graduate levels must prepare competent providers of home health care. Curricula have to include concepts related to the suprasystem, health service delivery system, and home subsystem, which includes structural, process, and outcome elements. At the undergraduate level, it is important that students have at least one clinical observation or experience in a home health care agency. This will facilitate understanding of the elements important to home care. It will also facilitate transition from student to professional in an area in which many nursing graduates will be working in the near future, given the advent of diagnosis-related groups and consumer preference (Auerbach, 1985; Shaw, 1985). At the graduate level, programs specializing in home health care will have to include specific courses covering the identified concepts in the model. General areas include knowledge on education, preventive, supportive, therapeutic, and high-technology nursing interventions for home health care; a multidisciplinary approach to home health care; health law and ethics; systems the-
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ory; economics covering supply, demand, and productivity; and, finally, case management and coordination, finances, and organizational structure. At the graduate level, it would be mandatory to have a clinical practicum in a home health care agency to observe, apply, and analyze the model in action. CONCLUSIONS AND RECOMMENDATIONS
The proposed model was developed to reflect the complex nature of home health care as well as the dynamic relationship among the structural, process, and outcome elements. The use of a conceptual model is important in designing research since it facilitates the identification of pertinent variables and a definition of the relationships among variables (Fawcett, 1984). Many of the variables are incorporated from models of health service delivery; however, this model is significantly different from earlier ones in that it incorporates both nursing and home health variables. In sum, it includes those crucial to the definition of home health care and identifies sources of variance in outcome of care. The purpose of home health care nursing is to promote self-care capability in the client at home. In doing this, the family can maintain their status within the social, political, and economic suprasystem. This model facilitates predicting those variables that contribute to care at home. Nursing practice needs, as well as needs for in-service programs, are readily identifiable. The model is a synthesis of important variables necessary for home care and is congruent with consumers’ demand for accessible, available, and affordable care. It also appears congruent with consumers’ demand for a voice in provision of care (Auerbach, 1985; Institute of Medicine, 1979; Jahiel, 1982). Finally, it affords a degree of prescription for research agendas in home health care and for educational content in nursing programs, and suggests ideas for improving nursing practice in the home. Additional work must be done to move this model from a descriptive, conceptual stage to an explanatory prescriptive, theoretical one. Testing of hypothesized relationships between variables with reliable and valid measures will increase the ability to confirm the structure-process-outcome relationships between nursing interventions and changes in self-care capabilities of clients. Once these relationships are tested, they can be either supported or not supported. Regardless of status, with the right combination of structural and process variables, the client can have an outcome of self-care capability. Research on the model would provide data on the combinations of structural and process variables that provide for the most desirable outcomes.
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Institute of Medicine. (1979). Health services research. Washington, DC: National Academy of Science. The author wishes to acknowledge the assistance Jahiel, R. (1982). Health services research in the health serof Drs. Judith Sullivan, Pamela Kulbok, and Judith vices system. Annals of the New York Academy of SciStorfjell for their review and critique on this manuences, 387, 5747. script. Landau, T. (1981). A methodology for the analysis of rural primary health care delivery systems. Computers in Biology and Medicine, 11(92), 51-72. REFERENCES Mundinger, M. (1983). Home care controversy. Kockville, Adams, E. (1985). Toward more clarity in terminology: MD: Aspen. Frameworks, theories, and models. Journal of Nursing Ed- National League for Nursing. (1987). Accreditation division ucation, 24(4), 151-155. for home care and community health: Accreditation, criAmerican Nurses’ Association. (1986). Standards of home teria, standards, and substantiating evidences. Publ. No. health nursing practice, Kansas City, MO: Author. 21-1306.New York: Author. Auerbach, M. (1985). Changes in home health care delivery. Shaw. S. (1985). A home care technology. Caring, 4, 21-25. Nursing Outlook, 33(6), 29&291. Shortell, S., Richardson, W., Logerfo, J., Diehr, P., Weaver, Braden, C., & Herban, N . (1976). Community health: A sysB., Green, K. (1977). The relationship among dimensions tems approach. New York: Appleton-Century-Crofts. of health services in two provider systems: A causal model Coombs, E. M. (1984). A conceptual framework for home approach. Journal of Health and Social Behavior, 18(2), nursing. Journal of Advanced Nursing, 9, 157-163. 139-159. De Crosta, T. (1981). Home health care is red hot right now. Spiegel. A. (1983). Home health care: Home birthing to hosNursing Life, I , 54-60. pice care. Owing Mills, MD: National Health Publishing. Dreher, M. (1984). District nursing: The cost benefits of test- Stevens, B. (1984). Nursing theory: Analysis, application, ing of a population-based practice. American Journal of evaluation. Boston: Little, Brown. Public Health, 74, I 107-1 1 1 I . Stuart-Siddall, S. (1986). Home health care nursing: AdminFawcett. J. ( 1984). Analysis and evaluation of conceptual istrative and clinical perspectives. Chico, CA: Aspen. models of nursing. Philadelphia: F. A. Davis. Warhola, C. (1980). Planning for home health services: A reHammond, J. (1979). Home health care costs effectiveness: source handbook. DHSS Publ. No. (HRA) 80-14017. An overview of the literature. Public Health Reports, Washington, DC: Public Health Service, Department of 94(5), 305-3 1 I . Health and Human Services.
ACKNOWLEDGMENTS
