Chapter 13. Patient Safety and Quality in Home 

Health Care 

Carol Hall Ellenbecker, Linda Samia, Margaret J. Cushman, Kristine Alster 

Background 

Home health care is a system of care provided by skilled practitioners to patients in their 

homes under the direction of a physician. Home health care services include nursing care; 

physical, occupational, and speech-language therapy; and medical social services.1 The goals of 

home health care services are to help individuals to improve function and live with greater 

independence; to promote the client’s optimal level of well-being; and to assist the patient to 

remain at home, avoiding hospitalization or admission to long-term care institutions.2–4 

Physicians may refer patients for home health care services, or the services may be requested by 

family members or patients. 

The Centers for Medicare and Medicaid Services (CMS) estimates that 8,090 home health 

care agencies in the United States provide care for more than 2.4 million elderly and disabled 

people annually.5 To be eligible for Medicare reimbursement, home health care services must be 

deemed medically necessary by a physician and provided to a home-bound patient. In addition, 

the care must be provided on an intermittent and noncontinuous basis.5

 Medicare beneficiaries 

who are in poor health, have low incomes, and are 85 years of age or older have relatively high 

rates of home health care use.6 Common diagnoses among home health care patients include 

circulatory disease (31 percent of patients), heart disease (16 percent), injury and poisoning (15.9 

percent), musculoskeletal and connective tissue disease (14.1 percent), and respiratory disease 

(11.6 percent).7

Delivering Health Care in the Home 

The home health care environment differs from hospitals and other institutional 

environments where nurses work. For example, home health care nurses work alone in the field 

with support resources available from a central office. The nurse-physician work relationship 

involves less direct physician contact, and the physician relies to a greater degree on the nurse to 

make assessments and communicate findings. Home health care nurses spend more time on 

paperwork than hospital nurses and more time dealing with reimbursement issues.8, 9 Certain 

distinctive characteristics of the home health care environment influence patient safety and 

quality of outcomes: the high degree of patient autonomy in the home setting, limited oversight 

of informal caregivers by professional clinicians, and situational variables unique to each home. 

Respect for patient autonomy is valued in hospital-based care. Nonetheless, many decisions 

are made by clinicians on behalf of hospitalized patients. In home health care, clinicians 

recognize that the care setting—the home—is the inviolable domain of the patient. Therefore, 

compared to the hospitalized patient, the home health care patient often has a greater role in 

determining how and even if certain interventions will be implemented. For example, in a 

hospital, nurses, physicians, and pharmacists may all play a role in ensuring that the patient 

receives antibiotics at therapeutically appropriate intervals. At home, however, the patient may 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

choose to take the medication at irregular times, despite advice about the importance of a regular 

medication schedule. Thus, interventions to promote patient safety and quality care must account 

for the fact that patients will sometimes choose to act in ways that are inconsistent with the 

relevant evidence, and the clinician’s best efforts may not result in desired outcomes. 

In addition to deliberate choices made by informed and capable patients regarding their care, 

individual patient variables may also influence home-based outcomes in ways that are different 

from those patients who are hospitalized. Ellenbecker and colleagues10, 11 reported that reading 

skill, cognitive ability, and financial resources all affect the ability of home health care patients 

to safely manage their medication regimens. Yet, none of these variables may play a meaningful 

role in the safe administration of medications to hospitalized patients. 

In addition to self-care, some home-bound patients receive assistance from family members 

or other informal caregivers. Professional clinicians have no authority over these caregivers. 

Further, the home environment and the intermittent nature of professional home health care 

services may limit the clinician’s ability to observe the quality of care that informal caregivers 

deliver—unlike in the hospital, where care given by support staff may more easily be observed 

and evaluated. For example, because of limited access to transportation, a husband may decide 

not to purchase diabetic supplies for his dependent wife. This behavior may not come to the 

clinician’s attention until an adverse event has occurred. Evidence-based interventions are 

predicated on careful assessment. However, limited opportunity to directly observe the patient 

and informal caregivers may hinder efforts to quickly determine the etiology of an adverse event. 

If a home health care patient is found with bruises that the patient can’t explain, is the cause a 

fall, physical abuse, or a blood dyscrasia? In both self-care by patients and care by informal 

caregivers, safety and quality standards may not be understood or achieved. 

Another distinctive characteristic of home health care is that clinicians provide care to each 

patient in a unique setting. There may be situational variables that present risks to patients that 

may be difficult or impossible for the clinician to eliminate. Hospitals may have environmental 

safety departments to monitor air quality and designers/engineers to ensure that the height of 

stair risers is safe. Home health care clinicians are not likely to have the training or resources to 

assess and ameliorate such risks to patient safety in the patient’s home. 

Finally, given the large number of elderly persons who receive care from Medicare-certified 

home health care agencies, it is reasonable to anticipate that some patients will be in a trajectory 

of decline. Due to both normal aging and pathological processes that occur more frequently with 

advancing age, some elderly persons will experience decreasing ability to carry out activities of 

daily living (ADLs), even when high-quality home health care is provided. Thus, an implicit goal 

of home health care is to facilitate a supported decline. That is, patients who do not show clinical 

signs of improvement may nonetheless receive quality care that results in a decelerated decline 

or increased quality of life. This is consistent with the American Nurses Association’s assertion 

that promoting the patient’s optimal level of well-being is a legitimate goal of home health care.3

 

Assessing Quality of Care in the Home 

The goals and multidisciplinary nature of home health care services present challenges to 

quality measurement that differ from those found in a more traditional hospital setting. The CMS 

mandates reporting of home health care outcome measures. The Outcome-Based Quality 

Monitoring (OBQM) program monitors, reports, and benchmarks adverse events such as 

emergent care for injury caused by fall or accident, increased number of pressure ulcers, and 

substantial decline in three or more ADLs.5

 

2 
Patient Safety, Quality in Home Care

Pay for performance, a mechanism that ties a portion of an agency’s reimbursement to the 

delivery of care, is another CMS quality initiative anticipated in the near future.12 In preparation, 

quality-improvement organizations and providers are working to identify and develop a set of 

performance measures proven effective in home care. A 2006 Medicare Payment Advisory 

Commission report to Congress identified patient safety as an important component of quality 

and the need to expand quality measures to include process and structural measures. An 

expanded approach to quality measurement should accomplish the following goals: broaden the 

patient population being evaluated, expand the types of quality measures, capture aspects of care 

directly under providers’ control, reduce variations in practice, and improve information 

technology.13 

In January 2007, the home health community, health care leaders, and quality-improvement 

organizations launched the Home Health Quality Improvement National Campaign 2007. The 

campaign focuses on improving the quality of patient care in the home health care setting by 

providing agencies with monthly best practice intervention tools. The goal is to prevent 

avoidable hospitalizations for home health care patients. The Home Health Quality Improvement 

National Campaign uses a multidisciplinary approach to quality improvement that includes key 

home health, hospital, and physician stakeholders.14 

Research Evidence 

In many respects, home health care clinicians and clinicians working in other settings have 

similar concerns about patient safety and care quality. For example, patient falls occur both in 

homes and in hospitals, and some measures aimed at preventing falls are equally applicable to 

both settings. However, the significant differences between home health care and other types of 

health care often require interventions tailored to the home health care setting. 

This chapter includes an analysis of the evidence on promoting patient safety and health care 

quality in relation to problems frequently seen in home health care. The following six areas were 

selected for review: 

• Medication management 

• Fall prevention 

• Unplanned hospital admissions 

• Nurse work environment 

• Functional outcomes and quality of life 

• Wound and pressure ulcer management 

Adverse events in these areas could jeopardize achievement of one or more home health care 

goals. 

Medication Management 

Nearly one-third of older home health care patients have a potential medication problem or 

are taking a drug considered inappropriate for older people.15 Elderly home health care patients 

are especially vulnerable to adverse events from medication errors; they often take multiple 

medications for a variety of comorbidities that have been prescribed by more than one provider. 

The majority of older home health care patients routinely take more than five prescription drugs, 

and many patients deviate from their prescribed medication regime.11 The potential of 

medication errors among the home health care population is greater than in other health care 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

4 

settings because of the unstructured environment and unique communication challenges in the 

home health care system.11 

A search of the literature identified only three studies testing interventions to improve 

medication management and adherence in home health care patients.16–18 The studies are 

summarized in Table 1. All three studies used a controlled experimental design, with random 

assignment of patients to one or two treatment groups and a control group of usual care. The 

populations studied were elderly Medicare patients receiving home health care, ranging from 41 

to 259 patients. 

The interventions tested were patient education delivered by telephone or videophone with 

nurse followup, education tailored to individual patients, and medication review and 

collaboration among providers (e.g., nurse, pharmacist, physician) and patient. Specific 

outcomes included identifying unnecessary and duplicate medication, improving the use of 

specific categories of medication such as cardiovascular or psychotropic drugs, and identifying 

the extent of use of nonsteroidal anti-inflammatory drugs (NSAIDs). The effectiveness of the 

interventions was measured by improved medication management and adherence to drug 

protocols. Adherence was estimated objectively from medication refill history and medication 

event monitoring, and subjectively from patient self-report scores on pre- and postintervention 

questionnaires testing knowledge, understanding of disease, and adherence. 

Evidence from these studies suggests that all of the interventions tested were at least 

somewhat effective. Medication use improved for patients receiving the intervention, while 

control groups had a significant decline in adherence to drug protocols. The educational 

interventions were most successful when individually tailored to patients’ learning abilities. The 

interventions were most effective in preventing therapeutic duplication and improving the use of 

cardiovascular medications, less effective for patients taking psychotropic medication or 

NSAIDs. Generally, as knowledge scores improved, adherence improved. When more than one 

intervention was tested, there was generally no difference between the two intervention groups. 

Evidence-Based Practice Implications 

Nurses must be vigilant for the possibility of medication errors in the home health care 

setting, recognizing the associated risk factors. Technology provides many opportunities to 

improve communication with patients, to provide patients with accurate information, to educate 

them about their medications, and to monitor medication regimes. Paying close attention to atrisk patients is most effective; therefore, accurate documentation and review of medications 

during each patient encounter is important. The evidence suggests that frequent medication 

reviews and collaboration with other members of the health care team, especially pharmacists, 

will help to prevent adverse events associated with poor medication management. 

Research Implications 

More effective methods are needed to improve medication use in the home health care 

population. Research should continue to expand the knowledge of factors that contribute to 

medication errors in home health care and determine what interventions are the most effective in 

improving medication management in the home. 
5

Table 1. Summary of Evidence Related to Medication Management

Source 

Safety Issue Related to Clinical Practice 

Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Fulmer 199918 

Medication compliance 

Randomized controlled trial 

Randomized controlled trial. Outcomes: prescribed cardiac medications taken 

n = 50 patients, 65 years or older with congestive heart failure, receiving home care or clinic services 

1. Daily videophone 2. Regular telephone reminders 3. Control: usual treatment 

Control group medicadropped significantly compared to interven(telephone or videopNo significant differenintervention groups. 

Gates 200517

Medication improvement 

Randomized controlled trial 

Randomized controlled trial. Outcomes: medication knowledge and adoption of medication list 

n = 41 patients from 2 homecare agencies, 2 educational groups 

1. Video 2. Tailored to individual 

Knowledge improved tailored to individual (Group 2 members wespeak with a providean over-the-counter d

were significantly moupdated medication l

Meredith 200216

Medication improvement 

Randomized controlled trial 

Randomized controlled trial: Outcomes: unnecessary therapeutic duplication and inappropriate cardiovascular, psychotropic, and NSAIDs use. 

Medicare home health care patients, more than 65 years of age with at least one medication problem, from 2 large urban home care agencies; n = 130 intervention, n = 129 control 

1. Medication program to identify potential med problems and collaboration with clinical pharmacist and nurse 2. Control: usual care 

Medication use improintervention patients patients (P = .051). Intervention effect greduplication (P = .003

intervention group imcardiovascular meds There were no differefor psychotropic medproblems. 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Fall Prevention 

Emergent care for injury caused by falls or accidents at home is one of the most frequently 

occurring adverse events reported for patients receiving skilled home health care services.19

Thirty percent of people age 65 and older living in the community fall each year. One in five of 

these fall incidents requires medical attention.20 Falls are the leading cause of injury-related death 

for this population.21 Among the elderly, Stevens22 reported direct medical costs in 2000 totaled 

$179 million for fatal fall-related injuries and $19 billion for nonfatal injuries due to falls. 

Although there is strong evidence of effective fall-prevention interventions for the general 

over-65 population,20, 23, 24 knowledge of fall prevention in home health care is limited. For the 

general older population living in the community, evidence suggests that individualized home 

programs of muscle strengthening and balance retraining; complex multidisciplinary, 

multifactorial, health/environmental risk factor screening and intervention; home hazard 

assessment and modification; and medication review and adjustment can all reduce the incidence 

of falls.20 However, patients in home health care are often older, sicker, and frailer than the 

average community-residing older adult, and it is not known if knowledge from other settings is 

transferable to home health care. 

Research studies specific to home health care are predominantly retrospective, descriptive, 

correlational designs in single agencies, using matched control or randomized control groups to 

explore patient characteristics and other factors contributing to patient falls.25–27 Findings suggest 

that factors related to falls for home health care patients are previous falls, primary diagnosis of 

depression or anhedonia, use of antipsychotic phenothiazines and tricyclic antidepressants, 

secondary diagnoses of neurological or cardiovascular disorders, balance problems, frailty, and 

absence of handrails.25-27 

A literature review located only three studies testing interventions to prevent falls.28–30 The 

studies are summarized in Table 2. All three interventions were quality-improvement programs 

in single agencies. The findings suggest that risk factor screening and intervention using a valid 

and reliable instrument and physical therapy aimed at improvement in gait and balance may 

reduce injury and emergent care for falls. Unfortunately, there is no evidence that the number of 

falls incurred by the home health care population can be reduced. It may be that improved 

provider assessments increased the number of falls reported and documented. 

Evidence-Based Practice Implications 

Home health care providers need to know the risk factors for falls and demonstrate effective 

assessment and interventions for fall and injury prevention. Falls are generally the result of a 

complex set of intrinsic patient and extrinsic environmental factors. Use of a fall-prevention 

program, standardized tools, and an interdisciplinary approach may be effective for reducing fallrelated injuries. 

Research Implications 

There are several limitations in the current evidence on falls in home health care. Most of the 

research is descriptive, and there are no randomized controlled studies. Findings from small, 

single-agency quality-improvement projects cannot be generalized. It is not known if predictors 

for falls in home health care patients are the same as those for other community dwellers over 

6 
Patient Safety, Quality in Home Care

7 

age 65. Research is needed to expand the knowledge of factors that contribute to falls in this 

population and to develop effective interventions. Research is also needed to explore factors to 

prevent injury from falls, as it is likely that the incidence of falls in this population cannot be 

completely eliminated. 
8

Table 2. Summary of Evidence Related to Fall Prevention 

Source 

Safety Issue Related to Clinical Practice 

Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding

Bright 200528 Fall prevention/risk reduction Quality improvement 

project/research 

Observational study without controls. Outcomes: improvement in balance and gait, number of falls, and emergent care for falls or accidents. 

Year 1 n = 153 patients and year 2 n = 183 patients age 62 and over and at risk for falls from 1 Midwest home care agency. 

Fall prevention/risk reduction program: screening with Tinetti assessment, education, physical therapy intervention, and followup. 

Emergent cafall or accidefrom 2.58% tmonths. Improvement scores from 1There was no falls in home

Sperling 200530 Fall prevention (see also 

medication management) 

Quality improvement project/research 

Observational study without controls. Outcomes: patient falls. 

n = 228 patients 65 years of age or older from a medicalcentered home care agency. 

Medication management model: medication review and oversight for patients at risk. 

The number increased, poincreased stareporting. 

Yuan and Kelly 200629

Fall prevention/risk and injury reduction 

Quality improvement project/research 

Observational study without controls. Outcome: rate of falls, injury from falls. 

Unknown number of atrisk patients for falls from 1 hospital-based home care agency. 

Fall prevention program, multidisciplinary risk assessment with Morse scale, evidence-based guidelines. 

Number of parelatively stabwere injured 
Patient Safety, Quality in Home Care

Unplanned Hospital Admissions 

A primary goal of home health care is to discharge the patient to self or family care and avoid 

subsequent hospitalizations. Unplanned admission to the hospital is an undesirable outcome of 

home health care that causes problems for patients, caregivers, providers, and payers. Unplanned 

hospital admissions are associated with complications, morbidity, patient and family stress, and 

increased costs.31 An estimated 1,034,034 home health care patients were hospitalized in 2004. 

The national rate of unplanned hospital admissions for home health care patients has gradually 

increased from 27 percent in 2000 to 28 percent in 2006,32 and it is the only publicly reported 

home health care patient outcome that has never improved at the national level.33 

Several researchers have explored the characteristics of home health care patients and other 

factors associated with hospitalization.31, 34–39 The studies have been predominantly 

retrospective, descriptive, and correlation designs examining home care populations from single 

or multiple agencies.31, 35–38 One study is a prospective study of a random sample of agencies.39

Evidence suggests that unplanned hospital admissions are due mostly to an acute exacerbation of 

chronic disease—exacerbations that could be prevented through knowledge of risk factors, 

provider communication, and careful monitoring.39 Risk factors associated with unplanned 

hospital admissions are polypharmacy,31, 35 length of home health care episode,34, 36 development 

of a new problem or worsening primary or secondary diagnosis,36 wound deterioration and 

falling accidents,31 and age.31, 37 Based on this evidence most experts31, 37 conclude that 20 to 25 

percent of unplanned hospital admissions are preventable. For example, Shaughnessey and 

colleagues2 found that agencies actively involved in Outcomes-Based Quality Improvement

(OBQI) monitoring reduced their rate of patient hospitalizations when compared to non-OBQI 

agencies.

The Briggs National Quality Improvement and Hospitalization Reduction Study33 convened a 

panel of experts to identity best practice strategies that agencies should implement to prevent 

unplanned hospitalizations. Recommended best practices included implementing a fall 

prevention program, front loading visits, management support, 24-hour on-call nursing coverage, 

medication management, case management, patient/caregiver education, special support services, 

disease management, positive physician and hospital relationships, data-driven services, safety 

and risk assessment, and telehealth. These recommendations were not empirically tested, 

however. 

Only eight studies have tested the effectiveness of interventions to prevent unplanned 

hospital admissions for home health care patients. Five of these studies employed a randomized 

controlled trial design, and three used a nonrandomized control or comparison group design. The 

tested interventions consisted primarily of increasing the intensity of care provided through a 

disease management program, a team management home-based primary care program, a 

multidisciplinary specialty team intervention, advanced practice nurse (APN) transitional care, 

telehealth services, and intensive rehabilitative care prior to hospital discharge.40–43 Most of these 

interventions were effective or somewhat effective in preventing or delaying hospitalization. 

Additionally, four of the studies reported lower mean costs or charges for the intervention groups 

related to lower hospital costs,40, 42–44 and one study45 reported higher costs for the intervention 

group based on the costs of the team-managed primary care intervention. 

In these studies, patients with congestive heart failure (CHF) had fewer unplanned hospital 

admissions and longer survival times prior to first admission39–42 if they received APN 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

10 

transitional care, team-managed home-based primary care, or a multidisciplinary specialty team 

intervention.40–43 Patients with CHF who received telecare and telephone interventions also had 

significantly fewer emergency room visits, but no change in hospital admissions.42 Teammanaged home-based primary care has been found to be most effective for people who are 

severely disabled.45 Daly and colleagues 44 reported that long-term mechanically ventilated 

patients who received a disease management program intervention involving APN services and 

interdisciplinary coordination had significantly fewer mean days of hospitalization. 

Results from one nonrandomized controlled study suggest that patients with chronic 

obstructive pulmonary disease (COPD) who received APN transitional care also experienced 

fewer unplanned hospital admissions.46 Intrator and Berg47 reported that patients hospitalized 

with hip fractures had fewer unplanned hospital admissions when they received home health care 

services following inpatient rehabilitation compared with those patients who received inpatient 

services only. Findings are summarized in Table 3. 

Evidence-Based Practice Implications 

Evidence suggests that specialized, coordinated, interdisciplinary care has a positive impact 

on unplanned hospital admissions in select home health care populations. Agencies can identify 

patient characteristics associated with hospitalization unique to their patient population. Highrisk patients may require specialized interventions beyond the traditional scope of home health 

care services. Targeted interventions using process-of-care analysis and data available from the 

Outcome and Assessment Information Set (OASIS), within the framework of OBQI, may result 

in fewer unplanned hospital admissions for home health care patients. 

Research Implications 

The available evidence suggests that in addition to the use of APNs for care of complex 

cases, traditional home health care professionals, individually or through interdisciplinary 

practice, may be effective in preventing unplanned hospital admissions with targeted 

interventions. Although numerous strategies have been recommended by researchers and other 

home care experts, most interventions have not been empirically tested. Costs and benefits of the 

various interventions also need further exploration. The measurement of intervention costs and 

cost savings from prevented hospitalizations are not well understood. Some patient populations, 

due to the nature and complexity of advanced disease process, may require more intense and 

specialized home health care services that will not result in cost savings. On the other hand, use 

of seemingly more expensive transitional resources, such as APNs, have been proven cost 

effective, although adoption of such research-based best practices may be impeded by lack of 

reimbursement and incentives.48 Research is needed to understand the impact of shifting care and 

cost to home health care on patient outcomes and home health care industry fiscal status. 
Table 3. Summary of Evidence Related to Unplanned Hospital Admission 

Source 

Safety Issue Related to Clinical Practice 

Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population Study Intervention Key Fin

Briggs 200633 Hospitalization 

reduction 

Quality improvement project/ consensus report, and retrospective cohort study 

Nonexperimental descriptive Outcomes: 15 best practice strategies to prevent hospitalization. Type and percent of agencies implementing best practices.

Convenience sample of 400 agencies with lowerthan-average hospitalization rates 

Panel consensus on 15 best practice survey of agencies 

Best praFall preFront loManage24-hour coveragMedicatCase mPatient/Special Disease PhysiciaData-drSafety aHospitaDischarTeleheaSuccesintentionmore of Most strinvolve 

Daly 200544 Hospital 

admission 

Randomized controlled trial 

Randomized controlled trial. Outcomes: hospitalization rate, duration, and cost effectiveness 

Chronically ill, longterm mechanically ventilated patients discharged from academic medical center: n = 231 intervention, n = 103 

control 

1. Disease management program, care coordination, family support, teaching, from a team of APNs, a geriatrician, and a pulmonologist 2. Usual care 

Intervensignificaof hosp(P = .03The avepatient group w

11
Table 3. Summary of Evidence Related to Unplanned Hospital Admission (continued) 

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key FinHughes 200045 Hospital readmissions (See also Table 5) Randomized controlled trial Randomized controlled trial. Outcomes: hospital readmissions and costs over 12 months Patients with a mean age of 70 years who had 2 or more ADL impairments or a terminal illness, CHF, or COPD. 

n = 981intervention, n = 985 control 

1.Team-managed home-based primary care (HBPC): primary care manager, 24-hour contact for patients, prior approval of hospital admissions 2. Customary Department of Veterans Affairs and private sector care 

Team-mpatients experiendecreasreadmiscontrol git was nomonths. person chigher in at 6 mon$17,97112 mont$28,008 

Intrator and Berg 199847 Hospitalization or nonskilled nursing 

facility admission 

Retrospective cohort study 

Observational study with controls. Outcomes: hospitalization and any nonskilled nursing facility admission. 

324 patients age 70 or older who had acute hospitalization for hip fracture and were discharged to home after inpatient rehabilitation 

1. Inpatient rehabilitation discharge with additional home care services  2. Inpatient rehabilitation with no additional home care 

Patients additionaservices likely to those whrehabilitathey werhave a nfacility a23.3%), survive tsubsequ(65.6% v

12
Table 3. Summary of Evidence Related to Unplanned Hospital Admission (continued) 

Source 

Safety Issue Related to Clinical Practice 

Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population Study Intervention Key Fin

Jerant 200142 Hospitalization for 

CHF and cost 

Randomized controlled trial 

Randomized controlled trial. Outcomes: CHFrelated readmission charges and allcause readmissions, emergency department (ED) visits, and associated charges 

CHF patients discharged from 1 large medical center: n = 13 intervention (group 1), n = 12 intervention (group 2), and n = 12 control (group 3) 

1. Home telecare 2. Telephone care 3. Usual care 

Mean Creadmis86% lowintervenlower in than in tThe betwwas not significagroups hCHF-rela0.0342) 0.0487) group. Tstatisticadifferencreadmisgroups. 

Naylor 200440 Hospitalization 

(See also Table 5) 

Randomized controlled trial 

Randomized controlled trial. Outcomes: time to first hospitalization, number of hospitalizations, and costs 

Patients age 65 and older from 6 academic and community hospitals, n = 118 intervention and n = 121 control 

1. APN transitional care from hospital to home care 2. Routine care (58% received skilled home care services) 

First timlonger fo.026); infewer reweeks (1and lowevs. $12,4

Neff 200346 Hospitalization, 

acute care, and emergency room visits (See also Table 5) 

Nonrandomized controlled trial 

Nonrandomized controlled trial. Outcomes: length of stay, hospitalization, emergent care. 

Medicare patients age 62 or older, from a large home care agency, with a primary or secondary diagnosis of COPD, n = 39 control and n = 41 intervention 

1.Transitional care APN model with  pulmonary disease management team 2. Routine home care 

Intervenhad a sh< .05). Fewer reacute camore rem

.05). 

13
14

Table 3. Summary of Evidence Related to Unplanned Hospital Admission (continued) 

Source 

Safety Issue Related to Clinical Practice 

Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population Study Intervention Key Fin

Rich 199543 Hospitalization 

(See also Table 5) 

Randomized controlled trial 

Randomized controlled trial. Outcomes: hospital readmissions and cost. 

Patients age 70 and older hospitalized with CHF in a large urban hospital, n = 

142 intervention and n = 140 control 

1. Intensive multidisciplinary inpatient intervention by specialized geriatric team, discharged with home care and telephone followup by research team member 2. Usual care 

Interven90-day sreadmisfor contrfewer re(P = .04Cost of hwere higby an avpatient (= .03). 

Shaughnessy 20022 Hospitalizations 

(See also Table 5) 

Pretest and post-test study 

Observational study with control. Outcomes: measures of hospitalizations 

2 groups of home care agencies 73 OBQI agencies (263,465 patients) intervention Non-OBQI agencies (248,621 patients) control 

1. Clinical and administrative OBQI intervention at demonstration agencies, patient outcome reports for comparison with a reference population 2. Control: usual care 

The intedecline iover a 3 < .001) w
Patient Safety, Quality in Home Care

15 

Nurse Work Environment 

Evidence from the acute care setting suggests a relationship between nurses’ work 

environment, patient safety, and quality of patient care.49–51 A positive work environment is one 

that supports nurse autonomy and control over the work environment, including shared 

governance or decisionmaking.52–55 It is an environment with strong and visible nursing 

leadership, organizational support, peer support, and positive physician collaboration.53–55

Research exploring the relationship of the work environment, patient safety, and quality in 

home health care is in early stages of development. There have been no randomized controlled 

studies to date. Feldman and colleagues56 examined the relationship of patient adverse events 

with characteristics of the nurses’ work environment at one very large urban home health care 

agency. Characteristics of 86 home health care teams within the agency were examined. 

Researchers reported that adverse events were lower for teams with higher patient volume and 

visits, fewer weekend admissions, more equitably distributed incentives, and more teamwork. 

Rates were higher when teams perceived supervisor support for adverse event reporting. This is 

the first rigorous study to identify organizational factors associated with potential adverse events, 

and there were limitations. It was a descriptive, correlational study, and the agency involved in 

the study is not typical of most agencies in the United States as it serves a disproportionately 

diverse urban population. Several of the findings approached significance only at a probability 

level (alpha) of 0.10. 

Kroposki and Alexander57 explored the relationships among patient satisfaction, nurse 

perception of patient outcomes, and organizational structure in a descriptive study. They reported 

that higher patient satisfaction scores were more likely in home health care agencies where 

nurses and supervisors had good working relationships, opportunity for shared decisionmaking 

was present, and formalization of organizational and professional guidelines existed. Limitations 

of this study included its descriptive, nonrandomized design of multiple agencies from one State 

and the lack of a reliable and validated tool to measure nurse perception of patient outcomes. 

Findings are summarized in Table 4. 

Evidence-Based Practice Implications 

Agencies should consider how characteristics of the work environment may be influencing 

patient safety and quality outcomes. It is necessary to explore the context of the environment 

when examining clinicians’ practices in an effort to identify necessary system changes. 

Research Implications 

It is not known what characteristics of the home health care nursing work environment are 

related to patient safety and quality. Home health care research is needed to investigate the 

relationship of work environment characteristics, nurse satisfaction, and patient outcomes. 
16

Source 

Safety Issue Related to Clinical Practice Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Feldman 2001–200556 

Adverse events Prospective 

cohort study 

Observational study with controls. Outcomes: team-attributable patient adverse events. 

51,560 patient care episodes from the largest U.S. home care agency with average age of patient 71 years 

86 home care teams Staff perception of work environment, especially aspects of organizational and team culture climate 

7% of the 51,560 episoadverse event. Adverse events were lhigher volume of patie≤. 05), higher concentramong staff (P ≤ .10), admissions (P ≤ .01), m(P ≤ .01), in noncongre(P ≤ .10), and more canurses without bacheloeducation (P ≤ .10). 

Adverse events were lgreater equity in distrib(P ≤ .10), more teamw

Kroposki and Alexander 200657

Relationship of patient satisfaction, nurse perception of outcomes, and organizational characteristics 

Crosssectional study 

Observational study with controls. Outcomes: relationship of nurse perception of outcomes and organizational structure to patient satisfaction. 

Convenience sample of 325 patients and 205 nurses from 38 home care agencies in a southeastern State 

Evaluation of patient satisfaction, nurse perception of patient outcomes, and organizational structure 

Significant correlation ability to meet client’s and patient satisfaction relationships existed bsatisfaction and outcomcomponents. There was a significanrelationship between oattributes and patient sagencies with shared dopen communication (rules and procedures (

Table 4. Summary of Evidence Related to Nurse Work Environment 
Patient Safety, Quality in Home Care

Functional Outcomes and Quality of Life 

The goal of care provided in the home is to restore or maintain patient physical and mental 

functioning and quality of life, or to slow the rate of decline to allow the patient to remain at 

home and avoid institutionalization. Most patients and family members prefer the home 

environment, when it is feasible. A patient’s and family’s ability to function independently and 

safely in the home increases the possibility of the patient remaining there. 

Improving patient safety and quality of care by educating and assisting caregivers (families 

and providers) is an approach tested in several randomized controlled trials. The findings are 

summarized in Table 5. Archbold and colleagues58 pilot tested preparedness, enrichment, and 

predictability (PREP), a formal nursing intervention designed to prepare family caregivers to 

provide care. While the study had many limitations, preliminary evidence on the effectiveness of 

the intervention suggests that families benefit from being informed and prepared. 

Other researchers have tested interventions to improve nurse providers’ knowledge and 

awareness.59–61 Intervention studies to educate and inform nurse providers have been conducted 

in small and large urban and rural home health care settings, with nurses randomly assigned to an 

intervention group or a control group. The interventions generally provided nurses with 

additional education, extra resources for patients, and specialized patient information. In one 

frequently reported study, evidence-based care with specific disease-related information was sent 

to nurses by “just-in-time” e-mail reminders.59, 60 

In all cases the interventions improved nurses’ performance, which resulted in better patient 

outcomes. Patients of nurses in these studies showed significant improvement in pain 

management, quality of life, satisfaction with care, and other variables associated with improved 

quality of care, including better communication with providers, better medication management, 

and improved disease symptoms. Nurses’ improved performance included increased 

documentation of critical patient assessments. In the case of “just-in-time” e-mail reminders, the 

intervention group that had additional clinical and patient resources had better patient outcomes, 

suggesting that the multifaceted approach or stronger dose of the intervention was more 

effective. 

A number of randomized controlled trials have tested the effectiveness of specific 

interventions to improve patient safety and quality in disease management,62, 63 urinary 

incontinence,64, 65 level of ADL functioning,44, 46, 66–68 quality of life, general health outcomes, 

and patient satisfaction.44, 46, 59, 62, 66–70 Corbett63 demonstrated that individualized patient 

education in foot care for diabetics was effective in improving patients’ self-care. Scott and 

colleagues62 demonstrated an improvement in quality of life in patients with CHF though a 

program of patient education and mutual goal setting. Dougherty and colleagues64 and 

McDowell and colleagues65 tested behavioral management interventions to treat urinary 

incontinence in the elderly and reported positive results based on behavior management 

interventions of self-monitoring and bladder training. Mann and colleagues67 tested the 

introduction of assistive technology (canes, walkers, and bath benches) and changes made to the 

home environment (adding ramps, lowering cabinets, and removing throw rugs) with populations 

of frail elderly. These interventions were successful in slowing functional decline in the study 

patients. 

Some of the research evidence suggests more efficient mechanisms for providing care. In 

exploring the amount of care that is effective, Weaver and colleagues71 decreased (compared 

17 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

with usual care) the number of post-hospitalization visits by patients with knee and hip 

replacements and added one preoperative home visit. No differences in functional ability, quality 

of life, or level of satisfaction between those patients receiving usual care (more visits) and those 

receiving the intervention (fewer postoperative visits and one preoperative visit) were found. 

Several studies have examined the use of technology in patient functioning and independence. 

Johnston and colleagues69 tested real-time video nursing visits and found no difference in patient 

outcomes or level of satisfaction with usual care or care enhanced by video technology. 

A number of randomized controlled trials have tested the outcomes of interventions based on 

the specialty of the provider combined with different models of care management, or 

interventions based solely on different models of care management.44, 46, 65, 70, 71 Research 

examining the effect of APN providers on the quality of patient care suggests they have a 

positive effect. In two studies testing the transitional care model, APN-directed teams delivered 

care to patients with COPD46 and CHF70 and found improvements in the group in the transitional 

care model. Patients experienced fewer depressive symptoms and an increase in functional 

abilities when compared with patients receiving usual care.46, 70 Patients in these studies also 

needed fewer nursing visits, had fewer unplanned hospital admissions, and had fewer acute care 

visits. A nurse practitioner’s urinary incontinence behavioral therapy was effective in decreasing 

the number of patients’ urinary incontinence accidents.65 The Veterans Affairs Team-Managed 

Home-Based Primary Care was an add-on to care routinely provided in the Veterans Affairs 

Home-Based Primary Care program.44 The added component emphasized continuity of care and 

team management with a primary care manager, 24-hour on-call nursing availability for patients, 

prior approval of hospital admissions, and team participation in discharge planning. The 

investigators found significant improvements in quality of life, functioning, pain management, 

and general health outcomes for terminally ill patients in this study, and an increase in 

satisfaction for nonterminally ill patients and family caregivers. 

However, mixed results have been obtained from the research to date on the effectiveness of 

models of care management.66, 68 Some intervention models have been less effective than others. 

The interventions are usually an add-on to routine care, and their effectiveness has been 

determined by a comparison to a control group of usual or routine home health care. An 

intervention model that does not appear to be effective is the Health Outcomes Management and 

Evaluation model tested by Feldman and colleagues66 This model adds a consumer-oriented 

patient self-care guide and training to improve nurses’ teaching and support skills. Study results 

showed no difference in patient quality of life or satisfaction. Tinetti and colleagues68 compared 

the outcomes of a systematic, multicomponent rehabilitation program, including therapies for 

physical and functional impairments, to the outcomes from usual home-based rehabilitation care. 

No differences were found between the two groups. 

Evidence-Based Practice Implications 

The preceding discussion suggests that working closely with and supporting family 

caregivers is, and will continue to be, an important aspect of helping patients to remain in their 

homes. It also suggests that nurses’ effectiveness in working with patients can be enhanced if 

nurses are supported in their work. Support can be provided by electronic communication, 

reminders of protocols, disease-specific educational materials for patients, and working with 

APN colleagues to serve as clinical experts for staff. Home health care nurses are relatively 

isolated in the field, and any mechanism to improve communication with supervisors in the 

office and with other providers will assist nurses in their practice. Incorporating the use of 

18 
Patient Safety, Quality in Home Care

19 

remote technology to substitute for some in-person visits can improve access to home health care 

staff for patients and caregivers.69 

Specific patient interventions can be helpful in improving patient health and quality of life. 

Interventions of individualized education and disease-specific programs, such as a behavioral 

management program for urinary incontinence or educational programs for foot care, should be 

incorporated into practice. The rate of a patient’s functional decline can be slowed and costs 

reduced through a systematic approach to providing assistive technology and environmental 

interventions to frail elderly patients in their homes. A patient’s need for these interventions can 

be determined with a comprehensive assessment and continued monitoring. 

Research Implications 

Evidence of the outcomes of health care provided in the home is limited; there are very few 

controlled experiments on which providers can base their practice. Research is limited in the 

areas of composition, duration, and amount of home health care services needed to ensure patient 

safety and quality. Research is needed to determine effective interventions to improve, maintain, 

or slow the decline of functioning in the home health care population. 

More research is also needed to determine mechanisms to keep nurses informed and 

supported. Providing communication and support is a challenge when providers are 

geographically dispersed and spend most of their time in the field. Remote technology has the 

potential to reduce costs: it can substitute for some in-person visits, and it can improve access to 

home health care staff for patients and caregivers. 
Table 5. Summary of Evidence Related to Functional Outcomes and Quality of Life Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Archbold 199558 Family preparedness Quasi- experimental retrospective without a control group Nonrandom trial. Outcomes: care effectiveness scale, indicating greater preparedness, enrichment, and predictability. Caregiver families referred to home care agency: n = 11 intervention and n = 11 standard home care 1. Nursing interventions, designed to increase preparedness (PR), enrichment (E), and predictability (P) in families providing care to older people. 2. Comparison Intervention (PREP

deviation higher tha< .05), rated their anurses significantly lower mean hospitaversus comparison 

Corbett 200363

Diabetic foot care Randomized 

controlled trial, pre/posttest 

Randomized controlled trial pre/post test. Outcomes: patient selfreport knowledge. 

40 home care patients with diabetes from 1 home care agency, 2 groups 

1. Intervention: individualized education about proper foot care 2. Control 

The educational intepatient’s knowledgereported foot care b

Dougherty 200264 Urinary incontinence Randomized controlled 

trial 

Randomized controlled trial Outcomes: severity and episodes of urine loss— frequency, interval, and quality of life. 

218 older women from 7 rural counties in north Florida 

1.Behavior management program—selfmonitoring and bladder training 2. Control 

Intervention group idecreased by 61%. Control group inconincreased by 184%

20
Table 5. Summary of Evidence Related to Functional Outcomes and Quality of Life (continued) 

Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design 

& Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Feldman 200466 Quality of life and patient satisfaction 

with care 

Randomized controlled trial 

Random assignment of nurses. Outcomes: service use and quality of life, satisfaction with care. 

371 patients with CHF and 205 nurses from a large, urban, nonprofit home care agency 

1. Formal nurse protocol of “Health Outcomes Management & Evaluation,” patient self-care guide, and nurse training in teaching and support skills 2. Usual care 

No difference in physmortality, quality of lifesatisfaction. 

Feldman 200560

Functional status, quality of life, and service use (see also Table 3) 

Randomized controlled trial 

Randomized controlled trial Outcome: clinical, functional, and quality of life status. 

1,242 patients from a large, urban, nonprofit home care agency: 390 basic 404 augmented 448 control 

1. Nurse e-mails highlighting clinical recommendations 2 Augmented: e-mails and additional clinician and patient resources 3. Usual care 

Both intervention grouimproved patient clinioutcomes (symptomslimitations, quality of llimitations) (P < .05). 

Both intervention groubetter management o.05) Intervention group 1 squality of life relative t

21
Table 5. Summary of Evidence Related to Functional Outcomes and Quality of Life (continued) 

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Hughes 200045 Functional ability, quality of life, patient satisfaction, and cost (see also Table 3) Randomized controlled trial Randomized controlled trial. Patient functional status, patient and caregiver HR-QoL and satisfaction, caregiver burden, hospital readmissions, and costs over 12 months. 1,966 patients average age of 70 with 2 or more ADL impairments or terminally ill, CHF or COPD 981intervention 985 control 1. Home-Based Primary Care: with team manager, 24- hour contact, prior approval readmissions, and team discharge planning 2. Home-Based Primary Care VA and private sector care Significant improveme

terminal intervention gpatients in HR-QoL scrole function, social fumental health, vitalityhealth. TM/HBPC nonhad significant increain 5 of 6 satisfaction-wThe caregivers of termTM/HBPC group imprHR-QoL measures. Cnonterminal patients isignificantly in QoL mreported reduced care

.008). Johnston 200069 Quality of patient care and cost Quasi- experimental study with random assignment Randomized controlled trial. Outcomes: medication compliance, knowledge of disease, self- care ability, 

service use, patient satisfaction, and costs. 

212 patients with CHF, COPD, cerebral vascular accident, cancer, diabetes, anxiety, or need for wound care 

 1. Routine care and video visits, nurses and patients interact in real time, included equipment for assessing cardiopulmonary status 2. Routine care 

No differences in the control groups in qualpatient satisfaction, ocare cost savings rea

22
Table 5. Summary of Evidence Related to Functional Outcomes and Quality of Life (continued) 

Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design 

& Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Mann 199967 Functional ability (independence), 

quality of life (pain reduction), and costs 

Randomized controlled trial 

Randomized controlled trial. Functioning and pain, measured with valid and reliable instruments; health care costs. 

Frail elderly persons referred from community agencies, hospitals, and home care agencies in New York State: n = 52 intervention, n = 52 control 

1.Usual care, assistive technology, (canes, walkers, etc.), and environmental interventions (ramps, removal of rugs, etc.) 2. Usual care control 

Both groups showed functional motor scoresignificantly greater dcontrol group. Pain scores were signthe control group. Treatment group expethan the control groupControl group had sigexpenditures for institsignificantly greater enurse visits and case 

McDonald 200559 Quality of life (pain management) 

through provider behavior change

Randomized controlled trial 

Randomized controlled trial. Outcome measure: Estimate of treatment effect on nursedocumented care practices and patient’s pain management. 

Nurses, from a large, urban, nonprofit home care agency: n = 121 basic, n

= 97 augmented, and n = 118 control 

1. Basic group –nurse e-mails highlighting clinical recommendations 2 Augmented group – additional clinician and patient resources 3. Usual care 

Patients in augmenteimproved significantly ratings of pain intensi

0.05). Patients in basic interratings of pain intensi0.05). In both intervention gnurse assessment inc

23
Table 5. Summary of Evidence Related to Functional Outcomes and Quality of Life (continued) 

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key FindinMcDowell 199965 Functional ability (urinary continence) Prospective, randomized controlled clinical trial with cross- over design Randomized controlled trial, observational study with controls. Outcomes: bladder diaries, urinary accidents Home health care patients ages 60 and older with urinary incontinence: n = 53 intervention, n = 52 control 1. Nurse practitioner delivered behavioral therapy of biofeedback-assisted pelvic floor muscle training, urge and stress strategies, and bladder retraining 2. Control Interventio

significantly reeducatioaccidents pAverage nudecreased treatment (

Naylor 200440 Mortality, quality of life, and satisfaction Randomized controlled trial Randomized controlled clinical trial. Outcomes: patient report, physical and emotional quality of life, functional status, and satisfaction. Patients 65 years of age or older with CHF discharged from Philadelphia academic and community hospitals: n = 118 intervention, n = 121 control 1.Transitional care intervention – 3- month APN-directed discharge plan and home care followup 2. routine care (1/2 home care) Interventio

in quality o

functioning 

satisfaction control gro

Neff 200346 Quality of patient outcomes Non-randomized trial controlled Nonrandomized controlled trial. Outcomes: ADLs, 

IADLs, dyspnea, anxiety, and depression 

Medicare patients from a large home care agency: n = 41 urban control group n = 39 rural 

1.Transitional Care Model: APN pulmonary disease management team 2. Routine home care 

Interventioexperiencefeelings (P 

better ADL 

There were IADLs or dgroups. 

Scott 200462 Quality of life and mental health Randomized controlled trial Randomized controlled trial. 

Outcomes: Mental Health Inventory and Quality of Life Index. 

88 patients with heart failure from 2 nonprofit home care agencies in the Midwest 

All got routine care and 1.Mutual goal setting, 2. Supportive educative 3. Placebo 

Mutual goasignificantly health scormonths. Mutual goasupportive had significof life (P = 

24
Table 5. Summary of Evidence Related to Functional Outcomes and Quality of Life (continued) 

Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design & 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Tinetti 199968

Functional status – self-care ADLs 

Randomized controlled trial 

Randomized controlled trial. Outcomes: a battery of selfreport and performancebased measures of physical and social function. 

304 persons age 65 who had undergone surgical repair of a hip fracture at two hospitals in New Haven, CT, from 27 home care agencies 

1. Systematic multicomponent rehabilitation strategy addressing both modifiable physical impairments (physical therapy) and ADL disabilities (functional therapy) 2. Usual care 

There was no significaproportion of participagroups who recovered levels in self-care ADL vs. 75%) or 12 months groups), or in home m6 months (35% vs. 44(44% vs. 48%). There difference between thsocial activity levels, ttasks, balance, or lowstrength at either 6 or Compared with particiusual care, those in threhabilitation program greater upper extremimonths (P = .04) and gait performance (P = 

Vallerand 200461 Quality of life (pain 

management) 

Longitudinal, multilevel, randomized controlled trial 

Randomized controlled trial. Outcomes: nurse knowledge and attitudes of pain management, patient’s selfreported pain level. 

Home care nurses: n = 100 intervention, n = 102 control, from 11 home care agencies in Midwest United States 5 intervention 6 control 

1. Nurse education program – Power over Pain (POP) 2. Control 

Patients of nurses’ intself-report worst pain significantly (P < 0.04

Nurses’ intervention gsignificantly improved attitudes, and perceptpain (P < 0.05). 

25
26

Table 5. Summary of Evidence Related to Functional Outcomes and Quality of Life (continued) 

Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design & 

Study Outcome Measure(s)

Study Setting & Study Population

Study Intervention

Key Finding(s)

Weaver 200371

Functional status and quality of life 

Randomized controlled trial 

Randomized controlled trial. Outcomes: functional status, lower extremity functioning, health-related quality of life, satisfaction, use, and cost. 

136 patients with surgical hip or knee replacements from a hospital home care agency. 

1. Pre-op visit by nurse and physical therapist, 9 to 12 post-op home visits 2. Usual protocol with more visits (11 to 47) 

There was no differenquality of life, or satisfIntervention group cothan control (due to fe
Patient Safety, Quality in Home Care

Wound and Pressure Ulcer Management 

Adverse wound events are monitored under the OBQM program. Emergent care for wound 

infections, deteriorating wound status, and increase in the number of pressure ulcers are 

monitored and reported as adverse events.70 The data are used to reflect a change in a patient’s 

health status at two or more times, usually between home health care admission and transfer to a 

hospital or other health care setting. Data for these outcomes are collected using OASISdesignated intervals. Patient outcome measures related to surgical wounds that are monitored 

under the OBQI include improvement in the number of surgical wounds and improvement in the 

status of surgical wounds.18 

Wound Management 

Over a third of home health care patients require treatment for wounds, and nearly 42 percent 

of those with wounds have multiple wounds. Over 60 percent of wounds seen in home health 

care are surgical, while just under one-quarter are vascular leg ulcers and another one-quarter are 

pressure ulcers.71 Most home health care nurses can accurately identify wound bed and 

periwound characteristics; the majority (88 percent) of wound treatments have been found to be 

appropriate.72 The appropriateness of wound treatments in home health care is significantly 

related to wound healing. Patients with healing wounds had shorter home health care visits and 

shorter home health care lengths of stay.

71 

A literature review identified seven studies that tested interventions to improve wound care 

management in home health care.73–79 Findings are summarized in Table 6. Three compared 

effectiveness of various wound treatments. Capasso and Munro74 found no significant difference 

in wound closure between amorphous hydrogel dressings and wet-to-dry saline dressings, but 

costs were found to be significantly higher for the saline dressings due to the need for more 

nursing visits. Kerstein and Gahtan76 found the percentage of venous leg ulcers healed using 

hydrocolloidal dressings was six times higher than with saline gauze dressings and nearly four 

times greater using an Unna boot; the hydrocolloidal dressings were most cost-effective. Use of 

negative pressure wound therapy resulted in successful closure of 43 percent of wounds that 

failed to respond to previous treatment.78 

Four studies reported positive outcomes from interventions to improve and support home 

health care nurse practice.73, 75, 77, 79 Use of telemedicine to provide consultation with wound 

management experts resulted in improved healing rates, decreased healing time, and decreased 

home visits and hospitalizations related to wounds.73, 77 Fellows and Crestodina75 studied the rate 

of bacterial contamination of normal saline solutions prepared from distilled water and table salt, 

a practice common for wound care in the home, and found refrigerated solutions essentially 

growth-free at 4 weeks. A quality improvement project reported a reduction in adverse events 

through structured nurse education, introduction of protocols, and competency review.79 

Pressure Ulcer Management 

Rodriques and Megie80 found that 37 percent of wounds in home health care patients were 

pressure ulcers, with a mean wound duration of nearly 27 months. Nearly 1 in 10 patients 

admitted to home health care had pressure ulcers and approximately one-third were at risk of 

developing new ulcers; yet according to one study, only 27 percent of patients with existing 

27 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

28 

ulcers and 14 percent of those at risk were receiving appropriate pressure-reducing treatment.81

Incontinence, limitations in ADLs, mobility impairment, skin drainage, recent fractures, anemia, 

use of oxygen, and recent institutional discharge were associated with pressure ulcer 

development.81, 82 Guidelines from the Wound, Ostomy and Continence Nurses Society83 call for 

an initial risk assessment for pressure ulcers of all patients on admission to home health care, and 

reassessment every visit thereafter, using a validated risk assessment tool. However, one study 

found that only 21 percent of agencies used a validated tool such as the Braden Scale84 to 

identify patients at risk, nearly 8 percent performed no assessments on admission, and only 33 

percent used risk prediction or pressure ulcer prevention protocols.85 Just over half of agencies 

reported routine skin inspections by nurses of at-risk patients. 

A literature review resulted in identification of five studies relating to pressure ulcer 

management in home health care. The findings are summarized in Table 7. Three studies were 

randomized controlled trials testing interventions to improve pressure ulcer healing.86–88 One 

intervention tested the use of air-fluidized bed therapy with services of a nurse specialist;87 a 

second intervention used noncontact normothermic wound therapy.88 Both resulted in significant 

improvement in wound healing compared to conventional moist dressings. Overall healing rates 

were similar for polymer hydrogel and hydrocolloidal dressings, although debridement 

performance of the hydrogel dressing resulted in more favorable clinical evaluation.86 

The remaining two studies evaluated the use of the Braden Scale for prediction of pressure 

ulcer risk in home health care patients, with mixed results. Ramundo89 reported that the Braden 

Scale had validity in identifying at-risk patients, but limited predictive ability, while Bergquist82

found that the summative score of the scale was significantly associated with pressure ulcer 

development. All subscale scores except nutrition were significantly and negatively associated 

with pressure ulcer development. 

Evidence-Based Practice Implications 

When compared with wet-to-dry or moist saline dressings, most wound treatments tested 

showed greater effectiveness or lower cost. Home health care nurses should be knowledgeable in 

the use of the full range of existing and emerging wound products, practices, and treatments and 

demonstrate skill in accurate wound assessment and staging. Provision of structured resources, 

expert consultation, and competency testing for home health care nurses can improve home 

health care wound management. Nurses must be knowledgeable in risk factors for pressure ulcer 

development and relevant preventive measures; they must assess every patient using a valid and 

reliable instrument, such as the Braden Scale, on admission to home health care and regularly 

thereafter. 

Research Implications 

Relatively little is known about the most effective practices for wound care in the home 

health care setting. Although studies have compared different treatments for wounds, the most 

efficacious treatments for different wounds are unknown in the presence of various risk factors 

found in the home health care setting. Randomized controlled clinical trials exist comparing 

different pressure ulcer treatments in the home, with the exception of care of other types of 

wounds. Promising findings from studies with small sample sizes should be replicated with 

larger samples and diverse populations. 
Table 6. Summary of Evidence Related to Wound Management 

Source 

Safety Issue Related to Clinical Practice 

Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Find

Capasso and Munro 200374

Wound management, treatment, and cost 

Retrospective cohort study 

Observational study with control (Level 4) Outcomes: wound size, predominant tissue type, type of exudates; cost of treatment. 

Patients 25 years of age or more with superficial wounds without undermined areas: 1. Arterial surgical wound dehiscence or 2. Nonhealing arterial or diabetic ulcerations In 3 home care agencies, n = 25 intervention, n = 25 control 

1. Amorphous hydrogel dressings 2. Control wet-todry normal saline gauze dressings 

No signififound in tclosure btypes of d

Costs wehigher (P($3,774) interventi($2,634) higher nunursing vThere wadifference wound ca

Fellows and Crestodina 200675

Wound management, treatment, and cost 

Nonrandomized trial 

Nonrandomized trial. Outcomes: bacterial growth on agar-agar plate (Level 2) 

7 1-gallon jugs of normal saline prepared from distilled water with 8 tsp of table salt added 

Saline solutions were tested for bacterial growth at 1-week intervals for 4 weeks or until growth appeared. 1. Researcher prepared, nonrefrigerated (2) 2. Researcher prepared, refrigerated (2) 3. Patient prepared, refrigerated (3) 

Researchnonrefrigepreparatiobacterial compared solutionsbacteria-fTwo patierefrigeratremained weeks, wshowed t

29
Table 6. Summary of Evidence Related to Wound Management (continued) 

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key FindiKerstein and Gahtan 200076 Wound management, treatment, and cost Nonrandomized controlled trial Nonrandomized trial. Outcomes: complete wound healing, recurrence, and cost of treatment. 81 patients with venous ulcers, 47 in a home care agency and 34 seen in a physician’s office n = 32 intervention (group 1) n = 33 intervention (group 2) n = 16 intervention (group 3) 1. Hydrocolloidal dressing and compression hosiery 2. Unna’s boot 3. Saline gauze dressing and compression hosiery 13% of ulc

interventioheal or reccompared the seconand 88% pgroup. Hydrocollomore cost Unna’s bodressingsNo differebetween hphysician’Patients pbut costs w

Kobza and Scheurich 200077 Wound management, provider support Nonrandomized controlled trial Nonrandomized controlled trial. Outcomes: healing rates, average weeks to healing, average visits per wound patient, condition on discharge from 

home health. 

76 patients ages 28 to 94 with Stage III or IV pressure ulcer, diabetic foot ulcer, venous stasis ulcer, or with orders for twice-daily dressing change (191 wounds), urban and suburban hospitalbased home care agencies 

Two-way in-home video visit via telemedicine for wound specialist with home health nurse present to evaluate wound and recommend treatment Baseline retrospective patient sample per agency 

Interventioimproved wounds expressure uaverage hwound catdischargehealed/ hebaseline cdecreased of home hfrom 60 pedecreased hospitalizawound cowith intervbaseline. 

30
Table 6. Summary of Evidence Related to Wound Management (continued) 

Source 

Safety Issue Related to Clinical Practice 

Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Findi

Philbeck 199978

Wound management, treatment 

Nonrandomized controlled trial 

Nonrandomized controlled trial. Outcomes: reduction in wound area over time, wound volume, and healing rate; cost of treatment 

1,032 Medicare home care patients with 1,170 wounds failing to respond to previous intervention; 989 wounds over 30 days old, 566 were Stage III or IV pressure ulcers 

Negative pressure wound therapy 

498 (43%) in successinterventioshowed no Interventiodays and reduction volume. 

Sturkey 200579

Wound management, provider support 

Quality improvement project 

Observational study comparing pre- and postintervention. Outcomes: OASIS Adverse Event Outcome Reports “Emergent Care for Wound Infection/ Deteriorating Wound Status”; number of visits required for wound care; State survey and JCAHO/Medicare survey observed breaches in infection-control practices. 

One home care agency, Georgia 

Educational program including best practice video and skills laboratory; education on wound care staging, healing and appropriate protocols; observation of actual practice in home using competency skills checklist; certification in negative wound pressure therapy 

Adverse EReports, EWound InfDeterioratimproved 1.09%, conational adecreased wound paachieved observed JCAHO su

31
Table 7. Summary of Evidence Related to Pressure Ulcer Management Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Berquist 200182 Pressure ulcer management, prediction Retrospective cohort study. Retrospective cohort study without controls. Outcome measure: development of Stage I to IV pressure ulcers or no ulcer development. 1,684 patients age 60 years or older without pressure ulcers on admission, with documented Braden Scale scores, one large Midwestern urban home care agency None Braden Scale summat

significantly lower for sdeveloped pressure ulremaining free of press.01). All subscale scores exsignificantly and negatwith pressure ulcer dev.01), but only the summremained significantly completion of a backwprocedure (

P < .001).

Motta 199986

Pressure ulcer management, treatment 

Randomized controlled trial 

Randomized controlled trial. Outcomes: healing rate, debridement using BatesJensen Pressure Sore Status Tool 

Home care patients with Stage II or III pressure ulcer, in home care setting: n = 5 intervention (group 1), n = 5 intervention (group 2) 

1. Polymer hydrogel dressing 2. Hydrocolloidal dressing 

The overall healing ratwas similar. Intervention 1 had morclinical evaluation baseautolytic debridement 

Ramundo199589

Pressure ulcer management, prediction 

Prospective cohort study 

Observational study with control. Outcomes: Braden Scale scores, development of pressure ulcers 

48 newly admitted patients free of skin breakdown who were unable to leave bed or chair, one suburban, communitybased home health care agency 

None 7 patients (17%) devel

ulcers; Braden Scale s11 to 22. At a score of the tool was 100%; howas only 34%, indicatihas validity in identifyinbut has limited predictihealth care. 

32
33

Table 7. Summary of Evidence Related to Pressure Ulcer Management (continued) 

Source 

Safety Issue Related to Clinical Practice 

Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Strauss 199187

Pressure ulcer management, treatment 

Randomized controlled trial 

Randomized controlled trial. Outcomes: wound status, inpatient hospital days, inpatient hospital charges, Medicare DRG, and physician payments. 

Patients with Stage III or IV pressure ulcers and severely limited mobility, in home care setting: n = 47 

intervention, n = 

50 control 

36 weeks of treatment, either 1. Air-fluidized bed therapy with services of a visiting nurse specialist, or 2. Control – conventional therapies 

A higher proportion of patients were classifiewithout statistical signiIntervention patients sfewer days in the hospdays, P < .01) and use

total inpatient resourceinpatient and outpatienutilization was lower, b

Whitney 200188

Pressure ulcer management, treatment 

Randomized controlled trial 

Randomized controlled trial. Outcomes: wound healing and periwound temperature changes, measured using valid, reliable instruments. 

Patients, age 18 or older with Stage III or IV pressure ulcers in primary care, home care, acute care, or long-term care facilities: n = 15 intervention, n = 14 control 

1. Noncontact normothermic wound therapy 2. Control – moist dressings 

The intervention group faster (P =.01), and avtemperature increased .001). 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

34 

Conclusion 

Home health care clinicians seek to provide high quality, safe care in ways that honor patient 

autonomy and accommodate the individual characteristics of each patient’s home and family. 

Falls, declining functional abilities, pressure ulcers and nonhealing wounds, and adverse events 

related to medication administration all have the potential to result in unplanned hospital 

admissions. Such hospitalizations undermine the achievement of important home health care 

goals: keeping patients at home and promoting optimal well-being. Nevertheless, the unique 

characteristics of home health care may make it difficult to use—or necessary to alter—

interventions that have been shown to be effective in other settings. Therefore, research on 

effective practices, conducted in home health care settings, is necessary to support excellent and 

evidence-based care. 

In reviewing the extant studies, the authors of this chapter found useful evidence in all 

selected areas. However, the number of studies was few and many questions remain. 

Replications of investigations originally conducted in health care settings other than the home, 

and studies considering home health care-specific issues are needed to support evidence-based 

clinical decisions. The available evidence suggests that the work environment in which home 

health care nurses practice may indirectly influence patient outcomes in many areas, and that 

technology can be used to support positive patient outcomes. Thus, studies that link nurse-related 

variables to improved care safety and quality are needed, as well as studies that focus directly on 

patients. The demographics of an aging society will sustain the trend toward home-based care. 

Home health care practices grounded in careful research will sustain the patients and the 

clinicians who serve them. Given the focused review of evidence-based studies comprising this 

chapter, many informative sources of use to the practicing home health care nurse are omitted. 

Table 8 lists additional key resources. 
35

Source Area(s) Addressed Web Access AHRQ Electronic Catalog 

Pressure ulcer treatment http://www.ahrq.gov/gils/00000108.htm 

http://www.ahrq.gov/gils/00000109.htm http://www.ahrq.gov/gils/00000110.htm 

AHRQ Evidence-Based Practice Reports 

Nurse work environment:  Staffing and quality of patient care Wound healing technologies 

http://www.ahrq.gov/clinic/tp/nursesttp.htm http://www.ahrq.gov/clinic/tp/woundtp.htm 

AHRQ National Guideline Clearinghouse 

Medication management Fall assessment and management Functional outcomes and quality of life:  Continence promotion  Diabetic foot complication prevention,  ulcer management Pain assessment and management Wound management, lower extremity:  arterial disease, neuropathic disease,  venous disease Pressure ulcers: prediction, prevention,  and treatment 

http://www.guideline.gov/browse/guidelin

Home Health Quality Improvement National Campaign (HHQI) (development in process) 

Medication management Fall prevention Unplanned hospital admissions 

http://www.homehealthquality.org/hh/ 

Journal of Wound Care (UK) Wounds and pressure ulcers http://www.journalofwoundcare.com Journal of Wound, Ostomy and Continence Nursing 

Functional outcomes  Continence Wounds and pressure ulcers 

http://www.jwocnonline.com 

MedPac Report to Congress, Chapter 5: Adding quality measures in home health 

Fall prevention Wound care of pressure ulcers 

www.medpac.gov/publications%5Ccongr6_Ch05.pdf 

National Pressure Ulcer Advisory Panel 

Pressure ulcers www.npuap.org 

Ostomy Wound Management Wound management http://www.o-wm.com Table 8. Additional Resources 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Search Strategy 

The literature review for this chapter focused on identifying evidence-based practices that 

supported the goals of home health care: to promote independent functioning; to remain at home, 

avoiding hospital or nursing home admission; and to achieve optimal well-being. The search was 

conducted using multiple variations of key terms informed by the characteristics of home health 

care described at the beginning of this chapter, adverse events used in the OBQM,5 goals of the 

Home Health Quality Improvement National Campaign 2007,14 and the nurse-sensitive quality 

indicators developed by the American Nurses Association.15 The Cumulative Index to Nursing & 

Allied Health, Cochrane Library, Medline, and ProQuest Nursing & Allied Health databases 

were searched, as well as the grey literature and government Web sites, including the CMS and 

Agency for Healthcare Research and Quality. Hand searches were conducted of the reference 

lists of retrieved articles. Search limitations were English language, United States or Canada, 

peer-reviewed journals or scholarly literature, published between 1990 and the first quarter of 

2007. Studies cited in the evidence table were accepted for review using the following inclusion 

criteria: 

• The study was published between 1990 and the first quarter of 2007, inclusive. 

• The research was conducted in the United States or Canada. 

• The study included an intervention that directly or indirectly influenced a patient 

outcome. 

• The intervention took place under the auspices of a home health care agency. 

• Subjects in the study had to be home health care patients (not community-residing or 

outpatient ambulatory) and 18 years of age or greater. 

Author Affiliations

Carol Hall Ellenbecker, Ph.D., R.N., professor, University of Massachusetts, Boston. E-mail: 

carol.ellenbecker@umb.edu. 

Linda Samia, Ph.D., R.N., program manager, Healthy Choices for ME, MaineHealth’s 

Partnership for Healthy Aging. E-mail: samial@mmc.org. 

Margaret J. Cushman, Ph.D.(c), R.N., F.H.H.C., F.A.A.N., research associate, University of 

Massachusetts, Boston. E-mail:margaret.cushman@umb.edu. 

Kristine Alster, Ed.D., R.N., associate provost, University of Massachusetts, Boston. E-mail: 

kristine.alster@umb.edu.

36 
Patient Safety, Quality in Home Care

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40