Home Health Services

Home-based health services refer to medical and care-oriented health services provided by healthcare teams to individuals in non-hospital settings, particularly in their own homes. These services may include preventive, curative, rehabilitative and, when necessary, palliative care components. The primary objective of home-based health services is to improve the individual’s health status, maintain or enhance quality of life, and reduce hospital admissions and inpatient rates. The World Health Organization defines home-based health services as care provided in the patient’s home by professional healthcare workers or trained caregivers.

Historical Development

Home-based Health Services Worldwide

Home-based health practices began in the West in the late 19th century in the form of home nursing services. In 1883, home nursing activities were initiated in the United States, and in 1893, the Henry Street Nursing Settlement institutionalized home nursing practices. In 1909, the Metropolitan Life Insurance Company included home-based services within its insurance coverage. These developments enabled home-based health services to evolve beyond nursing into a comprehensive model encompassing other healthcare professionals.

In Europe, home-based health services were first implemented in Denmark in 1937 and later became state-supported in countries such as the Netherlands, Sweden, and the United Kingdom. In Germany, these services are delivered through collaboration between the state, municipalities, NGOs, and insurance companies.

Home-based Health Services in Türkiye

The history of home-based health services in Türkiye dates back to the 15th century during the Ottoman period. Records indicate that physicians visited patients door-to-door on designated days under the reign of Fatih Sultan Mehmet.

The first legal regulation during the Republican era was enacted in 1930 with Law No. 1593 on Public Health Protection. This regulation covered practices such as home visits and physician consultations at home.

Modern home-based health services gained official status with the “Regulation on the Provision of Home Care Services” published in the Official Gazette No. 25751 on 10 March 2005. This was followed by the “Guideline on the Procedures and Principles of Home-based Health Services Provided by the Ministry of Health,” issued in 2010.

Structure and Components of the Service

Home-based health services are delivered by a multidisciplinary team that may include physicians, nurses, physiotherapists, psychologists, social workers, dietitians, health administrators, and patient transport personnel. Services provided include patient examinations, injections, wound dressings, oxygen therapy, physical therapy, psychological support, medical device assistance, and home-based oral and dental health services. In Türkiye, these services are delivered through mobile teams, home-based health units, and oral and dental health teams.

Legislation and Institutional Structure in Türkiye

Legislative Process

The legal foundation for home-based health services in Türkiye dates to 2005. The “Regulation on the Provision of Home Care Services”, published in the Official Gazette No. 25751 on 10 March 2005, is the first regulatory text in this field. This regulation defined the scope of services, implementation principles, and responsibilities of service-providing institutions.

Subsequently, on 1 February 2010, the “Guideline on the Procedures and Principles of Home-based Health Services Provided by the Ministry of Health” came into effect following official approval. This guideline mandated that all home-based health services be carried out by institutions under the Ministry of Health and provided detailed provisions on application, assessment, and service scope.

The most recent legislative update is the “Regulation on the Provision of Home-based Health Services by the Ministry of Health and Its Affiliated Institutions”, published in the Official Gazette No. 29280 on 27 February 2015. This regulation defines both the mode of service delivery and the principles of inter-institutional coordination.

A visual representing Home-based Health Services.Pıxabay)

Service Delivery Models

In Türkiye, home-based health services are delivered through three models:

1. Services Provided by Family Physicians: Implemented within the framework of family medicine legislation. Family physicians provide home visits and necessary health services to their patients.
2. Home-based Health Units Established Within Hospitals: Operate under educational and research hospitals, state hospitals, and oral and dental health centers.
3. Services Provided Through Mobile Teams: Teams established by provincial directorates of health primarily serve rural and remote areas.

Service Process and Application

Requests for home-based health services can be made through various channels. Applications may be submitted via:

• The national call center at 444 3 833,
• Community Health Centers (CHC) or Family Medicine Units (FMU),
• Referrals from hospital staff upon patient discharge.

Applications are evaluated at the provincial coordination center. Based on the patient’s health condition, place of residence, and accessibility to services, the patient is referred to the appropriate unit. A home assessment is then conducted, and the patient is either enrolled in the service or rejected with notification sent to the family physician.

Eligibility and Termination Criteria

The groups eligible to benefit from home-based health services are as follows:

• Bedridden patients,
• Cancer patients in terminal stages,
• Patients with advanced neuromuscular diseases,
• Patients with chronic respiratory conditions such as COPD,
• Newborns requiring phototherapy,
• Individuals requiring home-based oral and dental health services.

Services may be terminated for the following reasons:

• Patient recovery,
• Reduction in care needs to a level no longer requiring professional healthcare personnel,
• Request by the patient or their legal representative to discontinue services,
• Death of the patient,
• Non-compliance with treatment,
• Change of residence.

Scope of Services and Activities Provided

An analysis of home-based health services provided across Türkiye between 2012 and 2017 revealed the following key activities:

• Patient examinations (3,563,826 applications),
• Wound dressings (1,471,351 applications),
• Educational interventions (1,438,282 applications),
• Other procedures including blood sampling, injections, bladder catheterization, psychological support, physical therapy, EKG recordings, report preparation, and ventilator monitoring.

A total of 3,702 medical devices have been allocated to patients for home use. The most common include functional hospital beds, air mattresses, oxygen cylinders, pulse oximeters, and glucose meters.

Financing of Home-based Health Services

General Framework

In Türkiye, financing for home-based health services is primarily provided through the social security system and public resources. The financial sustainability of these services has become increasingly important due to the growing elderly population and the rising prevalence of chronic diseases. Individuals not covered by the Social Services and Child Protection Agency may access services by paying a specified fee.

Health Implementation Circular (SUT) Regulations

Following amendments to the Health Implementation Circular (SUT) on 1 March 2011, certain treatment and material costs associated with home-based health services began to be covered by the Social Security Institution (SSI). Under this framework, injections, dressings, medications, and necessary medical supplies provided through hospital-affiliated home-based health units are invoiced to the SSI for payment. For this arrangement to be valid, services must be recorded through the relevant health institution’s automated system and processed as day-care treatments.

Comparison with International Financing Models

Globally, three primary financing models for home-based health services are prominent:

1. General Tax Revenue: Used in countries following the Beveridge model, such as the United Kingdom, where services are funded through the national budget.
2. Social Health Insurance (Bismarck Model): Employed in countries like Germany, where funding is based on payroll contributions within a social insurance system.
3. Out-of-Pocket Payments: In some countries, services are purchased directly by individuals based on their personal financial capacity.

Türkiye employs a mixed system combining general tax revenue and social insurance mechanisms. However, compared to developed countries, an independent and institutionalized financing structure specifically for home-based care and health services has yet to be fully established.

Ethical Principles and Implementation Challenges

Ethical Principles

When delivering home-based health services, fundamental principles of medical ethics must be observed:

• Beneficence
• Non-maleficence
• Justice
• Autonomy
• Confidentiality and privacy

Providing care in the home environment necessitates special attention to the privacy of the patient and their family.

Challenges Encountered

Challenges in implementing home-based health services can be grouped into four main categories:

1. Operational and Implementation Issues: Lack of standardized service processes and insufficient coordination among institutions.
2. Quality and Standards: Absence of mechanisms to evaluate service delivery based on qualitative rather than quantitative metrics.
3. Economic Issues: Sustainability of funding sources, limitations in insurance coverage, and constraints of public budgets.
4. Human Resource Issues: Shortage of sufficient and qualified personnel, particularly in rural areas where specialized staff are difficult to recruit.

Additional practical limitations include the unsuitability of home environments for medical interventions, technical errors in the use of medical devices, and the inability of patients to maintain continuous contact with healthcare personnel, all of which can negatively impact service quality.

Advantages and Disadvantages of Home-based Health Services

Advantages

Home-based health services offer multifaceted benefits for both individuals and the healthcare system:

• Cost-effectiveness: Lower costs compared to institutional care, resulting in savings through the prevention of unnecessary hospital admissions.
• Patient comfort and satisfaction: Receiving care in one’s own home provides psychological comfort and improves adherence and satisfaction.
• Personalized care: Services can be tailored to the individual’s specific needs and circumstances.
• Reduced infection risk: Eliminates exposure to hospital-acquired infections.
• Maintenance of family unity: Family members actively participate in the care process, supporting recovery and strengthening familial bonds.
• Improved quality of life: Particularly beneficial for elderly, chronically ill, or terminally ill patients by preserving dignity and daily functioning.

Disadvantages and Limitations

However, home-based health services also present certain risks and constraints:

• Weakened medical authority: Healthcare professionals may struggle to establish full authority in the home setting, potentially affecting treatment adherence.
• Continuity challenges: Healthcare providers cannot be present at all times, posing risks for conditions requiring constant monitoring.
• Inadequate home environment: Homes often lack the hygiene and technical infrastructure required for safe medical interventions, increasing the risk of complications.
• Risk of privacy violation: The presence of healthcare workers in the home may be perceived as an intrusion into family privacy.
• Risk of incorrect use: Misuse of medical devices or medications by patients or family members can lead to complications.
• Patient psychological state: For some individuals, receiving care at home may be interpreted as abandonment of curative hope, leading to psychological distress.

Overall Evaluation

In Türkiye, home-based health services have been institutionalized both legislatively and operationally. Services are delivered under the coordination of the Ministry of Health by family physicians, hospitals, and mobile teams. The system, shaped by regulations and guidelines since 2005, offers a comprehensive approach tailored to the needs of elderly and chronically ill individuals. However, challenges in human resources, financing, quality, and coordination continue to limit service effectiveness. For long-term success, the following improvements are essential:

• Training of service providers,
• Establishment of quality standards,
• Integration of health and social services,
• Implementation of an effective monitoring and evaluation system.

Home-based health services function as a complementary and supportive component within Türkiye’s healthcare system, offering a patient-centered, cost-effective, and efficient alternative model of care.