Home Health Nursing
Bringing comfort, care and patience from the hospital to the home
Home is where the heart is, and for more and more patients it is also where the care is. Out-of-hospital care, even for acutely ill patients, is more the norm than ever. An annual industry growth rate of eight percent will probably continue, regardless of health care reform, and that is good for nurses. Some of the shift is due to an increase in less invasive procedures. Drastic cardiac interventions no longer require large chest incisions; gall bladders and even uteri slip out via laparoscopy; and new mothers and babies now get to know each other with the help of extended family, not a hospital routine that once kept them apart for most of the first week of life.
Yet another factor is reimbursement. More and more, government and private insurers determine ahead of time how much they will pay for a specific diagnosis, and hospitals caught in this payment squeeze rely on home health care to ease the transition back into the community. Patients who five years ago would stay in the hospital for IV antibiotics or wound care now go home to complete therapy. In some cases, doctors can avoid hospitalization for the patient altogether.
The key to this is the team of professionals, including nurses, who provide the care — home health care. It is not that the patients no longer need professional help; rather, their care will be more comfortable and more cost-effective at home.
Working Under the Umbrella
The original agency in the field is the Visiting Nurse Association of New York. Often, any nurse who works in the home, including hospice and private duty, is called a visiting nurse. But unless they actually work for an agency with “visiting nurse” in its title, it’s more correct to call them home health nurses. Currently, almost every community of any size has a VNA. These separate entities form only a loose affiliation with one another, if that, but they are all an example of a not-for-profit freestanding home health agency.
In Southern California, the Visiting Nurse Association and Hospice of Southern California is one of the largest. Gayle Wilson, RN, is the vice president of clinical operations, and she explained how the nurses work. The organization’s current patient “census” runs about 450 per day, with its hospice component seeing an added 300 clients — close to twice the number of a large hospital. One hundred nurses coming from two offices work all three shifts and, unlike many agencies, at VNASoCAl there is no such thing as being on call, and night visits are not routinely scheduled.
Most registered nurses work as case managers, each handling about 35 patients. Some will require daily visits, some only one a month. The productivity standard is variable, but generally the VNA nurse expects to see six patients a day, five if one is an admission. Team nurses, often LVNs, will see seven.
In the more urban parts of the service area, each nurse drives 20-50 miles per day. In the eastern part of the Inland Empire, the rural nature of the community leads to mileage that may reach 100 miles per day.
Sometimes nurses see patients for Foley catheter changes, wound or ostomy care. Other times they focus on patient teaching, such as insulin injections and blood sugar testing. VNASoCAl offers Telehealth, a new program that allows patients on service and receiving the intermittent assessment of a nurse case manager to have vital signs checked daily via telephone.
This helps patients modify behavior that might be exacerbating illnesses like congestive heart failure. The assigned nurse in the office will check for aberrations in the data and intervene, often with directed patient teaching. Wilson gives an example: If a Telehealth patient notes a weight gain or spike in blood pressure, the nurse can explore related dietary lapses like last night’s pizza and help the patient see the link. The early intervention between doctor visits can help reduce readmission to the acute facility.
Nurses use computers for record keeping and information transfer, so each patient’s complete record is available to other staff if the need arises. Then if the night nurse receives a call from a patient, he or she is working with the most up-to-date material.
Diana Armas, RN, and Kelly Gage, RN, nurses at Providence Little Company of Mary Home Health in Torrance, describe a slightly different method of record keeping. A communication tool or “quasi-chart” remains in the patient’s home for each nurse to enter vital data and relay information. Other professionals treating the patient also have access, including the home health aide, physical therapist, occupational therapist or social worker. Frequent cell phone contact between nurses is also possible.
There are other differences in their hospital-based agency. It is smaller — 25 field nurses altogether — as is the geographic region it serves. Nurses log fewer driving miles, and the individual caseload is about 15 patients. Still, each nurse visits a comparable number of patients, decided in a similar way. Little Company home health nurses do not work evenings or nights.
A Wall-less Routine
What does it take to be a successful home health nurse? To comply with mandated guidelines, agencies require at least one year of acute hospital experience. Strong nursing skills, including the ability to assess patients for subtle changes and act autonomously, are important. Wilson likens it to “hospital nursing, but without the walls.” Patients are much more acute than the uninitiated realize. Most home health nurses agree the work is more challenging than they anticipated; and truly, home health is no place to go if you are looking to coast.
According to Gage, home care is increasingly high-tech and requires many of the same skills as in-house. The need to act independently depends on a strong medical/surgical background, which she obtained by first working on a surgical floor, then ICU, followed by outpatient nursing in a G.I. lab. Armas, too, had extensive med-surg, orthopedic and oncology experience before working in home care.
The greatest luxury is time. Patient teaching, a critical component of any patient care, is often slow going, and in home health you help ease the burden the hospital nurse may have. It is one of the features home care nurses like best, along with the opportunity to have a real impact on patients and their families. According the Gage, “You get the full spectrum of nursing care,” while being able to make a real difference.
Almost everyone agrees paperwork or computer documentation is the special challenge of home health. The close relationship among admitting diagnosis, outcomes and reimbursement is more obvious in home health. That connection makes the individual nurse more aware of the need for accurate and timely paperwork. Forms like the Medicare-required OASIS admission and discharge packet can take up to 15 pages, and failure to reflect properly the condition of the patient and outcomes of care can have a serious impact on payment, regardless of how well the patient does.
Armas, who has worked in home health for about a year and a half, sees time management skills as most critical. Because she has a background in accounting, so the paperwork itself is not a burden; but she sees challenge in planning how to structure the day’s visits, taking into account traffic patterns and other factors that can throw the schedule off. Many patients love to chat about their families or earlier life, and doing so can contribute greatly to a fuller understanding of the patient as a person — a part of home health she loves. But it also makes it hard for the nurse to accomplish visit goals within a reasonable time. It took about six months for her to finesse this!
Cell phones and fax machines help. Dedicated phone lines for physician callbacks do, too. Gage uses these to keep her office visits to twice a week. Still, some agencies may require nurses to check in at the office daily.
Armas mentions another constant challenge, one she is eager to meet. “We are there as [the patient’s] guests.” This is a complete turn-around from the hospital, a “real shift in power.” While most patients appreciate the care, it’s essential for the nurse to give “exceptional customer service.”
Certification in home health is possible, and many graduate programs focus on community health. There is, however, no degree beyond the basic nursing licensure that agencies require. The pay is comparable to hospital nursing. Nurses use their own cars, and current IRS allowance generally determines mileage reimbursement. Many nurses work per diem in home health, especially in pediatrics and infusion specialties. Almost all agencies require some weekend rotation.
Not all home health care is by nonprofit agencies. One segment of the industry looks for profit and even lists on the stock exchanges. Many also offer private duty home care, although in most cases the operations are separate. Private duty care differs sharply, both in its form of payment and in its nursing assignments.
Many home health agencies — for profit or not — have a hospice component as part of their services. It, too, is a different specialty. In home health the patients expect to recover from the current episode and maintain some degree of wellness. Many remain on service two months, although some linger longer, and others may be ready for discharge within a week. The care is intermittent and episodic, even if sometimes, as Armas points out, home care is the last step before patients move to an institutional setting. Helping them to make that decision, establishing the trust, and serving as an ally and advocate are all part of the nursing role. “I can’t think of anything I’d rather do right now,” Armas says.
Tips for Home Health Nurses
Courtesy of AllNurses.com
Have a sense of humor. If you take yourself too seriously, no career will be enjoyable.
Be open minded. If the patient requests you enter their home and take your shoes off because of religious reasons, you do. Diversity is one of the wonderful aspects of home care. Learn to appreciate different cultures.
Be flexible. The day you planned will change, guaranteed. If you can't be flexible, home care may not be your bag.
Be organized. For those who drive a car between patient visits, your car is your office, and the trunk should look like a supply closet. Learn to plot your visit route. With the cost of gas now-a-days, you don't want to drive needless miles.
Have basic computer skills. If you don't have them, learn them. Many home health agencies have field staff carry a lap top into the patient's home. It is the way of the future.
Be alert and be safe. You may be presented with many new dangers that you won't see in the hospital. Always be alert to your surroundings. Don't talk on your cell phone while driving. Follow safety rules.
Don't be afraid of paperwork. If you work for a home health agency that performs Medicare visits, the questions need to be asked and
documented. Practice does help speed up the documentation process.
Keep up your skills. Take continuing education classes online. Attend seminars. Read articles. Knowledge is power. You are autonomous in the patient's home and good skills and quick thinking are mandatory to survive.
Elizabeth Hanink RN, BSN, PHN, is a freelance writer with extensive hospital and community-based nursing experience.