Providing Quality Care as a Home Health Care Nurse

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Introduction

In April 2021, and for the third time since September, the United States Bureau of Labor Statistics reported job losses for facility-based care centers. In March, hospital-based caregivers saw a reduction of 600 jobs, while the home care setting gained 4200 (5). Overall, healthcare jobs are in demand, particularly for nursing, but the location of care shows a definite trend since the development of a worldwide COVID-19 pandemic. As a result, many long-term facility-based admissions have either been avoided based on fear or denied due to safety concerns driving increased demand for home care services. It remains to be seen whether that trend will continue as the country becomes vaccinated and the risk of severe COVID infections decreases. Still, the broad adoption of remote care services and Amazon’s expansion of their in-home and on-demand healthcare company are likely bellwethers for the future of healthcare (3).  

Nurses working at hospitals are experiencing high turnover, short staffing, and low morale. The higher demand for home health care nurses comes at an opportune time for both the nurses and home health care agencies. New remote and in-home care service agencies will benefit significantly from the experience of hospice and home care providers, and there has never been a better time to consider your options in nursing.   

For the home health care nurse with mainly facility-based experiences, this role can pose unique challenges, as well as obstacles relating to the independence of practice; in some cases, this can be nerve-wracking, while in others, it can be empowering. Understanding the differences between the philosophical and practice-based approaches is the best start to a smooth transition for the new home health care nurse.

Home as a Place of Practice 

The home health care setting serves as a healing environment for most patients and families, whether they have just received care at a hospital, or the interventions are being implemented in the home rather than at the facility. At first glance, the home may seem less than optimal for healing with the absence of the aseptic environment, but remember, the patient and family have likely been exposed to the germs in their home without detrimental effects. On the other hand, the hospital has a more varied germ pool than what is found in the typical family home due to the variety of people and illnesses being treated on site. One of the worst outcomes risked by a stay in the hospital is a hospital-acquired infection; patients are far less likely to contract an antibiotic-resistant disease outside of the hospital.  

In the home setting, the environment and the caregivers are familiar, lending more comfort and relaxation for all family members. The addition of rest and the absence of confusion regarding surroundings can also improve safety. So why, given a chance to discharge, would any patient or caregiver want to spend more time in the hospital?  

The reluctance to leave the hospital setting in a minority of patients and families is based on fear and a lack of confidence related to new skills required to care for the acute or exacerbating illness of the patient concerned. Regardless of a home health care referral, in-home visits will only provide on-site services for two to three hours per week on average, so the family has reason to be concerned, which leads to the first big difference between home and hospital nursing practice. 

Goals for the Home Health Care Nurse 

First things first, if you are new to being a home health care nurse, your previous clinical skills remain essential. The Centers for Medicare and Medicaid Services (CMS) often require that you have two years of experience in a medical-surgical setting before going into a home health setting. The home setting requires autonomous nursing practice with little to no on-site resources. This is a sharp contrast from the hospital, and your assessment and the resulting care plan will now serve as the guide to drive both the patient and family toward improved health and confidence. As the home health care nurse, you will require written orders for all treatments and medications, as well as consult with the physician on all changes. Even so, the primary care physician will most likely depend on your assessment and critical thinking skills to guide decision-making.  

Since your time is limited in the home, the family and patient will assume 24-hour care. Once you become a home health care nurse, your role as the primary provider of care changes to the educator. Your primary goal is to instill confidence in patients and families to safely and consistently provide care that will maintain or improve their current level of health. It is indeed a disservice to the family for you to provide care other than for highly specialized and limited treatment, modeling, or for educational purposes. The family and patient must develop the hands-on skills to assume care for the hours you are not in the home. Education will need to progress very quickly, so you must test the family and patient for knowledge before discharging nursing or other services in the home. 

 Now that your goal is clear let’s discuss the families’ goal, which may change with each visit. The family and patient are likely experiencing a high degree of stress whether it’s due to the recent illness or other factors. High stress often impedes education and the ability to focus. It is essential that after the introduction during a visit that you follow with the question of what has transpired since the last time you were there. This question lets the patient know you are interested and as a result, it builds trust that you understand their health issue may not be the only source of stress.  Ask,

“What’s your biggest concern today?”  

Don’t assume that you will not be able to solve their issues. As a home health care nurse, you will have access to other resources, such as a social worker or case manager. You will also have community resources that you can seek help in making referrals as needed. Suppose the person’s primary concern is a domestic or financial situation. In that case, you likely won’t be able to resolve it that day but listening and letting them know what you can or cannot do often gives them enough peace to allow other information to sink in and get them back on track to health.  

After you have learned what’s weighing heavy on their mind, you can begin negotiating goals for a visit. An example of negotiating goals for a visit may go something like this,  

“I understand you want to work on making sure your care comes with no out-of-pocket expenses, and I will be making a referral to the social worker to address your concern. I would also like to make sure you know how and when to take your blood sugar. Do those both sound like reasonable actions to take today?”  

Allow the patient or family member to agree or add to the plan until you know you have their attention and focus; this conversation will make your visit more efficient and satisfying for everyone.  

Education and Staying Ahead of the Disease Process 

Educating the hands-on care is often the more obvious part of the nurse’s role in the home, but for an in-home visit to be initiated, there is often a triggering event. This could be a new onset illness or an exacerbation of chronic disease. Regardless, education must be future focused on what the family and patient could expect to occur related to the disease process or progression. It is a goal that they are not panicked by the onset of symptoms associated with the disease, but instead, they confidently act to alleviate symptoms or seek the necessary assistance to resolve the issue in its early stage.  

To avoid unnecessary visits to the emergency room, families and patients should understand the realms of normal for the disease process and have the tools and knowledge to confidently manage any symptoms outside the ranges of normal. The use of each medication, including the symptoms intended to resolve the issue as well as directions, particularly regarding PRN, or as needed, is essential to document for the patient and family. The use of tools such as weight and blood pressure trackers, dyspnea, and other rating scales, should be incorporated for patients and families to build habits that allow changes to be noticed quickly. They should then have a written plan on what to do should any of their symptoms go beyond the normal range. Test the patient and family frequently by asking questions such as:

“Which medication would you take if you were experiencing shortness of breath?”

or,

“Explain to me what you would do if your scale shows you gained more than 5 pounds today?“ 

Limit monitoring and tracking only to aspects of the disease that you can act on. Otherwise, tracking and monitoring become stress-inducing and challenging to maintain. An example of unnecessary tracking would be monitoring oxygen saturation in a dying patient. Telemonitoring equipment can help the family build good habits for monitoring and tracking treatable aspects of the disease before discharge and is encouraged as a teaching tool.

Telehealth and Telemonitoring 

We have all heard about the benefits of telehealth and that it is here to stay. It was proven to be a lifeline during the COVID-19 pandemic, and CMS has approved the use of this in many home care settings, including hospice and home health care. What you may not have heard is that it can be burdensome until you become efficient at its use. Telehealth and telemonitoring require patient education and frequently involve assistance with setting up. It is generally dependent on wi-fi, which remains an issue in rural areas, and in some cases, the nurse may coordinate the receipt and return of equipment.         

During the COVID-19 pandemic, CMS approved the use of several previously HIPAA-excluded technologies due to concerns, including FaceTime; depending on the organization, these still may not be approved. Be sure you check with your organization before using any technology to communicate with your patient and family to ensure it is an approved form. Otherwise, you and your organization could be subject to fines for violating HIPAA guidelines.  

Despite the burdens, telehealth can be a valuable tool for you and your patient. It can reduce your travel time, allow monitoring, documentation, and reporting of your patient’s well-being and enable you to visit virtually when weather or other circumstances prohibit an in-person visit. It also helps your patient and family to feel confident providing care because it can allow them to develop a routine of reporting and analyzing their data and implementing approved treatments when needed. Telemonitoring also provides a level of accountability for the patient and family, which may be helpful to build new habits during times of stress.  

Setting Boundaries as a Home Health Care Nurse

As a home health care nurse, when you are in the home setting, you get to know the patient and family in their unique surroundings. You have a better understanding of their circumstances, challenges, and support systems when you can experience those along with the patient. This closeness can also have the disadvantage of blurring professional lines, so you must take caution to develop consistent habits which maintain solid boundaries between all your in-home interactions.  

On all your visits, let the family know how long you intend to be in the home. A good time to do this is just after you have negotiated shared goals with the family. Communicating a time limit lets them know that your intention is focused and gives them a sense of urgency to discuss important matters. It also discourages unfocused conversations and even gossip that can delay you from your next visit. Adopting this routine will help ensure you are focused on the right things to get everything you need to get done that day.  

Don’t accept gifts or food; it always turns out bad even when it seems like the kind thing to do. Patients and families are at a very vulnerable time, and they appreciate your help and may want to show you. It may be difficult or even seem cruel to turn down a family’s offering, but you are with them temporarily and not intending to build a friendship, though you may be very fond of them. If boundaries are crossed, a timely discharge from services could be akin to losing a friend for the patient and family, which is ultimate cruelty. Also, I have personally been involved in formal complaints when well-meaning family members provided gifts of food that other family members perceived as actions of vulnerability. Getting yourself caught between warring factions of the family or even a misunderstanding will not be what you want to spend your energy on, and I can assure you, neither will your manager.  

While we are on boundaries, here are a few other hard and fast rules:  

1. Give the family a time that you will arrive and call if you are going to be late. 
2. If you cannot come when the family requests, give them the option of two other times.  
3. Never give out your phone number unless you plan to answer it 24 hours every day.  
4. Always make sure the patient and family know how to access care by calling the organization.  

Medication Management 

Medication management, in my opinion, is the biggest asset of the home health care nurse. The home health care nurse will manage medications at every visit. Mismanagement of medications and the resultant side effects are the number one reason patients are re-hospitalized after an acute episode. During transitions from one level of care to another, handoffs are prime times for miscommunication and errors (2). Detailed medication reconciliation should be performed on the initial visit, with a review occurring each visit thereafter. 

A medication reconciliation will involve five steps, as stated by the Agency for Healthcare Research and Quality (2). I have modified that list for the home environment:   

1. Make a list of current medications from the discharge medication profile, if any;  
2. Make a list of medications found in the home; 
3. Compare the medications on the two lists; 
4. Make clinical decisions based on the comparison; specifically medication interactions 
5. Resolve any conflicts by calling the patient’s primary care physician and communicate the new list to appropriate caregivers, the PCP, and the pharmacist.  

During the medication review, ask your patient/family member to get all the medications that the patient has taken or are available in the home if needed. It is acceptable to ask the family to go to the bathrooms and the kitchen cabinets to look into medications they may have on hand, such as over-the-counter pain relievers, supplements, allergy, and other symptom relief medication. Over-the-counter medications and supplements must also be included in your new medication profile, reviewed for interactions, and communicated to the patient’s care team, including the pharmacist.  

Though not required, unless you are with a home care hospice agency, the medication reconciliation should conclude with a pharmacist review and recommendation. Consult your specific agency to determine your resources or call the patient’s community pharmacist to seek assistance. The pharmacist review has been shown to significantly decrease re-hospitalization and poor outcomes due to adverse reactions from dual therapies, medication interactions, and allergies (4).  

You will need to make a habit of reviewing medications at every visit for new additions. The medication regimen can change quickly due to physician appointments attended by the patient, well-meaning family and friends recommending supplements, and family members taking responsibility for symptoms by seeking over-the-counter remedies. The medication review is the same review that will be done by any home surveyors, including The Joint Commission, state and federal regulators. It is one of the most common causes of deficiencies in the home care setting.  

Tips for the Road 

As part of being in the home health care practice environment, you will likely log many miles by vehicle, either your own or company owned. Generally, the average mileage from home to home is 15 or less. When it’s possible, close geographic proximity will ensure most of your day is spent providing nursing care and not driving. It is more challenging to reduce windshield time with emergent calls in rural areas and during high traffic times.  

 My recommendation for making your drive the most efficient possible, given you have flexibility, is to start from a further geographic point and work your way back home. This will ensure your end-of-day drive is the shortest when you are likely more tired and ready to end your day.  

Your car is now your office and needed supplies should be readily available and neatly stored in a closed container. During the week, you will need to ensure that you are carrying the necessary supplies based on the admission care plan for any new patients, such as those required for wound care or labs. In most cases, routine patients will have the option of having supplies delivered directly to their homes. Supplies should be ordered with the discharge date in mind, so you do not end care with supplies to be discarded. Once in the home, regardless of the condition, the supplies cannot be reused. If you are making on-call visits, your home care agency should have a standard list of supplies you will be carrying. When you don’t have a needed supply, there are multiple solutions- request an order for an alternative, have a team member deliver, or order a rushed delivery. There are no alternatives for having too many supplies that can expire or become unusable due to temperatures and poor storage, which must be discarded. Supply waste is expensive, detrimental to the environment, and the ultimate bad outcome.  

Tools for a Home Health Care Nurse

You won’t have a library available to you or reference books at the front desk, but you’ll need them. This is where technology and preparation before the visit come in very handy. Items you will want to prepare prior to going into the patient’s home are education for their specific disease process and tools for tracking and measuring, such as dyspnea rating scales and vital sign trackers. You may not always have a solid internet connection or a working printer, so these may be tools that you print out in advance to have on hand; however, please note that a printer may not be a necessity but can be very useful.  

To ensure the involvement of the family in the plan of care, it is best to leave printed copies of the updated medication profile, plans of care, and a calendar of expected visits for their reference.  

Families need multiple exposures to education, so verbal discussions, pictures, written education, and videos on YouTube should all be part of your offerings. These various tools reinforce education and serve as a reference when you are not in the home. 

Up-to-date reference manuals for drugs, disease identification, and policy and procedures are essential. Your organization may have easy access to these tools online, particularly policies and procedures. There are several apps available in app stores that also make good reference tools. Here are a few of those:  

• Epocrates-pharmacology, adverse effects and safety information 
• Medscape-drugs, diseases, and clinical tools 
• WebMD- research conditions, drug and treatment information, first aid 
• Taber’s Medical Dictionary- in-depth definitions, therapy, abbreviations  
• Pill Identifier- helps identify pills by a visual view 

Documentation 

A home health care expert and proponent of the standardized visit, Andrew Reed, said, “Memory has the half-life of a French fry.” His point is to finish your documentation during your visit, which means at the patient’s home. Most home health care organizations will require you to have your documentation completed the same day and many within two hours of the visit. Due to distractions, never take your documentation back to the office or to your home, where you likely have other responsibilities to attend to.  

Timely documentation is in the best interest of you, the patient and family, and the care team.  Aside from the documentation being more accurate, your team members have information readily available if the patient should call in or if another discipline is seeing the patient after you. Completed documentation ensures you are not taking your work home with you when you leave for the day.  

A habit of reviewing the documentation from previous visits is essential to promote effective communication. It is good to reference meaningful or engaging information from other visits with the patient and family. Referencing information from past visits builds trust in the care team and gives a sense of safety for those you are caring. It also ensures the patient and family are not retelling the same stories and that you and other team members are working together.  

Patient and Family Satisfaction 

Like the hospital, CMS requires surveys with defined questions be sent to patients and families to determine their satisfaction with the care received from home care agencies and specifically provided by the nurse.  

Like the hospital, overall quality of care is one of the most highly regarded measures. Whether or not an individual rates your care as positive is dependent on the satisfaction with different aspects of care. A high rating for overall care in the home care setting is often reliant on positive responses to Training Family to Care for Patients and Getting Timely Help. By assuming the role of an educator of care and disease process, your patients and families are more likely to respond positively to the Overall Quality of Care survey question.   

Conclusion 

While there are some vast differences between home health care and hospital-based care, a home health care nurse is an excellent, independent, and autonomous nurse. The work is still difficult and can be stressful, but there are other advantages to not being contained by four walls, like the flexibility to plan your day and schedule. Home care agencies are most interested in your outcomes and not as much when and how long you work. A few stops in the day to take care of personal matters are not unheard of and generally expected to be part of happy employment. To take advantage of the flexibility and ensure positive outcomes, you will need to develop some consistent habits which include, creating a negotiated care plan with patient and family goals, identified, consistently being prepared with needed supplies, education, and tracking tools, but not too many, timely documentation, maintaining strict boundaries and routine medication management.  

The home health care practice setting can be fulfilling both personally and professionally when you prepare your transition with this different mindset for practice.  

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