Home Health Nursing
Attempting to fit it in a box
“What kind of nurse are you?”
“I work in home health”.
“Oh… okay!”
The end.
What follows is what I wish I had the time to explain (to my patients, their caregivers, my family, acquaintances, and internet strangers) about what Home Health is and what it isn’t. I start with how I came to Home Health after 10 years of working in hospitals, the best and hardest parts of working in the home, and end by shining a dim light on an unclear path forward. This is a longer post, because the answers are nuanced. I appreciate you taking the time to look through this lens of healthcare and nursing! Click the play button at the top to listen to me talk you through it :)
Journey Home
Home Health is a version of healthcare unlike any other. I didn’t know it until I jumped onboard, and I did so by telling myself “I can do anything for a year”. Well, here I am 3+ years later and still certain that home care is the last frontier of Modern American Healthcare. Or at least the best version of Nursing right now.
I got here by chance, which is a similar path to many.
Before coming to home health, I never truly understood what home health clinicians did. I had discharged hundreds of patients home with a referral for “home health services”. I explained their discharge instructions, told them to expect a call from the home health nurse, and left it at that.
In nursing school, we did a rotation in “Community Health”, and part of my clinical experience was supposed to be home health. I got as far as the Visiting Nurse’s Association clinic, but never stepped foot in the home of a patient. Ever. And it took a layoff for me to even consider it.
I took what I consider a pretty big leap of faith by applying, interviewing, and accepting a position for a job I had literally zero understanding of what I would be doing. I was an eager learner, an experienced nurse, and no other level of care appealed to me anyway. I’d done acute care (hospitals) for 10 years and knew, unequivocally, that I was done with that indefinitely. I’d never worked in a Skilled Nursing Facility (SNF), but the horror stories I’d heard from patients, caregivers, and healthcare workers was enough to deter me entirely. I considered a position in a clinic (like a doctor’s office or specialty clinic), and had even interviewed in a few. I probably would have enjoyed it fine, but one office was a heart failure clinic and my background was primarily neurology/stroke/telemetry and a bit of medical/surgical management. The other interview was at an outpatient cardio/pulmonary rehab center and they chose an internal candidate who was spooked into applying when they brought in an external interview candidate for the position (me).
I also considered a remote or telephone job, one where I wouldn’t be “patient-facing”, but could still positively impact the lives of patients in some way. There were also nursing jobs that never interacted with patients at all, but reviewed patient records and collaborated with insurance companies to try to maximize the reimbursement for services. Gross. Not for me. Too little patient interaction for me.
I also knew then that I had no interest in a management or leadership position. I’d had a management job that tried to kill me, and if it wasn’t for a well-timed lay-off (or “reduction in force/RIF” as it’s quietly described in the biz), I truly don’t like to imagine the bloated bloody pulp of my body and spirit after that place was done with me (I’m being a bit dramatic here for literary flair, but that job was the hardest I’ve ever had, and I poured my whole self into it until I was rescued). You can’t pour from an empty cup, and Modern American Healthcare Leadership seemed to keep poking holes in the bottom of mine.
So, okay, Home Health. A position in my own town, at a company I’d worked for previously and had a good experience with on the acute care side. Let’s see what this is like.
What is Home Health?
Here’s what I’ve learned through experience:
Home Health (the kind that’s covered by most health insurances) is short-term, intermittent care provided by skilled disciplines such as nursing, rehab (physical, occupational, and speech therapy), medical social work, and home health aides (CNAs).
Okay, what does that mean?
It means that these Healthcare Workers (We, the HCW) come to the homes of patients (admit), develop a plan of care including goals and interventions, provide care according to our specialties, teach patients and their caregivers how to do what we’ve come to do, and eventually leave (discharge).
But what do you do?
Depends on the discipline, and since I’m a nurse I’ll speak to that. Nurses have a variety of skilled interventions we can perform (and teach patients/caregivers to do in our absence). This includes
Simple and complex wound care (assessment, negative pressure wound therapy, wound packing, staple and suture removal, and so on)
Infusion management (IV line care, pump or device teaching, assessment of the line, labs, etc.)
Medication teaching and management (pillbox set-up, teaching about the purpose, side effects, timing, etc., collaboration with providers about dose adjustment, etc.)
Disease teaching and management
Diabetes - new or existing people with diabetes, including checking blood glucose (sugar), teaching about avoiding/managing high/low blood sugar, teaching and monitoring for complications of the disease (peripheral neuropathies, wounds), medications
Heart Failure - diet, weight monitoring, symptoms to report and to whom and so on
COPD
Stroke
Infection treatment and prevention
Device management and teaching
Pleural catheters and chest tubes
Urinary catheter
NPWT/Wound vacs
Caregiver training
Teaching the patient’s caregivers/family how to do everything to safely manage this human body from the safety of the patient’s home, and who to call when things don’t go as expected.
The list feels endless.
Jack-Of-All-Trades
When I worked on the Neuro/Stroke unit, I knew my specialty. It fit into a pretty box. I would, of course, see patients outside of that box quite regularly, but a majority of my patients had been diagnosed with a stroke, seizure, or other neurologic disorder or disease. I occasionally saw patients from the surgical unit, rarely saw any from oncology, and almost never saw anyone pregnant or post-delivery. I would see a chest tube every now and then. Some of my patients had feeding tubes following a stroke, some were detoxing from substances like alcohol, and others were suffering from complications of gastrointestinal problems like Crohn’s Disease and ended up on IV nutrition or with a perforated bowel and emergency abdominal surgery. I took care of people before, during, and after they elected hospice. We had specialists and specialty units for all kinds of problems: diabetes, heart failure, ostomy, wound care, NPWT, oncology, and so on). No job is perfect or they wouldn’t pay you to do it. I didn’t know until I was given the view looking back that it was nice knowing, generally, what to expect.
The med-surg/telemetry unit I found myself managing several years later was much much different. I got to see a bigger variety of patient conditions, surgeries, and complications.
And yet nothing could have prepared me for my dive into Home Health.
Mary-Gary-Barry-Sam Poppins — Master of Some
I say I’m like the Mary Poppins of Healthcare. I arrive with my bottomless healthcare bag and timeless experience in my mind. I’m a Jack-of-all-trades (and a master of some). I have a referral with some important information, spend some time assessing and interviewing, compile a list of problems and intended interventions, document my findings, and turn it into a Home Health Plan of Care with goals and interventions. Then I come to people’s homes a few times a week, usually for several weeks, but sometimes shorter, and often longer. Nursing visit lengths vary depending on the needs of the patient. Could be an hour or two for an admission or a medically complex patient, could be as short as 45 minutes when we’re getting close to ready for discharge and the needs are dwindling. I get to use all my senses when I’m in a home to figure out the patient’s needs. Some are forthcoming and honest, thankful to have the help and offering up anything that will get them additional assistance or services.
Others are like a puzzle surprise box. You don’t know what you’re getting till you walk in, and every visit is something new and different. Not home at the agreed upon time. Home, but somehow all the home health supplies have disappeared, missing meds, mixed up meds, mismanaged wounds, yanked out catheters, misplaced papers, and so on.
I took you down and around the long way, because Home Health doesn’t fit into a pretty box like specialty units in large suburban teaching hospitals. Home Health can’t be explained in a sentence as simply as “I take care of patients after they’ve had a stroke”. Even Neuro/Stroke, Nursing, and Healthcare are nuanced.
Shine a Light Through the Gaps
More than anything, what I’ve found coming to the home as a nurse is GAPS. Gaps in care and services. Gaps between what’s needed and what’s available or affordable. The big one is gaps in time and caregiver services. Patients seem to be left wanting and needing more. More of our time in the home, more help with meal prep, bathing, toileting, or housekeeping. More help with transportation to doctor appointments, grocery shopping. More access to healthy fresh foods, prepared and served, and sometimes fed to them. More socialization. More connection.
People who qualify for Home Health services must be homebound. Meaning they can’t leave the home except with great difficulty, and only when absolutely necessary.
Home Health is filled with loneliness.
I’d like to believe I got to fill that void for some of my patients. I’d also like to believe someone will do the same for me in my loneliness.
Because our human needs are quite simple, really:
Feed me
Water me
Bathe me
Clean my surroundings
Play with me
Keep me company
Protect me
We have Health Insurance to help with some of that, temporarily. But after that’s exhausted, the other options can be quite a financial burden. And another gap I’ve found in home health is the income/wealth disparities. The extremely rich can afford private duty caregivers at whatever rate and frequency they request. They can throw money at the problem. The extremely poor qualify for community resources through the county or the state, which might include a caregiver, homemaker, rides, etc. Sometimes those services suffice, but often they are too little, too late. And in between? Across the spectrum? Are folks choosing between paying for the necessary services, or getting by with almost enough.
If a caregiver service through an agency is $30-35/hour (good luck finding pricing online, you have to call for a consultation first), people are deciding which 4 hours a day are the most necessary. Or they’ll find someone through Craigslist or word-of-mouth, and hope they’re a caring and trustworthy person to invite in their home and care for their most intimate needs. (Of note, those caregiver services do not pass the whole $30-35/hr on to those providing the care. The private paid caregiver or CNA is likely making $13-15/hour. And those services include laundry, dishes, light housekeeping, meal prep, grooming, bathing, toileting, incontinence care, and transferring. That’s right, they take care of our most private of parts and make less than a worker at Whole Foods. What the fucking fuck is wrong with our country’s priorities right now?)
How about Whole Foods, just for kicks?
I could break down costs of rides in wheelchair busses, the costs of prescription medications, the high insurance premiums and rising deductibles and out-of-pocket limits, the cost of office visits for specialists or those out-of-network providers….
Look at her go, folks! Another tangent, but we’re bringing it back around.
What I Do Now
What I do in Home Health now is teach. I teach new clinicians how to provide this care, to protect their peace, and to maintain boundaries so they don’t overcommit or give too much of themselves to a job/profession/vocation that will quietly suck the life out of us if we let it. I teach and I listen.
I listen to the stories of patients who’ve been to other levels of care. To clinicians coming from acute care, skilled nursing facilities, other home health agencies, wherever. I hear these stories, and I know I have a purpose in carrying them forward. In bringing our lights together and shining brightly on what Healthcare should be. Could be. Will be.
So as we set our sights on where we’re heading, does it help to understand what’s happening in the community? Because, in the words of our friend Dorothy, “There’s no place like home”. And if everyone wants to be there, nobody is prepared to support them… yet.
What Can WE Do?
Our next steps are to leverage those in home settings. Remote workers, students, part-time workers. Leverage whatever time we can get to train people to care for folks in their homes. Help them see the dire need for these services, urgently, so we alleviate the burdens on other levels of care (including Home Health). Neighbors caring for neighbors, college students accompanying homebound elders to doctor’s appointments, or prepping meals, or light housekeeping, or gardening, or socialization, or care navigation…
If I squint, I can start to see it.
Then reality presses my eyes closed. And I lose sight of it again.
Do you see it?
Love,
Jessie, RN