Currently, there are a total of 20,000 providers that deliver home care services to 8 million individuals because of acute illness, long-term health conditions, permanent disability, or terminal illness.¹ Like much of the health care industry, home care has undergone major changes since the beginning of the new millennium. During the previous two decades, home care provided nursing services to millions of patients, predominately within the Medicare system, and with payment based on a traditional Medicare model of reimbursement. The advent and popularity of the managed care programs in the 1990s brought the first of many modifications in the model of care and reimbursement. A managed care case manager, rather than the home care nurse, determined the appropriateness of services and only those visits authorized by a case manager would result in reimbursement.

With the enactment of the Balanced Budget Act of 1997, many far-reaching alterations to the health care system including home care resulted in further modifications in health care services. The Prospective Payment System (PPS) now in place for home care caused significant changes in reimbursement and led to a reduced number of agencies able to provide this care. The PPS mirrors the acute care Diagnostic Related Groups (DRG) system, which pays based on a grouping of diagnoses using a rather complicated coding system rather than the actual cost of services.² The fact that nursing assessment and documentation have a direct correlation to reimbursement for home care services and supplies provided reflects the impact of PPS. Documentation from the nurse always had a significant role in reimbursement for home care services because homebound status and skilled need always had to be noted on most home care visits to continue with services. Now the goal of care is to achieve desirable patient and family outcomes within predictable time and resource parameters.³ Nurses who are considering or who have recently entered the home care practice setting need to acquire new and different skills to prepare them for the challenges and opportunities unique to home care.

Getting started

Before hiring nurses into this specialty, most home health agencies require certain basic qualifications, such as at least one year of experience in an acute care setting. Because home care nurses are the “eyes and ears” of the physician, they should have both general clinical knowledge and confidence in their assessment abilities. Keen assessment skills are key to success as a homecare nurse. One also needs to have access to a reliable car, possess a current driver’s license and car insurance, and be willing to travel to locations that are not close to home. Candidates can anticipate seminars and study in order to become familiar with regulatory agencies, regulations, the procurement of medical supplies, and frequently changing documentation styles. Even then, the transition from hospital practice to home care is rarely an easy one, even for the most experienced clinicians. The differences between the two milieus can cause anxiety and frustration in RNs who are not prepared for the adjustment. One of the most common frustrations is being able to balance the workload with documentation requirements so that learning how to manage time is important. Nurses who are considering home care can benefit from spending a day with a home care nurse, after obtaining agency and patient permissions, possibly including a HIPAA waiver. Once you’ve been hired, orientation is not the time to find out that you’re not comfortable providing care in patients’ homes.

Understanding the differences

Both patients and nurses feel more protected in the hospital environment. Patients are assured that someone is always available to provide care; pressing a call button brings qualified staff to a patient within minutes. Nurses also feel secure knowing that other health care personnel and supplies are accessible. Even the routine in an institution is comforting to nurses.

Home care places different demands on practitioners and patients who are accustomed to care in hospitals. It does not attempt to replicate an inpatient setting in patients’ homes⁴ but provides an arena where patients learn to become independent. New home care nurses also acquire autonomy as they learn to function effectively without readily available support systems. Critical thinking and imagination become important, as does making do with less.

A paradox in home care today can occasionally relay confusing messages to both nurses and patients and their families. In the hospital setting, nurses are typically the “doers”; patients and/or family members anticipate a continuation of this role upon admission to home care. However, the primary role of today’s home care nurses is to assess, teach, and assist patients and families to become independent in their care. Both nurses and patients should be prepared for a limited presence of the nurse and use allotted time wisely with maximum efficiency. Explaining your goals to patients and their support system caregivers, as well as understanding the stressors placed on caregivers when services are limited, are essential in obtaining positive patient outcomes and cooperation.

Primary concerns of new home care nurses: protecting the patient, protecting the nurse

New home care nurses are often concerned about the unfamiliar practice setting, personal safety, documentation requirements, and professional advancement opportunities. The practice setting and personal safety can be addressed as parallel themes because they are, in many ways, interconnected.

The Practice Setting: The goal of home nursing is to help the patient and family to be as independent as possible while preserving their usual lifestyle and living arrangements. To achieve these priorities, nurses first need to be sure that the practice setting is safe for their patients as well as themselves. They often deal with elderly or needy clients who may lack such basic services as electricity and running water, which are necessary to comply with instructions about infection control, including the disposal of infectious waste. They become experts in evaluating homes for pests, lead exposure, plumbing, electricity, ventilation, and climate control. Home care nurses routinely check for loose rugs and bathroom mats, exposed wires and cords, loose banisters, and nonfunctioning smoke detectors. Nurses even have to arrange simple safety measures, such as planning an exit in the event of a fire for patients who live with caregivers or alone.

Familiarity with community resources and government agencies can help when they have to intervene on the patient’s behalf by calling a utility company or making a referral to Adult Protective Services or other local agencies. Home care nurses assess settings beyond physical appearance — even the most attractive home can house potential violence, dysfunctional family patterns, and inadequate support systems that can threaten a patient’s well being. Home care nurses come to rely on the participation of patients in their care and family members as full-time allies to achieve positive patient outcomes.

Hospital nurses making the transition to home care need to realize that patients perceive them as guests in their home rather than authority figures. Hospital-like rules do not regulate home environments where personal preferences regarding diet, hygiene, lifestyle, and family relationships are important issues that must be considered in the care plan. Few people are comfortable allowing strange people into the personal space of their homes, and a glance, tone of voice, or attitude of a nurse can build or destroy the patient’s trust in a moment.

Flexibility and dependability are important in the home care relationship. A routine day is an uncommon occurrence and successful visiting nurses acquire keen adaptability to revise schedules and plans as needed and to overcome inclement weather, last-minute changes in case load, and staff sick calls that can challenge a well-planned day. They know that showing up on time for appointments and scheduling visit times for the convenience of the family demonstrates their respect for patients’ need to maintain some control over their lives. Unlike the hospital setting, home care nurses tend to work around the patient’s schedule, rather than the patient conforming to hospital or nursing routines.

Personal safety

When considering home care, many nurses express concern or feel a sense of vulnerability when entering unfamiliar neighborhoods or patient homes. We seem to be inundated with media images of random violence, which raises understandable questions regarding home care and personal safety. As Gates and Krueger point out in their study of workplace violence,⁵ only recently have health care workers actively addressed what the authors call “the silent epidemic.” They have shown that all health care workers, regardless of clinical setting, cope with risks presented by aggressive patients, families, or circumstances. Each of us, regardless of clinical milieu, must be increasingly aware of how to protect ourselves while still providing care to those that require it the most.

Home health nurses often work alone in high crime areas or remote locations and have no means of obtaining assistance such as alarm systems or communication devices.⁵ In addition, they work with patients, family members, and visitors in isolated situations where alcohol and drugs, guns and knives, and dangerous animals may be present.⁵

Nurses need to ensure their own safety when visiting homes in unfamiliar neighborhoods. Although home care agencies, like hospitals, frequently have committees to develop policies and procedures for the security of personnel, several practices can maximize personal safety.^6,7 An important first step for nurses considering home care occurs during the interview process with a potential home health agency employer. When investigating employment opportunities, look for home health agencies that actively work to “eliminate the attitude that violence is part of the job.”⁵ Ask the right questions:

• What steps does the agency take to protect my safety? Do you provide safety training, both during and after orientation?
• What security is available if I ask for it?
• How is nurse safety addressed in committees (e.g., field nurse participation in the safety committee)?
• What role do supervisors play when I report a potential safety concern?

Once out in the field, there are many practices that experienced visiting nurses have developed to reduce potentially unsafe scenarios.⁸

• Be observant and alert to what is happening around you. “Trust your gut” means following your innate instincts. If something feels unsafe, remove yourself from the situation, notify your supervisor, and document the incident.
• Inform the patient what time you will be arriving. When accessing high-risk areas, start as early as possible. Map out the route beforehand and become familiar with street names.
• Don’t carry a pocketbook. Wear a “fanny pack” for essentials, such as a driver’s license, and lock your pocketbook in the trunk of your car before leaving to visit the first patient. Carry only your nursing bag and/or necessary equipment.
• Have a working, fully charged cell phone. Today, this item is as essential as a stethoscope.

In potentially dangerous areas, make joint visits with a coworker or use an escort. If relatives or neighbors become a safety problemIf potentially unsafe relatives do not leave the home, investigate the possibility of the , make visits when they are away from the home. patient residing elsewhere for the duration of home care servicesdocument clearly and unambiguously.

Involve your supervisor, and

• Avoid generalizing or judging the safety of a neighborhood by its apparent affluence. Potential violence can be found in the most affluent areas, and it can take several visits to determine psychological problems or mental health issues of those living in the home. Be alert and observant regardless of perceived socioeconomic status.
• Be careful how much you tell your patient about yourself. In an increasingly technological age, it has become even more important to maintain professional boundaries and limitations. Never share private e-mail addresses, cell phone numbers, or home addresses, and consider removing your name and address from the Internet where patients could locate your residence.
• Many patients have caller ID and can therefore obtain your home telephone number. If you call patients from your home, be sure to block the identification of your personal phone number.
• Most patients are as concerned about your safety as you are. If they suggest that a family member escort you in or out of the neighborhood, take them up on it. However, never enter a stranger’s car under any circumstances.
• Use common sense. Don’t park on deserted streets and keep your gas tank full. Stay alert and keep car windows and doors locked at all times.
• If agency policy permits, wear attire such as scrub suits or lab coats that make it more obvious that you are a nurse. Know your agency’s policy regarding appropriate attire because there are mixed opinions about which apparel increases safety — scrubs or street clothes.
• Attend agency-provided classroom instruction on personal safety and self-defense, especially programs conducted by the police department.
• Keep your car well maintained and be prepared for weather emergencies, especially if visiting patients in rural areas. In the summer, keep a cooler with cold water available; in the winter, keep a shovel and blankets in the car. Always have a current street map available or directions from Mapquest.

Using proper safety measures and recognizing that most neighborhoods are protective of their home care nurses should help alleviate fears about working in the community. Remember that the appearance of a neighborhood is in no way reflective of its safety. Be careful wherever you go.

Documentation

The volume of paperwork required after each visit is a primary cause of dissatisfaction for home care nurses.⁹ Recognizing this problem, many agencies are moving toward computerization. Meanwhile, nurses juggle, by hand, the documentation required by the government, insurance carriers, and their own agencies.

Many home care nurses minimize their notes by using negative charting, a form of charting that only includes patients’ progress in areas that need skilled nursing. Medicare, a federal insurance program for individuals older than age 65 and for those who have permanent disabilities or end-stage renal disease, as well as many other insurance carriers, requires such nursing documentation for reimbursement of home care visits. Documentation standards set by the Conditions of Participation from the Centers for Medicare and Medicaid Services (CMS), the federal governmental body that administers the Medicare program, are so detailed and stringent that they are not only used by Medicare-certified organizations — all Visiting Nurses Associations and many home health agencies — but by many third-party payers as well. All home care patients under Medicare are admitted for one or more of the four qualifying services:

1. Skilled observation and assessment
2. Teaching
3. Therapy (including all prescribed treatments requiring the skill of a professional to perform or supervise)
4. Management and evaluation of a complex plan of care³

Skilled use of the nursing process ensures both individualization and accommodation when assessing and planning for care with complex comorbidity-driven needs. When the nursing process is used, care is planned based upon problems actually experienced by the patient rather than upon expected problems based on the medical diagnosis.³

When services are initiated, the visiting nurse must complete a physician-certified Plan of Treatment (POT), which needs to be periodically reviewed and updated by the nurse and signed by the physician. The initial visit determines services such as nursing; home health aide support; and physical, occupational, and speech therapy, along with the frequency of visits, potential for improvement, and homebound status, all which must be documented for reimbursement purposes. Objective clinical evidence of patients’ needs for intermittent skilled care includes overall management of patient care; procedures, such as tube feedings or ostomy care; and patient/caregiver teaching. Changes in medication regimens, vital signs, or mental status also validate the need for home care visits.¹⁰ The home visit pattern will depend upon the patient’s needs and goals for treatment that are identified during the initial assessment.

Since 1999, all Medicare-certified home care agencies are required to complete home care documents called OASIS (Outcome and Assessment Information Set) for all patients, regardless of payer.^11,12 This documentation is required even if patients need only one or two visits. Some patients find the questions intrusive; however, patients are not required to answer the questions on the OASIS forms.

The Medicare system approves visits for a 60-day period which is referred to as an “episode.” Each visit requires the formulation of a nursing diagnosis, short- and long-term goals, and status of progress toward the goals. Patient care goals need to be stated in terms of what should be accomplished in a specific period of time and have relevance to outcomes measured.¹³ An example would be a home care patient that has a stage-3 pressure ulcer on the heel that occurred in the hospital. The home care RN would document “patient or caregiver demonstrates proper dressing change of wound by eighth visit.” The agency outcomes data that is collected from the OASIS is then evaluated against a national benchmark and reported publicly. Home care staff at all levels are involved in the implementation of these quality initiatives.

Approval is based upon the initial assessment by an RN and the amount of agency reimbursement is determined using a prospective payment system (PPS), which replaced the Interim Payment System (IPS) (based on cost of service) in October 2000.¹⁴ Home care beyond the approved 60-day period requires recertification based upon OASIS documentation and POT.

The advent of OASIS and PPS has changed the home care reimbursement strategy. Reimbursement is based largely on the information documented by the nurse on the multitude of OASIS forms that must be completed at admission and at different intervals throughout the period the patient is receiving care. The questions on the OASIS focus on determining the patient’s clinical severity, functional status, and need for rehabilitative therapy.¹ The information gleaned from these documents is essential for agencies to receive the reimbursement they deserve for the care provided — especially since before the initiation of the OASIS, documentation had been hit or miss and flawed through poor comprehensive assessments.³ Accurate, thoughtful, and comprehensive clinical assessment provides the necessary foundation for planning care for the patient.³ At the present time, the OASIS documentation is not required for private-pay clients. PPS, like DRGs for the inpatient system, can result in financial difficulties if the patient requires lengthier care than PPS will reimburse.

Many patients eligible for Medicare services are inclined to join a managed care plan that manages their Medicare benefits (also called a Medicare wrap-around program). Patients choose this form of insurance because the managed care plan provides prescription plans that the federally funded Medicare program does not offer at the present time. In these circumstances, the nurse may be required to complete documentation that satisfies both Medicare and managed care.

To receive Medicare approval and reimbursement, a patient needs to be homebound and the primary health care provider must document orders for skilled services. If the payer source is a managed care program, it is generally not necessary for the patient to meet the Medicare requirements. However, a managed Medicare program usually follows Medicare guidelines.

Ideally, nurses chart at the time of the visit, and some agencies provide them with laptop computers so they can chart their activities in the field while the information is fresh in their minds. Technology can be used to improve the quality of patient care in the home by allowing the full patient record to be viewed at every visit, thus improving the monitoring of the patient’s status between nursing and therapy visits.¹⁵ Communication and coordination of care are large components of the home care nurses’ responsibilities and are key to the successful provision of home care services.

Because computerized documentation requires certain fields to be completed, visit-to-visit documentation is improved by requiring assessment of objective measures vital signs. Home care nurses should be comfortable with a computer and know how to use of Microsoft Word.

Interventions should correspond with the nursing diagnoses and must be skilled services that only an RN has the ability and education to provide. If a nurse neglects to correctly document a visit, reimbursement may be jeopardized. Home care has also entered a new outcomes environment that emphasizes accountability, responsibility, and the evaluation of agency information against a national benchmark.¹³ In 2002, CMS (2002) defined an outcome as a change in patient health status between two or more points in time that may be due to the care provided or the natural progression of the illness.

Obviously, the documentation requirements prompted by both OASIS and PPS are complex. The OASIS is the key to documentation of patient outcomes; home care providers use the phrase “outcome-based quality improvement” (OBQI) to refer to performance improvement initiatives that enhance the quality of patient care.¹⁶ The OBQI initiative directs the use of these outcomes to improve the quality of home care. The identification and evaluation of best practices in home care — for example, assessing, monitoring, and documenting patient medication compliance and administration — can be found through the OASIS webpage <www.cms.hhs.gov/Manuals> of the USHHS Centers for Medicare and Medicaid.

Be sure that your home health agency provides a complete orientation to the documentation process and requirements, as well as periodic updates as these forms are modified.

Professional advancement opportunities

Home care continues to create many new nursing positions in case management and nursing management that are being filled by nurses with field experience. This underscores why obtaining clinical home care experience is so important for career growth and advancement for nurses new to home health. Experienced home care RNs are also assuming the role of discharge planners, a position once only open to medical social workers. RNs are effective in this position, typically in hospitals or rehabilitation facilities, because of their practical experience with the complex issues of newly discharged patients and the complexity of reimbursement issues. Insurance companies now rely heavily on RNs as case managers. In this capacity, nurses oversee the entire management of a case, including physician intervention and utilization. They are not only responsible for supervision of the clinical component, but also its cost-effectiveness. Other experienced home care nurses are opting for administrative positions within their agencies, but unlike traditional hospital tracks, promotion does not necessarily lead away from patient contact.

Some home care nurses prefer to remain in the field. Because many agencies are developing specialty teams, “specialist” nurses, including nurses with acute care backgrounds, may be able to apply their talents as nurse practitioners, enterostomal therapists, and oncology, rehab, maternal-child, psychiatric, and intravenous therapy nurses.

The right qualities

Successful home care nurses need practical, current clinical experience to care for patients who are being discharged “quicker and sicker.” Physical assessment skills need to be sharp and accurate, especially when immediate decisions regarding patient care must be made. Patients who routinely require home care intervention are those that have conditions that are related to the circulatory system, such as congestive heart failure; injury and poisoning; musculoskeletal and connective tissue disease; respiratory system failure; and neoplasms.¹ The home care nurse must research and remain current on various diseases and conditions to effectively care for the patient and project quality outcomes of care. The home care nurse often first discovers subtle clinical changes that reflect improvement or deterioration. Knowledge of new and current medications is necessary to teach patients how to manage their therapy at home. Expertise with new technology is also essential because of the pumps, tubes, and intravenous medications that now accompany patients to their homes.

To be effective, a home care nurse must be assertive, articulate, and persistent in collaborating with other health care professionals. For example, home care nurses usually do not work face to face with physicians, but must communicate through telephones to relay important information about patient symptoms or to clarify treatment plans.

Another quality found in home care nurses is advanced time management and organizational skills. Juggling patient visits with voluminous paperwork requires self-discipline and structure. Excellent communication skills are also crucial when working with patients, families, and the interdisciplinary team. Being cognizant not only of language, but of the nonverbal cues and perceptions of both nurse and patient help provide clarity to instructions and attitudes regarding illness.

Knowledge of the multiplicity of cultural differences has become more crucial to good home care than it was in prior decades. With the diversity of cultural and religious backgrounds found in the American population of the 21st century, home care nurses must not only be aware of, but also respect these differences in their patients and caregivers. Differences in language can become an obvious barrier to effective communication and teaching, but less obvious cultural differences regarding the conceptualizations of the meaning of “health” and “care” exist within specific cultures.¹⁷ Remember that cultural differences regarding the significance of gender, religion, rituals, diet, birth, and death, all play a crucial role in the nurse-patient relationship.¹⁷ Cultural sensitivity and understanding on the nurse’s part helps to empower the home care patient to have full access to the health care system without sacrificing intense and ingrained cultural connections. Home care nursing can become a true intersection of the cultural attitudes of both the nurse and the patient. It is important, however, to avoid stereotyping or approaching cultural differences in a “cookbook” manner.¹⁸ Rather than assume cultural beliefs or practices, asking the patient about his or her culture in a sincere and respectful way will engender understanding and greatly assist in planning for the patient’s home care experience.

Is home care for you?

Home care is full of rewards, complexities, and independence. The flexibility of this specialty seems to provide nurses with a freedom that they simply cannot find in more traditional clinical settings. Visits can be more accommodating to nurses looking to work part-time or balance family life with work requirements. And the mature nurse has both the life skills and nursing expertise highly valued by patients who depend on the creativity and empathy of the home care nurse developed through years of experience.

But freedom has a price. Home care can be both physically demanding and emotionally draining.¹⁹ A nurse may have difficulty maintaining a well-defined professional boundary when becoming, for a time, a “member of the family.” In the emotion-packed arena of home care, nurses constantly learn valuable lessons about themselves and the people who receive their care.

Home health demands are distinctive, presuming maturity and compassion from its practitioners. It also enables nurses to make profound and long-lasting differences in the quality of their patients’ lives. Home care nurses participate in the many profound milestones in the lives of their patients, sharing sorrow and joy, failure and accomplishment.

The 21st century has indeed introduced new challenges for home care such as the PPS system, which places a greater responsibility on nurses to be sensitive to the financial impact of their clinical decisions. However, being part of the positive clinical outcomes and experiencing the intense nurse-patient interactions are what make home care a gratifying and care-oriented career decision.