The nursing shortage. For years, those three words have invoked concern, fear and even panic among nurses, healthcare leaders and recruiters.
Though the phrase is usually mentioned regarding hospital settings, a home care nursing shortage is being felt specifically by families who have children with complex medical needs.
Though the home care nursing shortage is widespread, some locations have been hit harder than others, such as rural areas.
Complex pediatric patients and their families are often on the receiving end of the shortage’s devastating effects, said internist and pediatrician Garey Noritz, who serves as director of the Comprehensive Cerebral Palsy Program at Nationwide Children’s Hospital in Columbus, Ohio.
Contributing factors to home care nursing shortage
According to Noritz, a professor of pediatrics at Ohio State University, the home care nursing shortage is severe because of several key factors, including:
- Significant pay disparities between hospital-based versus home care nursing jobs (hospitals pay more).
- A shortage of nurses overall, and the availability of higher-paying positions elsewhere.
- Isolation in home care nursing because of a lack of socialization with colleagues.
- Complex pediatric patients are hospitalized frequently and, when they are admitted, their assigned home care nurse is temporarily out of work, which means a loss of income.
“It’s not difficult to hire RNs, but it can be challenging to find experienced RNs to care for children with special needs,” said Nick Provost, president of New Jersey Total Care of Paramus, N.J. “Many nurses don’t stay in home care. It can be a revolving door. The pay rates are lower in home health due to the lower reimbursement rates that kicked in since 2014 in New Jersey with the Affordable Care Act.”
Pediatric patients pay the price
So how does the home care nursing shortage impact young patients? Noritz said a lack of nurses typically leads to longer hospital stays for medically complex children.
“It impacts our ability to get these kids home,” he said.
In a report published in January 2019 by the journal Pediatrics, researchers conducted a 12-month study of multiple home care sites in Minnesota involving medically complex children, all of whom were discharged with home health.
“The average child going home for the first time with an order for in-home nursing care spent nearly 54 additional days on average in the hospital due to the lack of in-home nurses to provide care after discharge,” said Roy Maynard, MD, FAAP, medical director at Pediatric Home Service based in Roseville, Minn., a provider of high-tech home care for children with medical complexities in Minnesota and Wisconsin.
Maynard was the lead author of the study, which concluded that a lack of home care nurses was the most frequent cause of delayed discharge of patients and increased costs.
A cost analysis in this study revealed “delayed discharge resulted in an added cost of approximately $170,000 per patient and an overall increased cost of $5 million to the healthcare system in Minnesota alone,” said Maynard, a former executive committee member for the American Academy of Pediatrics Section for Home Care, and a retired neonatologist and pediatric pulmonologist at Children’s Hospital in Minneapolis.
Findings also discovered the pediatric population with tracheotomies and ventilators is increasing.
“One reason for the increased number of children with medical complexity is better cardiac surgical techniques for children,” the study stated. “More kids are saved. However, they’re dependent on tracheotomies and ventilators. Their survival rates have increased, they’re living longer and their quality of life has improved — but they’re not liberated from their dependence on medical technologies.”
Insurance and time challenges
Getting in-home nursing care approved by a patient’s insurance — and in a timely manner — can be challenging, as well. “Once approved, the second hurdle is finding nurses available to staff all of the hours that have been approved,” Noritz said.
The lack of approved hours by insurance, along with the home care nursing shortage, requires parents pick up the slack. “The typical number of hours approved for patients on a ventilator is only eight hours per day,” Nortiz said. “This requires us to always train the parents.”
The impact on the families of children with medical complexity also is significant. “This causes increased stress on the family as they try to provide care to their child,” Maynard said. “Many parents are unable to work. A parent cannot work if they have to be home providing care. This decreases their earnings and increases financial burdens.”
In a 2018 study published in the Journal of Hospice and Palliative Care Nursing, researchers wrote that nursing shortages are mostly discussed based on how they impact the hospital setting rather than the impact on parents and families.
In fact, family members provided an average of 73.5 hours per week of nursing care for their ill children, said the study, which was led by Meaghann Shaw Weaver, MD, MPH, who serves as chief of the division of pediatric palliative care at the University of Nebraska Medical Center in Omaha.
Impact on the elderly
The lack of in-home nurses also adversely affects the elderly, said Ron Ordona, DNP, FNP-BC, chairman of the Gerontological Advanced Practice Nurses Association’s House Calls Special Interest Group and a primary care medical house call provider for home-bound seniors with Senior Care Clinic Medical House Calls, based in Lincoln, Calif.
Ordona, who is board certified in gerontology and family practice, said there is a great need for home-based primary care providers for home-bound elderly patients.
“A 2018 report prepared for the Association of American Medical Colleges projected a primary care shortage of between 14,800 and 49,300 physicians by 2030. Nurse practitioners can help fill the gaps as primary care providers, including the provision of home-based primary care for home-bound elderly patients,” said Ordon, clinical faculty at Boise State University and volunteer clinical faculty and founding donor at UC Davis Betty Irene Moore School of Nursing.
The shortage of in-home nurses and home-based primary care providers for the elderly leads to the exacerbation of chronic conditions, Ordona said.
“This creates stress for family members and assisted living staff, and results in an increased use of the emergency department for primary care access, costing an average of $2,500 to $5,000 per visit,” Ordona said.
Strategies to resolve the shortage
Ordona suggests three ideas to address the home care nursing shortage:
- Expose undergraduate nurses and graduate/advanced practice nursing students to community-based care.
- Allow full practice authority for APRNs.
- Remove barriers for NPs for signing home health orders, which delays care for patients.
Maynard proposed recognizing home care nursing as a specialty, paying nurses for what they do, and not for where they work.
“Home-based nurses provide complex care to patients with ventilators, for example, just like ICU nurses do,” he said.
Additional suggestions from Maynard include offering flexible scheduling and if a patient is hospitalized, finding another place for their nurse to work so they can make ends meet.
There is a critical need, according to Noritz, to increase salary rates for home care nurses. “The competition from hospitals is stiff. They can pay nurses more,” Nortiz said. “Also, finding ways for in-home nurses to connect with each other is important, so they don’t feel so isolated.”
Provost said increasing reimbursement rates for in-home nursing care from Medicaid, Medicare and private insurance would help increase pay rates for nurses.
Despite the challenges for nurses providing in-home care, it’s very rewarding work, agreed Noritz and Ordona.
Take these courses to learn more about home care:
Becoming a Home Health Nurse
(2.5 contact hrs)
According to statistics and projections from the National Bureau of Labor and the Health Resources and Services Administration, the need for nurses skilled at providing care to patients in their homes is growing. This is a good time to consider a career in home health nursing. This course provides an overview of the type of care provided by home health nurses, their roles and responsibilities, and the challenges associated with home healthcare.
Managing Legal Risks In Home Healthcare
(1 contact hr)
The demand for providers of home health services, especially RNs, continues to increase. In a May 2017 summary, the U.S. Bureau of Labor Statistics reports 12.84% of RNs, or 179,310, worked in home healthcare. While some legal risks for nurses translate across all settings, the home care setting has some unique situations nurses should be prepared to recognize and manage.
Team-Based Healthcare: Helping to Improve Patient Outcomes
(1 contact hr)
Use of the interprofessional team approach has led to improved outcomes in some patient populations and disease states. Many different models exist and all can be adapted to fit specific population needs. As healthcare reimbursement continues to evolve, team-based approaches may be warranted to optimize patient care.