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Nursing in the Home

Humphrey, Carolyn J. MS, RN, FAAN

AJN, American Journal of Nursing: January 2009 - Volume 109 - Issue - p 20–21
doi: 10.1097/01.NAJ.0000343103.39308.6d
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As the population ages, the home health nurse's role will become even more important.

Carolyn J. Humphrey is a home health nurse and owner of the consulting firm CJ Humphrey Associates in Louisville, KY.

Contact author: cjhumphrey@bellsouth.net.

I've been a home health nurse for more than 30 years, and in that time home care has changed radically. In the 1980s procedures were relatively simple, such as dressing wounds with plain gauze and monitoring the medications of patients who were discharged only when their course of IV fluids was complete. Today, with patients discharged from hospitals “quicker and sicker,” home health nurses provide complex, high-tech care. We now care for patients on ventilators, deliver IV medications, and monitor patients recently home after major surgery.

Every day approximately 7.6 million people receive care from 83,000 home health care providers.1 Although there are no “typical days” for home health nurses, most see five or six patients per day; however, they may see fewer if any patients are new. To increase efficiency and save driving time and gas, nurses usually work in particular geographic areas. This also helps them become familiar with the neighborhood and its resources. A home health nurse's car is her or his office on wheels, stocked with paper and extra patient supplies as well as the equipment bag that home health nurses have proudly carried for more than a century; however, home health nurses never carry medications.

Patients may be seen at home if they are experiencing acute episodes of chronic conditions, such as heart failure or diabetes, or require assistance with or need instruction regarding wound care. If the patient is terminally ill, the nurse focuses the care plan on the patient and the family to ensure that the patient's wishes are met and that her or his death at home is peaceful. The responsibilities of the home health nurse are self-care education; disease management; safety in the home, including fall prevention; medication management; nutrition; and other aspects of health care that improve patients' quality of life and, above all, keep them in their homes and out of the hospital.

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HOME HEALTH CARE TRENDS

As with all sectors of health care these days, the challenge facing in-home care is paying for it. Most of the cost is borne by Medicare and Medicaid. In 1996, Medicare spending for home health care was $16.8 million; in 2005, it dropped to $12.9 million.1 The struggle for funding is ongoing. Nevertheless, the following factors ensure that there will be a population base for in-home care for some time to come:

  • Baby boomers are aging, and the number of older Americans is expected to more than double to 71 million by the year 2030.2
  • Many people would rather be cared for in their homes than in institutions.
  • The nursing shortage will require us to learn to care for each other.
  • In the future, consumers will pay more of their health care costs.

The benefits of home health care make it a desirable option for many patients:

  • Patients are less likely to be exposed to the drug-resistant “superbugs” that can be found in institutions; thus, they may avoid serious infections.
  • Patients are well rested when given treatments rather than exhausted from traveling to the service site.
  • Home health care is often less expensive than care provided in hospitals and other institutions.
  • Patients who live far from inpatient facilities don't have to arrange or pay for travel.
  • Nurses can teach patients or caregivers how to perform procedures themselves.
  • Family-centered end-of-life care can be provided in the home for terminally ill patients.
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OPPORTUNITIES FOR HOME HEALTH NURSES

Based on my experiences and those of my colleagues, home health care is frequently, and erroneously, viewed as an easier practice setting that requires less clinical competence than a hospital. But home health care requires nurses to have excellent environmental, social, and physical-assessment skills; clinical decision-making and problem- solving abilities; expertise in working with families and communities; and the ability to work autonomously. It also offers nurses a chance to branch out and follow their professional interests. For example, many NPs and other advanced practice nurses have carved out niches for themselves by developing in-home programs for wound care and cardiac, diabetic, and disease management.

In October 2007 the median hourly salary for a home health RN was $25.50.1 Keep in mind, however, that pay varies depending on several factors, such as whether a nurse practices in a rural or urban area or works for a large or small agency.

Working in home care doesn't deprive nurses of the opportunity to take advantage of new technologies. Use of telehealth in the home care setting is steadily growing. For example, placing a small, simple telemonitoring device in the home allows the patient to measure her or his daily heart rate, weight, blood pressure, blood sugar, oxygen saturation, and other measures. This information can then be sent from the home device to a central monitoring area or to the home health agency. In either case, a nurse reviews each patient's information against the previous day's data and the patient's baseline data. If deviations from the normal value ranges are found, the nurse calls the patient to assess possible causes and intervenes by directly teaching the patient, collaborating with the patient's physician, or modifying the patient's care or treatment plan.

Another technologic breakthrough for the home health nurse is use of electronic point-of-care systems. During a visit, the nurse can document most data on a laptop computer, personal digital assistant, or pen-based computer clipboard, saving time and reducing errors. Many homes don't have adequate space to allow nurses to do their necessary paperwork. Having a safe and secure way to collect this information—one that is also compliant with the Health Insurance Portability and Accountability Act of 1996, known as HIPAA—frees up a nurse's hands and time, and the information is immediately available for agency access, physician orders, and quality improvement studies.

With America's aging population increasing, home health care is likely to be needed by an increasing number of patients in the years ahead. But how can the nursing profession meet this growing demand?

I believe home health care will be the choice of more and more nurses once they experience the autonomy of working as home health nurses, the one-on-one relationships they can establish with patients and families, and the creative ways they can treat patients in their homes.

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Home Health Nursing Resources

Home Healthcare Nurses Association; www.hhna.org.

Home Healthcare Nurse, the journal for home care and hospice professionals; www.homehealthcarenurseonline.com.

Home Health Nursing Scope and Standards of Practice, a book published by the American Nurses Association and written primarily for practicing nurses, is helpful for anyone interested in the field; http://nursingworld.org/books/pdescr.cfm?cnum=15#97815.

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REFERENCES

1. National Association for Home Care and Hospice. Basic statistics about home care. Updated 2008.http://www.nahc.org/facts/08HC_Stats.pdf.
2. Centers for Disease Control and Prevention and The Merck Company Foundation. The State of Aging and Health in America 2007. Whitehouse Station, NJ: The Merck Company Foundation; 2007.http://www.cdc.gov/aging/pdf/saha_2007.pdf.
© 2009 Lippincott Williams & Wilkins, Inc.