HELP! New to HHN and sinking....

lossforimagination · Dec 29, 2004

You know...the issue is so far above the agencies. It really has to do with the value of nursing in general and of course, Medicare.

I don't really agree with that; I think it's just some crapola they're feeding you so they can get away screwing you over.

I'm new to HHN and I'm paid $18/hr, get 0.30/mile, and have a company cell phone. I write all time worked on my weekly time sheet and get paid for all of it.... including time and 1/2 for over 40 hrs/wk. (And I thought my pay was lousy!) I don't get paid for any on call time though, unless I have to go see a client.

I think the problem is that nurses just go along with whatever screwing employers want to dish out. I guess all you can do is negotiate all this stuff up front before you hire on for your next position.

RetiredMSN · Dec 29, 2004

lossforimagination, you definitely have a point. I have come to the place where I feel that until nurses see the need to organize and be empowered, instead of complaining helplessly, no progress can be made in any of these work situations. The beginning is to join your professional nursing organization, then become acquainted with collective bargaining. Until then, we will continue being the rugs the administrators and bureaucrats walk over! (Pretty strong for a retired person, but that's where I am now. Once a nurse, always a nurse!)

RetiredMSN :nurse:

alintanurse · Jan 2, 2005

lossforimagination, you definitely have a point. I have come to the place where I feel that until nurses see the need to organize and be empowered, instead of complaining helplessly, no progress can be made in any of these work situations. The beginning is to join your professional nursing organization, then become acquainted with collective bargaining. Until then, we will continue being the rugs the administrators and bureaucrats walk over! (Pretty strong for a retired person, but that's where I am now. Once a nurse, always a nurse!)
RetiredMSN

Dallas RN--Please read retired MSN's replies as they are very helpful. I have been in home health for eleven years,when I first started I had usually eight pts. but the paperwork is not what it is now. You have to be very organized but because you're new to this field you don't may not have the clout of a more experienced nurse,if you can stick with it to learn and then move on to another agency where you can negotiate. I recently have hired on with an agency that will pay me an hourly rate if my open's go beyond 2 hours. I also am per diem. I made sure that I would not have to do call or case manage. I will strictly do visits,recerts and open's if needed and I have the option to go PT with benefits in the future if I like it there. I made sure I am only covering a small area travelwise and am getting mileage at 37cents a mile.I will work one weekend every 6 weeks,because I've been around the block I knew what to ask for up front. The agency is very happy to get me too,so they were very willing to negotiate. I am also doing work comp case management (as you and I communicated about earlier today) I would be happy to assist you in anyway I can,it may take me a few days to get back to you--but I will reply! Good Luck ! also in the eleven years I have never had a cell phone,I have managed this as others have suggested-by calling the doctor from the pts. home then calling the office to let my supervisor handle it from there,also if I was on the road and needed to make a call I would call the agencies 800 number to either speak with my supervisor or have them connect me to the number I needed. You have to be very creative and push the costs where they belong-- on the employer. :) :)

DallasRN · Jan 2, 2005

RetiredMSN,

I just read your posts and wanted to respond - haven't finished reading the others yet.

You make some very valid points in terms of organization, cell phone usage, etc. I do spend a lot of time teaching my patients, and also, I give them my home phone number. I even tell them point blank...don't call me on the cell phone unless it is really important - it's expensive! And believe me, these elderly that are living on fixed incomes understand and respect this. And very, very rarely do they call me at home. Once or twice - only - and that was from family regarding patients that had gone to the hospital. Most of the incoming cell phone usage is from the office staff and me having to respond to their calls. I do use the patients phone when in their homes, tho' I was initially told not to. Perhaps I misunderstood that comment.

Anyway, one of the things I did the past two days was take a tape recorder with me and tape all the pertinent info. Yes, that leaves me to come home and have to transcribe. However, I found that it really did speed things us. On Friday, I saw 5 patients, starting at 8:15 AM and was home at 4:00 PM with a little time for lunch thrown in. And a bathroom break! The transcription took up time at home, but for me, that was far better thangetting home at 7:30 - 8:00. The other thing...with the tape recorder, I can listen to the tape for just a couple of minutes, and the entire visit rushes back into my brain. I recall all details without listening to the entire tape and can whip through the documentation. PLUS! I don't leave out salient points, either, in terms of exactly the teaching I did. That is good, too.

Last week, I talked to my supervisor's manager, the DON (with my sups permission) about the issues. He was very pleasant and really listened, but there isn't too much he can do, either. He did make a couple of offers in terms of cell phone usage (a cell-phone "sliding scale" of sorts based on the number of visits per week) and if I have to travel in excess of XX miles to admit, he'll reimburse at a higher rate. But that was about it and frankly, tho' it is something, it is a drop in the bucket. The one thing he DID offer was a day to ride with another nurse that is known as the epitome of organizational skills. I'm going to take him up on that offer before I start making any final decisions as I want to be positive nothing can be done to help myself prior to making the decision to leave. I honestly do feel that a portion of the issue is me - organizationally speaking - and want to give the company and myself a fair shot.

Now...what prompted my response was your comment about writing to the congressman/woman. Yeah, that, too, was something I discussed with the DON...making the comment that I would go to Congress if necessary because the people REALLY affected by people like me leaving are the Medicare recipents. Reimbursements are ridiculous! The gov't got involved in the nursing shortage and funnelled bucks into lessening the affects of the shortage (fed funds to schools, tuition forgiveness, etc.), yet this? And to think, the baby-boom generation is just now getting to the age of qualifying for Medicare. What then? You give me the time (and appropriate pay) and I can keep some of these elderly OUT of the hospitals (to the tune of an average of around $4,000/day) with teaching, assessments, communication with physicians and other providers. Yet they want to begrudge me a decent wage? Me? The same person they are trying to KEEP in the field of nursing? Oh, yeah...I have lots to say on the subject. My State Senator, Kaye Bailey Hutchison (Texas) is primarily involved in defense, but she is wonderful and "listens" to her constituents. On my schedule for next week is the note to call her office. I want to actually visit her. And I bet I'll be successful! It may require wait time and more than one phone call, but I've taken this on as a rather personal thing since I'm rapidly approaching the age of Medicare, too.

I told the DON the other day, and I believe it to be true...they can either pay me more and keep me as an employee, OR...they can be in a perpetual hiring mode accompanied by the costs of orientation, the costs of mistakes and misuse of supplies that all new people go through, the costs of advertising for nurses and the endless weeding out of good and bad, putting the stress of the caseload of the nurse that quits on the other nurses, decreased credibility with referral sources, etc...all those sorts of things. I didn't say all of that as a "threat" but as reality. It's true, and he knows it, too. He's a sharp cookie! Unfortunately, the hands of many of these agencies are tied by the reimbursement system.

OK...my diatribe. Very much enjoyed your comments RetiredMSN. I'm sure I'll have more to say later. :)

DallasRN · Jan 2, 2005

lossforimagination, you definitely have a point. I have come to the place where I feel that until nurses see the need to organize and be empowered, instead of complaining helplessly, no progress can be made in any of these work situations. The beginning is to join your professional nursing organization, then become acquainted with collective bargaining. Until then, we will continue being the rugs the administrators and bureaucrats walk over! (Pretty strong for a retired person, but that's where I am now. Once a nurse, always a nurse!)
RetiredMSN

Yeah! Exactly! See? I knew I'd have more to say, and the Retired one is saying it for me! Thanks!

DallasRN · Jan 2, 2005

Dallas RN--Please read retired MSN's replies as they are very helpful. I have been in home health for eleven years,when I first started I had usually eight pts. but the paperwork is not what it is now. You have to be very organized but because you're new to this field you don't may not have the clout of a more experienced nurse,if you can stick with it to learn and then move on to another agency where you can negotiate. I recently have hired on with an agency that will pay me an hourly rate if my open's go beyond 2 hours. I also am per diem. I made sure that I would not have to do call or case manage. I will strictly do visits,recerts and open's if needed and I have the option to go PT with benefits in the future if I like it there. I made sure I am only covering a small area travelwise and am getting mileage at 37cents a mile.I will work one weekend every 6 weeks,because I've been around the block I knew what to ask for up front. The agency is very happy to get me too,so they were very willing to negotiate. I am also doing work comp case management (as you and I communicated about earlier today) I would be happy to assist you in anyway I can,it may take me a few days to get back to you--but I will reply! Good Luck ! also in the eleven years I have never had a cell phone,I have managed this as others have suggested-by calling the doctor from the pts. home then calling the office to let my supervisor handle it from there,also if I was on the road and needed to make a call I would call the agencies 800 number to either speak with my supervisor or have them connect me to the number I needed. You have to be very creative and push the costs where they belong-- on the employer. :) :)

I know this is going to sound rather "stupid" - maybe naive would be a better word. But I don't know if I am "case managing" or not? My supervisor has made the comment on several occasions about "your background in case management..." Can someone please define for me exactly what the role of the CM in HHN is? Then, perhaps, I can determine if this is what I'm doing. Talk about feeling dumb with these comments!!! But until you ask...

My mileage is reimbursed at $0.30/mile but the trip to the first visit of the day is NOT reimbursed nor is the FINAL trip home. They consider that driving to and from work. However, the numerous trips to and from the office are not reimbursable. That's something I don't get at all. I'm working from my home, yes...but, I'm doing their work from my home. I often think I'd be better off driving into the office at 7:30, starting my day there, and ending my day there. One of the things I'm learning is that I have to watch things very, very carefully. For example, on Monday AM's, I DO have to go to the office to drop off paperwork. Following that, I make my first visit. Now, I'm watching my checks carefully, because, yes...the mileage from the office to the first visit SHOULD be paid as I was in the office! See what I mean?

Lots and lots of issues - many of which I responded to in Retired's post. Excellent post, by the way! And I am getting better at calling or faxing the office and saying..."you call the doctor, etc." The other thing...cell phone. I've about decided...no where in the pre-employment stuff was the necessity of having a cell phone discussed. In other words, not a requirement that was discussed up front. Therefore...I've told everyone - do not call me on that cell unless it is an absolute emergency. Period. If you have a referral that needs to be handled ASAP, too bad. When you decide to reimburse me, you can contact me. It's such a petty thing, I know, but it's just part of it. The DON I spoke with suggested I get some particular plan for $59.99/month with 3000 minutes. Not a bad deal, but IMO, the company should pay for that plan and not expect me to fit the bill to meet their communication needs.

Lots of issues - a very few with my particular company, but many with the system itself. Thanks for your words.

Traveler · Jan 2, 2005

Several people have brought up the very good point of hh not being respected in the way of reimbursement, etc. Hospitals have many more lobbyists than hh does. I happened to be in the office the other day in between patients and a family member of one of our patients called in a panic, reporting that she had "passed out", became disoriented, lost all color and then vomited. My first reaction was to tell him to get her to the hospital until I started asking more questions. It turns out she was on the commode when this happened. This led me to believe it was probably a vagal reaction, so I told him that I would be right over to assess her. When I got there the patient was fine and over her "spell." I did some teaching about vagal things and instructed the family to increase fluids, fiber, and consider a stool softener and keep track of her bowels. I also told them to report any further indcidents and try to avoid enemas, manual disimpactions, etc. The family was very relieved and thankful. Two days later the daughter of the patient came into our office with homemade potholders and apple butter for all of the staff. Tearfully she told us how thankful she was for us and wondered why hh had to fight so much for recognition, reimbursement, etc. Things like that really make it all worthwhile. But, it does point out that the big problem is that what we do and the cost saving that we provide is immense. With the increase in shorter hospitalizations and sicker patients going home, maybe we will come into our own one day. A big part of it is educating the public about what we do. I have found the best way to do this is to just do a good job and take good care of our patients. The doctors see that and so does the community.

alintanurse · Jan 2, 2005

I know this is going to sound rather "stupid" - maybe naive would be a better word. But I don't know if I am "case managing" or not? My supervisor has made the comment on several occasions about "your background in case management..." Can someone please define for me exactly what the role of the CM in HHN is? Then, perhaps, I can determine if this is what I'm doing. Talk about feeling dumb with these comments!!! But until you ask...
My mileage is reimbursed at $0.30/mile but the trip to the first visit of the day is NOT reimbursed nor is the FINAL trip home. They consider that driving to and from work. However, the numerous trips to and from the office are not reimbursable. That's something I don't get at all. I'm working from my home, yes...but, I'm doing their work from my home. I often think I'd be better off driving into the office at 7:30, starting my day there, and ending my day there. One of the things I'm learning is that I have to watch things very, very carefully. For example, on Monday AM's, I DO have to go to the office to drop off paperwork. Following that, I make my first visit. Now, I'm watching my checks carefully, because, yes...the mileage from the office to the first visit SHOULD be paid as I was in the office! See what I mean?
Lots and lots of issues - many of which I responded to in Retired's post. Excellent post, by the way! And I am getting better at calling or faxing the office and saying..."you call the doctor, etc." The other thing...cell phone. I've about decided...no where in the pre-employment stuff was the necessity of having a cell phone discussed. In other words, not a requirement that was discussed up front. Therefore...I've told everyone - do not call me on that cell unless it is an absolute emergency. Period. If you have a referral that needs to be handled ASAP, too bad. When you decide to reimburse me, you can contact me. It's such a petty thing, I know, but it's just part of it. The DON I spoke with suggested I get some particular plan for $59.99/month with 3000 minutes. Not a bad deal, but IMO, the company should pay for that plan and not expect me to fit the bill to meet their communication needs.
Lots of issues - a very few with my particular company, but many with the system itself. Thanks for your words.

I actually think you're pretty intelligent to ask if you are doing case management or not,as I have known a few nurses who thought they were case managers when they were not. Case management is when you are assigned agroup of pts. that are your responsibility. You are the nurse that coordinates their care,although other nurses may see your patients-it is ultimately your responsibility to oversee this case from beginning to end. Any changes in condition ,supplies needed,referrals to ancillary depts. or MD followup is done by the case manager. If you have a few days off, it is your responsibility to followup on any problems that occurred--your supervisor can assist you but the responsibilities all fall on your shoulders. Believe me you will be held accountable for any mistakes that are made so you have to cover your butt and write up incident reports if needed. Most nurses just making pt. visits will dump on the case manager because where I used to work they would not be held accountable to the degree of the case manager.This is why I made sure in my new job,that I would not be case managing although I plan to treat each pt. as if I were. Does that explain enough?

DallasRN · Jan 2, 2005

I actually think you're pretty intelligent to ask if you are doing case management or not,as I have known a few nurses who thought they were case managers when they were not. Case management is when you are assigned agroup of pts. that are your responsibility. You are the nurse that coordinates their care,although other nurses may see your patients-it is ultimately your responsibility to oversee this case from beginning to end. Any changes in condition ,supplies needed,referrals to ancillary depts. or MD followup is done by the case manager. If you have a few days off, it is your responsibility to followup on any problems that occurred--your supervisor can assist you but the responsibilities all fall on your shoulders. Believe me you will be held accountable for any mistakes that are made so you have to cover your butt and write up incident reports if needed. Most nurses just making pt. visits will dump on the case manager because where I used to work they would not be held accountable to the degree of the case manager.This is why I made sure in my new job,that I would not be case managing although I plan to treat each pt. as if I were. Does that explain enough?

Based on that, I think I am doing a form of Case Management. Now, that being said, we don't have "designated" CM's, but essentially, I am totally responsible for my patient load although the manager does help me as much as she possibly can. Even when she can't really help me, I can rely upon her for advice, suggestions and recommendations. I think she serves in more of a "consultative" role, but that works well for me since I'm the type that best learns by actually doing things (and making the occasional screw-up!). I do the follow-ups, communications, referrals, etc. Thus far, I haven't encountered a situation where another nurse had to cover for me, although I have covered for others while they were on vacation. In fact, I've made it rather clear that even tho' I don't take call, if one of my patients needs something on weekend/nights, I want to be called. That's just my preference.

When I first started a few weeks ago, I was skittish about taking the initiative in some things for fear that I would make a mistake. After a short while, though, I decided that my actual nursing care/assessments/judgements were good and if I messed up the paperwork, that could always be fixed. I began to take a more aggressive approach after that. And I've always been a rather aggressive type of nurse anyway so it works.

Thanks for the explanation! Yes, it does help. I didn't realize the ins and outs of CM in HH. But I will say this...if I am ever in the position of actually case managing a population of patients, I probably won't last long if other nurses think they are going to dump. I don't go for that. Regardless of the position we are in, we have professional accountability and I'm big (and sometimes forceful) on that issue.

alintanurse · Jan 10, 2005

I hope things at work are going well for you!

CseMgr1, ASN, RN · Jan 13, 2005

once i was on call, had a newly released patient with a draining wound, when the call came, i rushed to the office and attempted to get the supplies requested. i literally took every 4x4, abd pad, sterile water, tape, underpads, and so forth that i could think of. i was at the patients home until 1:00 am and back on the road seeing my other patients by 08:30 ama the next morning. at 10:00 am i get a "snooty" call from the clinical supervisor asking why i had not taken enough supplies to the patient i had seen less than 24 hours ago. i attempted to explain in detail what i had taken and just what type of wound we were dealing with. i was shot down by her rudeness and inability to understand that the dressings ordered were not adequate for this patient. when i went into the office, she did say she had spoken to the family and they did confirm the amount of supplies i had taken. she then lit into me about not taking the right supplies, mind you, this was the first time i had any contact with this patient and was doing what was on the order sheet. i looked at her, told her i was not capable of reading the doctor's mind at midnight and if the wound care was wrong or needed changed she could now call the doctor, she blanched, did make the call, needed me to describe what was happening to the best of my feeble knowledge, and when i handed her the phone back to take the orders she just about exploded. i repeat, the world of home health is not for me. of all of the positions i had ever had, these agencies are the most ungrateful to the employees, most underhanded in dealing with patients, and just uncaring

no, they don't care. not anymore. i loved hh when i first began working it back in 1982, for the emphasis back then was on quality of care. i had time to meet the needs of my patients and their families, and the doctors were happy. by the time i left hh in 2000, i, like you, was totally fed up with the politics, and endless, mindless paperwork and second-guessing by likewise managers in which you have described. i cannot begin to tell you all the horrible situations in which i was also placed in, at 1:00 am, from caring for a desperately ill hiv patient whose primary cg was totally blind, teaching myself how to load and prgram a pdca pump on a newly discharged patient with terminal cancer who had no iv access (i had to fight with her pcp, just to get her referred to a surgeon, to get a central line placed), getting called in the middle of the night to replace a keofeed on a patient who had yanked his out, then getting no direction from the supervisor on-call about how to do it, as i had never delt with one, before ("i don't know what to tell you", she tells me, before hanging up), and having 4 back-to-back-to-back 24-hr. ivab dosing cases, and then getting a page in the middle of my 4pm visit and being told by the area director that my paperwork has to be in the main office (which was 60 miles away) by 6pm, for billing. when i try and explain to her that i have a patient due to receive his iv rocephin at 6pm, she literally growls at me over the phone: "you will be here at 6pm!", and slams down the receiver. her message was loud and clear: "i don't care if your patient drops dead! get that paperwork in!" :angryfire thank god i was able to locate another nurse who worked with me who was not on call, but who was more than willing and able to cover that 6pm ivab case.

not only are they are ungrateful and uncaring, they are downright hateful.

DallasRN · Jan 13, 2005

Yeah, I did. After just a little over 2 months.

I really enjoyed the work, and as said before, felt like I was really doing something to make a difference in the lives of some patients. However, after I sat down and put pen to paper, I decided it just wasn't worth it. I spent too much money on my education and too many years gathering practical experience and knowledge to work for what ultimately boiled down to an average of $10 - $15 dollars and hour. If that, even, when all things were factored it. The wear and tear on my car, running back and forth to the office to drop paperwork, pick up supplies, adjusting my schedule (resulting in having to call patients to reschedule, etc.) to allow me to do the sudden admit, cell phone bills (huge!), often trying in vain to contact a doctor via every method known - phone, fax, pidgeon birds (lol)...fax, fax, fax, call, call, call...over and over sometimes. Not getting any info to speak of on a patient and having to walk in blindly - scarey! And then, to find "significant" findings and not have anyone even show you the courtesy of a callback? And, yeah...you can always say that as long as you put it in writing, you are 'covered' legally, but that isn't true. As a R.N., I have a legal obligation to follow through if I don't get a response. But who? When? How? It's a private patient. Whose head do I "go over" to get an answer. In just my short time, I had two MAJOR incidents where I could not get a response. At one point, I even told my manager that I would just go to the docs office, but oh, no...can't do that. Might upset him and of course, we need our referrals. Huh?

For me, the worst of the worst was constantly being told, "Well, this is just the way it is in home health." I detest that sort of attitude. That is the way it is because you let it be that way. If we all took that attitude about everything, we'd still be living in caves or something. People have to be pro-active to make changes. So, I'm one person and I have to support myself. I wish I could find the time/money to effect changes, but since most HHA's take that very attitude, I'd be fighting an uphill battle forever and it just isn't worth it. Not to me. Not at this stage of my career and life. Much like the nursing shortages we've all seen over the years...when they find themselves without nurses, the changes will come about. But not as long as any of us continue to work for practically minimum wages.

I may be different, but for me, nursing is, was, and always has been a profession I chose for the primary purpose of supporting myself on a long term basis. Sure, I like people and want to help people, but I am the person I like first. And part of that leads to wanting to support myself and be valued for my skills and knowledge. I hate to be so crass as to reduce things to the almighty dollar, but fact is, I have bills to pay just like everyone else. Like most nurses, my standard of living isn't real high and there isn't too terribly much I can "cut back" on. It may not be too significant to you, Mr. Administrator of the Agency, that I am paying $3.00/day to run up and down the tollroad to the office, but that is $15.00/week for me, and $780/year. Based on what you are paying me, it IS significant. I was told by Admin to get a new cell phone plan...something for $59.00 for 3000 minutes per month. That wasn't my point. My cell phone was being used exclusively to do the business of the agency. Therefore, in my mind, the agency should provide the cell phone. Seems reasonable to me, but who am I? So OK...now I've got the toll fees added onto the cell phone bill for a total of roughly $1500/year - non-reimbursable - but yet I have to pay taxes on the income they are paying me....and then, I came to the conclusion. I'm backing up.

There you have it. I decided I'd rather clean houses for a living if I had to. It would be more financially rewarding and leave me at least SOME time to call my own.

Kudos to those of you that have managed to figure out how to do this home health stuff. And I sincerely mean that. Perhaps had I joined with a different agency, things would have been different. However, I adamantly refuse to devalue myself in this profession. To my way of thinking, as skewed as it sometimes is, it merely devalues every RN out there.