Home Health-The good, The bad, and I'm getting out.

[lsvalliant]

I've been working in home health now for almost 3 years as a RN case manager in southern California. I'm posting this so those of you that are thinking about home health know what to expect and I'm basically just venting why I have a love/hate relationship with this job.

First why I love it: I love autonomy and independence and not having my boss look over my shoulder at all times. I feel like no one is really watching me most of the time unless there are random chart audits or I accidentally miss a recert oasis. I get to drive around beautiful So cal all day, which most days is absolutely stunning. If I'm having a bad day, my car is my refuge and I can blast that radio really loud. I see about 5-7 patients a day and love that my current agency does not have me drive over 100 miles per day like my old one. I drive about 60 a day on average now. My patients for the most part are really appreciative and I develop a rapport with them and their families. I still use most of my med surg skills. I do alot of PICC lines, wound care, phlebotomy, gtube, and teaching, a few trachs here and there. Mostly it's teaching which I love.

The bad: Every agency I've worked for is a disorganized mess. My supervisor does not remember her own name half the time. She will call me at all hours, text me at 630am for report on a patient I did not see, and call me on the weekends. Calls from co-workers and patients on my days off constantly gets on my nerves. I had last Thursday off and my phone rang every 15 minutes and I did have to take some of those calls. All agencies try to milk medicare patients to the fullest extent they can. I feel like I am a part of the problem and not the solution as far as medicare overspending. I was pulling into my driveway one day last week at 445pm (I work 8-5) and I get a call from my boss.."OH I forgot to tell you that admission for tomorrow actually needs an IV dose today at 5pm oops!." So that ruined my plans for the evening and that is typical. Typical example of disorganized non-sense that I have experienced with all 3 of the agencies I have worked for. 2 of these agencies are top 500 national agencies. I feel like I am a money machine for these agencies and they do not value me as a person who has a life outside of work. Last gripe, If i refuse to admit a patient because they do not meet medicare guidelines its a huge deal and I get interrogated by multiple managers as to what my rationale is, with the constant reminder that each patient they don't admit is a $4000 loss. Its all about money.

So I'm out of home health starting next month by miraculous devine intervention. One of my dear friends who I worked with in HH, got out about a year ago and started working in an infusion room in a local outpatient clinic associated with a big hospital here. Her manager wanted to hire a HH RN as an assistant to two specialty doctors in a clinic/hospital setting, so she recommended me and I got the job. I had about 24 hours to think about it, happened so fast. This position would require that I become wound certified and I still will be doing infusion and teaching patients. I get to round with the doctors and work closely with them in developing a POC for the patients. Sounds like a great job and I get to use my HH skills and independence to my advantage. We will see, they always say grass is greener on the other side. Good luck in home health. I may be back some day.

[youngheartoldhead]

the problem with home care, whether its hospice or home health, that field attracts ***** in the management position. sorry, just no other way to put that.

[SuzieVN]

Timely post. I've been researching why there appears to be an explosion in home health- and who pays for it. Turns out that it is from pressure from CMS to reduce LTC costs (I found this via online CMS seminars that explain the new purposes of the 'HCBS' plan). n the past 5 years or so, long term nursing home patient populations have dropped by 10%, in favor of home based care, even as 10,000 Americans turn age 65 every day, now. Who really pays? The 'home health nurse', who is wrecking her vehicle, running ragged, absorbing fuel costs, and etc.- while the 'agency' makes a profit.

[paradiseboundRN]

Timely post. I've been researching why there appears to be an explosion in home health- and who pays for it.

Medicare's recent ruling about hospital reimbursement is part of the reason for growth. If a patient is readmitted to the hospital within 30 days after discharge with the same diagnosis, Medicare does not pay for the second admission. This pressures the hospital physicians to order HHC so the nursing interventions can prevent re-admission. This saves money!

Another reason is the new seniors want to "age in place". They don't want to leave their home and live in a facility if they don't have to. With the housing bust of 2008, many seniors lost a lot of equity in their homes and now they can't afford to move if they wanted to.

The biggest reason for growth is that mutiple studies have shown that HHC saves money with less ER visits and less admissions to the hospital. This prevents unnecessary labs, scans, etc.

Not all agencies are for-profit.

Lastly, home care nurses should be reimbursed for their mileage which covers the wear and tear on your car.

[monkeybug]

the problem with home care, whether its hospice or home health, that field attracts ******* in the management position. sorry, just no other way to put that.

I don't think management attracting those, umm, types is exclusive to home health.

[Not_A_Hat_Person, RN]

I wanted to be a home health nurse from the beginning. I've worked in home health for 2 years. It has its ups and downs, but on the whole, It's worth it. It can be boring, there's lots of paperwork (though we're trying to go paperless), and there's lots of wear and tear on the car. Family dynamics can be tricky. My agency treats employees well, but it doesn't pay well, and health insurance is expensive (and I'm paying for 2). Firm boundaries are a must, or work will take over your life.

[SuzieVN]

Medicare's recent ruling about hospital reimbursement is part of the reason for growth. If a patient is readmitted to the hospital within 30 days after discharge with the same diagnosis, Medicare does not pay for the second admission. This pressures the hospital physicians to order HHC so the nursing interventions can prevent re-admission. This saves money!

Another reason is the new seniors want to "age in place". They don't want to leave their home and live in a facility if they don't have to. With the housing bust of 2008, many seniors lost a lot of equity in their homes and now they can't afford to move if they wanted to.

The biggest reason for growth is that mutiple studies have shown that HHC saves money with less ER visits and less admissions to the hospital. This prevents unnecessary labs, scans, etc.

Not all agencies are for-profit.

Lastly, home care nurses should be reimbursed for their mileage which covers the wear and tear on your car.

Interesting. I see that CMS has determined that 10% of Medicaid $ has been switched from LTC to HCBS, also, meaning there is a push to get them out of nursing homes to save money. With 10,000 people turning 65 every day now in America, soemthing has to give. Too bad the mileage rate doesn't begin to cover gas and the tearing up your vehicle all day every day working HH.

[netglow, ASN, RN]

One big problem is that many HH and hospice have nobody in administration or ownership with any kind of real pertinent medical/nursing background. Just guys out for a quick buck. All you need is money for a website, EMR, laptops really and you are off and running. Pretty much no liability for them as they are not licensed professionals. It's all going to fall on the nursing staff. It's easy to screw Medicare and insurance. EMR makes it easy - and these guys will only be concerned that you chart, chart, chart. Clinical infrastructure will be non-existent, and that is purposeful.

[paradiseboundRN]

One big problem is that many HH and hospice have nobody in administration or ownership with any kind of real pertinent medical/nursing background. Just guys out for a quick buck.

That is a big generalization! Thank goodness, the HC agencies that you are referring to are struggling to stay in business, and they don't make a quick buck anymore. The hospital agencies are consolidating, getting larger and hoarding their patients. They are demanding that their case managers only refer to their own hospitals agency unless they don't take the patients insurance. The hospitals are preparing for "bundling" and they are not going to share any health care dollars with these little guys.

[babynurse73]

Just wondering if the HH company you work for is for profit or non-profit, and if that makes a difference? Also, anyone work for Masonicare and what do you think of it?

[jrock17]

Where I previously worked, a new employee was 'precepting' with a case manager, learning how to be a HH nurse/case manager. The preceptor had taught the new employee to 'set up' her visits the night before (meaning, chart on the patient based on the initial assessment/order the night before the visit, leave out the vitals, of course), and then just go through and change the answers that needed to be changed at the actual visit. This was to save time (the preceptor told the new employee). Well, upper management found out about this because the new employee transferred her computer the night before on accident (documentation fraud), and confronted the new employee. New employee says my preceptor taught me to do this (truth) but the preceptor lied and said,' I didn't teach her that.' Pretty much threw the new employee under the bus. New employee was immediately terminated.

Know what upper management did to the preceptor??

Well, they promoted the preceptor, OF COURSE!

***DURRRR!!!!***

[luckyshamrock22]

Interesting post.... I am a hospice nurse with the same love/hate relationship. I feel a little more fortunate however that the hospice company that I work for is well staffed. I see an avg of 3 people a day. Lvns cover cocs but there's alot involved besides visits. We get mileage reimbursements but some get company vehicles. I have the same pros and cons as OP and the good outways the bad for me. My husband says I make a good living to "visit people." MY issue is that I am a newer RN (with plenty lvn experience) with an ITCH to pursue that ER/ICU craziness. I have read posts where other hh/hospice nurses missed the icu/ER and hated hospice/hh. Maybe I feel like I'm one of those that is not "professionally satisfied" as a hospice nurse. I love my job but I feel like it's not my calling. Has anybody done both? Am I just living a "fantasy" of what the other side is? I truly appreciate honest perceptions. I will say though that hospice is alot more gratifying than hh. (My company has both and I've filled in at times) I will also add as a big NEGATIVE to the OP......I am getting sick of going to other people's homes. Ugh.....

[Not_A_Hat_Person, RN]

I was an ER volunteer (non-nursing), and I admit that I miss the ER, but without hospital experience, I don't see any way into the ER. I've thought of getting certified as an EMT; most of the Boston ambulance crews I saw had RN-EMTs.