Considering a change to home health nursing

caliotter3 · Oct 24, 2010

Continuous care nursing or extended care or shift care are when you work with the same patient for shifts of anywhere from four to 16 hours, usually eight hours. You can get long term positions with the same client for 40 hours a week. These cases end, of course, if the patient is discharged from service, passes away, or if the patient or family tells the agency they no longer want you to be the patient's nurse. Stability of income here as long as the family doesn't get the idea to get rid of you. The other type of hh nursing is intermittent visits, where, you do several visits per day for short term care, such as a dressing change. This is the type of hh nursing that RNs are more involved with. Less stability if you are paid by visit. If you do visits, you probably want to see that you are paid on salary. Then you would have to meet productivity goals. As you can see, more uncertainty and day to day involvement with scheduling and changes here. You can also get a job as a nursing supervisor on salary. This is probably the best bet for you if you want the same salary guarantee from week to week or month to month.

caliotter3 · Oct 24, 2010

Forgot to add that sometimes you can get a salaried office position where you will be involved with quality assurance, chart upkeep, care planning, notification of doctors, etc. This may or may not be combined with aspects of the field nursing supervisor role.

KateRN1 · Oct 24, 2010

Caliotter's description of shift work (private duty, extended care, whatever-you-want-to-call-it) is spot on. However, I would not recommend a supervisory capacity in any home care agency when you haven't actually been a field nurse. It's just not good practice to be supervising a role that you are not familiar with. Any agency that hires you to supervise work you haven't done yourself is asking for a "yes man" (or woman) and should send up a huge red flag.

While shift work may provide some stability in some cases, the pay tends to be very low (at least in my area of FL), the care becomes boring and routine, and you mind find yourself dragged into family politics and unsavory situations. It is a good place to start for those who are new to home care nursing or who need more structure. You only complete one nurses note and the job generally doesn't follow you home.

Intermittent visits, on the other hand, are just that. You are in a patient's home 30 minutes to an hour (sometimes longer) to teach on disease processes, medications, and treatments, and sometimes wound care. The work tends to be feast or famine, but if you are full-time you are required to meet productivity. You may be able to find a salaried field position, although the trend seems to be pay-per-visit. Most nurses tend to breeze through the visit and save the paperwork for home (a practice I heartily discourage), and then you have physician offices calling you after hours and patients who get your phone number calling you after hours, so the work tends to follow you home. The pay tends to be better than shift work but you have to be incredibly flexible with your time and expectations. You may also be expected to be on call.

The differences have been discussed many times in this forum, so I'd advise also reading back over the threads for more information. Ultimately, the only way to know if you'll like home health is to give it a try.

Luv2care0907 · Oct 25, 2010

I am writing solely about being a bedside nurse in the hh setting. I am pretty convinced that it takes a special type of person to be consistently in a person's home for 40 hours a week taking care of one patient. Kate is right. You can't help but see the issues that the family is going through outside of the issues that the client has. OTOH, it is a great opportunity to make a difference. I admit that I like making a difference. :rolleyes:

I want to add one more thing about this type of setting and that is that the family is in charge as opposed to say a head nurse in the hospital. This will be one of the biggest changes for you personally. Clients can make decisions in the hospital setting, but it is much different in the home because the family is calling the shots where it comes to medicine and so, for example, the alternative medical treatments might come into play or other such decisions. My agency backs those decisions 300%. I work with children and their protocol is that the parent makes the decisions. I have done colloidal silver nebulizer treatments just to name one such example. That type of thing would never happen in a hospital setting. This particular client had a naturopathic physician that prescribed this, btw.

The medical community is moving toward taking patients that would typically be placed in a rehab type situation to a home setting if there is a family willing to take this on. It is way more cost effective all the way around. I have had clients, that in the past, would never be taken care of at home. That is the paradigm shift that I personally believe we are going to be seeing more and more of in the future. The hotel hospital is just too expensive for most insurance companies not to mention that the nosocomial infections are a legitimate issue to contend with. The home, in that regard, limits those things and the one-on-one nursing care makes for a much better outcome.

Case managers, which are what is being described as the ones making the care plans etc, are really qualifying these clients for Medicaid/Medicare. That's what the OASIS-C is. If you like to deal with paperwork, as opposed to patient care, case management is for you. In HH, case managemers are the nurses making the money, btw. They make several more dollars per hour than the nurses working these Medicaid clients. Private insurance pays more, but those cases are few and far between.

The OASIS-C is a tool to make the determination for nursing care and equipment based on the case manager's assessment. This assessment leads to a care plan. However, I personally find these care plans to be sadly lacking and have taken to writing my own. Based on that assessment, Medicaid/Medicare approves a particular number of months of care for the client.

So, let's say that you are given a particular client that suits your expertise, you are allowed to care for them as long as the insurance holds out, which is typically government insurance. The government says if X, Y, and Z are part of this patient's illness, then we will pay for these particular things. I have been denied O2 saturation monitors because Medicaid deems them unnecessary, just for example. I am now making LPN wages because Medicaid says that an LPN can handle what I do. If you look at some of my past posts, you can hear me whining about that little fact. :crying2: Nobody seems to care about that little problem and it has not raised any kind of alarm with anyone. It should, but it isn't. It will when the rest of medicine takes a pay cut per Medicaid's payment policies. There is simply not enough money to pay nurses the kind of wages they are used to getting.

At some point, the client may recover and so Medicaid no longer will cover the cost of the care. At that point, you would move on to a new client. Prior to getting that new client though, if nothing is available, you might be filling in for the other nurses who need a night off. God has been good to me. I have had several really great clients and babies to care for.

Hope that helps.

KateRN1 · Oct 25, 2010

Case managers, which are what is being described as the ones making the care plans etc, are really qualifying these clients for Medicaid/Medicare. That's what the OASIS-C is. If you like to deal with paperwork, as opposed to patient care, case management is for you. In HH, case managemers are the nurses making the money, btw. They make several more dollars per hour than the nurses working these Medicaid clients. Private insurance pays more, but those cases are few and far between.
The OASIS-C is a tool to make the determination for nursing care and equipment based on the case manager's assessment. This assessment leads to a care plan. However, I personally find these care plans to be sadly lacking and have taken to writing my own. Based on that assessment, Medicaid/Medicare approves a particular number of months of care for the client.

Just to clear up a few points, although most is spot on. Medicare and Medicaid are completely different payers and the rules are very different for each. OASIS-C is not always a requirement for Medicaid reimbursement, that depends on the state, although it is required for all Medicare cases. Medicare never approves a particular number of months of care for the client and the agency is not reimbursed on a per-visit basis, nor does it cover custodial care. Medicaid and waiver programs cover custodial care and as such approve care hours for the patient.

Please don't assume that case managers make more money than the field staff. In most cases, managers are paid salary, which means that they never receive overtime for the hours that are worked past the required 40-hour work-week. Medicare requires each patient to have a case manager and the model used is decided by the agency. When nursing care is involved, an RN is required to be the case manager but if it's a therapy-only case, a PT or SLP can be the case manager. Some agencies have an RN field nurse as the case manager and others have office designated as case managers. And private insurances don't always pay better than Medicare, often they pay less and allow fewer visits than Medicare. However, they do typically pay better than Medicaid.

Keep in mind that the Medicare program is a federal program that is consistent in all 50 states but the Medicaid progam is administered by individual states, so rules and regs may vary.

Home health can be a very bewildering experience for those who are new to the arena, it takes a while to get a good handle on all of the different kinds of care models, payer sources, and rules. It's a huge learning curve.