Effectively Managing Your Case Load

I need help when you find it too!!! I have been doing home health for about 2 weeks now and still do not know how to manage all of these cases. Any advice is accepted!

I'm still working on my organizational skills, and I find that what works at one agency doesn't always work at another agency. Currently, here's what's working for me, subject to change at any moment.

First, I have a large binder that I keep all current pt info in. I keep it alphabetized with tabs so that I can flip from one pt to another with some degree of ease. The first page is always the pt's calendar for that cert pd with frequency, pertinent phone numbers (pt and physician), if any PRN visits have been used/remaining, and pencil in the prospective visits. After the calendar comes the current 485, followed by any previous 485s. I also keep all referral information and any notes that I write at admission which I scrawl on the referral forms. If I write mod orders, we use NCR forms, so I have a copy to keep in my book.

The scheduler gives us a computer-generated schedule on Friday with each pt and frequency, whether it's an OASIS visit, etc. Then we transcribe them all onto handwritten schedules with the visits where we want them for day and time. The handwritten schedule includes the pt's phone number and a space for frequency remaining. I also write in the end of the cert pd so that I don't get caught unprepared for a recert.

I hated the bag that my current agency gave, so I invested in this one from Hopkins and I love it. It keeps everything I need right at my fingertips. The back section that is supposed to be for a laptop I have file folders with all the most frequently used forms: nurses notes, wound care notes, mod orders, communication notes, HHABNs, and lab forms. The middle pocket has most frequently used wound care supplies and phlebotomy needs. The front part has my VS equipment, drug book, hand sanitizer, alcohol preps, scissors, kelly clamps, tweezers, etc. The "executive organizer" part has extra pens, pencils, and business cards.

I keep extra supplies in a large Rubbermaid box in my trunk, along with an expanding file with extra forms and those that are not used very frequently like IV orders, Wound VAC orders, fax cover sheets, etc. I have a few books for reference, including a couple of wound care books, the "doctors book" a local phonebook of sorts listing all the docs in the area, Wound VAC reference material, OASIS manuals, and Marrelli's handbook for homecare.

During the day, I make liberal use of sticky notes to jot information down. Sometimes it's about scheduling, sometimes lab results, sometimes just reminders for me. The pt info book stays in my car, never take it in a home for a visit. I take a 2-pocket folder in with me for visits that has the current schedule and next week's prospective schedule in a plastic sleeve, and any information that needs to be shared with patients. I prepare this folder every morning with 485s that need to be distributed or anything that affects pt care for the day, like lab orders, in the pocket on the left, all finished notes go on the right. I try hard to finish notes either in the pt's home or (more often) in the driveway after the visit while it's still fresh in my mind. At night, I review all notes for completeness, call pts for the following day and give them an idea when I'll be there or let them know that the LPN will be seeing them if it applies. If I've sent a pt to the doctor or hospital that day, I call that evening to check with family, see if pt needs a follow-up visit the next day, was admitted, etc. During the day I keep a running list of supplies that are needed for the next day, whether for me or for pts, like hand sanitizer, gloves, more notes, wound care supplies, etc.

That's probably waaaaaaay more information than anyone needs or wants, but once I started I couldn't stop. Hope some of it helps someone, somewhere.

Such great information! Not too much info at all, all very helpful. I have been in home health for three weeks and noone at the agency I'm at has a good handle on organization or efficient management of paperwork or supplies, so this is very helpful. I am still struggling with completing the oasis and identifying specific patient needs that justifies the patient getting skilled nursing unless it is obvious, like wound care. Always a learning curve!

I am right there with you. I have been at my agency for about 2 weeks now and I feel like it is so disorganized. I am trying to get myself organized because I think that will help. I think the above post was wonderful and I will get to work on getting this all done. I really love doing the visits, hate doing the paperwork, but I am learnign a lot and it really is a challenge for me. I will get to do some dressing changes on wound vac's today and Friday, so I just feel like I am just getting so much experience. It is overwhelming at times, but I like it. How about you Karleigh?

Very overwhelming at times! I'm a new nurse, just passed boards last September, worked in surgery/trauma ICU from Sep through Feb, and wasn't happy with the 'hospital work life'. I've always had an interest in geriatrics, and home health allows me the flexibility with my family and I love it! I struggle with the autonomy in the field, wound care for one. Still trying to figure out how to decide on the skilled needs of the patient and how long it will take to meet goals, ie frequency. I had one week of orientation where I watched videos and read through policy and procedure manuals, but other than that it has been in the field training. I've been on my own since the second week, and have 9 patient's I'm case managing now. Granted, the clinical coordinator I work with is great about asking if I need anything. I think the agency just doesn't have a set procedure for orienting and training. Would love to hear about your orientation and training.

This was GREAT advice!!! Thank you so much!!

That was really interesting to hear how other home health nurses organize themselves.

My agency does not allow me to take patient's information out of the office because of Hippa. So what I do is I initial the pt name on a handwritten paper and write the most importatant information on it, like dx, medication, code status... but no complete name, phone number, adress or sozial.number and keep it in a folder.

On the end of day I go to the office and look up the files of my next day clients and check if there is something new.

Such great information! Not too much info at all, all very helpful. I have been in home health for three weeks and noone at the agency I'm at has a good handle on organization or efficient management of paperwork or supplies, so this is very helpful. I am still struggling with completing the oasis and identifying specific patient needs that justifies the patient getting skilled nursing unless it is obvious, like wound care. Always a learning curve!

Remember that Medicare patients on your case load, must be homebound, to receive HH care, so include that they can't leave home, and why, in the OASIS (which is only for Medicare).

Here's a tip that our Administrator gave us today when searching for that skilled need. As educated, licensed professionals, we have the knowledge to change someone's life. It's easy to go in and assess the patient, complete wound care or other tangible skills, but we must remember that it really is our duty to effect change in the patient's life. Our ability to teach them life-altering skills is our greatest nursing skill, although it is not as tangible. I can go in to a patient's home weekly and weigh him, looking for that tell-tale gain that signals a CHF exacerbation, but by teaching him to weigh himself every morning and what to look for, and when to call the doctor, I am giving that patient the tools he needs to change his lifestyle and be healthier. So when you are wondering "What is my skill here?" rather think, "How can I effect change in this person's life? What tools does he need to manage his own care?" There you will find your answers for those less-tangible skills.

Wow...that was great! Thanks everyone. Please keep the suggestions coming. Any help will be of assistance!

Every agency is different, but here's a great thing that I learned to do at my current agency: at start of care, give yourself PRN visits along with your standard frequency. Let's say I admit "Betty" on Monday for diabetic education and wound care to a diabetic ulcer to left ankle. I'll give her a frequency of 3W1, 2W4, 1W4 and 2 prn visits for diabetes complications (can be anything, hyper- hypoglycemia, change in insulin orders, etc), 2 prn visits for labs (which I do for all pts), 2 prn for med changes, and 4 prn visits for wound complications. That way, if something comes up in the cert period, I already have prn visits and don't have to call a doc if I need to go out in addition to my routine visits. If I don't use them, that's fine, no problem. Better to have them and not need them than to need them and not have them available. I keep track on my pt's calendar page of when and what type of prn visits I've used (if any). If Betty's doctor decides that he wants a HgbA1c before her next office visit and I've already seen her that week, I can use a lab prn to draw the blood. If she has a day or two of consistently higher-than-normal blood sugars, I can use a prn visit to go assess her situation. I find this works very well with CHF and CRF patients who often have labs ordered and can't get to the outpatient testing center easily, or can't wait hours in line, or can't fast for the time it takes to get in for the lab and get back home to eat.

A website that emails articles of note about healthcare, sent me one today, that boggled my mind. It was about a 68 year old female medical patient who was discharged from hospital with several new prescriptions for her angina, severe anemia, and inability to to perform ADLs. She lives alone.

Blood tests were ordered for her every other day, and she was given some kind of wired setup, to have her vital signs taken and submitted to her physician.

That was quite a costly endeavor, yet it never occurred to that physician to order HH care.

With the reform of health care, there will be efforts to curtail medical costs. Because of that, I predict that HH caseloads will become even greater, to prevent complications caused by noncompliance, for patients newly discharged from hospital. It will be up to nurses in HH to effectively plan and organise the care for those patients so that they will be able to stay at home safely.

The success of that program is up to those of you who are involved in their care, to thoroughly teach them how to organize their medications, report untoward effects of them, and draw their blood for tests in an accurate and timely manner. Explaining all aspects of their treatment in an effort to assure their cooperation is critical, as is reporting lack of expected progress to their physicians.

More nurses will be necessary to deliver their care, resulting in increased employment opportunities for nurses.

I wrote a response to the article, encouraging the use of HH, and hope it will yield the above results