New grads and Home Health -placed on Vent Cases

[ShannonShidler]

I have a question about working in home health. I'm a registered nurse in IN and employed at a small home health agency. My concern is that they have such a high need for staff that they are hiring brand new graduates, mainly LPN's and placing them with critical cases such as patients who are on vents; etc. With no training. My concern is for both client and nurse. We were all new to the field and naive at one time. Is it legal to hire a new grad for home health? And especially for complicated cases, such as vents being LPN's? I'm not downgrading LPN's and their capabilities,I've worked with some of the best LPN's who could run circles around me.

I fear that these new grads are being manipulated and placed in situations that may be out of their scope, especially as a new nurse, just for the company's sake of making a profit. And it's the nurse and the client whom are both being placed at risk.

[NRSKarenRN, BSN, RN]

Moved to Private Duty Nursing as shift care being provided.

New grads should not be assigned shifts caring for vent dependent children/adults They need stable clients to build up skill and assessment levels. After 6 months, they can complete ventilator training classes and then should be assigned to stable long term vent clients with in-home orientation with another nurse for 2-3 shifts before spreading their wings.

Only takes one experience of power failure in home, dislodged trach, vent failure to change a life forever and end a career if not properly handled.

[caliotter3]

Whether intermittent visit home health or extended care, the agency is taking a risk when they place a new graduate without experience or training into these positions. The same agency that staffs a case or visit roster with an inexperienced nurse is the same type of agency that takes no action when illegal, dangerous, incompetent, negligent, or otherwise unethical employee behavior takes place. They count each dollar until some authority puts a halt to their business activity and someone wonders why the agency or nationwide company makes the headlines.

[oliegirllvn]

And that's why I'm looking for a new position even though I've only been with this company about2months.

[forgivenfaith119]

This is dangerous on so many levels. I would be looking for a different job or ask the agency to put you with a low acuity patient. It's frustrating to hear when agencies or hospitals put new grads in these situations to save money.

[LadyFree28, BSN, LPN, RN]

This is dangerous on so many levels. I would be looking for a different job or ask the agency to put you with a low acuity patient. It's frustrating to hear when agencies or hospitals put new grads in these situations to save money.

This.

OP, is it possible for you to advocate for lower acuity cases for these new grads, and to arrange a Trach/Vent training session?

And to the other poster who is a new grad; I started out as a new grad in PDN home health; I was on a stable case before I went for trach vent training and I still had ample training with someone who was competent with trach/vent cases before I had one on my own. Advocate for you to

be on a lower acuity case; if you are looking for another job and find another Home Health Agency, find out their policy of placing new grads with Trach/ Vent cases.

Best wishes.

[brillohead, ADN, RN]

Now I'm getting confused. Haha! Can you please enlighten those of us who work for Home Health Agencies (per diem 2, 4, 8hr+ shifts per case) the differences between the two?

Also the OP is specifically talking about experiences at the Home Health Agency she/he works for so I guess I'm curious where this Private Duty topic came from. Is it called different things depending on location or are they actually two different jobs?

I'm just trying to learn, not give anyone a hard time. I start nursing school in the fall and I never heard the term private duty before. Thanks!

"Home Health Nursing" is typically task-oriented intermittent visits -- you go to a client's home to accomplish a particular task (or list of tasks), and then you leave and go to another client's home to accomplish a task there, and then you go to another client's home, yada yada yada. You might be doing a dressing change / wound care for one client, drawing blood for labs for another client, checking BP/pulse and doing some education for another client, giving an injection for another client, all in the same day.

"Private Duty Nursing" is shift work at one single client's home (or school or wherever the client is) the entire shift. Length of shift can vary depending on the client's needs and insurance coverage, but it's typically a "full shift" (8 or 12 hours).

Most (but not all!) of these are pediatric / young adult cases where the presence of a Private Duty Nurse allows the person to live at home with family rather than being placed in a nursing home or hospital to receive care. Many of these cases are funded via a special Medicaid program specifically for keeping kids at home, and since Medicaid reimbursement rates are so low, these cases often have lower pay rates and may be seen as being less desirable as a result. For example, RNs in a hospital in my area start out at around $27/hour with benefits, and RNs doing Medicaid-funded PDN cases make around $20-$22/hour with no benefits. (Note that wages are *very* geography-based.... some areas make much more and some areas make much less based on overall cost of living, etc. That's why I gave the local hospital rates as a comparison.)

Private Duty Nursing can also be privately paid -- the client/family pays out of pocket for the care that is provided. Very few people can afford this type of expense, so these cases are few and far between. And regular health insurance can also provide for private duty nursing when medically indicated, but there is usually a limit to how much coverage is offered per benefit year, and deductibles/copayments apply. It's generally cheaper for the insurance company to have someone go into a nursing home rather than provide a Private Duty Nurse, so you don't see many private insurance cases, at least in my area.

My state is the only one in the USA that offers lifetime unlimited medical care for vehicle accident victims through every person's auto insurance policy. Auto insurance cases pay more than Medicaid cases -- I make $30/hour on my auto cases vs. $20 on my Medicaid cases. A lot of our auto cases have a Home Health Aide 24/7/365, because they need assistance with transfers, ADLs, light housekeeping, etc., but not actual Nursing Care. But some cases (vents, trachs, etc.) are staffed by nurses due to the patient's acuity.

Private Duty Nursing is "home health" in the sense that you're usually working in the client's home (I also go to therapy/doctor appts with my client, or to the store, or to visit family, etc.), but because it's one-on-one care with a single client, you're acting as their private/personal nurse and it's considered Private Duty Nursing. Home Health Nursing can also be thought of as "visiting nurse" services, where the nurse sees several clients per day for a relatively short period of time each visit. Both private duty nurses and visiting nurses typically work through a home health agency -- most agencies will provide both types of nursing services (shift or visit).

So if you're a Home Health Aide who goes to someone's house for a couple of hours just to help them get out of bed / bathe / get dressed, and then you leave and they're on their own, that would be more like a "home health visit" situation -- you go and accomplish a specific. But if you're a Home Health Aide who goes and spends an entire shift with the client, that would be more like a "private duty shift" situation.

Hope that helps!

[brillohead, ADN, RN]

Also, please note that I used "typically" and "in my area" a lot in the previous post.

There is no hard-and-fast rule on any of this, and things can and do vary significantly from one area to another, from one insurance company to another, from one agency to another, etc. There certainly are situations that are different from what I described, and it's impossible to define every single possible situation in a single message board post.

[nekozuki, LPN]

Wow. My company does put new grads on vent cases, but only after they have gone through special classes, testing, and demonstrate how to operate and put together the entire thing (although we train pretty much exclusively on the LTV-1150). The biggest problem I've seen is the non-nurses in the staffing department trying to fill available shifts regardless of the nurse's ability or support in the home. Sometimes a desperate staffer will take advantage of a new hire's inability to say no, or downplay the severity of the patient.

My company had a few "beginning houses" where new nurses could work with eager and willing moms to hone their skills, OR the nurse could train/orient with the regular nurse for as long as they needed (although it was only at training pay). I was lucky enough to have my first independent vent case with a wonderful mom who was close by as I became more comfortable, but I have also showed up on cases where I had to say "Nope, this is beyond my level of expertise."

Everyone has to start somewhere, but what new nurses really have to learn is how to say "NO!" or "I need more time/training." If the agency isn't cool with that, consider it a blessing, because you know to hit the road and not look back!

[Adele_Michal7, ASN, RN]

Yeah. Yikes. You need the training.

[tinybbynurse]

I'm a new grad RN (but getting paid as an LPN ...?? Yes, they take advantage of you). My first patient was a trach patient. FIRST patient. I now have a trach / vent patient. Both were stable. But still. They consider me "certified" all by an open book quiz and watching me do something one time. Sometimes with assistance at that. I don't know if I'm actually truly "certified" but I feel comfortable...that is unless something goes wrong. I think I could handle it BUT should a new grad really be alone with no other fellow nurses around to aid you in the event of turmoil? Probably not.

I've been there 2 months and I'm running. For many reasons. It's true that they just want warm bodies to place in a home.

[Girlafraid13]

If what happened to me today at work had happened to me years ago as a new grad I believe things could have gone horribly wrong. Maybe as a new grad a very stable patient would be fine. Sometimes new grads don't know how to react or know what to do in an emergency. It can be very dangerous

[smartnurse1982]

Im finding even so called experienced nurses do not know what to do at times.