New job in home care...how fishy is this?

[givingitmybest]

Hi all,

In the last month I landed my first nursing job ever since I became an RN this past winter. It's at a home health agency where I will be a supervisor that opens new cases and conducts follow-up visits every two months to see if the care plan is meeting the patients' needs. Pay and benefits are excellent, and they didn't have a problem with me being a brand new nurse when I was hired.

Problem is, the agency is starting to seem increasingly more disorganized and unprofessional to me and I'm afraid that my license is on the line if I continue to work with such little guidance and so few opportunities to ask questions.

There has been no training or orientation. I'm working for a relatively new department that hasn't ironed out the kinks yet, and even my manager can't give me complete answers to my questions because he doesn't know how the system works yet. I was sent to do patient visits immediately with just a stack of blank assessment forms and care plans. The only information they provided me with was a patient's name, phone number, and home address (no history, reason for seeking care, principal diagnosis, etc). The patient's info was sent directly to my personal email address because I was not yet issued a company email and they were still working on the logistics. In order to schedule visits, I was expected to use my personal cell phone to call the patient at home. I was also given paper copies of the patient's info to take home, in hopes that I could map out visits to patients' houses while I'm at home (on my own computer)?

On one hand I am scared because my nursing assessments directly influence the type of care that my patients will receive, and I don't want to miss anything. I'm new, and newbies tend to miss things that experienced nurses will pick up on. Had I been trained a little and allowed to shadow an experienced nurse, I'm sure I would feel more confident. But I'm being sent to visit patients who live alone and are often not the most reliable sources when I'm asking about health history (one couldn't even provide her birthdate). The home care aides often know as little as I do about the patients' needs, other than "she needs assistance with toileting and bathing." Shouldn't I at least be supplied with some more information before I go in? My assessment isn't going to be complete if my patient is nonverbal or confused and can't provide me with any of his/her medical paperwork or show me all the medications he/she is taking. Am I supposed to dig through their house and find the contact info of their doctors and family members myself so I can call them and get the full story? Am I supposed to search their house for their meds if they're unable to answer my questions? I want my assessments to be as complete and correct as possible, but if I don't have a clue what's wrong with my patients other than what I can visibly observe then I will be missing key information that can lead to my patients not receiving the care they need.

On the other hand, I'm very uncomfortable having unencrypted patient info sent to and from my personal email address, having to call and receive calls from patients from my own personal phone, and having a stack of forms with more patient info in my house. I don't want to violate HIPAA and put patients in harm's way because my department isn't organized enough to figure out a safer way to do all of this.

The more I think about it, the more I realize that the company might have made their decision to hire me even before the interview. The screening process was unusually minimal for such an important job (I've been asked for a whole lot more even just for volunteer positions!), and I feel that they would've hired absolutely anyone that applied. I should've realized something was off when there was no skills assessment and only a few, basic questions related to clinical decision-making, assessment, and planning (all of my responsibilities!!). They seemed almost too eager to get me on board right away and throw me right into the action. In hindsight, I should've asked what the training process was like, but I was too blinded by the excitement of being offered the job to even realize that I wasn't even provided with an opportunity to ask questions. When I told friends and family (including several experienced nurses), they were happy for me and the general consensus was "of course they'll train you, they wouldn't just throw you to the wolves right away!" I checked out this forum to see if home health nursing was appropriate for new grads, and saw both positive and negative experiences. (Everyone knows that internet forums and comments are full of negative nancies, sour grapes, etc so I tried to take the naysayers' words with a grain of salt and just give it a chance for myself). The naysayers were totally right.

My nursing license means a lot to me. To me, it's a symbol of how I overcame so many obstacles because I wanted to make a difference in peoples' lives. I don't feel that I can deliver what I owe to my patients because I work for a company that doesn't see the need to train a brand-new nurse that they already decided to hire. I may be an absolute newbie nurse and I may be an idiot for not running away from a job that might have been too good to be true, but I'm not a dishonest jerk who fudges assessments or turns in incomplete information and then signs her name at the bottom.

Should I call my manager tonight to share my concerns and request more training before I'm out doing patient visits, and quit if my concerns aren't addressed satisfactorily? Any thoughts would be appreciated, but please don't beat me up for this because I already feel like the dumbest person ever. /:

[schnookimz]

1. If you go into someone's home and they are confused or nonverbal like you are worried about and have no caregiver or family around, I would be calling social work or 911. How could they be safe to care for themselves? That said, I don't know how often you'll truly come across that situation.

2. I don't think the cell phone thing is weird. Although I would be asking for a phone stipend. If you're uncomfortable with giving out your main number then carry a cheap pay as you go phone without anything fancy that just accepts calls.

3. Trust your judgement. You can only chart what you see. I know following another nurse would be helpful, but it wouldn't teach you everything either. Do the best and most thorough job that you can.

4. As far as mapping out visits from home, I thought all home health nurses did that.

[MrChicagoRN, RN]

Home care requires a very high degree of organization from a self starter. It can be challenging for even experienced nurses who have trouble making the transition. Doing the paperwork, coordination, and scheduling is not unusual at all.

since this is all new to them, perhaps they haven't figured out that they need to give a deeper orientation to new grads. You need to talk to your manager.

[givingitmybest]

Thanks for your advice, both of you.

If none of that seems especially weird then I guess that's what home health is all about. They seriously don't train? If that's the case, I know that home health is not right for me at all and I don't feel the least bit comfortable doing it. I should've done more research on home care before I took the job. Still, I'm not impressed with the company's organization and communication. My gut feeling is that this is not what I want to do. Better to get out before I'm in too deep.

[Cohiba]

If your employer isn't giving you the tools to do your job, i.e. procedures in place to prevent HIPAA violations/inappropriate PHI disclosures or sufficient training to perform safely, then that's a failure on their part and unless they fix themselves quickly, in a hurry, and right-bleeping-now, I'd recommend you leave with your license intact...

[caliotter3]

My initial reaction would be to advise you to leave this situation but after recalling some of the cases with gaping "holes" in the initial assessment/opening done by very experienced nurses, I would also say to go with what you find. You will pick up on this if you stick with it. Give yourself (and your manager) enough time to get it together. You will know when to throw in the towel if that is what you must do in the end. Good luck.

[adreamdeferred, MSN, RN, APRN, NP]

This is most certainly NOT what home health is about. The company sounds like it is still relatively new and should have had its policies and procedures in order before they started operating. And YES, you should have received a lot more training. My company gives us a company phone number that goes to our cell phone so patients don't have our direct line. We have Ipads that have built in security devices to ensure we are HIIPAA compliant along with company email addresses. There is a whole packet to be completed for skills check off and ongoing training in a variety of areas. The fact that you are not receiving more information regarding your patients before visiting them also says the company doesn't have its processes in place either. I would definitely move on. There seems to be a lot more disorganized home health care agencies than organized but there ARE good ones out there. Please know that. Best wishes.

Thanks for your advice, both of you.

If none of that seems especially weird then I guess that's what home health is all about. They seriously don't train? If that's the case, I know that home health is not right for me at all and I don't feel the least bit comfortable doing it. I should've done more research on home care before I took the job. Still, I'm not impressed with the company's organization and communication. My gut feeling is that this is not what I want to do. Better to get out before I'm in too deep.

[amoLucia]

#1 - make sure you have your own malpractice insurance. Should NOT be an option. You really do need your own. I'm not preaching to scare you personally or anything as I really do recommend insurance all the time. All nurses, new and experienced and in ALL fields should carry their own. You'll note that many of the vintage staff nurses here on AN strongly recommend it also.

#2 - get a cheapo alternative phone. As you may have read here, almost all HH nurses recommend NOT to give out your phone number to pts as you will be receiving phone calls from pts, family, and/or other staff all hours of the day/nite, holidays, weekends,etc (and they'll all sound like emergencies). Change your original number if you have to - I'm dead serious about this. Also you should be keeping receipts to be reimbursed for your phone work-related expenses. (Just FYI - some experienced nurses will tell you they still get phone calls long after they quit a particular agency.)

Likewise, keep receipts for your work supplies, like fax paper and ink. I hate to ASSUME, but you have addressed travel expenses with your agency?

#3 - somebody, somewhere has to have some pt information. How else would your agency have received its referrals? The administrator, DON, Soc Worker, Admissions/Intake Coordinator has to have something. They wouldn't have OK'd the referral if they didn't have some billing info and some info to determine that there was some kind of need for HH services. The hospital discharge staff should be able to provide you with duplicate info. Immediate needed info I can think of = allergies, DNR and next-of-kin.

#4 - purchase an inexpensive locked file box (like from Staples) if you must keep documents at home. Then just keep the box in a safe spot. You can only do the best effort that you can. Present them the receipt reminding them of HIPAA.

New start-up agencies almost always have a disorganized breaking-in period. I know this from LTC but I believe HH is the same. It takes a while to get all the working systems in place with a cohesive staff, administrative and field. In the beginning, things may be very chaotic. It is tough even for experienced nurses. NO job will be perfect; it's the real vs the ideal. But your place definitely has problems that it shouldn't have had if they did their preparations.

I worked HH a loooong time ago. Even way back then, I learned that pts' and families' wants and expectations of agency services needed often DO NOT match those that can be provided within Medicare & "caid guidelines. That was very difficult for me as I recognized the potential for fraud was very easy. Coordinating care plans with unsupervised staff was also problematic. I was not about to allow myself or my agency to get in trouble because of service problems r/t pt/family wishes. So your need for that info is crucial.

That you had so little or no orientation and are working with minimal direction is truly, truly sad. They SHOULD know that that can most likely lead to burnout or mistakes (SHAME on them). You're going to have to allow some 'wiggle' room r/t your agency's growing pains. But if you really feel that there's questionable or poss illegal activities/practices, then follow your instincts to move on.

There are some tricks that veteran HH staff know where to look or questions to ask, but they're more than I know and my post here is long enough.

PS - You are NOT the dumbest person. You bring up some really good observations and questions. Good luck!

[schnookimz]

One more bit of advice, no matter what area of nursing you go into you will experience this sense of "new grad panic" to some degree when you are on your own.