UpTheLadder12

I do home health and hospice, and even though I love the nature of the work, I was at first very miserable, broke, and fairly certain that I was going to have a stroke before I was 40. I have learned some valuable things, and here's my Ultimate Guide to Enjoying Home Health: Work for several agencies at once if you are Per Diem- Donn't give one agency a monopoly on your time. This way you can be a little more picky on accepting patients and you can keep your service area within a reasonable distance of your home, or in less trafficky spots. This also gives you more job security as the patient load fluctuates throughout agencies, you have more control over keeping steady income. Become super ultra organized. I made myself a huge binder with reference to data like lab values, wound assessment, and common home health and hospice diagnoses and interventions. No matter how much experience you have or how good you are, your brain will be fried after a long day of work and traffic, and it helps to have the data right in front of you so that your mind can go straight to the critical thinking and planning. *Like previous posters have said, you must to do your charting in real time, otherwise you will be charting when you should be sleeping or spending time with your family. I have learned to put nothing off. I used to try to see several patients in a row and then block out time for charting and giving reports, but something always gets in the way, there is just no way to plan other than to expect the unexpected. So I do spend part of each visit with my face in the computer, or the paper chart, depending on the agency, but I still manage to find some time to visit to listen and engage with the patient and give a thorough assessment, and even though this makes it feel like the visits are longer by charting on site, my days are anywhere from an hour to three hours shorter by forcing this habit of finishing all charts and reporting on the patient before even thinking about the next patient. *Also regarding organization, the back of my car is literally a mobile supply closet, with everything I might need for visits. My nursing bag is huge and organized as well with everything from my paperwork to paper towels, hand sanitizer, small trash bags etc. so that I don't have to spend a lot of time asking the patient and family for things when it comes to my infection control measures, wound care etc. I pretty much just need to find a workable surface and I have everything that I need in my bag. I went to a lot of trouble to invest in specific plastic bins to organize things in a way that makes sense to me personally in the back of my trunk and my car used to literally look like a trash dump, so I finally got into the habit of always bringing my supplies from the visit and putting them directly into their place in the trunk, and keeping a food trash bin in the car for eating on the road. *And I also used to do a lot of drive-thrus for coffee and food, BECAUSE IT'S SOOO TEMPTING when you drive past all of your faves all day, and you technically have the time to stop if you want to. and I now save sooooo much money and time by taking a little extra time in the evening or early morning to prepare food for myself, and I bring a couple large thermoses as well as a reusable Starbucks cup with all of the coffee and tea that my heart desires, as well as lots of water and lunch and snacks, because for some reason I just get so hungry out on the road. Any "quick" stops are surprising time suckers. Making my own food has also helped me to stay healthy and lose a little bit of weight and I spend so much less. if you are a contractor, which you almost always are per diem except for very rare cases, take advantage of this and keep all receipts and write everything off on your taxes. I mean literally anything that you bought that you're using in the course of your workday. You are essentially your own small business, the government is taxing you accordingly, so it is literally giving money away if you do not write off the same expenses that any other small business would write off. And last but not least is boundary setting- Of course when you are brand-new you don't have a lot of options, you are at the bottom of the food chain, and that's natural in any job. But after almost 3 years in the field, and garnering a good reputation from coworkers and from patients and families, I was able to start demanding more. I now set a bar for what I will accept in pay, including additional mileage for distance or extremely complicated cases with a lot of wound care and/or complicated family dynamics. So it pays to work hard, go the extra mile, but then do not let a company or administrator run you into the ground. Like previous posters have said, the turnover is very high. These companies are not stupid. Whether they are clearly willing to let people go in order to find new people to abuse, at least half of the companies that I've worked with are smart enough to see that when you have someone who really knows what they're doing and can save everyone's butt in certain situations and/or train other staff , and help them pass survey; often times they will be willing to pay that extra bit, meet your demands, because they are after all saving so much money by being cheap in any way they can, unfortunately. Remember, since they have chosen to go Per Diem in order to be cheap, that also gives them the disadvantage of not having control over their nurses' time. Most of these companies are extremely disorganized and chaotic when it comes to having nurses available for distance cases and after hours cases, or they have a lot of turnover very suddenly. This is why working for several agencies is important, that way you won't feel desperate when one company is asking a lot of you and you know it's because they have a nursing shortage, you can turn the tables and say "sure I'll do these visits for you for X amount of additional pay and mileage, etc." Any visits that go over 1.5 hours, or are so outside of the area that my round trip plus visit is 2.5 hours total time from the next patient or the agency office, I get authorization for increased pay for my time. They'll agree when they know that you are thorough and you won't end up costing them time with QAPI problems or having to send out another nurse because you missed something, or if they simply have no one else to go. I often am not fond of some of the agencies that I work for and their practices, but I have learned that regardless of Home Health, SNF, Hospital, almost every nurse I know is burnt out and feels that the company they work for is money over people. So instead of trying to take on the whole system myself, I just try to give the patients my absolute best, and take comfort in the fact that regardless of what else they experience in healthcare, that they at least received quality, genuine care while I was assigned to them. And then I make sure to take care of myself as well. I have friends and family who depend on me, so I am not doing anyone any favors by allowing some money hungry company to burn me out and make me a less effective mother, friend,etc. The $$$ -I've done the math on my current status, and I am making approximately $27 an hour as an LVN in Los Angeles in home health and hospice after my travel and other expenses are figured. This includes factoring in unpaid time at the office, meetings, and the rare occasions that I do have to go back into the chart when I'm not "working". ( RNs can make $50 per hour after expenses, based on their visit rates at my agencies, if they follow the same system. But of course they have a more volatile schedule since the nature of their visits are different and can be harder to anticipate ) This does not include any benefits, so if you did the math on what I'm paying out-of-pocket for my health insurance and considering the lack of vacation, sick time, and other benefits, it would probably be the equivalent of $25 an hour at a salaried position. Another major plus is that I have a lot of flexibility and freedom, even though I don't have paid vacation, I also don't have to miss work to see my son's school performances, attend his field trips, or attend any other important family gatherings or other things in life that matter. Essentially all I have to do is reschedule my patients and I can still get my hours in around my personal life. Also pays big time to make allies at your companies, cover for them if they do need to have you see their patients for a day or week, and it'll get you some extra pay, and then you can rely on them to see your patients at times that you can't or don't want to reschedule if you are going out of town or sick etc. As much as I want to pull out my hair a lot of the times, I hear the same complaints from my friends who work in hospitals and SNFs about horrible management, unpaid time, and stress, so based on the overall freedoms I enjoy in the field, I can never imagine going to a salaried position again.

Our company has one person take on call from Friday night until Friday morning the next week, and not just case managers but LVNs too, for a flat weekly rate. It involves handling all distress calls and scheduling cc if needed during the weekend and 5pm-8:30am weekdays. The CMs only do it if absolutely no one else takes it. Usually the field RNs and LVNs do it.

I should add that we serve the greater Los Angeles area, my route averages 90 miles a day total driving, there is no "rush hour" here, freeways and major streets are jammed from 7am to 7pm and sometimes later, and finding parking for patients in apartment buildings or Assisted Living can take 15-20 minutes if parking lot not available.

I'm an LVN, 2 1/2 years in hospice as a visiting nurse and continuous care nurse, and I also occasionally take the On Call phone on weekends. I'm finally morphing from the bright-eyed bushy tailed new nurse to Hospice Hulk. I'm really having trouble with some boundary setting with families, and I'm not sure if it's related to the lack of leadership and organization at the company I'm with, or if I just need to be firmer and/or meaner. but I'm losing the ability to have compassion and give good care to my patients due to manipulative and extremely needy caregivers. the first company I was with was mid-sized, and very organized with an emphasis on training. Nurses were either full time in the field, on call after hours for distress calls, or CC with a set schedule. the company I'm with now is smaller, the same general pool of nurses covers routine visits, distress calls and CC with a skin-of-the-teeth haphazard style of scheduling and organization. Payment for visits is per diem, CC by the hour, most field nurses are contractors (but paid by W-2 with taxes taken out), you can get overtime for CC beyond 8 hours but not if your visits and CC combined are over 8 hours, no paid breaks on CC. Basically the main advantage of working with this company is that I have never missed a single dance recital or sports game of my little one, because I can always turn down a shift and can usually reschedule visits. However, I am finding that a lot of my routine pts have complicated family dynamics, and because this company assigns the same nurse to visit the pt 2-3 times per week on contract, and the Case Manager does not see the patient in person under most circumstances, the families and caregivers are relying too heavily on me instead of viewing their care as being provided by the company. and then most families are extremely picky and stubborn about visit times: they all want a visit between 11-2, they expect me to be able to come at EXACTLY 2pm (not gonna happen in LA traffic and a full day of visits) and then many of them are manipulative, tell different stories to me vs case manager. And both the families and case manager expect me to be available 24/7 for extra visits and distress calls for "my" patients. I finally blocked my cell number on outgoing calls because when I would call or text them they would get my number and then call ME at 3am Sunday for distress instead of the hotline, text me with supply orders,etc. just any time of day or night. i often end up zig zagging around town instead of taking the direct routes from visit to visit, yanked in different directions by the needs of families and case managers. Because I'm payed per visit, sitting in extra traffic costs me sometimes half a day's pay, and disrupts my schedule enough that I might end up seeing pts all seven days of the week for a few hours a day instead of getting any 'real' days off, and I end up turning down CC shifts because of one or two rescheduled visits for that day. How do you seasoned hospice visiting nurses manage families and keep your schedule under control? Am I being to soft with families that need to work with me on scheduling and communication, or do I need to find a company with better leadership where the patients understand that I am just one arm of the care team, not their personal concierge? HELP!!!!

I'm a CC LVN in California. Here, any RN or LVN can do the death visit and/or call the death if it occurs during CC. I don't know if that is only for California, but I know that in hospice we can call the death and it isn't even a physician's order as far as I know. At least we don't chart it that way. We just have to chart that the physician was notified. I was thinking of applying for a visiting job with a per diem rate and was told by another nurse who worked as the office manager that I should ask for $30 per visit. This was also at a place that did not pay mileage. Going rate here for an LVN with some experience is $20-$24/hr, so that seems in line considering mileage. I know it's a different state but hope this info helps.

Thanks for the input! I have family in AZ and am seriously starting to take the idea of moving out of state seriously. At first I thought it was off the table to uproot because my kid's dad does make an effort to spend time with him a couple days a week, and I didn't want to disrupt the relationship. But in the last few weeks, my depression is starting to really take on the "textbook symptoms", so I have been trying to sell the idea of a better life out of state to him as well. He is a cook at a well known fine dining restaurant and makes peanuts compared to the cost of living out here, so he probably would fare better in a smaller city too. So I am actually considering uprooting myself and my ex, as strange as that sounds. But whatever works!!! :-)

I know the job market is tough right now, what are you all doing to cope with it? Right now I'm working 50 hours a week at a low wage job that I absolutely hate, and I often have to go to the bathroom because I break into tears spontaneously. I sooo regret not going straight to RN. My plan was to do LVN to RN to BSN, so that I could work a decent paying job while attending school. HA! I was always a top student throughout school and got 1490 on my SATs, but family and financial issues caused me to stop going to college after one year. After that I worked full time, got married, had a kid. Then at 25 after a turn of events I was a divorced single mom with very little financial support from my ex, and was laid off from a marketing company, so I decided I just had to go to school finally no matter what, and nursing had been my goal for a few years by then. I went to one of the public programs that is very low cost but only picks the top scoring students. I passed every class with flying colors, was the first in my class to take the NCLEX, passed, and then got my IV Cert and ACLS, and took a certificate course on Spanish for medical professionals, to try and be competitive on the job market. My background is in sales/marketing, I also have taught yoga classes to kids and adults, so I highlighted my management and teaching skills on my resume. After 6 months and over 280 applications, either going in person, to job fairs, or online-NOTHING!! I have only even had two interviews, one of which was for a sketchy position that was not really above board, and the other turned out to be a mistake, they needed someone to give IV meds but they had mistakenly put out an ad for LVNs with IV Cert. (out of the scope of practice in my state) I am now so stressed and still too financially crippled to seriously jump into continuing my education. I'm taking a couple of general ed courses online now through my local community college. I feel like, if I knew it was going to be like this, it would have been worth it to just find a way to push right through RN school. I would be just as broke and stressed as I am now, but closer to a higher credential. I know that RNs are also having trouble finding that first job, but the higher up you go with the education, the smaller the pool gets, so they may have to hire new grad RNs and BSNs even when they don't want to. Not the case for LVN- it is truly saturated! I had been turned away from even filling out an app- some places just ask right away if you have experience, and when I give a little shpeil about my leadership and teaching in other fields, they cut me off and tell me sorry, must have one year experience, and don't even let me fill out their application. I have also received response e-mails stating that I must be an idiot if I did not read the job ad stating NO NEW GRADS. I have tried networking with my friends from school but to no avail. My friends who are working now either were CNAs or MAs prior to LVN school, so they were able to either move up at their current workplace, or count that as experience. When I go in to apply, I have even been introduced to the DON by my LVN classmate, and still the first question out of their mouth is "How long have you been WORKING as an LVN?" And then no response, and upon calling back I was told that when they are ready to hire they will review ALL applications and call all QUALIFIED applicants. I have been volunteering for a hospice agency in the meantime (in my "spare" time when I'm not working or parenting) LOL. But I am told by potential employers that only PAID experience counts. I am getting to the end of my emotional rope! What should I do????

I'm so sorry to hear that it went down like that! But don't let it get you down too much. Did they OK you resigning instead of being fired? If so, it should be relatively easy to find a new job. You can always spin your choice to resign at future interviews to relate to a toxic work environment. If you don't need to be working STAT and can afford to be a little picky, start visiting LTC's or whatever type places you want to work and get a feel for it. You can tell pretty quickly if there is a lot of tension between staff or if the residents seem stressed. Of course no place is perfect but there are definitely places that have strong, capable management, where the DON knows how to take control and wouldn't let things get this bad. You should have had a QA review right after your first mistake, where you could discuss with supervisors and peers how to avoid future mistakes. And all that stuff about not being suited for LTC and a previous career in accounting was totally out of line. That was none of their business to say that, it was unprofessional and had nothing to do with the situation. That's what caused me to ask about tension with staff. Sounds like toxic management, and it all trickles down from the top. If the admin can't control troublemakers, good employees will suffer and the then the whole place will suffer. And if the admin themselves are toxic gossipers, run run run to the nearest emergency exit! Good luck in the future! You made a couple mistakes, but your place of employment made some mistakes too. Learn from yours and be better for it!

Wow! I am not working yet but in clinicals I saw these things happen OFTEN, and the nurses often had a careless attitude. In fact, this happened more in the hospital than LTC, which I would think is worse since those patients are acute. Did you have a touchy or tense relationship with your supervisor, or with a staff member that has some pull? I have seen some nasty backstabbing in clinicals and hearing from my friends who are currently working as LVNs. This doesn't sound like you are 'unsafe' at all. You had a bad week. They should be supportive and help you find ways to avoid these errors in the future instead of putting you down. It's not like you gave the wrong med or wrong amount or wrong patient, which IMO would be wayyyy worse. And I know people who have done that and were not reprimanded. Don't put yourself down, and next time you have an issue with a med being delivered from pharmacy or when giving a PRN, just approach your surpervisor every time so that it's in her hands and not yours. And in the meantime, look elsewhere for work! That sounds like a crappy environment to be working in, especially for a relatively new nurse.

Thanks! :) I definitely learned my lesson about starting with home care! It's true, I need to hone those clinical skills. I did good in school academically, but nothing replaces experience when it comes to actually performing the tasks related to nursing care. And I will benefit from having a mentor. I can see how an agency can also serve as a barrier between you and the patient, when there is a disagreement about what should be performed or how, you have a manager to report to who can mediate, instead of having tension with the family. Well, I will chalk this experience up to LESSONS LEARNED! :)

I'm not saying that its specifically discriminatory to not hire new grads, I'm saying it's lazy to use a blanket policy. You might have a new nursing grad with 10+ years of experience in fields that contribute to being a good nurse, and references that prove them to be reliable, flexible, competent, a fast learner, etc. Then you might have someone who's been a nurse for 15 years, and maybe they are lazy and incompetent, but the hiring manager can't bother to actually weed through candidates, so they just generalize and lump everyone together. So this is similar to the not hiring anyone with a BMI over 35, because essentially that is just a lazy rule based on an assumption that a thinner candidate will be able to to a better job (often based on claims of higher health insurance costs and/or more missed days) without actually considering the individual's work history and reputation. So I'm not saying they are both discriminatory in a legal sense, I am saying they are both examples of incompetent hiring policies. As a hiring manager for a small marketing company for five years before i went to nursing school, I used to just laugh to myself when the owner would tell me who he thinks should be hired based on his bizarre biases about people. He was always pleased and surprised when the candidates I picked turned out to be good, because he had what i considered to be very shallow reasons for thinking someone might be a good employee (I guess that's why he needed a hiring manager hahaha)

Thinking more about it, the idea of a hiring rule based on BMI is similar to the "No New Grads" blanket policy that is rampant everywhere. Lazy, incompetent management that can't figure out how to size up a good candidate, so they make broad generalizations instead of taking the time to look at individuals. Everyone loses here- the person doesn't get considered for the job, and they may have been a fantastic nurse that would have benefited the company and the patients.

I think if someone's primary duty is going to entail a lot of lifting and transferring and physical work, they can do a fitness test to make sure that the employee can do the job related tasks BUT a blanket BMI rule is totally unacceptable. That really is judgemental and discriminatory. It says nothing about the capabilities of the individual. And not to mention enforcing that blanket rule across the facility???? So a BMI can tell the employer how good the employee will be at case management or supervising, or making clinical judgements? I think not. I am not a skinny person, not big either, very 'average'. But sometimes I am running out of steam half way through my day, and I have worked with people in all kinds of fields whose energy level and stamina surpasses mine even when they are twice my size or more. Weight/ BMI is not a singular determinant of energy, strength, stamina, or physical ability. Why not just enforce a simple test of physical ability, when appropriate based on the job requirements, without regard to the weight. ​ if you can do the job you can do the job-period.

Honestly I would be more freaked out to work with animals than people. I don't know why exactly. i love animals and I'm a vegetarian, but the thought of starting an IV on a dog kinda makes me want to vomit. If I had a choice between working in a people clinic or an animal one, even if the animal one paid more, I'd go with people. :) So from my perspective, I wouldn't mind that woman referring to herself as a nurse if she's doing all the same stuff- assesment, evaluation, IVs, meds, treatments, education the family, immunizations, etc...... I mean is the schooling really that different? The main difference would be the liability. If you give the wrong med to a dog you are probably a lot less likely to lose your job or license than if you give the wrong med to someone's child or grandma. but other than that, I think she has more right to call herself a nurse (especially since she's specifying 'animal nurse') than MAs or CNAs, and they do it all the time.

The chart is there but i was told that since I'm not from the agency I "don't deal with the chart". I know that parents can give herbal supplements themselves, but to have the nurse give it, they need to mention it to the doctor to have it added to the plan. I am a mom myself, so i know that as the parent you still want control over your child's care, but if I had nurses working in my home and wanted them to give my child supplements, I would mention it to the Dr., because the nurse can't take those kind of orders from the parents. Otherwise the parents can give it. Also, supplements are mixed in to the formula that is made by a recipe i think the mom made (which is fine) but the mix is made in the AM and then poured into unmarked bottles for use throughout the day. Once again, not a huge risk here but- supplements not ordered should only be given by the parents, and nurses are giving a nutritional mix that isnt dated and that they didnt make or watch being made. Maybe that is one of the things that you let go when it comes to home care, but it was just on top of the other stuff. The child was on a g-tube, so he could be given meds at night without being woken up. And some of the meds are to prevent seizure activity, some for sleep. But it was the timing of the meds that made me uncomfortable- the typed up schedule was not according to the pill bottles, which was my only available info that came from the actual physician.