If you have ever considered working in home health, then you might want an inside glimpse at what it is really like. To help those with questions, I am going to walk you through a typical day in my life as a home health nurse.
I enjoy home health for many reasons, but I find that I can’t do this job full-time. I mostly do travel nursing but when I need a break from the fast-pace and stress of the hospital, I take a PRN job in home health for a little break. So, let’s begin a walk through a typical day as a home health nurse and I will share with you what I love and hate about it.
First, your shift actually begins the night prior. On Sunday night I look at my schedule for Monday. I see who I am to visit and review the file. First up is Mr. Soandso, he is a new admit and I review the information that the hospital has provided. Next, I look at Mrs. Someone, who I will be visiting to provide wound care, so I review her file to see what wound care I will be doing and make sure I will have the supplies needed. Then I take a look at Mrs. Whatshername and find that I will be administering IV Rocephin, taking note of the general time frame in which she needs to get her infusion. After that, I read Mr. Whoeverheis’s file and find that he will also be a new admit, and so I read the file from rehab to find out what happened to him that brought on a referral to home health.
After reviewing all my patients for the next day, I write down a list with a notation of where they live. This allows me to have a general idea of the order in which I will plan to visit them. Then I begin to make my phone calls. On a really good day, I am able to reach them all on the first try. On the worse day, none will answer their phone and I have to wait for them to each return my call.
Here we have some of the reasons that I do and do not like home health. On the one hand, I get to plan my day. I decide how early or late I will start, but it is guided by how many patients I am scheduled to see on a given day. As a PRN nurse, I can tell the company how many I want to do each day, but if I were a full-time nurse, I would have an expected minimum, which might be 7 or 8 patients.
I do not like the fact that I have little control over how available my patients will be to me. Sure, they are supposed to be homebound, so one would think that I could show up anytime and they would be happy to see me, right? But humans do not behave that way. Needless to say, I will have a vision of how I would like to manage my group of patients, but some will refuse to be seen in the morning, while others will want me to show up at 8 a.m. So, while I am supposed to be in control of this, some of that control is taken away by the patient’s preference. This can be a challenge because my patients may be geographically 30 miles or more apart from each other.
Another challenge that I might face as I try to plan my workday is that my new admit patients may, in fact, still be in the hospital, so I won't really get to see them and chances are good that I will not have a replacement patient to see. This is one reason that working PRN in home health might not work for someone. You are paid by the visit. So, if my patient is still hospitalized and I can’t see them tomorrow, I am losing the pay that I would have gotten if they were home by now. As a full-time nurse, this would work out because I would be on a salary and the company will make sure that I get the minimum number of patients or I would get paid my salary anyway.
Moving on, let's assume that I can reach and schedule each of my patients and it is now Monday morning. I scheduled Mr. Soandso’s admit for 9 a.m. I arrive at his home on time and I ring his doorbell. I immediately hear the sound of a huge dog barking on the other side of the door. I imagine that this beast could tear my leg off and I hope that Mr. Soandso will put the dog elsewhere for our visit. Mrs. Soandso answers the door, cracking it open just enough to tell me not to let Rover out while I come in. This dog is massive and drooling, and he is sniffing me and growling, but Mrs. Soandso assures me that Rover will not bite me as she leads me to the living room to meet Mr. Soandso.
I sit down, all the while the dog is still growling a bit but starting to settle down. He finally positions himself at Mr. Soandso’s feet but continues to watch me closely. I pull out the mountain of forms that I need to fill out and have the patient sign. Mr. Soandso was hospitalized for CHF exacerbation and after doing the paperwork, I open my tablet and start the computerized charting. I perform a full assessment and interview the Soandso’s to find out how much they understand about CHF and how to manage this condition. This information allows me to put together my plan of care for the patient. I begin the education process by telling them that Mr. Soandso should be doing daily weights and keeping a log. He has never done this before, but he does have a scale. I ask Mr. Soandso to weigh himself so that I can get a baseline weight. As soon as he stands up, the dog goes back into protection mode, threatening to attack if I make a wrong move.
We finally get through weighing the patient, starting a weight log, and I have documented as much as I can. I have been in Mr. Soandso’s home for over an hour and I need to be going, so I review the plan of care with him, let him know that the physical therapist will be seeing him tomorrow, and I feel relieved to get out with all my body parts in place.
Next up is Mrs. Someone. She lives about 20 miles away, so I put her address into my GPS and start the drive to her house. I need to make a bathroom stop, but as a home health nurse, I am fully aware of which gas stations have clean bathrooms, so I make a pit stop at the Wawa. I grab a snack to eat on the drive.
Mrs. Someone lives in a large apartment complex. I drive around a bit to find her building, then I drive a bit more to find the closest available visitor parking space. I haul my tablet, clipboard and huge bag up the 3 flights of stairs to her apartment.
I find Mrs. Someone to be a delightful lady. She is so sweet and funny. I am able to complete all of my documentation while at her home and I perform her wound care. She had an abscess inside the fold of her buttock just above the rectum, but she made jokes about what a “pain in the butt” this has all been. I spent about 45 minutes with Mrs. Someone and then I moved on to the next patient, Mrs. Whatshername.
After driving 10 miles to the home of Mrs. Whatshername, I find that the lawn has not been mowed in what looks like a year. The path to her door is very grown up and narrow. My arachnophobia is on high alert as a squeeze through the jungle of plants hanging over her sidewalk. I get to the door and see webs in every corner and on the eves above. I take a deep breath and ring the bell. She answers the door and welcomes me into her home.
As I walk in, I find that the inside of her home is no better than the outside. The living room is full to the brim. There are magazines and newspapers piled up on all the furniture. There are boxes stacked in every corner and under every table. Beside her chair is a large stack of mail that is falling over in disarray. There is a hodgepodge of stuff everywhere, leaving only a narrow path through the living room to the kitchen, which is no better. I can see dirty dishes spilling out of the sink and all over the counters. The kitchen table is covered with papers, boxes, dishes, and pill bottles. She has two coffee makers on the counter with another one on the floor below. The top of the refrigerator is loaded down with small appliances, books, and more mail. To make things worse, as I am taking in all the clutter, I glance down and see a roach walking past my foot. Oh boy! I just want to get out of here, but she must have her antibiotics, so I open my tablet and get started.
After taking her vital signs, I ask her where she is keeping the Rocephin. She points to a box that is on top of a couple of other boxes. I try to hide the look of disgust on my face as I find roaches in her box of supplies. Thankfully, everything is in zip-lock bags, so protected if the bags are sealed. I quickly check the bags to make sure that there are no bugs inside. I mix the medication and begin her infusion. While we wait for the medication to infuse over 30 minutes, I talk to her about the possibility of getting help cleaning up her home. The poor dear is 82 years old, has no children to help and she can’t do it herself. I ask her permission to have a MSW visit. She is agreeable, so I put in the referral.
After Mrs. Whatshername’s infusion is complete, I drive over to Mr. Whoeverheis. This time, I find myself in the driveway of what I would consider a mansion. This home is gorgeous and huge, with a perfectly manicured lawn and expensive statues lining the driveway. Mr. Whoeverheis had fallen and broken his hip. He went to rehab for a week and now needs home physical therapy. This man is very kind and very appreciative. I learn that he lives all alone in this huge house, and he is quite lonely. While I fill out the forms and do my computerized documentation, he tells me stories of being in the military and then of this life as a bodyguard to some impressive people. He also tells me about losing his wife a year ago and how much he misses her.
This brings me to one of the reasons that I absolutely love home health. I love the one-on-one time that I can spend with my patients. I listen to their stories and I get to create a real relationship with them. Sometimes this means just getting to listen to them and being someone that they can talk to, other times, it is having the ability to really give them the quality teaching that they need to take care of themselves. I get a real sense of satisfaction from this.
But as you can see from the examples I chose, it also means going into some really dirty and gross environments, facing ferocious dogs, and worrying about carrying home bugs in your bag. I didn’t even mention homes with 16 cats and the odor that comes with that, or the occasional confrontational family members. I also didn’t give an example of some neighborhoods that I would rather not be in but have to face.
Home health has it’s good and bad sides, as you can see. I love not having a supervisor watching every move I make, but on the downside, they often call you on your day off to discuss a case. You also take a lot of work home.
Continuing the scenario above, when I get home, I now have to call the doctors of the two admit patients. I need to confirm that the PCP will sign our home health plan of care and orders. Sometimes this is smooth, but other times, it takes multiple calls over a few days to reach someone. This delays turning in your documentation, and it’s frustrating. I also need to finish my documentation. In this case, I must finish the admit documentation from Mr. Soandso. This may take up to an hour after I get home. However, on some days I have multiple patients to finish documentation on. This might be because I had so many patients to see that I simply couldn’t take the time needed to do it all while in their home, or it might be because the home was so disruptive that I didn’t want to sit there and try to work with a dog barking at me constantly, or cats climbing all over me, or I didn’t want to sit in a home with a bug infestation any longer than I had to. For whatever reason, I find that I have to do a little or a lot every afternoon, which takes away from my home time.
I also have to plan my next day. I can’t begin this until 5 o’clock in the evening because my schedule can change up to that time. On most days, I spend two hours reviewing charts and calling to set up appointments, further taking away from my home time.
I find that the downside is worth the upside. I don’t feel stressed every minute of my day. I can stop for lunch whenever I want. I am always dealing with just one patient at a time. There are no call lights constantly going off, and I don’t have to rush to pass meds in a 2-hour window that is full of interruptions.
While I’m talking to you about home health, I will give you the pros and cons of working PRN vs. full-time. As I mentioned before, PRN allows you to control the number of patients you see every day and set limits based on how much you want to do, plus choose the days you want to work. This is all good, but the income can be irregular because the full-time salaried nurse’s schedules will be filled first. They get the assurance of regular reliable income, but they do not get to choose what days they will work or how many patients they will see. The full-time home health nurse’s schedule is set up on a point system, and they are expected to perform a minimum number of points each week. If the points are not met on any given day, they will often have to do more later in the week to make up for it. I do not like this lack of control over my work day. The salaried nurse will also have on-call shifts. This might mean leaving their home multiple times a day because it is unpredictable if a patient will need an emergency visit.
If you have thought about home health in the past, then I encourage you to give it a try. There are advantages and disadvantages to this job choice, just like everything else. If you can tolerate spending a lot of time in your car, animals of all kinds, and going into some very poor environments, then it might be for you. I suggest trying it on a PRN basis at first, while not giving up your regular job. This way, you can try it out. If you love it, you can always go full time. There is a lot of need in home health right now, partly because many nurses come to home health, but then can’t deal with the downsides. Insurance companies are pushing for more home health because it is cost effective and prevents rehospitalization, so there are many available jobs to be filled.