Why HH nurses quit

KateRN1 · Mar 6, 2011

Please understand that I am only playing Devil's Advocate here, I don't know how your particular office works, I only know about the places that I've worked and the things you've posted online. Here are a few things that I've picked out of your above post and some suggestions. Just some food for thought.

You don't have to answer your phone every time it rings. Let it go to voice mail if you're with a patient or leave your phone in the car. If your agency insists that the phone needs to be answered every time it rings, ask them to reconsider the policy. Don't give patients your phone number if you don't want them to call your personal phone. Granted most will get it from caller ID if you don't block it, but you can insist that they call the office and have the message relayed. If you are driving and it's something that needs to be looked up, let them know you'll call them back when you reach your destination. The phone doesn't have to be your enemy.

If you are calling the doctor's office with an assessment and request for orders, that is really not something that should be done second hand. You wouldn't ask a fellow field nurse to call in your assessment of the patient, so don't think that the nurse in the office should do it. If the doctor's office has questions, how will someone who didn't do the assessment answer? There are things that need to come directly from the nurse who does the assessment. Yes, they frequently want something faxed, but you can remind them that you are a visiting nurse without a fax in the car. Let them know that you will not be able to fax anything until X time and that the patient will be without treatment. On the flip side, maybe you can call the office and dictate the fax to be sent if it truly needs to be sent immediately. Sometimes the doctor's office policies don't consider the limitations of home care and they don't realize it. By educating them in a gentle manner, you may be able to get them to reconsider their policies or make an exception for the current event.

As for documentation, well, that's a sticking point for me. Medicare *requires* particular verbage for payment or to avoid recoupment via RAC or zpic audits, so don't think of it as "micromanaging" when you get that call from the office to change your documentation. Use it as a learning tool for the next time. If you find that you are being asked to change the same things over and over, consider that you might want to adopt the verbage that you are being asked to adopt instead of fighting it. For example, I frequently see one nurse document "discussed with patient blah blah." This is a non-payment statement. Nurses don't discuss, they educate, teach, instruct. Notes that have "discussed" don't get paid. If you're asked to change it a million times, consider just using the right terminology from the start. If you're being called in a lot for documentation, maybe it's your understanding of the documentation that is lacking. Home health is completely different from hospital in that how we word things is directly linked to our payment or denial of such.

Discharges and recerts are a sticky situation at any home health agency. We have to have a solid reason for recert, not just a feeling that something is going to happen. There has to be documentation that the patient has not met goals, that a new problem has developed, or an exacerbation of an existing problem. When someone is asking you to explain something, maybe it's because your documentation didn't paint a clear enough picture? Every note should stand alone, so that if I walk into your agency from the middle of nowhere, I should be able to read your documentation and have a clear understanding of what you did with that patient at that visit or what reason you had for recert or discharge. If you are irritated that someone looking at a flowsheet knows the patient better than you, consider the documentation on that flowsheet. That person should know the patient *just as well* based on your documentation.

I have three completely unsolicited pieces of advice for you:

1. Set reasonable limits on the phone.

2. Learn more about the documentation standards for home health care and incorporate them into your practice.

3. Ask to spend a day in the office with a clinical manager and learn what the role is and isn't. You may be surprised.

twokidsmom,rn · Mar 7, 2011

Home health documentation books? I have been working in HH for 6 months still having trouble writing the correct wording on daily notes. Wondering if there is a book that may help me with this.

berube · Mar 7, 2011

very well said!!!!

Please understand that I am only playing Devil's Advocate here, I don't know how your particular office works, I only know about the places that I've worked and the things you've posted online. Here are a few things that I've picked out of your above post and some suggestions. Just some food for thought.
You don't have to answer your phone every time it rings. Let it go to voice mail if you're with a patient or leave your phone in the car. If your agency insists that the phone needs to be answered every time it rings, ask them to reconsider the policy. Don't give patients your phone number if you don't want them to call your personal phone. Granted most will get it from caller ID if you don't block it, but you can insist that they call the office and have the message relayed. If you are driving and it's something that needs to be looked up, let them know you'll call them back when you reach your destination. The phone doesn't have to be your enemy.
If you are calling the doctor's office with an assessment and request for orders, that is really not something that should be done second hand. You wouldn't ask a fellow field nurse to call in your assessment of the patient, so don't think that the nurse in the office should do it. If the doctor's office has questions, how will someone who didn't do the assessment answer? There are things that need to come directly from the nurse who does the assessment. Yes, they frequently want something faxed, but you can remind them that you are a visiting nurse without a fax in the car. Let them know that you will not be able to fax anything until X time and that the patient will be without treatment. On the flip side, maybe you can call the office and dictate the fax to be sent if it truly needs to be sent immediately. Sometimes the doctor's office policies don't consider the limitations of home care and they don't realize it. By educating them in a gentle manner, you may be able to get them to reconsider their policies or make an exception for the current event.
As for documentation, well, that's a sticking point for me. Medicare *requires* particular verbage for payment or to avoid recoupment via RAC or zpic audits, so don't think of it as "micromanaging" when you get that call from the office to change your documentation. Use it as a learning tool for the next time. If you find that you are being asked to change the same things over and over, consider that you might want to adopt the verbage that you are being asked to adopt instead of fighting it. For example, I frequently see one nurse document "discussed with patient blah blah." This is a non-payment statement. Nurses don't discuss, they educate, teach, instruct. Notes that have "discussed" don't get paid. If you're asked to change it a million times, consider just using the right terminology from the start. If you're being called in a lot for documentation, maybe it's your understanding of the documentation that is lacking. Home health is completely different from hospital in that how we word things is directly linked to our payment or denial of such.
Discharges and recerts are a sticky situation at any home health agency. We have to have a solid reason for recert, not just a feeling that something is going to happen. There has to be documentation that the patient has not met goals, that a new problem has developed, or an exacerbation of an existing problem. When someone is asking you to explain something, maybe it's because your documentation didn't paint a clear enough picture? Every note should stand alone, so that if I walk into your agency from the middle of nowhere, I should be able to read your documentation and have a clear understanding of what you did with that patient at that visit or what reason you had for recert or discharge. If you are irritated that someone looking at a flowsheet knows the patient better than you, consider the documentation on that flowsheet. That person should know the patient *just as well* based on your documentation.
I have three completely unsolicited pieces of advice for you:
1. Set reasonable limits on the phone.
2. Learn more about the documentation standards for home health care and incorporate them into your practice.
3. Ask to spend a day in the office with a clinical manager and learn what the role is and isn't. You may be surprised.

Willow Moonsidhe · Mar 8, 2011

You don't have to answer your phone every time it rings. Let it go to voice mail if you're with a patient or leave your phone in the car. If your agency insists that the phone needs to be answered every time it rings, ask them to reconsider the policy. Don't give patients your phone number if you don't want them to call your personal phone. Granted most will get it from caller ID if you don't block it, but you can insist that they call the office and have the message relayed. If you are driving and it's something that needs to be looked up, let them know you'll call them back when you reach your destination. The phone doesn't have to be your enemy.

I have tried leaving my phone in the car and I end up with 30 min of picking up messages and calling patients back as instructed.

If you are calling the doctor's office with an assessment and request for orders, that is really not something that should be done second hand. You wouldn't ask a fellow field nurse to call in your assessment of the patient, so don't think that the nurse in the office should do it. If the doctor's office has questions, how will someone who didn't do the assessment answer? There are things that need to come directly from the nurse who does the assessment. Yes, they frequently want something faxed, but you can remind them that you are a visiting nurse without a fax in the car. Let them know that you will not be able to fax anything until X time and that the patient will be without treatment. On the flip side, maybe you can call the office and dictate the fax to be sent if it truly needs to be sent immediately. Sometimes the doctor's office policies don't consider the limitations of home care and they don't realize it. By educating them in a gentle manner, you may be able to get them to reconsider their policies or make an exception for the current event.

I don't mind calling the doctor when I have a problem that needs addressing with a patient but you would have to be with me to hear some of the calls that could easily have been managed from the office if they even tried to ask what was needed. I have literally had to pull the car over and look things up on the computer then call the pt back ask a question then call the MD back and finally get an order, find a WiFi hot spot and transmit so the order gets transmitted. Before you know it you are an half hour to an hour behind schedule. Then you have to stop and call all your patients to let them know you are running late so they don't get angry. I actually got called into the office to fax an order for a mobile chest xray and the CM was sitting reading the internet and I was down 1.5 hours of drive time to get the order faxed. She did not have time to help me but time to go personal shopping on the internet.

As for documentation, well, that's a sticking point for me. Medicare *requires* particular verbage for payment or to avoid recoupment via RAC or zpic audits, so don't think of it as "micromanaging" when you get that call from the office to change your documentation. Use it as a learning tool for the next time. If you find that you are being asked to change the same things over and over, consider that you might want to adopt the verbage that you are being asked to adopt instead of fighting it. For example, I frequently see one nurse document "discussed with patient blah blah." This is a non-payment statement. Nurses don't discuss, they educate, teach, instruct. Notes that have "discussed" don't get paid. If you're asked to change it a million times, consider just using the right terminology from the start. If you're being called in a lot for documentation, maybe it's your understanding of the documentation that is lacking. Home health is completely different from hospital in that how we word things is directly linked to our payment or denial of such.

I always use terms like what you are saying such as I instructed, educated. I love the non-payment statement. It is always about money not people. Medical care has changed so much in the 25 years I have been a nurse and we let it happen. We use to never chart for money but rather to show we did good nursing care. That we assessed everything and maybe we worried about what we charted it was to cover us legally not receive a payment. Nurses and doctors have Let insurance companies dictate what a patient can receive. They don't get what they need anymore.

Discharges and recerts are a sticky situation at any home health agency. We have to have a solid reason for recert, not just a feeling that something is going to happen. There has to be documentation that the patient has not met goals, that a new problem has developed, or an exacerbation of an existing problem. When someone is asking you to explain something, maybe it's because your documentation didn't paint a clear enough picture? Every note should stand alone, so that if I walk into your agency from the middle of nowhere, I should be able to read your documentation and have a clear understanding of what you did with that patient at that visit or what reason you had for recert or discharge. If you are irritated that someone looking at a flowsheet knows the patient better than you, consider the documentation on that flowsheet. That person should know the patient *just as well* based on your documentation.

Yeah this has become a joke also. Our guideline for diabetes has 65 teaching points that have to be typed back out and sometimes they place a patient on 4 guidelines with 5 visits counting the SOC to complete them. I have rode with various other nurses before in the past and they run in and see a patient for 15 mins then chart all the glowing guidelines they taught. What a joke this is. It is a lie they are charting; but if they stayed an hour and taught all that stuff they would finish at midnight every night. I have been tempted many a time to walk into a Medicare audit office and just say what a joke of a system we have now. You are checking to see if things are done that are never done. Most of the time people are just sitting around typing crap they did not even do because it is required. If anyone is truly honest they will admit nursing has become one big lie that we tell ourselves. It would be wonderful if we actually got to see the patient enough to really teach all the things we say that we do, but that would mean a couple a visits a week for 60 days not 5 15 to 25 min visits over 60 days. If we are lucky the patient gets a little education but not what they truly need or deserve. I wish someone would truly go in with a heavy hammer and say enough already. What have we done? We need to revamp the whole thing and let it once again be about caring for the sick not the almighty dollar. These corporations admit people with no skill every day and call it assessment, evaluation and education. They find a problem that they can throw some fancy program on to get all disciplines involved and make money off of adding PT, OT etc. All the catchy little names like Medication in Motion, etc. Big corporation at its best. Nurses barely have time to assess the patient for majority of the stuff let a lone teach a 100 page book that most patients never even get a copy of at SOC. But we charted it so we must have done it. Yet we all spend hours each day charting this junk so we can keep a job. I know what they want charted and I do it. When my recert was audited it hit 100 % with medicare. No errors at all. Too bad the patient was not the focus but rather the appropriate wording.

The whole point I am trying to make with this thread is how long do we let it go on. Working 10 and 12 hours a day for 8 hours pay. Lying on charts by saying we taught what would take days to do in maybe a couple of hours actually with the patient. Just my 2 cents worth. Clinical managers and field staff see things so differently. Clinical managers are about making money and field staff are about caring for patients.

Willow Moonsidhe · Mar 9, 2011

i spent my weekend drafting and sending letters. i hope i get a response.
mrs. rn
01/17/2011
the honorable
united states house of representatives
washington, d.c. 20515-4201
dear ,
my name is mrs. . i am a _______ resident and a registered nurse in the state of __________. i have a concern i would like to present to you. i work as a home health nurse. are you aware of how home health nurses are paid in__________? we are basically hired in as salary but we have to see patients to get our points for the week. the average home health agency requires 31 points a week. this changes the salary thing to actually being paid by the visit. most weeks i work 10 to 12 hours a day and i am only paid for 8 hours of that. this week by thursday i had already worked 41 hours. it started snowing and the roads got slick. i called my boss to let her know i was headed home. she said i could put 1.5 hours on my time card for today and use 6.5 of pal time (vacation time) for the rest of the day. well long story short the home health agencies are cheating registered nurses out of paying them what they actually should. with the work load we see 6 to 7 patients a day and drive an average of 100 miles a day. this adds up to a 10 or 12 hour day. they say it should be done within 8 hours. this is impossible. i run as fast as i can and then chart when i get home. they say we are supposed to chart in the home. well while i do wound care, change a picc line dressing, assess the patient, review medications and teach the patient, call the doctor for any complications i guess i could chart and not really do my job. i am not that kind of nurse or person. i have been a registered nurse for 25 years. our elderly and sick deserve our full attention. the patients we mainly serve are the elderly on medicare. these companies are milking medicare and cheating nurses. they will not even pay us for our true gas mileage instead they use bing mileage calculated by an internet bing search. routinely my pay for mileage is way lower than what i actually drive.
i would like to see _________ look into these things. it would be prudent to have an investigative committee look into the labor practices of home health agencies in the state. i have worked for three different agencies this year and found they all do the same thing. one nurse in oregon brought this same issue to their senators and congressmen and their law changed. below is how their law reads now.
http://www.leg.state.or.us/ors/652.html
652.260 payment to nurses providing home health or hospice services; rules.
(1) a home health agency providing home health services may not compensate a nurse providing home health services for the agency on a per-visit basis.
(2) a hospice program providing hospice services may not compensate a nurse providing hospice services for the program on a per-visit basis.
(3)(a) the bureau of labor and industries shall enforce compliance with the provisions of this section.
(b) in accordance with the provisions of ors chapter 183, the commissioner of the bureau of labor and industries may adopt rules to carry out the provisions of this section. [2009 c.141 2]
we are not in the dark ages now and labor laws protect our workers. somehow these companies have found a loop hole to cheat our state's nurses of well-deserved pay. please give this your full attention. i know if it is investigated you will find what i say to be the truth.
attached is an email i received from my boss regarding putting down my time on the time card.
sincerely,

i got a phone call from the state labor board today and they feel this is illegal on a federal level and are contacting an agency to speak with me. i know it is wrong. i have put in 24 hours already this week for 16 hours of pay and have 25 more visits scheduled. i hope this brings down the whole pay point system and they have to go back to actually paying by the hour for time you actually work. the whole system now is nothing but labor abuse.

thanks

~raven

BrookeeLou_RN · Mar 10, 2011

Wow...you ladies have certainly been at it....I just discovered this forum.. So I thought I would add my 2 cents worth.. First off been doing HH since 1991, so have been fee for service, the many forms of Oasis, PPS etc. I have not worked in last yr because of caring for both parents who were terminal but up till then I am pretty with it. KateRN1, I have done all you have stated doing but I think the point needs to be made that it is not every day of the week or every week of the yr that you can do all of those things. Yes I have been the Clinical supervisor, CM in office also and have been CM in field.. Every single job takes total max effort.

Willow, I applaud you for contacting legislators. And I hope the rules do change as it is fast food nursing. If any one has noticed ..even McDonald's has slowed way down in favor of customer service!

As supervisor I helped my nurses more than anyone ever helped me..some utilized the help and appreciated it..others felt entitled and would be picking up their kids at 3 pm every day.. And not to just take them somewhere and return to work.. they actually felt they were done for the day.. One nurse actually kept saying certain patients were not home or refused visits to make her day shorter. Of course within 2 weeks, patients actually decided to report this... it was explained thoroughly to her she was expected to actually see all assigned patients. ( this agency actually allowed 6 pt per day due to acuity) Now some days even 6 were tough but Oasis counted as more than one pt. This nurse then stopped turning in Oasis paperwork for over a week. She must have been one of those that thought HH was easy.. Finally gave up trying to help her and had to terminate her. But most nurses know it is hard..some are better with time mgmt then others.

I actually went back to the field as being Clin sup started to require fillling in and making visits in addition. I felt that was just too much. In the field I was Clin sup's dream.. as I knew what she did and made sure not to leave the crazy stuff to her. I think the thing that made me the craziest was when field RN would call MD but not tell me WHY? To take the MD's call and have to say i will contact the RN and get back with you was not good! Now if the office nurse called I would play 20 questions and try to guess what the Field RN might have wanted..but MD's will not play 20 questions. And I can not tell you how time consuming this is for Clin Sup....

The last company I worked for.. had reasonable goals, 6 per day but sometimes they would add on. I meet productivity the majority of the time but I was one of just a few who did. Even when it was reasonable many nurse just could not/would not get there. And we even got paid for charting at night, yep...not encouraged mind you...and OT was frowned upon and if you did it too often there would be a "talk" but if you had a horrible day/ week.. at least you were not doing it for nothing.

My point is even when things are fair not everyone can do it. I have seen nurses crying and yet they stay when it is obvious HH is not best suited to their needs. And this was before jobs got tight.

My problem was I was 32 hr person, 4 days a week yet was still field case manager.. that is tough to do.. I mentioned that to NM and was told well work every day but less per day! I just did not see purpose of being 32 hrs then...

I never wanted to..but resigned to go back to FL to care for my dad. I even worked my notice. But NM is angry I chose my family over my job! Of course I was just short of FMLA status. But it all happened for a reason as after my father died my mother fell apart and died (of broken heart)6 months later.

I even called NM to see if I could get rehired by her after they died. She said I was welcome to apply.. but I have 3 times and never even got a call or denial letter. But I think working for her might cause me to be resentful so it is all for the best.

So it has been over 3 months since Mom died and no job. Luckily I have good finances. I am not sure going back to HH or hands on pt care for that matter is best for me right now...

I am considering opening non-nursing business, seriously.

But I had a Exec Director call last week from resume she found online from last Nov, and she3 has begged me to come talk to her. She was actually so nice I said I would come "talk" and that talk is tomorrow morning. So who knows what she might have in mind.. Kinda nice to know someone does want to talk with me at least.

To sum it up,, no one is wrong.. everyone comes with their own set off outside stressors that makes one aspect harder for ont than for another.. But please take time to enjoy life..it is very precious and very short and there are no 'do overs!"

Luv2care0907 · Mar 10, 2011

I never wanted to..but resigned to go back to FL to care for my dad. I even worked my notice. But NM is angry I chose my family over my job! Of course I was just short of FMLA status. But it all happened for a reason as after my father died my mother fell apart and died (of broken heart)6 months later.

My parents are going through that time of their lives as well. I am sorry for your loss.

Your career situation helps a lot of us because it is telltale of the times we live in. I would think you would land a job easily. Thank you for sharing your story!

Willow Moonsidhe · Mar 11, 2011

01/17/2011
the honorable
united states house of representatives
washington, d.c. 20515-4201
dear ,
my name is mrs. . i am a _______ resident and a registered nurse in the state of __________. i have a concern i would like to present to you. i work as a home health nurse. are you aware of how home health nurses are paid in__________? we are basically hired in as salary but we have to see patients to get our points for the week. the average home health agency requires 31 points a week. this changes the salary thing to actually being paid by the visit. most weeks i work 10 to 12 hours a day and i am only paid for 8 hours of that. this week by thursday i had already worked 41 hours. it started snowing and the roads got slick. i called my boss to let her know i was headed home. she said i could put 1.5 hours on my time card for today and use 6.5 of pal time (vacation time) for the rest of the day. well long story short the home health agencies are cheating registered nurses out of paying them what they actually should. with the work load we see 6 to 7 patients a day and drive an average of 100 miles a day. this adds up to a 10 or 12 hour day. they say it should be done within 8 hours. this is impossible. i run as fast as i can and then chart when i get home. they say we are supposed to chart in the home. well while i do wound care, change a picc line dressing, assess the patient, review medications and teach the patient, call the doctor for any complications i guess i could chart and not really do my job. i am not that kind of nurse or person. i have been a registered nurse for 25 years. our elderly and sick deserve our full attention. the patients we mainly serve are the elderly on medicare. these companies are milking medicare and cheating nurses. they will not even pay us for our true gas mileage instead they use bing mileage calculated by an internet bing search. routinely my pay for mileage is way lower than what i actually drive.
i would like to see _________ look into these things. it would be prudent to have an investigative committee look into the labor practices of home health agencies in the state. i have worked for three different agencies this year and found they all do the same thing. one nurse in oregon brought this same issue to their senators and congressmen and their law changed. below is how their law reads now.
http://www.leg.state.or.us/ors/652.html
652.260 payment to nurses providing home health or hospice services; rules.
(1) a home health agency providing home health services may not compensate a nurse providing home health services for the agency on a per-visit basis.
(2) a hospice program providing hospice services may not compensate a nurse providing hospice services for the program on a per-visit basis.
(3)(a) the bureau of labor and industries shall enforce compliance with the provisions of this section.
(b) in accordance with the provisions of ors chapter 183, the commissioner of the bureau of labor and industries may adopt rules to carry out the provisions of this section. [2009 c.141 2]
we are not in the dark ages now and labor laws protect our workers. somehow these companies have found a loop hole to cheat our state's nurses of well-deserved pay. please give this your full attention. i know if it is investigated you will find what i say to be the truth.
attached is an email i received from my boss regarding putting down my time on the time card.
sincerely,

response received today:

carolyn sherrod

executive administrative assistant, wrc

tn department of labor & workforce development

220 french landing drive, 2-b

nashville, tn 37243

(p) (615) 532-2784

(f) (615) 253-5831

email:[email protected]

this e-mail, including attachments, is intended for the exclusive use of the person or entity to which it is addressed and may contain confidential or privileged information. if the reader of this e-mail is not the intended recipient or his/her authorized agent, the reader is hereby notified that any dissemination, distribution or copying of this e-mail is prohibited. if you think you have received this e-mail in error, please advise the sender by reply e-mail and then delete this e-mail immediately.

>>> arthur franklin 3/9/2011 2:58 pm >>>

dear :

i am in receipt of a letter regarding home health agencies that you sent to congressman phil roe. it appears that the congressman sent the letter to your state representative matthew hill. subsequently, the letter was sent to me within the tennessee department of labor and workforce development for assistance.

our department enforces the wage regulation act. this act ensures an employee's right to wages legally owed. we investigate complaints of an employer's failure to pay an agreed salary and aid the employee in recovering such wages owed.

your letter seems to speak more about overtime and mileage issues as well as an overall complaint regarding the labor practices of the home health agencies in tennessee.

from my research, the following are the entities that can assist you further: regarding the complaints of the home health agencies-the tennessee department of health oversees these agencies; they can be reached @ 877-287-0010, regarding the overtime and mileage issues-the usdol (united states department of labor) enforces those issues; they can be reached at (865) 545-4619 knoxville office or (615) 781-5344 ext 16 (direct line for a federal inspector in the nashville office of usdol.

if there is anything further that i can assist you with please feel free to contact me from the information listed below.

arthur e. franklin jr., administrator

department of labor & workforce development

220 french landing drive

nashville, tn 37243

(615) 741-1627

BrookeeLou_RN · Mar 11, 2011

Kinda seems like the buck was passed several times. Did you contact any of the people indicated?

Willow Moonsidhe · Mar 12, 2011

The State Labor person called me with multiple questions. After I had answered them he told me that he feels they are breaking two federal rules. That is where he wants me to send further information. I hope it finally gets to the place it needs to be. This weeks grand total was worked 66.5 hours and paid for 40. lol

~Willow

Willow Moonsidhe · Mar 12, 2011

PS At this point I am filling out applications for other types of RN jobs. I am just too tired all the time.

~Willow

BrookeeLou_RN · Mar 12, 2011

I did not realize you were in TN.. Me too. I hope somehow you are able to get them to actually make changes. I have not experienced the same unfairness you have recently but have in the past. I for one am very proud of you having the guts and determination to make them listen. You are quite a woman. God speed.