1. Elliott, Brenda PhD, RN

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HAVE YOU EVER considered leaving the acute care setting and stepping out into the world of home healthcare? Practicing in a community setting where you're mobile and on the go, not always within the four walls of a hospital, may be enticing. This specialty affords an opportunity to practice in a setting within a community where autonomy and coordination of care are the focal points. Keeping patients safe at home, avoiding hospitalizations, and helping them return to an optimal level of functioning are at the heart of home healthcare nursing.

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This article provides a general overview of home healthcare nursing for nurses considering a change in practice setting. The focus is on caring for adult patients. Here's what you need to know before making this decision.


Experience needed

Most home healthcare agencies require nurses to have a BSN and at least 2 years of experience as an RN in a medical-surgical setting.1 Nurses who've worked in medical-surgical or critical care areas generally succeed in home healthcare settings due to their broad range of assessment skills. Although no specific certification is available for home healthcare nursing, some nurses choose to maintain certification in medical-surgical nursing.


Most patients in home healthcare settings are older than 65 and have multiple medical diagnoses and chronic health issues.2 Some of the more common include heart failure and other cardiac problems, diabetes, chronic obstructive pulmonary disease, pneumonia, and osteoarthritis.2 Nurses with experience in these areas are a good fit for home healthcare:


* cardiac diseases


* pulmonary disorders


* orthopedics


* diabetes


* wound care.



Who's best suited?

If you're an organized person with good time management skills, you're well on your way to being successful as a home healthcare nurse.3 Critical thinking is important in any nursing specialty, but this skill is especially important for nurses working in patients' homes, away from the resources of a hospital setting.4 Being able to make on-the-spot decisions about a patient's health status or needs is crucial. Being a good listener and effective teacher are also important to help plan needed care and education.1


Excellent written and verbal communication skills help nurses succeed in home healthcare. Coordinating care among services including physical, occupational, and speech therapy; social work; and home health aides as well as with healthcare providers' offices draws on these skills daily. Communicating with families, caregivers, and community resources or agencies also requires these critical skills.


Critical assessment skills

One of the main goals of home healthcare is to keep patients in their homes or community and out of the hospital.1 To achieve this, nurses in this setting must be skillful at detecting early signs and symptoms of decompensation and act quickly to keep a patient stable.4 Sometimes this means advocating for a change in medication regimen or a primary care appointment within 24 to 48 hours. Now that preventing rehospitalizations is a priority across the healthcare continuum, these skills are crucial. Monitoring lab values over time and noting trends are also important.


Medication management is another critical skill needed in home healthcare. Older adults are taking more medications now than in any other time in history. Due to the number of trade, generic, and over-the-counter medications that people take and the number of prescribers who may be involved, keeping the medications organized can be overwhelming for patients.5,6 Many home healthcare nurses arrive at a home to find that patients haven't filled prescriptions provided at hospital discharge. Nurses may uncover such problems as multiple bottles of the same medication with different dosages, half-used containers of prescribed medications, and duplicate medications with different drug names. Nurses may spend an hour getting medications sorted out before they can even perform a physical assessment.5


Nurses working in a home environment need different assessment skills than their acute care counterparts. For example, assessing the home environment and living conditions can help to maintain patient safety. This can range from determining if the patient has a fire escape plan and working smoke detectors to ensuring that walking paths are clear of clutter and throw rugs.


Nurses work autonomously to determine if patients need further support services and community resources such as Meals on Wheels or transportation services. Home health nurses also need to assess family and caregiver involvement in care and evaluate their potential needs.


Weighing the pros and cons

As in any area of practice, home healthcare nursing has both rewards and drawbacks. Home healthcare is a highly regulated field of nursing that can be challenging to learn.3 It takes about a year to 18 months to really understand all the aspects of home healthcare practice, making it potentially overwhelming. Even experienced acute care nurses may feel like novice clinicians again.


Although the work day can be flexible, it can also create a false sense of having more time; some find it difficult to complete their visits and documentation in an 8-hour shift.3,4 Learning to get everything done takes discipline.


Home healthcare nurses must be flexible and work around patient's schedules, healthcare provider appointments, and the weather, to name just a few other challenges. Tracking mileage, recording time spent in patients' homes, and lengthy documentation are all potential drawbacks to this area of nursing. Home healthcare nurses may work in homes that aren't clean or where pets have taken over. Some nurses work in areas that present risks to their own safety; knowing how to stay safe is a priority. (See Staying safe on the road.)


Despite the drawbacks, home healthcare nursing offers as many if not more rewards than other fields of nursing. One of the biggest benefits many nurses seek when moving into home healthcare practice is a schedule that allows for some flexibility based on the nurse's case load, patient preferences, and skills needed. Many home healthcare nurses start work between 0800 and 0900 and finish by 1600 or 1700. They may have less work on weekends and holidays than other nurses, depending on the agency's size and structure.


Nurses in home healthcare find their practice to be autonomous and challenging, giving them many opportunities to put their assessment and teaching skills to use.3,4,6 Home healthcare is unique in that nurses and other healthcare professionals can care for patients one-on-one in the comfort of their own homes and in their own communities. These nurses might be the only person who checks in on a patient all week: Many patients have no family or caregiver support.


Typical day requires flexibility

Whether home healthcare nurses are case managers or are working per diem, most plan their days ahead of time. After determining their assignments for that day, they gather necessary supplies and make phone calls. Many nurses call patients the night before or the morning of the visit, giving them a window of time for their arrival. Once nurses leave the office or their own home, they travel from one patient to the next, completing visits, documentation, and phone calls along the way. Based on their findings, nurses must determine when each patient should be seen again or discharged, coordinate care with other disciplines as needed, plan and prepare for the next day, and complete any incomplete documentation or follow-up calls before ending their workday.1,4,7


Most home healthcare nurses would say that the planned schedule often changes over the course of the day, but that's all part of meeting the demands of this patient population. Being flexible and adjusting to change are characteristics these nurses need.


Still considering?

Home healthcare can be a great option for nurses today. Helping patients after hospital discharge to get the resources they need to resume their optimal level of functioning within the community can be very satisfying and highly rewarding.


Staying safe on the road


* Keep your car in good working condition.


* Call ahead so the patient knows when to expect you.


* If you're worried about safety, request an escort if your agency offers one or make a joint visit with another provider if possible.


* Carry only a small amount of money.


* Don't bring medications with you.


* Park in a well-lit area where others can't block you in.


* Don't leave electronics, a purse or wallet, or any other valuables out in the open.




1. American Nurses Association. Home Health Nursing: Scope and Standards of Practice. 2007. [Context Link]


2. Caffrey C, Sengupta M, Moss A, Harris-Kojetin L, Valverde R. Home health care and discharged hospice care patients: United States, 2000 and 2007. National Health Statistics Reports; no. 38. Hyattsville, MD: National Center for Health Statistics; 2011. [Context Link]


3. Hartung SQ. Choosing home health as a specialty and successfully transitioning into home health nursing practice. Home Health Care Manag Pract. 2005;17(5):370-387. [Context Link]


4. Ellis I, Chater K. Practice protocol: transition to community nursing practice revisited. Contemp Nurse. 2012;42(1):90-96. [Context Link]


5. Hohl D. Transitions in home care. Home Healthc Nurse. 2009;27(8):499-502. [Context Link]


6. Riker GI, Setter SM. Polypharmacy in older adults at home: what it is and what to do about it-implications for home healthcare and hospice, part 2. Home Healthc Nurse. 2013;31(2):65-77. [Context Link]


7. Elliott B. A day in the life of a home care nurse in Hawaii. Home Healthc Nurse. 2014;32(8):503-504. [Context Link]