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Home care, psychiatry, and geriatrics are not always used in the same sentence, but that's what I do for a living. Estimates are that by the year 2030 there will be more than 2.5 as many persons ages 65 and older than there are today. If you consider how many of that group will be home-bound at any given time needing all types of home care, the number is staggering. Estimating who in this group have psychiatric issues and are unable to see a provider, it is clear a large amount of patients will need psychiatric home care.


As a Master's-prepared advanced practice nurse (APN) specializing in psychiatry, you'd think I would have job security for the long run. However, considering the status of healthcare delivery today, funding for these services may be unavailable, or there may be insufficient psychiatric APNs to provide the needed services.


I worked on an inpatient psychiatric unit for many years and never thought I'd fall in love with home care; but I have. The freedom of working with patients, their caregivers and families, and the privilege of being part of an agency that values the many roles I play and the patient outcomes I affect rather than just focusing on reimbursement, is rewarding.


Although I visit patients from a wide variety of ethnic, socioeconomic, and cultural populations, each is experiencing a pattern of loss. What follows is a typical patient profile:


The patient is an adult, usually over 60, who has suffered losses. Some losses are physical from an acute condition such as CVA, diabetes, cataracts, and cardiovascular disease. Some have lost independence in ADLs. For example, tying shoe laces is no longer an automatic, no-thought-involved type of activity. A stranger or loved one has to help them shower, to keep them safe from accidental injury. Modesty, independence, and simple choices are no longer in their control.


They may have lost their home, their local newspaper, the front stoop where they talked with neighbors, or their mobility through driving or taking the bus or train independently. It might be the loss of a spouse, a child, friends, siblings...their pastor, their rabbi, their occupation, their mind, or their everyday routine.


The longer we live the more loss we will experience. Our ability to cope with it depends on our background, our genetic makeup, how we've handled loss in the past, and how effectively we've handled it. The end result is that an accumulation of loss over a period of time can lead to sadness and, in many cases, depression.


The value of using APNs in home care has yet to be fully measured. It's not enough to say they are more expensive; APNs' impact on overall cost and patient outcomes should be further studied by agencies, especially in the psychiatric area.


Some people I visit only need a venting place; others need referrals within their community with churches, senior centers, day care programs, volunteer services, and mental health resources specializing in geriatric behavioral health that may be covered by insurance. Others may need antidepressants or other prescription drugs. All need education, in particular, psycho-social education.


I'm one of the lucky ones in this world. I love what I do, but we need more APNs in home care. Payers need to value and pay for psychiatric care as much as physical care. Agencies need to closely evaluate how APNs impact on care outcomes and costs. Salary and benefits for home care APNs must be competitive with institutions and programs on the college and university levels should place emphasis on preparing psychiatric nursing specialists.