1. Osakwe, Zainab Toteh PhD, MSN, NP
  2. Oni-Eseleh, Ohiro PhD, MBA, LCSW

Article Content

Q: How can management support nurses and promote retention during these uncertain times?


Home healthcare (HHC) nurses work largely in professional silos. This model is not sustainable given the increase in acuity of home care patients, many with advanced illness and high symptom burden (Bowles et al., 2021; Falvey et al., 2020; Jones et al., 2019; Osakwe et al., 2022). The current nursing workforce shortage poses a major challenge to the HHC sector that relies heavily on nurses for clinical visits, care coordination, and home health aide supervision (Buerhaus et al., 2022; Irani et al., 2018). The COVID-19 pandemic has served to intensify clinician burnout.


Thus, there is an urgent need to identify HHC patients with advanced illness and those nearing end of life, to facilitate access to palliative care or hospice. We need to develop new models of care to support the nursing workforce, while providing patients and families with high-quality care. Nurses cannot be expected to singularly manage the complex care of patients with advanced illness. One potential approach to support nurses in the field is nurse-social worker teams. Consistent collaboration between nurses and social workers is important to ensure patients and families receive emotional support, caregiver resources, and assistance with long-term planning.


One vital role of social workers is their ability to navigate sensitive conversations. Social workers are highly knowledgeable about resources, caregiver burden, and advance care planning-all crucial to the delivery of optimal end-of-life care. Because social worker visits are not considered skilled visits, their utilization in home care has been limited. There is a need to encourage and support shared nurse-social worker teams to optimize the delivery of high-quality HHC, particularly for patients nearing the end of life. This model promotes team visits, particularly for patients with advanced illness, and works best with weekly case conferences for nurse-social worker teams.


It is time to invest in greater utilization of social workers in the HHC setting for several reasons. First to support nurses in the field, and to decrease stress associated with care coordination for patients with advanced illness. Second, to provide a structured process to facilitate team-based end-of-life care planning in the HHC setting. Finally, with empowered nurse-social worker teams, home care nurses will gain mentored support and exposure in managing the end-of-life communication.




Bowles K. H., McDonald M., Barron Y., Kennedy E., O'Connor M., Mikkelsen M. (2021). Surviving COVID-19 after hospital discharge: Symptom, functional, and adverse outcomes of home health recipients. Annals of Internal Medicine, 174(3), 316-325. [Context Link]


Buerhaus P. I., Staiger D. O., Auerbach D. I., Yates M. C., Donelan K. (2022). Nurse employment during the first fifteen months of the COVID-19 pandemic. Health Affairs, 41(1), 79-85. [Context Link]


Falvey J. R., Murphy T. E., Gill T. M., Stevens-Lapsley J. E., Ferrante L. E. (2020). Home health rehabilitation utilization among Medicare beneficiaries following critical illness. Journal of the American Geriatrics Society, 68(7), 1512-1519. [Context Link]


Irani E., Hirschman K. B., Cacchione P. Z., Bowles K. H. (2018). Home health nurse decision-making regarding visit intensity planning for newly admitted patients: A qualitative descriptive study. Home Health Care Services Quarterly, 37(3), 211-231. [Context Link]


Jones C. D., Falvey J., Hess E., Levy C. R., Nuccio E., Baron A. E., Masoudi F. A., Stevens-Lapsley J. (2019). Predicting hospital readmissions from home healthcare in Medicare beneficiaries. Journal of the American Geriatrics Society, 67(12), 2505-2510. [Context Link]


Osakwe Z. T., Oni-Eseleh O., Bianco G., Saint Fleur-Calixte R. (2022). Symptom burden and activity of daily living (ADL) dependency among home health care patients discharged to home hospice. American Journal of Hospice and Palliative Medicine(R), 10499091211063808. [Context Link]