Changing Gears
Hospital nurses who move into home care find their new setting offers the opportunity to use their versatile skills and forge deeper bonds with patients

By Donna Hemmila
November 29, 2004

Fifteen years ago, Suzanne Travis, RN, closed the door on hospital nursing and walked into the world of home health care.

“It’s like a subculture of nursing,” she says. “Patients don’t know about it, and many nurses don’t really know about this kind of work.”

Those willing to try it, she says, will find great flexibility, autonomy, and most importantly, a chance to forge long-term, meaningful relationships with patients and their families.

Travis works for UCLA Home Health, an agency connected to a major teaching hospital, but she spends her working days driving around Los Angeles County visiting a caseload of about 30 patients in their homes. That’s as different as you can get from seeing people in a hospital, Travis says. She describes the relationship between patients and nurses as much more intimate and rewarding for both parties.

It’s not unusual for Travis to see a patient on and off for several years. She has taken care of one elderly couple for eight years. She finds it easier to develop a relationship with patients in their own environment rather than when they are in an institutional setting, and she believes patients feel and heal better in the comfort of their homes.

Home health nursing began in the United States in the 1800s with visiting nurses who dedicated themselves to providing care for frail elderly and other homebound patients. These works of charity evolved into modern home care practices run by hospitals or freestanding agencies. In 2000, according to the National Center for Health Statistics, more than 11,000 U.S. home care and hospice agencies were in operation, providing a range of services designed to care for chronically or terminally ill patients who wish to remain in their own homes or in assisted living facilities. About 1.4 million people in the United States were home care patients in 2000, according to the National Home and Hospice Care Survey conducted by the National Center for Health Statistics.

When Travis, who had been working in a hospital oncology department, first started as a home health nurse, many of her clients were AIDS patients. Now, she sees more geriatric patients, a group that makes up about 70% of the home health patient population, according to the home and hospice survey. Nearly 22% of that senior group is 85 or older. Changes in Medicare reimbursement to hospitals during the 1980s made home health care a more cost-effective treatment for elderly patients.

With Medicare paying hospitals for each patient discharge rather than by the day, length of hospital stays began to decline. Medicare also expanded the home health services it covers.

Home health nurses perform a range of skilled nursing services including chemotherapy, hydration, pain management, and wound care. The home health nurse also assesses the patient’s living situation and makes recommendations for personal care aides, physical therapists, meal programs, and other social services.

“The goal is to keep them from being admitted to the hospital,” Travis says.

Unforgettable

An aspiring stand-up comic, Travis believes humor and laughter play an important role in coping with illness.

For a year, she took care of one patient who was dying of AIDS. “He’d help me write jokes while he was on morphine,” she says. “I’ll never forget him. That was the most meaningful relationship I’ve ever had with a patient.”

The home setting allows Travis time to joke and laugh with her patient rather than just discuss symptoms and medications. That kind of communication, she says, makes home health such a rewarding type of nursing.

“There are many times when I leave home [when] I think the patient was lucky that I was there,” says Rosemary Gerber, RN, BSN. “We do make a difference, but I think it’s really the patients who touch us.”

Gerber is coordinator of the Advanced Illness Management program at Sutter VNA & Hospice, a home health agency that serves 10 Northern California counties.

The program, based in the Sutter VNA & Hospice Emeryville, Calif., facility, cares for patients who aren’t yet physically or psychologically ready for hospice care. Sutter plans to expand the program to all of its facilities, Gerber says, giving nurses new opportunities to practice palliative care.

With a background in labor and delivery nursing, Gerber says she didn’t find it difficult to move into geriatric care. Her work has given her a new understanding of the elderly and the low-income communities where many of them live.

“When I first started, I felt like Alice in Wonderland,” Gerber says. “You drive through these neighborhoods and you see these houses, and you never know what’s going on inside them. You open the door and worlds and worlds open to you.”

For Kathy Daniels, RN, MSN, BSN, a former cardiac intensive care nurse, one of the biggest attractions to home health is the opportunity to do patient education. She enjoys teaching patients and family members how to live with their illnesses and care for themselves or their loved one. The assessment skills she honed as a critical care nurse have helped her in home health.

“We’re the eyes and ears of the doctors,” she says, because it’s often the nurse making a house call who sees a patient’s deteriorating condition or need for different treatments.

Home health also has given her a way to stay active in the nursing profession. “I’m 60 years old, and at some point critical care would become too exhausting,” Daniels says. “I love teaching, and I love working with seniors.”

Unknown territory

Of course, there are downsides. Many times nurses don’t know exactly what they’ll encounter going into unfamiliar neighborhoods or a stranger’s home. If a frail elder lives alone without family or social support, sometimes the home can be dirty, and sometimes the neighborhood can be intimidating.

Travis remembers getting caught in the crossfire of a drive-by shooting on one of her first home health visits to an elderly man in South Central Los Angeles.

“I got my supplies and was walking into the house when I heard this rat-a-tat-tat,” Travis says. “I didn’t know it was gunfire because I had never heard gunfire. When I turned around, I saw a car speeding by with a person with a gun and a black hood.”

After she got inside, she and the patient’s family sprawled on the floor until the shooting stopped, and no one was hurt.

However, those kinds of experiences can happen to anyone anywhere, says Mary Gumbrecht, RN, BSN, PHN, a field supervisor for UCLA Home Health. Violence, or the threat of it, can happen in a hospital just as easily as someone’s home. Home health nurses do receive annual safety training, she says, and they’re cautioned not to put themselves in dangerous situations.

“We’re not expected to risk our lives to be supernurses,” she says.

If nurses are considering going into home health, they do need to be able to hit the ground running every morning and feel confident with their assessment skills, Gumbrecht says.

“A lot of focus is on teaching, which is what I felt was lacking in the hospital,” she says. “In the hospital, we just pieced them back together and sent them out the door.”

Gumbrecht, who says she didn’t enjoy the “go-go” pace of hospital work, initially tried home health when she started having back problems and needed a job with less lifting. She found the home health work suited her and she finds a lot of room for personal growth and developing specialties.

“I think home health nurses are awesome,” she says. “I know that sounds simplistic, but we have to be so well-rounded. In home health, we have to change gears from visit to visit. You really use what you learned in nursing school.”

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