NurseWeek: No place like home

No place like home
Visiting nurses talk about challenges, rewards of bringing care to patients

By Rachael Kagan
November 27, 2000
Photo: Artville

The home care business is demanding and rewarding – and getting tougher as the patient load increases while payments decline.


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Home health nursing is not for everyone. On that, nurses of all stripes can agree. "I love it," said Lisa West, RN, a visiting nurse in Houston since 1992. "Every day is different. I don’t have a doctor breathing down my neck every five minutes."

But Connie Glenn, RN, a psychiatric nurse at John George Pavilion in San Leandro, Calif., who tried home care for a few months, found that isolation troublesome. "Support is less available to you if there’s an emergency,’’ she said. "You have to wait for the doctor to call back. I didn’t like that."

These two nurses describe flip sides of the same coin. The home care business is demanding and rewarding – and becoming tougher as the patient load increases while payments decline.

Some aspects of home care haven’t changed since visiting nurse agencies first started knocking on doors 120 years ago. Back then, public health nurses ministered to the sick in areas without hospitals. They trained patients and their families to do everything from dressing wounds to caring for a newborn baby.

"You have to have very good clinical skills and judgment," said Carolyn Markey, RN, president and CEO of the Visiting Nurse Associations of America. "You have to be pretty creative."

Lately, however, home care agencies across the country are facing new challenges. "Acuity is tremendously greater now," Markey said of today’s in-home patients. "They’re much sicker, much needier."

In response, VNA of the Midlands in Omaha, Neb., now recruits specialty nurses with expertise in cardiology, cancer and diabetes. "We really are looking at a higher level of nurses," said Janice Treml, RN, CEO of VNA of the Midlands.

In Houston, visiting nurses are piloting a telemedicine program, which uses two-way interactive televideo conferencing, making it possible to check in on high-maintenance clients without the expense of sending a nurse to their door several times a day.

"We’re being asked to do more with less," said Paula Wehrman, RN, executive director of the VNA of Houston.

The latest challenge for home health is Medicare’s new payment structure. As of Nov. 1, the government pays a predetermined amount based on the patient’s diagnosis, leaving it up to the home care agency to stretch the dollars to fit all the visits and staffing required.

Judith Clinco, RN, president and CEO of Catalina In-Home Services in Tuscon, Ariz., fears that system will leave many long-term, chronic patients out in the cold. "They’re going to have to look at alternative levels of care for those people," she said.

Others, however, look forward to knowing the amount of reimbursement in advance and the stability that pre-payment could offer.

"We’re going to become much more expert about how to provide care in not so many visits," said Judy Sutherland, MBA, president and CEO of the Visiting Nurse Corp. of Colorado. "So in the long run it will be good, but you’re going to have to run a real lean operation for the next three years of transition time."

Managed care is a big driver of home care. As hospital stays shrink and more procedures move to an outpatient basis, discharges are coming earlier all the time. Technology also plays a role. Home care nurses administer IV medication, maintain respirators, even give blood transfusions. As people live longer, the elderly population – still the bread and butter of home care – will expand.

"People are getting older. They’re more chronically ill. But they’re living longer with their chronic illness," said Connie Little, RN, senior vice president of the California Association for Health Services at Home.

The majority of at-home clients are people with diabetes, stroke, wounds and broken hips, Little said.

Another fast-growing group is babies born prematurely or with birth defects who need near-intensive care in a home setting.

While it takes a doctor’s orders to assign a home care nurse, once inside, the nurse is largely in charge, coordinating a patient care team of physical and occupational therapists, social workers, LVNs and aides. Sometimes, they even see to the care of family pets, arrange for groceries, read letters or visit with their charges.

"I like the closeness you get with patients," said Maryann Panarella, RN, a Denver visiting nurse who has been at it for 16 years and sees as many as 50 clients per week.

The downside includes below-hospital wages, lots of driving and reams of paperwork. Add to that a nationwide nursing shortage that makes home care slots hard to fill and a drop in Medicare reimbursements that has put hundreds of home care agencies out of business.

"It’s a catch-22 for home care," said Sarah Keating, Ed.D., RN, former dean of nursing at Samuel Merritt College in Oakland, Calif. "If they have a shortage of nurses, they have less cases they can take in; therefore, they get less reimbursement."

Paperwork has been a particular sore point since the introduction of the federally mandated OASIS (Outcomes and Assessment Information Set). The 18-page survey must be completed on all clients upon admittance and discharge from home care.

"I love my work, but right now I hate my job," Panarella said. "Why do I have to answer 10 questions on depression to teach a diabetic how to give insulin injections?"

But for some, the benefits outweigh the hardships.

"It’s an experience of a lifetime," West said. "I can’t even measure the growth I’ve had as a person in this field."