Learning Objectives
By the end of this section, you will be able to:
- Discuss the nurse’s role in a home health setting
- Explain the process of conducting a home health visit
A holistic approach, community-based care goes beyond typical medical treatments for specific conditions to address broader factors affecting health outcomes in a community. It is centered on delivering patient-centered care, which includes cultural sensitivity and considers the emotional, physical, social, and environmental factors that impact an individual’s health. Community-based care includes home health care, school nursing, prison health, and more. Best practices for each of these specialties are established by the Home Health Agency Center, the National Association for Home Care and Hospice (NAHC), and the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services (CMS).
Providing community and health-care services within a home setting, often referred to as home health care or home-based care, offers numerous benefits for patients who require medical attention, rehabilitation, or ongoing support. This approach allows individuals to receive personalized, high-quality care in the comfort of their own homes, promoting a sense of familiarity and autonomy. Home health care encompasses both medical and nonmedical services to address various needs and provide peace of mind for individuals, particularly older adults and those who are chronically ill or recovering from surgery or illness.
Due to its advantages, home health care has grown increasingly common within modern health-care systems. The Cleveland Clinic declared that the use of home health after an inpatient hospitalization decreases the rate of readmission hospitalizations, complications, and even death (National Association for Home Care & Hospice, 2021). Further, it saves at least $6,500 per patient in government Medicare costs (National Association for Home Care & Hospice, 2021). In this module, we explore the essential elements and advantages of home health care, particularly its role in improving overall quality of life and health-care outcomes for patients.
The Nurse’s Role in Home Health Settings
Nurses play an instrumental role in developing comprehensive home-care plans for their patients. An important step in transitions of care, these plans should outline health-care needs, goals, interventions, and strategies that address conditions for patient health.
To prepare for planning, nurses perform a detailed assessment of patient health status, which involves reviewing past medical histories and present conditions, medications, allergies, physical abilities, environmental factors such as home fall risks, and any support systems in place. This preparation enables care plans to be customized to each person’s unique requirements. Based on assessment findings, nurses collaborate with patients, their family, and members of their health-care team to set realistic and obtainable goals that meet SMART (specific, measurable, attainable, relevant, and timely) criteria. Examples could involve food preparation, medication administration, wound-care services, patient education sessions, and rehabilitation exercises, as appropriate. Following is an example of a SMART goal that a nurse could set with an older adult patient to help with improved medication adherence:
- Specific: The patient will take their prescribed blood pressure medication every day at 8 a.m. without fail.
- Measurable: The patient will track their medication adherence using a pill organizer or a medication adherence app, accurately recording each instance of medication taken.
- Achievable: The patient will consult with their health-care provider to ensure that the prescribed medication schedule fits their lifestyle and does not conflict with any other medications or personal commitments.
- Relevant: Maintaining consistent medication adherence is crucial for managing blood pressure effectively and reducing the risk of complications associated with hypertension.
- Timely: The patient will achieve 90 percent medication adherence within the next three months, as evidenced by their medication adherence records and discussions with their health-care provider during follow-up appointments.
Recognizing the unique circumstances surrounding home care, nurses tailor care plans specifically to each patient’s home environment, the resources available, and personal preferences. Nurses consider each patient’s cultural background, beliefs, and values when creating care plans; this ensures care is culturally sensitive and respectful.
Nurses engage patients as active participants in care planning by including their input and preferences and acknowledging the patient has ownership over their own health care. This collaboration allows care plans to remain relevant over time. Nurses work collaboratively with health-care team members such as physicians, therapists, social workers, home health aides, and home-care aides, with each contributing their unique expertise toward patient care. A nurse educates both patient and family on their care plan, including its purpose, techniques for performing self-care tasks, and potential signs of complications to watch out for.
A registered nurse documents the care plan, detailing goals, interventions, expected outcomes, and changes made at subsequent visits. Accurate documentation ensures continuity of care and communication within the team. Nurses understand that care plans may need to change with time due to patient progress, health status changes, and new developments. Once established, nurses share the plan with primary care doctors and other health-care providers involved with managing patient care, which ensures a cohesive approach toward improving health management for each patient.
Nurses also must consider ethical considerations when providing care plans or making health-related decisions on behalf of others. Nurses ensure the care plans they create respect the autonomy, values, and rights of home-care patients. Producing such plans requires an assessment of patient needs as well as collaboration from health-care teams to promote efficient communication with positive results for home-care patients.
The nurse’s role in home health care clearly extends beyond medical treatment. Nurses provide comprehensive care, education, and emotional support, enhancing patients’ well-being and promoting optimal recovery within the familiar and comforting surroundings of their own homes. The nurse plays a central role in coordinating and delivering these services effectively (Chen, 2022).
Home Health Visits
A home health visit is an opportunity to conduct a nursing assessment in the patient’s home, documenting the patient’s health, monitoring their progress, and making sure they receive the care and support needed. A nursing home health visit may include different components depending on the patient and the purpose, but they usually include the following activities:
- Assessment of home environment: Nurses assess the patient’s living conditions and make recommendations for modifications or adaptations to ensure safety and accessibility.
- Medical assessment and monitoring: Nurses conduct thorough assessments of the patient’s health status, including vital signs, and monitor wound care, medication management, and chronic conditions. Regular assessments help detect changes in health and ensure timely interventions.
- Medication management: Nurses educate patients and caregivers about medication regimens, administer medications as needed, and monitor for adverse effects or interactions. They play a critical role in ensuring medication adherence and preventing medication-related issues.
- Wound care: Patients with wounds or surgical incisions require specialized care to promote healing and prevent infections. Nurses assess the wound’s progress, change dressings, and provide guidance on wound-care techniques.
- Pain management: For patients with acute or chronic pain, nurses work to assess the nature and intensity of pain, administer pain medications, and implement nonpharmacological pain management strategies to improve comfort and quality of life.
- Rehabilitation services: Physical therapists, occupational therapists, and speech therapists may visit patients at home to provide rehabilitation services after surgeries, injuries, or medical events like strokes. Nurses collaborate with these therapists to ensure comprehensive care.
- Patient and family education: Nurses educate patients and their families about the patient’s condition, self-care techniques, and lifestyle modifications to promote recovery and prevent complications. This education empowers patients to actively participate in their care.
- Emotional and psychological support: Nurses provide emotional support and counseling to patients and their families as they navigate the challenges of illness, recovery, and lifestyle adjustments.
- Care coordination: Nurses serve as the point of contact between patients, their families, and other health-care providers. They coordinate appointments, facilitate communication among the care team, and ensure a seamless transition between different levels of care.
- Assistance with activities of daily living (ADLs): For patients who have difficulty with activities such as bathing, dressing, and grooming, nurses coordinate with home health aides to ensure the patient’s personal care needs are met.
- Chronic disease management: Patients with chronic conditions such as diabetes, heart disease, or respiratory disorders require ongoing management. Nurses help patients understand their conditions, manage symptoms, and adhere to treatment plans. Especially for older adults who deal with chronic conditions and polypharmacy, home health visits can be helpful in resource utilization (Cook et al., 2022).
- End-of-life care: Nurses play a vital role in providing palliative and hospice care at home, ensuring that patients with terminal illnesses are comfortable, pain free, and supported emotionally during their final days.
How Nurses Should Prepare for a Patient Home Visit
It is important to prepare for a home visit to ensure that the nurse is equipped to provide comprehensive and effective care to patients. The nurse should take the following steps to prepare for a visit to a patient’s home to maximize effective time with the patient:
- Review the patient information: Review the patient’s medication regimen, which lists all medications the patient is currently taking, including over-the-counter medications and home remedies. For each medication taken, the nurse should know what the dosage is, how often the patient takes it, and if there are any side effects. Additionally, examine the patient’s medical information, including referral information and any notes made by the health-care provider who referred the patient. If possible, interview the patient about their health, including any symptoms, medical conditions, allergies, surgery, family history, and medical history.
- Verify appointment details: To avoid scheduling mistakes, double-check the time, date, and address for the home visit. If necessary, confirm the visit with the patient’s caregiver or the patient themself. Plan the travel route in advance, particularly if the patient’s house is located in an unfamiliar area. This will ensure that the nurse arrives on schedule and is familiar with the area. Make sure to plan the visit to allow for adequate time to assess, intervene, educate, and document. It is important to be organized to maximize the time allowed with the patient.
- Gather the necessary supplies: Gather all the equipment and medical supplies before the visit, including tools to record vital signs such as a stethoscope and blood pressure cuff. Make sure any medical equipment that will be used, such as a stethoscope, pulse oximeter, glucometer, or thermometer, is in working order. Be sure to have all the necessary documentation tools such as a notebook or tablet for recording your findings, recommendations, and interventions.
- Prepare educational materials: Prior to the visit, prepare any handouts or visual aids needed to explain concepts to patients and their families.
- Prepare mentally: Review the care plan ahead of time to know what to focus on during the visit in order to best assist the patient. Be patient and empathic when you approach the visit. Prepare to actively listen to your patient’s concerns and adjust your care plan to their needs. Be flexible and adaptable to any unexpected needs or changes that may occur during your visit. Having this mindset will help you provide quality care, establish rapport with the patient and their family, and improve outcomes.
- Check communication devices: Make sure that all communication devices, such as a mobile phone or tablet, are fully charged. These devices may be used to communicate and access patient records as well as document the visit. Keep a list of emergency numbers handy in case an unexpected situation arises during your visit.
- Consider your personal presentation: Dress in professional clothing and ensure that your appearance is neat and clean. This will help establish professionalism and trust during the visit.
Personal Safety Precautions
Nurses who conduct home visits must also take care to ensure their personal safety. Personal safety is always a top priority. Trust your judgment if you feel your safety has been compromised during a visit to a patient’s home. Take the appropriate steps to ensure your well-being, and make sure to proactively plan for your personal safety while on home visits.
Prior to your visit, make sure to tell your supervisor or colleague about the details of your visit, such as the address and the expected duration. Schedule home visits during daylight hours as much as possible. Doing this will improve visibility and reduce the risk of visiting unknown areas at night. Also before your visit, make sure to research the area and neighborhood where the patient resides. You should be aware of local safety issues or concerns that may affect your visit. Additionally, make sure to bring the right personal protective equipment (PPE) with you, especially when dealing with situations that involve infection control or dangerous substances.
If taking public transit to the location of your visit, make sure to thoroughly research your route to avoid delays, unanticipated detours, or potentially unsafe stops. If you are driving, parking your car in a well-lit area will help you to feel safer. Avoid parking in driveways and alleyways that may obstruct your exit. Trust your instincts if something seems off or unsafe.
On arrival, assess the environment as you approach the home of the patient and be aware of the surrounding areas. Observe for hazards such as uneven pathways, poorly lit areas, or aggressive animals. Consider rescheduling your visit or asking for assistance if you are uncomfortable or have any concerns about entering the home. Wear the proper identification, such as a uniform or badge, to clearly identify you as a health professional. Secure your belongings and keep them out of sight. This is especially important if you are using a bag to carry equipment. Keep valuables locked and out of sight.
Identify possible exit routes for emergencies when entering the home of a patient. Be alert to doors and windows that could be used as escape routes. Once you are inside the home, keep a safe distance from unfamiliar pets or other animals that may be a danger. Ask the patient to restrain the animal if needed.
Unfortunately, taking proper safety precautions may not always be enough. It is smart to invest in critical personal safety skills, such as de-escalation techniques and self-defense classes, prior to starting your home visits. Learning how to de-escalate tense situations and defend yourself, if necessary, will help you handle potentially dangerous situations. Report any safety concerns you may encounter during your visit to your supervisor, and always document them in your report.
How to Conduct a Home Visit
As a nurse, you should understand what a typical home health visit entails so that you can plan your time accordingly. Your time is valuable, and there is often a lot to do during a visit. An example of a general overview for a nurse conducting a home visit is presented in the following Feature Box. Please be sure to adhere to individual state regulations and regulatory body procedures as appropriate.
Clinical Safety and Procedures (QSEN)
Conducting a Home Visit
- Review the patient’s history and care plan before the visit. (Revisit How Nurses Should Prepare for a Patient Home Visit for all the preparation steps you should take prior to a home visit.)
- Confirm with the patient or caregiver the date, time, and address of your visit. Inform the patient of any special instructions or preparations they should make.
- Arrive on time at the patient’s house. Introduce yourself to the patient, showing your identification (badge and uniform), and explain the purpose of your visit.
- Assess the patient’s current health. Differentiate prior and new changes since your last visit. If necessary, perform a physical exam.
- Check the patient’s medications to ensure they are being taken correctly. Answer any questions or concerns the patient may have about their medication.
- Perform any necessary interventions such as treating wounds, administering medication, or teaching patients to use medical equipment.
- Educate the patient and any caregivers about the illness, treatment plan, self-care strategies, and recommended lifestyle changes. Evaluate their understanding through a return demonstration or correct verbal response.
- Provide support to the patient or coordinate with a home health aide if they need assistance with ADLs, like bathing or dressing.
- Work with the therapists if you are a part of a rehabilitation program or therapy to ensure that all exercises and treatments are being performed correctly.
- Document all findings and recommendations, including interventions and patient feedback. Communication with other members of the care team is important to ensure coordination. Recognize the concerns of the patient and their family and offer reassurance.
At the end of the visit, provide a summary of the visit for the patient. Outline any actions to be taken and give clear instructions that the patient and any caregivers can follow until your next visit. Review your findings with your supervisor or the health-care team. Reflect on your experience after the visit and complete all required documentation, including visit reports, assessments, and interventions. Decide if any follow-up visit is needed; if so, make an appointment and explain the plan to the patient and any caregivers.
A successful home visit is dependent on effective communication, clinical expertise, and a patient-centered approach. Every visit is different, so nurses need to be flexible and responsive.
Initial Visit
To build trust, it is important to establish a respectful and friendly rapport with both the patient and their family, beginning with the first visit. A positive rapport will also make it easier for you to assess the patient’s needs and develop a care plan that is tailored for them. A simple but crucial first step is to respectfully introduce yourself and clearly explain your role as an at-home nurse.
Before beginning any treatments or suggesting interventions, the nurse needs to evaluate and gather critical information on the patient. Assess any health concerns, take vital signs, and perform a complete physical exam, moving from head to toe (Figure 36.2). Gather information about allergies, current medications, and previous treatments. The nurse should also evaluate the patient’s living environment for safety hazards and accessibility. Identify potential obstacles to the patient’s health or well-being.
Once the initial assessments have been made, the nurse should sit down with the patient and their family, if applicable, and discuss next steps and a care plan:
- Set goals and preferences: Discuss with the patient their health goals and care preferences. Ask what they want to achieve from home health care and how they see their plan of care. Inform the patient and family of the importance of home health care, the role played by the nurse, the level of coordination with other health professionals, and the results the patient can expect. Get informed consent to treatment and services. Emphasize that communication with the primary care provider, referring physician, and any other specialists involved in patient care is essential. This will ensure seamless coordination and an understanding of patient needs.
- Establish the initial care plan: Together with the patient, develop an initial plan of care. This plan should include goals, interventions, and a timetable for achieving the desired outcome.
- Create an emergency plan: Talk to the patient’s family about an emergency plan. Give emergency contact information and explain the steps to be taken in an emergency.
- Plan for a follow-up and next visit: Plan the next visit to the patient’s home and explain the purpose of a follow-up visit. Be sure that your patient is aware of when you will be returning and what preparations are needed. Address any fears or concerns the patient might have regarding their health or home health. Reassurance and emotional support are important. Keep a professional demeanor during the entire visit. Communicate clearly and respectfully to make sure the patient is comfortable and understands their care plan. The first visit to the patient sets the tone of the experience the patient will have with the service. This is an opportunity to collect comprehensive information, build trust, and lay the foundation for effective care planning.
- Last, make sure to document any information relevant to the patient record, including the care plan discussion, assessment findings, and other pertinent information. Documentation is essential for communication and continuity of care within the health-care team.
Link to Learning
Although there is much to prepare before conducting a home health visit, the patient’s perspective about the home health visit should be considered by the nurse. There may be pets present and areas or rooms that are off-limits.
Assessing the Need for Continued Visits
Assessing patients for continued home health visits requires an in-depth evaluation of their health needs and progress to determine whether home health-care services are meeting goals effectively. Start by reviewing a patient’s medical history, assessment findings, and care plan, which provide context for gauging progress and noting any changes in condition. Conduct a comprehensive assessment of their current health status. Take vital signs, perform physical assessments, and examine any symptoms or complaints the patient might be having. Review the medication regimen to ensure the patient is able to adhere to the prescribed medications and is experiencing no side effects or interactions. If a patient is not taking the prescribed medications, do not simply label them as “noncompliant”; instead, find out what the barriers are and work to help the patient overcome them. Sometimes, it is a poor understanding or financial constraints, which the nurse can help the patient navigate.
Evaluate patient progress toward meeting goals outlined in their care plan and identify any hindrances to progress. Ask the patient whether their needs are being fulfilled with the home health services provided to them, and encourage open dialogue about any concerns or suggestions that arise. As you discuss these topics, remember that you will need to communicate what you learn with the patient’s primary care physician and any specialists involved in their care; note any changes to the patient’s condition or care plan that you will need to mention and questions you may need to ask, including the extent to which future home health visits are needed as well as their frequency and duration.
Ending the Visit
Effective home health visits must end on a positive and professional note to ensure the patient and family members feel fully informed and supported by the health-care services provided during visits. Briefly recap the key points discussed during your visit, such as assessment findings, interventions conducted, and any changes to care plans.
Leave behind educational materials, handouts, or written instructions that reinforce what was discussed during your visit and that can easily be understood by recipients. Remind patients about self-care techniques discussed during their visit, and emphasize their role in managing their health and well-being. Provide your contact details should a patient or their family have questions or concerns or need anything else between visits. Reaffirm your dedication to their health, reassuring them of your support throughout their care journey. It is also important to address cultural sensitivity during these interactions, particularly for patients with different cultural backgrounds or communication preferences. Be certain that throughout their visit, the patient feels valued as an individual. Thank them for trusting in you to fulfill their health-care needs. Before concluding the visit, make sure you ask both the patient and their family members whether they understand all the information that was discussed during this appointment, including any lingering queries or uncertainties they have. Having them repeat back information provided is usually more effective than just asking them if they understand.
Document your visit as soon as it has taken place to keep details fresh in your mind and ensure important data do not slip by unnoticed. When documenting visits, you should use objective language without bias or judgment being applied toward those you visit. Stick with facts rather than make assumptions and include all relevant details, including the following:
- patient identification information such as name, birth date, and address
- date, time, and place of visitation
- interventions conducted, such as medications prescribed, wound care provided, and education offered
- aspects or topics regarding patient concerns discussed during the visit, such as safety precautions or instructions given directly to the patient or caregiver
When possible, include the patient’s own words when describing symptoms, feelings, or concerns, as this provides more depth and context to documentation. The following is an example of a simple nurse’s documentation following a home visit to check on wound care. Be sure to adhere to the agency and state’s policy and guidelines around specific requirements for nursing documentation.
Clinical Safety and Procedures (QSEN)
Documenting a Home Visit
Patient Name: John Doe
DOB: January 10, 1955
Location: Patient’s residence
Visit Time: 10 a.m. to 11 a.m.
Subjective: Patient reports mild discomfort at the wound site but denies any significant pain. He states that he has been following the wound care instructions diligently.
Objective:
- Wound inspected and measured:
- Length: 2 cm
- Width: 1.5 cm
- Depth: 0.5 cm
- Wound bed appears clean with no signs of infection.
- Minimal serosanguinous drainage noted on dressing, within expected limits.
- Surrounding skin intact; no signs of maceration or irritation.
- Patient’s vital signs within normal limits:
- blood pressure: 120/80 mm Hg
- pulse: 78 bpm
- respiratory rate: 16 bpm
- temperature: 98.6°F (36.9°C)
- Patient demonstrates understanding of wound-care instructions and is able to verbalize the steps for dressing changes.
Assessment: Wound healing progressing as expected without signs of infection or complications. Patient is compliant with the prescribed wound-care regimen.
Plan:
- Continue with current wound-care regimen:
- Clean wound with saline solution daily.
- Apply prescribed antibiotic ointment to wound bed.
- Cover with sterile dressing.
- Educate patient on signs and symptoms of infection and when to contact health-care provider.
- Schedule follow-up visit in one week for reassessment of wound progress and to reinforce wound-care instructions.
Provider Signature: [Name], RN
Date and Time of Signature: April 16, 2024, 11 a.m.