Home Health: A Comprehensive Review

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Introduction   

Home health care (HHC) is a quickly growing alternative to in-hospital care. As the population ages and life expectancy rises, keeping up with the availability of healthcare becomes increasingly challenging. HHC is an alternative to traditional hospital or clinic care. HHC allows patients to receive a variety of medical interventions in their homes performed by specially trained HHC nurses. The World Health Organization (WHO) defines home-based care as “any form of care given to ill people in their homes, including physical, psychosocial and palliative activities” [1]. 

“The main goals of HHC are to provide high-quality care to patients while keeping them at home. It has double benefit: reducing costs for regional and national health care systems and, increasing patients’ quality of life as they continue to live in a familiar environment” [2]. The care provided by HHC nurses is very similar to on-site care and allows older patients to “age in place” [3]. 

HHC nurses strive to allow their patients to age with dignity and decrease their dependence on expensive, away-from-home medical care. Studies reflect that HHC is associated with an overall improved quality of life, decreased mortality, and less need or delayed need for admission to a skilled nursing facility [2]. 

Home Health Care Utilization 

Home healthcare patients vary and have different medical needs that must be addressed. However, those over 65 are the largest consumers of HHC. The percentage of people aged 65 and over is rapidly increasing, driving the need for in-home health care. This is due to chronic conditions more prevalent in the elderly population, such as mobility issues, cancer, and overall frailty [1]. 

Medicare will cover home health services if the patient’s condition makes it unmanageable to leave home for treatment without significant help because of an illness or injury, it is recommended that the patient not leave their home due to their condition or can’t leave their home without it being a major undertaking [4]. 

Common conditions among home healthcare users include those with chronic illnesses such as heart disease, diabetes, and chronic obstructive pulmonary disease (COPD), as well as recent surgeries, mobility issues, and cognitive impairments like dementia [1]. 

Utilization studies demonstrate that patients with multiple health conditions or those requiring long-term care are more likely to use home health services. There is also an observed increase in the use of home health care for short-term recovery and rehabilitation [1]. 

Much of HHC consists of skilled nursing interventions and include but are not limited to the following: 

• Intravenous Therapy/Injections: Patients who need continual IV antibiotics, chemotherapy or nutrition therapy can receive these treatments at home provided by an appropriately trained nurse [1].  

• Wound Care: Patients with surgical wounds or chronic wounds such as pressure ulcers, diabetic ulcers, or traumatic ulcers benefit from skilled nursing care in the home. Nurses can effectively dress and manage wounds while educating patients and their families on preventing further injury. They can also help manage ostomy wounds or issues [5]. 

• Patient and Family Education: Patients and family members who need specific education on prescription medications or diabetes management benefit from skilled nursing in the home [1]. 

It should be noted that HHC services also include physical therapy, speech therapy, and occupational therapy, amongst other disciplines; however, this comprehensive review is directed at nursing specifically. 

Roles and Responsibilities of the HHC Nurse 

Home health nurses provide medical management of various conditions for their patients. A large part of their responsibilities includes direct patient care and hands-on nursing interventions. This includes administering medications, wound care, intravenous therapy, and monitoring vital signs. They also perform assessments and manage acute and chronic conditions [6]. 

HHC nurses also act as a communication center for their patients. They play a crucial role in coordinating care among multiple healthcare providers, including physicians, therapists, and social workers. They ensure that care plans are followed and that comprehensive patient needs are met [6]. 

Providing patient and family education is an important responsibility for most nurses and this is no different in the home health arena. Educating patients and their families about disease management, medication administration, and lifestyle modifications is a central responsibility. Home health nurses empower patients and caregivers with the knowledge to manage health conditions effectively [6]. 

Accurate and timely documentation of patient conditions, care provided, and outcomes is also an integral component to home health nursing. Effective communication with other healthcare professionals and agencies is imperative to ensure continuity of care [6]. 

Challenges of the Home Health Care Nurse 

Home health care provides an excellent alternative to inpatient or on-site clinic care for many patients. Nurses are the backbone of this unique healthcare delivery system, making it possible for many to age in place or circumvent the need for traditional healthcare outside of the home.  

Despite this patient-centered healthcare model, there are unique and complex challenges that HHC nurses face, including the following. 

• Clinical Complexity: Home health nurses frequently manage patients with complex medical conditions and multiple comorbidities. Ensuring patient safety in a home setting, where medical equipment and support systems may be limited, poses significant challenges. Unlike hospital environments, homes lack standardized protocols and emergency support, making it difficult for nurses to provide consistent, high-quality care [7]. 

• Infection Control: Maintaining stringent infection control practices is more difficult in-home settings, where resources and protocols are less robust than in clinical environments [7]. 

• Limited Resources: Home health nurses often need help with resources and support. Home health agencies may struggle with providing necessary medical equipment and supplies, impacting the nurse’s ability to perform certain procedures or manage chronic conditions effectively. HHC nurses also tend to work independently, so they don’t have the support of another nurse to complete procedures with or rely on in complex situations [6]. 

• Workload and Time Management: Home health nurses often manage high caseloads with limited time for each patient, which can affect the quality of care provided. Nurses must travel between patients’ homes, which can be time-consuming and impact their ability to adhere to tight schedules [8]. This is especially true if a patient presents with more increased needs than the nurses anticipated.  

• Emotional and Physical Demands: The significant emotional and physical demands of home health nursing can greatly affect a nurse’s overall well-being. Nurses may experience emotional stress due to working with patients who have severe or terminal conditions and often also end up providing support to family members, not just their patients [7]. The job’s physical demands, including lifting patients and performing various clinical tasks, can lead to musculoskeletal injuries and fatigue [8]. 

• Safety: HHC nurses face various situations that can be deemed unsafe. They might manage aggressive patients or family members or be subjected to illegal drugs, or violence in the home or neighborhood where they are providing care. The home environments where they work may have poor sanitation or other hazards, and they might work in structurally unsound places [7].  

Strategies for Support and Improvement 

Home health nurses need to be supported and provided with a variety of resources to ensure they can provide optimal patient care. Due to the solitary and stressful nature of the home health nurses’ work, HHC agencies should implement a variety of strategies to support, educate, and nurture them for the best outcomes. To address the challenges for HHC nurses as discussed above, agencies and employers can implement the following: 

• Enhanced Training and Continuing Education: HHC nurses respond to patients with complex health problems and comorbidities. Employers and HHC agencies should provide the most up-to-date education and opportunities to utilize evidence-based practice to incorporate into patient care [8]. This empowers the nurse to feel confident addressing complex cases that are unique to their patient load. Employers should recognize that HHC nurses have specific educational needs that are different from nurses practicing on-site.  

• Availability of Appropriate Resources: Employers should set HHC nurses up for success and have readily available supplies. This ensures nurses can perform tasks promptly and safely. They should have easy access to any equipment that ensures their safety, such as personal protective equipment, sharps containers, and whatever else is deemed necessary to provide appropriate care [9].  

Because HHC nurses don’t have immediate access to supplies like nurses in the clinic or hospital setting, employers need to ensure that they are well-stocked to provide in-home care, eliminating the need for return visits that could have been prevented.  

• Safety: Safety for HHC nurses is complex and dynamic. They work in unpredictable environments without the support of other nurses or ancillary staff. Safety issues affecting HHC nurses can range anywhere from an aggressive pet in the home to not having appropriate lighting to complete a blood draw [9].  

The safety concerns HHC nurses face are countless, and employers and HHC agencies should provide optimum support. 

Employers should make sure staff are provided with continuous, compensated safety training along with providing an escort for nurses delivering care in high crime areas. “Employee safety policies and procedures should encompass personal safety measures when making home visits, zero-tolerance for all incidents of violence, and specific steps staff should take if they’re concerned about their safety or experience violence during a home visit” [10].  

HHC employers and agencies should be prepared to support nurses in creating a safe environment for patients and staff. For example, the agency can facilitate having grab bars installed in the home for safe transfers, install approved medical sharps containers, or provide a HEPA air filter to increase air quality [9]. Most importantly, employers must listen to nurses’ needs to ensure safety and offer creative solutions to support them. 

• Decreasing Burnout: HHC nurses work in an emotionally and physically demanding field. HHC agencies should be mindful of their staff workload and provide safety measures for the job’s physical demands, such as lifting patients and carrying equipment [7]. HHC nurses are at high risk for musculoskeletal disorders, so agencies should provide appropriate ergonomic safety options for them [11].  

Nurses seeing patients at home respond to emotionally challenging situations, such as treating patients with cancer or terminal illness. This can be especially hard because HHC nurses are solitary and don’t have on-site counterparts to debrief emotionally charged cases with.  

Employers should provide meetings for debriefing and discussing stressors, offer employee assistance programs, ensure there are appropriate wage increases commensurate to the job, make sure supervision and staff support are readily available, and guarantee their staff have breaks and mealtimes [7].  

Emerging Trends 

Emerging trends in home health care are creating new options for patient management and nurse support. As in many areas of healthcare, the increased adoption of telehealth technologies enables real-time remote monitoring and patient assessment. This increases patient access to care and facilitates timely interventions for patients in the comfort of their own homes.  

Telehealth improves patient outcomes and supports home health care nurses by reducing the need for frequent in-person visits and enabling more efficient management of chronic conditions [11]. 

Furthermore, there is a trend towards interprofessional collaboration, with home health care teams increasingly working alongside primary care physicians, specialists, and social workers to provide holistic patient care. With the use of this technology and the ability to use telehealth and virtual meetings between providers, patients can anticipate more streamlined care [11].  

Conclusion

As the population ages, home health care allows patients to safely receive care outside of the traditional clinical or acute care setting. Nurses are at the forefront of providing home clinical care and are trained to treat complex medical issues. They have significant responsibilities ranging from medication administration to working with a multi-disciplinary team. 

Employers and agencies should ensure nurses have the correct equipment and supplies to provide prompt medical care. Nurses should also expect support to optimize their safety and manage their unique job stressors. As technology advances, nurses can use telehealth to monitor their patients and manage chronic conditions. 

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