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The following course content

Introduction   

Home health is a potentially wonderful option for those who need medical or personal care, but still wish to live in their own homes. While many individuals can qualify for home health care, nearly 90% of the population served is over the age of 65 (1, 4). In the United States, the over-65 demographic is growing at a nearly unprecedented rate; not since the late 1800s has the older population grown as fast as it did from 2010 to 2020 (2). In fact, more than 1 in 6 people in the U.S. were aged 65 or older in the 2020 census; 100 years prior, this proportion was not even 1 in 20 people (2).  

If family members are unable to care for their aging and/or ailing loved ones, a popular way to serve them is by utilizing home health services. The most current data show that there are well over 11,400 home health agencies in the U.S., serving over 3 million people each year (3, 4). The vast majority of this care is provided by nurses and nursing aides, with virtually all home health employing some sort of nursing services (4).  

As in other settings, the roles of the home health nurse differ from that of their counterpart, which is the nursing aide or assistant. It is thus helpful to home health staff to understand key differences in each member’s roles and responsibilities. This course will outline the scope of practice for home health aides and how the home health nurse can successfully coordinate care for the patient, while communicating effectively with other staff.  

Home Health Care Concepts  

In the United States, home health care is formally documented as early as 1813, with the Ladies Benevolent Society providing volunteer home care services in South Carolina (5). In the northern United States, various visiting nurse societies were formed to give home care to those who needed it; by 1890, nearly two dozen such visiting associations were operating (5). In 1965, with the creation of the federal health insurance program Medicare, home health was more fully covered by insurance than ever before (5). As of 2022, home health care spending reached nearly $133 billion, which is growing at a significantly faster rate than the previous year (6).  

After an illness or injury, particularly those that result in a hospital admission, home health care can be a bridge back to independence, or further services may be required as time goes on. For a person to qualify for home health services, a physician or other healthcare provider needs to write a referral (7). Once a home health agency is selected by the patient or their family, someone from the agency will come to the patient’s home to assess the health and needs to see what services can be provided.  

Generally, a whole team is involved at the advent of home health care, and may include any or all of the following professionals (8):  

• A physician (MD or DO) or other healthcare provider (advanced-practice registered nurse [APRN] or physician assistant [PA]) to oversee patient care, diagnose conditions, and prescribe treatments 

• A registered nurse (RN) to help coordinate and manage care, assess the patient, monitor test and lab results, monitor the patient’s condition, provide education, and administer treatments and medications 

• A licensed practical or vocational nurse (LPN or LVN) to give certain medications, check vital signs, collect blood or urine samples, provide wound care, and help with the patient’s activities of daily living (ADLs) 

• A physical or occupational therapist (PT or OT) to work with patients to gain mobility and independence with performing ADLs  

• A speech-language pathologist (SLP) to assist with swallowing and communicating, particularly for patients who have had strokes or other neurological problems  

• A registered dietitian (RD) to evaluate the patient’s nutritional intake and order an appropriate diet for the patient 

• A medial or licensed social worker (MSW or LSW) to help the family obtain services like financial assistance, counseling, and community-based services  

• A personal care aide (PCA) to help with ADLs and housekeeping tasks, but NOT to perform any medical tasks (in contrast to a home health aide, who may do these things)  

• A home health aide (HHA) to provide supportive care to patients, such as assistance with ADLs and medical equipment like wheelchairs and walkers  

Home Health Aides  

Home health aides (HHAs) have the most direct patient contact once home health services are started, and thus serve a very important role in this healthcare system. Presently, there are nearly 1 million home health aides in the United States, providing care to 3 million patients (4, 10). Combined with personal care aides (PCAs), this type of home health workforce is comprised of nearly 3.7 million people (10).  

HHAs work under the supervision of an RN, who will provide them with a care plan to follow (9). These care plans are updated regularly by the patient’s multidisciplinary team, and it is crucial that the HHA give their input into the patient’s condition.  

Roles and Responsibilities 

HHA roles and responsibilities may vary slightly by state, but usually include assisting patients with many or most of the following tasks (1, 9):  

• Bathing 

• Dressing 

• Eating (including meal preparation and, if needed, assistance with feeding) 

• Toileting (using any combination of bedpans, urinals, commodes, and/or toilets) 

• Taking vital signs 

• Medication dispensing under supervision (though this varies by state) 

• Light housekeeping (e.g., washing dishes, vacuuming, etc.)  

• Companionship 

Furthermore, it is part of the HHA’s role to document all the services they have offered and provided, and how the patient tolerated them. In some cases, the patient may refuse care, and the HHA should document the refusal as well. HHAs should also document the patient’s general condition and report it to their supervisor (9).  

Additionally, there are certain tasks that HHAs may not do, as they do not fall within the HHA’s scope of practice. Like a nurse’s scope of practice, HHAs must also adhere to their state’s specific laws and regulations. For example, in the State of New York, an HHA may not (9): 

• Administer medications (unless specially trained or certified to do so); they may assist a patient with self-administration of medications. 

• Insert or remove tubes from a patient’s body. This includes, but is not limited to, urinary catheters, intravenous (IV) devices, nasogastric (NG) tubes, and fecal containment devices.  

• Perform sterile procedures, including sterile dressing changes.  

• Perform a duty asked of them (e.g., by family members) that is outside of their scope of practice. 

Teamwork, Delegation, and Communication 

As part of the home health care team, the nurse and aide need to work together to achieve optimal patient outcomes. In most states, the RN is responsible for (8, 11):  

• The initial assessment of the patient 

• The creation of a patient-specific care plan 

• Providing nursing care within the RN’s scope of practice  

• Reevaluating the patient’s needs on an ongoing and regular basis 

• Supervising the HHA, PCA, and (if applicable) the LPN/LVN to ensure quality care is being provided.  

• Coordinating with all relevant team members regularly 

Thus, delegation and timely communication are paramount in this healthcare environment. It is up to the RN to create the care plan for the patient, and then to direct the HHA, PCA, and/or LPN/LVN to perform the tasks within their scopes of practice (7, 8, 11, 12).  

Conclusion

With an ever-growing population over the age of 65, the U.S. home health industry is booming. With over 3 million people seeking home health services each year and millions more providing that care, it is essential for nurses to understand each team member’s roles and responsibilities. For RNs, it is crucial to delegate tasks to each appropriate discipline and follow up on the completion of those tasks. It is also the role of the RN, HHA, PCA, and all other caregivers to constantly evaluate the patient’s condition and report any changes to relevant supervisors. With these concepts in mind, providing exceptional home health care to patients can be easy to facilitate. 

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