Sarah, age 4, is on a mechanical ventilator after surviving a near-drowning episode. Her parents, still grieving over her accident, also have a new baby girl. A nurse is providing ventilator care for Sarah in the home.

Mr. Palm, age 96, a widower, is referred for home care after a hospital stay because of a large wound and cellulitis on the lower part of his leg. He is taking 14 medications and sometimes forgets to eat. He’s also deaf.

Mrs. Whelan, age 58, was hospitalized several months ago for a surgical-site infection after a routine appendectomy. She was readmitted with a high fever and shaking chills. Blood tests confirm her previous infection has returned. She is referred for home care for I.V. antibiotic therapy.

As the examples above show, home care nursing can take the form of:

• intermittent skilled visits, where the nurse visits the patient or family at home to provide a skilled service, such as wound care
• private-duty home care (sometimes called staffing), where the nurse provides care for extended hours—for example, an 8- or 12-hour shift to care for a ventilator-dependent patient (similar to the care that would be delivered in a hospital)
• hospice care at home. Home hospice nursing care is a specialized care program.

Why home care?

Home care nursing is perhaps the most holistic, patient-centered care a nurse can provide. But it’s not for everyone. If you’re considering home care as your next career move, be aware that this specialty demands a certain mindset and a strong foundation of nursing skills coupled with good interpersonal skills.

Know, too, that home care isn’t for the faint of heart. In my years as a home care nurse, administrator, and consultant, I’ve seen squirrels kept as pets and bugs big enough to be pets. But for the right person, there’s nothing like the bond that forms and the feeling you get from helping patients meet their care goals in their own home. (See Comparing home care and hospital nursing.)

An important healthcare setting

Home care is bound to be an important healthcare setting in the future for several reasons.

• The aging U.S. population is a primary driver of health care, particularly home care. Baby Boomers are a large part of this. According to the Pew Research Center, as of January 1, 2011, 10,000 American turned 65 every day and will continue to do so through 2030.
• Americans are living longer with complex health diseases and disorders. With appropriate home care, they can stay in their own homes rather than receive care in higher-cost settings. Home care generally is less expensive than inpatient care and services.
• Many children and young adults need home care due to trauma, disability, or other conditions.
• Many states that formerly funded patient care in healthcare facilities have shifted funding to the home setting, enabling more patients to live in their homes.

Home care by the numbers

According to the Medicare Payment Advisory Commission, about 3.4 million Medicare beneficiaries received home care in 2012, and the program spent about $18 billion on home health services. In 2012, 12,311 home health agencies participated in Medicare. Medicare is the largest payer for home care services. Other payers, such as state Medicaid programs and private insurers, commonly follow Medicare rules.

To receive Medicare-funded home care, the patient must be homebound and require skilled nursing care or therapy. Certain conditions of participation apply, serving as the framework for home health agencies. These agencies may be hospital-, system-, or community-based; freestanding; not for profit (such as visiting nurse organizations); or for profit (such as some of the national chains).

Patient’s perspective

From the patient’s perspective, home care may be pref­erable to inpatient care because it can:

• reduce the risk of healthcare errors; in the home, the nurse deals with just a single patient, making medication errors and other mistakes less likely
• reduce exposure to nosocomial infections
• increase patient choice; patients at home can wear what they want, have whatever visitors they want, eat what they want, and have pets.

Also, many patients with terminal diseases prefer home care because they wish to die at home, not in a hospital or other facility.

Preparing for a career in home care

For the right nurse, the patient’s home is a great place to practice. If you choose this career path, make sure to ask your employer about the orientation you’ll receive. For instance, how long is the formal orientation? What does it cover? Will you have a preceptor, or will you be buddied with a senior or more experienced home care nurse?

Don’t consider making the move to home care until you have thoroughly assessed your own skills and have gone through orientation. Home care has many rules that every home care nurse must learn. And like all specialties, it has its own terminology—sometimes complex and requiring interpretation and clarification. (See Where to get more information.)

If you’ve decided to make the leap, welcome to what I believe is the best place to practice—the patient’s own home.

Selected references

Marrelli T. Handbook of Home Health Standards: Quality, Documentation, and Reimbursement. 5th ed. St. Louis, MO: Mosby; 2012.

Medicare Payment Advisory Commission. Report to the Congress; Medicare Payment Policy. Chapter 9: Home Health Care Services. March 14, 2014. Accessed November 2, 2014.

Pew Research Center. Baby Boomers Retire. December 29, 2010. www.pewresearch.org/daily-number/baby-boomers-retire. Accessed November 2, 2014.

List of the skills and knowledge that home care nurses should have.

Tina Marrelli is a healthcare consultant, developer of a home health educational system, and author of 10 books, including the Handbook of Home Health Standards. She is also the founding member of the International Home Care Nurses Organization. You can contact her at news@marrelli.com or through her website, www.marrelli.com/contact.html.