Home Health Nurses Bring Compassion and Considerable Skill to Patients—Wherever They Live

Walking into her first home health care visit 10 years ago, registered nurse Keli Gallagher didn’t know exactly what the next hour or  two would hold. Would her patient be doing well in his transition from hospital to home? Open to working with a stranger to move
toward better health and independence? Or struggling with his new reality?

Whatever the case, Gallagher knew that to really succeed—to ensure a patient recovering from a serious health crisis could heal and even thrive outside of a hospital setting—she’d need to provide more than medical care.

“Your first goal is to build that bond of trust,” says Gallagher, who provides services in Baltimore City and County for Bayada Home Health Care. “Then you get them to understand why you are in their home and what they can do themselves. Once you get that to happen, it’s amazing how much better people feel.”

Like many people released from the hospital to recover at home, Gallagher’s first patient was nervous. An avid baseball and football fan, the elderly man had suffered a serious exacerbation of his chronic illnesses and, though he was home, his challenges were far from over.

“He was overwhelmed and anxious about everything he had on his plate,” Gallagher recalls. After assessing him and ensuring he was safe, Gallagher got to work providing nursing care, plus a healthy dose of education and assurance. “I taught him and his wife how to manage his wounds and explained the chronic disease processes,” recalls Gallagher.

Over the next few weeks, Gallagher would return to the home regularly to provide care, assess her patient’s progress, offer encouragement, and connect the couple to community resources.

“The goal is to allow the patient to be confident and independent and then we just back off and supervise for a while,” she says.

Home health nurses like Gallagher are increasingly in demand due to an aging population, a rise in the prevalence of chronic conditions, shorter hospital stays, and a strong desire by many patients to remain in their home while they receive care. Such nurses provide essential skilled services—wound care, medication administration, post-surgical care, and disease management—and prepare patients and their families to manage their own treatment longer term.

For a patient hobbled with a fractured hip and newly home from the hospital, for example, Gallagher might visit one to three times a week for several weeks. “We go in to educate them on pain management, medications, diet, fluids, and fall prevention,” she explains. “I’m responsible for ensuring patients are safe and that they and their families are comfortable, confident, and competent in managing their care independently.”

To get the job done, Gallagher often coordinates with physical, occupational, and speech therapists, caregivers (like a spouse), and other health professionals involved in a patient’s care. She is among the roughly three percent of registered nurses who work in home health care, according to National Council of State Boards of Nursing.

Home health care is not the same as a private duty nurse, who may visit for longer blocks of time, for longer-term care, or to provide respite for family members or caregivers, with patients usually paying out of pocket. Home health nursing is often paid for by insurance, Medicare, or Medicaid for a limited period of time for patients deemed unable to leave their home for outpatient care.

“The benefit to the patient is that they get to stay in their home environment, they get one-on-one attention, a personalized plan of care, and a complete focus on them to meet their goals,” says Sarah Caro, a registered nurse and clinical assistant professor for Towson University’s Department of Nursing.

“Medicine is such a scary endeavor for so many people…I can’t tell you how many times people have said to me, ‘I’ve never had a nurse who taught me this,’ or ‘I didn’t know this is available.’”

Caro, a nurse for 30 years, has worked in hospital settings as well as in home health care and hospice. “We know people do better at home. With proper support, they really can have positive outcomes.”

It’s a benefit that has ripple effects beyond the patient, with care provided in a patient’s home—whether it’s in a house, apartment, assisted living facility, or other space—freeing up inpatient resources and lessening the burden on families once a patient is discharged.

For nurses, home health care offers autonomy, flexibility, and the chance to move beyond the confines of a facility. There’s also—for patients on the path to recovery—the reward of seeing someone regain independence, says Caro.

“Often in the hospital we don’t get to see that,” she says. “We’re happy when they get to go home, but we don’t get to see that independence come back.”

Even when recovery isn’t in the cards, there is the opportunity to develop deep and lasting connections with patients and their families. Caro’s career is peppered with such connections, including a special bond with one elderly patient in failing health. She’d often linger to chat—and frequently laugh—with her after the visit.

“I would usually save her for late in the day because we sure did enjoy visiting,” Caro recalls. “We worked together so long and she sat me down one day and she said, ‘I just need to tell you—and I don’t want you to argue with me—I am ready to be comfortable.’ She felt like she had to break it to me gently that she wanted to be a hospice patient. It was really precious.” (Caro’s response: “Sweetie, we can do whatever you want.”)

Beyond the relationships there’s also the opportunity for nurses to employ a wide range of skills as they encounter varied health conditions. While some care boils down to the basics, home health nurses also may also find themselves providing the type of complex care that was once limited to inpatient settings. Thanks to increased access to telehealth, remote monitoring, and other advances, these services can now be delivered at home.

“One of the things I really like about home care nursing is it gives me the opportunity to really use all the tools in my toolbox and to continue learning as well,” says Dawn Workman, a clinical nurse manager with Johns Hopkins (JHU) Care at Home’s Personal Care division, which provides private pay services for patients seeking the care of a nurse or certified nursing assistants.

On a typical day this spring, Workman started her day with a visit to a post-partum patient, then moved on to an elderly woman who needed drain and dressing care, plus help with medications, then on to a kidney transplant patient to draw labs and collect a urine sample. The day ended with a quick check-in on a patient who had a debilitating medical condition that has required extensive surgeries.

The variety requires home health nurses to be “expert generalists,” as JHU’s Care at Home likes to think of them. “There is really nothing typical about it,” says Workman, whose 26 years in nursing have included time in emergency care and as an EMT and a medic. “It is truly ever evolving.”

At times, the work requires tackling problems with skills you might not think of as traditional nursing. Polly Easton, a Stella Maris start-of-care nurse, recalls one patient early in the pandemic who was COVID-19 positive and recovering at home.

“So here I am with a double mask, gown, and shield, sitting in someone’s bedroom to go through her medications. She brought out a rolling suitcase filled with medication, and I was like, ‘What do I even do with this?’” Easton recalls with a laugh. A little digging revealed that the patient wasn’t actually taking the medications, unbeknownst to her doctors.

“They’d see her blood pressure was high and add another prescription, and she’d collect them all but never take them because she was too overwhelmed,” says Easton, who quickly devised a solution, working with the medical team to whittle down the medication list. “This is nursing,” she says, “but it’s not really what they teach you in school.”

As rewarding as it can be, providing nursing care outside of a facility brings its own challenges, the least of which may be the logistics of handling weather and traffic when you travel to multiple homes each day. While the autonomy that comes with the job can be appealing, it also brings weighty responsibility. While home health nurses work within a care plan, with an interdisciplinary team, and with a support team a phone call away, “you really are out there by yourself,” says Caro. “It can be a little daunting,” especially for nurses just starting out in home health care.

Home health nurses may also have to push past the worries patients and their families have as they take on medical responsibilities for themselves or their loved one.

“Medicine is such a scary endeavor for so many people and that creates more fear and more resistance,” says Gallagher. Often, she finds patients are surprised by what they can accomplish. “I can’t tell you how many times people have said to me, ‘I’ve never had a nurse who taught me this,’ or ‘I didn’t know this is available, I didn’t know that I could do this.’”

Another possible roadblock is the home itself. Easton has encountered patients whose homes had already been modified—with grab bars, wide doorways, even an elevator—for a parent or spouse. But often, homes are not ready to be makeshift care centers. Loose rugs, stairs, and slippery showers pose hazards for the elderly and infirmed. And then there are the pets.

“The pets are always interesting. There have been some that were small and mighty and gave me a run for my money,” says Caro, who once had a patient with a pet duck that would greet her at her car with a few not-so-friendly ankle pecks.

For Easton, the challenges of providing care in a home are also an opportunity. Walking into someone’s kitchen for example, Easton might notice their food is stored in hard-to-reach cabinets, or that their walk from the living room to the bathroom requires navigating a walker through a too-narrow path.

“I love that I can really figure out what people need that they may not be able to verbalize for themselves but that can really change their quality of life,” she says.

“The pets are interesting,” says Caro, who once had a patient with a pet duck that  would greet her at her car with a few not-so-friendly ankle pecks.

One of her easiest problems solved didn’t require any in-home modifications but instead involved removing a logistical obstacle. The elderly patient had always walked to a local pharmacy to pick up prescriptions, but after a hospitalization could no longer make the trip.

“He had been home from the hospital for three days and he didn’t have his meds yet,” she says. A quick call to switch the patient’s prescriptions to a pharmacy that delivers resolved the issue.

Of course, sometimes the problems are trickier, with medical needs that can’t be met in the home. “You come into the house and they’re like, ‘I don’t know if this looks good,’ and you’re like, ‘No, that does not look good, we’re going to call 911,’” says Easton, who developed the knowledge and skills to make such decisions over nearly 20 years of nursing.

Many home health nurses get their start in other branches of nursing, and some aren’t even aware the career path exists. For Caro, an introduction to in-home care came while she was working full-time on a telemetry unit in a small community hospital that sent nurses into the homes of congestive heart failure patients.

“Had I not had that opportunity early in my career I don’t know that I would have known how amazing home care is,” she says.

As a professor, Caro often encounters students who envision themselves tending to patients in an emergency room or an ICU after graduation. But she believes that nursing’s varied career paths are part of its appeal. “I don’t think people realize just how broad the field is and what can be done.”

The national nursing shortage has tightened the supply of all nurses—and that includes home health nurses. In response, the Home Care Association of America and the National Association for Home Care and Hospice have proposed a range of efforts, including implementing more loan forgiveness programs for nurses entering home health care, making salaries more competitive, and getting the word out so that more nurses consider home health nursing as a career option.

For Gallagher, home health nursing has been not only a viable and exciting career path, but also thoroughly rewarding. “It’s a really emotionally draining position but there are so many instances where it’s just a beautiful thing,” she says.

Often, the payoff comes as patients progress to confidently managing their own care. “I tell people all the time, the best thing is when I see them smile, when I know that they are comfortable enough and happy enough to be able to look forward to tomorrow instead of being scared,” says Gallagher, who recently had a patient burst into happy tears because she could finally leave the house on her own and take a bus to her doctor’s appointment.

Other times, the reward comes later. Gallagher will always remember her first home health patient, not just because she built trust and saw him improve enough to no longer need her care, but because a year later she got a call from his cardiologist with an update.

“He said, ‘I just saw the patient, he was in my office with his baseball cap on and he was about to go to an Orioles game,’” Gallagher recalls. “He thanked me and said, ‘You really made a difference.’”

Being an integral part of the team that helped the patient return to health and independence was its own reward, says Gallagher.

“That’s what makes us motivated to do what we do.”