What Does a Home Health Nurse Do? Understanding Skilled Nursing at Home

When someone comes home after surgery, hospitalization, or a change in health, recovery doesn't necessarily end at the front door.

Medications may have changed. A wound may need continued care. Symptoms may need to be monitored. Patients and family members may suddenly find themselves responsible for following a treatment plan that feels much more complicated than it did before.

That's where a home health nurse can become an important part of the care team.

Home health nurses provide skilled clinical services in a patient's home based on their individual medical needs and established plan of care. Just as importantly, they help patients and caregivers better understand that care so they can participate more confidently in the recovery process.

What Is Home Health Nursing?

Home health nursing is skilled nursing care delivered in a patient's home by a licensed nurse.

It is one component of home health care, which may also include services such as physical therapy, occupational therapy, and speech therapy depending on the patient's needs.

The specific nursing services provided are determined by the patient's condition, healthcare provider's orders, and individualized plan of care.

Rather than replacing a physician or other healthcare provider, the home health nurse works as part of the larger healthcare team.

What Does a Home Health Nurse Do During a Visit?

There isn't one standard home health nursing visit because every patient's medical needs are different.

Depending on the plan of care, a home health nurse may:

• Assess the patient's current condition

• Monitor vital signs

• Provide wound care

• Reinforce medication instructions

• Educate patients and caregivers about health conditions

• Monitor symptoms or changes in condition

• Provide certain physician-ordered treatments

• Communicate relevant changes to the patient's healthcare team

• Help patients and caregivers better understand the plan of care

As the patient's condition changes, the focus of nursing visits may change as well.

Monitoring Changes in Health

One important role of a home health nurse is observing how a patient is progressing between appointments with other healthcare providers.

Changes in symptoms, vital signs, wounds, mobility, or overall condition may provide important information about recovery.

Home health nurses assess patients during visits and communicate relevant concerns to the appropriate members of the healthcare team based on the patient's plan of care.

This communication can help physicians and other providers stay informed about what is happening with the patient at home.

Medication Education at Home

Medication routines can become complicated quickly, particularly following hospitalization or when someone is managing several health conditions.

A patient may return home with new prescriptions, changed dosages, or instructions that differ from the routine they followed before hospitalization.

As part of an established plan of care, a home health nurse may reinforce medication instructions and help patients and caregivers understand how prescribed medications should be taken.

Patients should not independently change, stop, combine, or adjust prescribed medications without guidance from the appropriate healthcare professional.

Questions involving prescriptions, interactions, side effects, or changes to medications should be discussed with the prescribing provider or pharmacist.

Wound Care at Home

Certain wounds require skilled assessment and treatment.

Depending on the patient's needs and physician's orders, a home health nurse may provide wound care, monitor healing, educate the patient or caregiver about the care plan, and identify changes that should be communicated to the healthcare team.

Receiving appropriate wound care at home can be especially valuable for patients who have difficulty traveling frequently to medical appointments.

Because wounds vary considerably, treatment should follow the individualized instructions established by the patient's healthcare providers.

Helping Patients Manage Chronic Conditions

Living with a chronic health condition often means managing health needs every day, not just during medical appointments.

Conditions such as diabetes, heart disease, and chronic obstructive pulmonary disease, or COPD, may require ongoing monitoring, education, and adherence to an established treatment plan.

For eligible patients, skilled nursing at home may help reinforce disease-management education, monitor certain symptoms, and help patients recognize changes that should be reported to their healthcare provider.

The goal is to help patients better understand their condition and participate safely in their care.

Patient and Caregiver Education Is Part of the Job

One of the most valuable parts of home health nursing isn't necessarily something you can see.

It's education.

Medical instructions can be overwhelming, especially when a family is simultaneously dealing with a new diagnosis, recovery from surgery, or the transition home after hospitalization.

A home health nurse can help reinforce information about the patient's plan of care and answer questions within the nurse's scope of practice.

Depending on the patient's needs, education may include topics such as symptoms to monitor, prescribed treatments, medication instructions, wound care, safety considerations, or when a concern should be communicated to another healthcare professional.

Helping patients and caregivers understand the plan can make them more active participants in care.

Home Health Nurses Don't Work Alone

Home health care is often a team effort.

Depending on the patient's needs, a home health nurse may work alongside physical therapists, occupational therapists, speech-language pathologists, physicians, and other healthcare professionals.

For example, a patient recovering from a stroke may need skilled nursing to monitor medical needs while also receiving physical therapy at home for mobility, occupational therapy at home for everyday activities, and speech therapy at home for communication, cognitive, or swallowing concerns.

Each discipline addresses a different piece of the patient's recovery while working toward the broader goal of helping that person function as safely and independently as possible.

When Might Skilled Nursing at Home Be Appropriate?

Skilled nursing may be considered in a variety of circumstances.

This can include someone who:

• Recently returned home following hospitalization

• Requires skilled wound care

• Needs certain physician-ordered nursing treatments

• Is experiencing changes related to a chronic health condition

• Needs education related to a new diagnosis or treatment plan

• Requires skilled monitoring during recovery

Needing help at home does not automatically mean someone qualifies for home health nursing. A healthcare provider can help determine whether skilled home health services are medically appropriate.

For eligible individuals, Medicare may cover certain home health services when applicable requirements are met.

Skilled Care in the Comfort of Home

Recovering at home can offer comfort and familiarity, but patients shouldn't have to navigate complicated healthcare needs alone.

Home health nurses bring skilled clinical care, education, observation, and coordination into the patient's everyday environment.

At PM Home Health, we work with patients, families, physicians, and healthcare partners to provide personalized home health services based on each individual's needs and established plan of care.

If you or someone you love may need skilled nursing following hospitalization, surgery, illness, or a change in health, contact PM Home Health to learn more about available services and the next steps for determining eligibility.