National Nurses United

remaining lifespan. "We bring the clinic to their home," said Hill. "I get to know their families because I am car- ing for them over a greater length of time." Hill's patients are nearly all elderly veterans who can- not leave their homes to go to VA medical facilities due to mobility issues, dementia, or inability to drive. She teaches them to how to manage their chronic illnesses— hypertension, congestive heart failure, diabetes—with the goal of keeping them out of the hospital. Some patients need more monitoring and more frequent visits due to flare ups in their disease or when their condition declines. Each month she sees anywhere from 25 to 30 patients, including paralyzed veterans and patients with all levels of chronic illnesses. Her patient visits can be as short as 30 minutes or a few hours for higher-acuity patients. A good portion of home health RNs' day is spent on the road, depending on the size of their territory, the overall patient census, and staffing. Hill's patients are within a 50-mile radius. Gagne sees patients in 17 towns in Cumberland County, located in the southern part of Maine. "It's not uncommon for me to drive 25 miles between patients," said Gagne whose patients range from babies to children up to age 17 and include prenatal and post-partum patients. "I have driven 86 miles between patients sometimes." Their cars are their mobile offices and double as a mini-supply station for some nurses. Patients should be sent home with the supplies and equipment they need, but that doesn't always happen. Or sometimes supplies are ordered but they haven't arrived. Casco- lan says his car supplies are limited but home health RNs improvise and use what they have until supplies are delivered. Stroud's supplies are more substantial than other home health nurses due to her scope of practice, which includes wound and ostomy consults. As the WON, Stroud services all of San Joaquin County, including the cities of Stockton, Tracy, Manteca, Lodi, and rural areas around Lockeford. Her patients need IV therapy, ostomies, or wound care, including vacuum-assisted closures. She also sees cancer patients, not hospice-level, but people who require skilled care with drains. She tries to schedule her patients by region per day, clocking 50 to 60 miles a day as she listens to spiritual music on the radio in between patients. Other nurses in her department are assigned patients within certain zip code pods so they do not drive as far as Stroud. But if they are short-staffed, "zip code pods go out the door," said Stroud, and everyone takes on extra patients to pick up the slack because they do not have a float pool. Meanwhile, Cascolan's patients all are centered around Escondido, where he sees roughly five patients a day, driving about 15 to 20 minutes between each appointment, sometimes less. However, Cascolan noted that his manager does not always take acuity into account in his patient assignments, which can make it tough to get to each appointment without feeling rushed and under pressure. When patient census is low or home health is short staffed, schedulers sometimes give nurses patient assignments outside of their geographic area. But that also means nurses are spending more time driving than seeing patients. "They don't see the big pic- ture when they send me all over the place," explained Longwell. "If they send me to a patient 45 minutes away, I see fewer people and I have less time to chart." Apart from driving and seeing patients, home health nurses spend countless hours charting. Some managers push RNs to chart the next day or when they are in the patient's home. Charting the next day could put their nursing license at risk so home health RNs refuse to do that. After all, Longwell pointed out, what if something happened to the patient at night, after the nurse leaves? Some nurses do not feel comfortable charting in front of their patients because some patients think it is rude or that the nurse is ignoring them. So the RNs often chart in their car or spend hours charting when they get home, which can make for a very long day. Hill's charting is very extensive because she sees the majority of her VA patients once a month. "I'm charting everything that has occurred since my last visit," said Hill. "The patient's appetite, what they threw up, their bowel movements, urine, everything." Covid has also had an impact on the acuity of the home health patient population. "The acuity of cases has increased tenfold because hospitals sent them home sicker," observed Melissa Stroud. "And skilled nursing facilities wouldn't accept them because of their restrictions on new patients." As a result, high-acuity patients were 20 N A T I O N A L N U R S E W W W . N A T I O N A L N U R S E S U N I T E D . O R G A P R I L | M AY | J U N E 2 0 2 2 Melissa Stroud, RN St. Joseph's Medical Center, Stockton, Calif. 11 years in home health; 15 years as an RN; Previous experience: post-operative care for open-heart surgery "You're going into an unknown every time. You have to work well autonomously and not be afraid of going into all kinds of different homes. People can have guns. People can be on drugs. It's not like working in a hospital where you go into a room."

• Cover