The New Normal: How Home Care Nurses Make All the Difference
The role of the home care nurse has taken on an additional layer of urgency during the COVID-19 pandemic, especially during surges when people of all backgrounds — whatever their level of illness or risk — strived to avoid hospitals and doctors’ offices. Home care nurses filled this vital gap, providing expert and compassionate care where their patients wanted and needed to be: in their homes, safely isolated and protected from others.
The pandemic also created significant changes in how nurses delivered care, whether that meant being dressed in head-to-toe personal protective equipment in the earlier waves of the virus, caring for sick patients without the usual surrounding support of family visitors or caregivers because of social distancing measures, or working remotely in lieu of in-home visits — which might include telehealth check-ins with their patients as well as meeting with the rest of their integrated care team over Zoom instead of in person.
Today, the state of the pandemic continues to change rapidly, with cases rising in certain regions and falling in others, even as the illness becomes increasingly controllable through vaccines and proven treatments. With COVID-19 restrictions loosening, then ramping up again, the threat of infection is still very much present, and we are entering a “new normal.”
I’ve been talking to several nurses at VNS Health, the home- and community-based health care organization where I work, about this new normal and how it amplifies the value that home care nurses deliver every day to patients and families. Even amid all the changes that the pandemic has brought, and will continue to bring, there are important constants in the way home care nurses make a profound difference in patients’ and families’ daily lives and hopes for the future.
Empowering patients through education
“Nurses are teachers,” says Ruth Caballero, RN, explaining how she works with a typical patient who has uncontrolled diabetes, for example, providing not only clinical care but also education about daily glucose testing, nutrition and lifestyle changes that can help the patient lower their dangerously elevated blood sugar to normal ranges. “Our goal is to have the patient be as independent as possible, so they can take the lead in managing their medications and conditions to be at their optimal level of wellness,” Ruth explains.
The pandemic magnified just how crucial patient education is to well-being, and the pivotal role nurses can play in this regard. During New York City’s pandemic surges in 2020 and beyond, Ruth cared for many homebound New Yorkers. Recognizing her as a nurse who’d been working in the Washington Heights area for years, she even had people stop her in the streets to ask questions. “People did not have enough information — especially at first,” she said. “The community knows I’m a nurse, so especially at the beginning of the pandemic, I was often sharing what I knew from the CDC and Department of Health. It’s harder to imagine now, but social distancing, hand-washing for 20 seconds, wearing masks — it all took a while for people to understand. Then there’s confusion again as things change.”
Home care nurse Fatima Shell-Sanchez has been caring for Bronx patients with and without COVID-19 over the last two-plus years. Even as the risk declined from its levels in the pandemic’s early surges, she keeps up her message on vigilance and commitment to patient education. “In these neighborhoods, people know the disease is out there,” Fatima said during one of the recent lulls in the virus. “They call it ‘the 19’ — but they say, ‘I hear it’s dying down. They’re opening up everything, so it’s okay for us to go out.’ That tells me how much work there is still to do to close those gaps in education.”
Providing care on the real front lines: the home
People live their lives at home — not in the hospital or a doctor’s office. The home care nurse is positioned on the front lines of health care to educate, treat and empower in the home setting, and get patients back on the road to better health. “We bring the clinical setting into the patient’s house,” says public health home care nurse Phil Leon.
“Before the pandemic, hospitals would keep people for weeks upon weeks just for wound care,” says Phil, who worked in a hospital ICU earlier in his career. “But now, we can deliver that care to the patient in the comfort of their own home.” He notes that many of his patients are retired nurses and doctors, “and they’re pretty surprised about the stuff we are capable doing in the home.”
This includes providing hospital-level care at home, a service that increased in use during the pandemic to help hospitals keep more beds open and meet more patients’ desires to recover at home.
Advanced nursing care at home also includes tailored end-of-life care for patients suffering from such illnesses as COPD, heart failure, and complex cancers. Diane King-Jones, a nurse with the VNS Health Hospice Care team’s specialized cardiac program, works closely with patients, their cardiologists and her integrated care team to help break the harrowing cycle of rushing to the hospital when someone with advanced heart failure struggles to breathe. She educates patients and families on techniques to use, for instance, if their loved one feels short of breath. “Many patients are afraid and don’t know what to expect,” said Diane, a hospice nurse for two decades. “When I tell them, ‘This is about you and what you prefer,’ it helps calm some of the fears about losing control.”
Listening, observing… and connecting to care
In a hospital, Phil says, “everyone has a gown on, and is kind of cleaned up by the time they are seen. We see our patients are at home in their daily lives.” By being immersed instead in the home environment, clinicians can provide holistic care that takes into account the full range of someone’s life and how it impacts their health. “You can see what the patient’s caregivers are all about,” Phil adds. “Does this patient have enough money to get their food or to get help? Are they capable of cleaning their apartment? Are they safe to be home? Are they taking their medications appropriately?”
Because they are in the home, carefully observing how their patients live and incorporate care into daily life and actively listening for what is both said and unspoken, home care nurses can serve as the eyes and ears of the entire integrated medical team, including the patient’s doctors.
When population health nurse practitioner Geralda Pellisier was called to the home of a health plan member, she found that although the older woman insisted nothing was wrong, she could not bear weight on her leg and her hip appeared misshapen. Geralda arranged for an immediate home visit from the member’s primary care doctor and remained until the doctor arrived. Indeed, the older woman had fractured her hip and was transferred by ambulance to the hospital.
These days, nurses can make careful observations remotely, as well. Nurse Elizabeth Almanzar-Wright, a care coordinator on the Health Plan team from VNS Health, noticed in her records that one of her members hadn’t been keeping doctor’s appointments for chronic diabetes and depression. She called him and learned from their conversation that he had feelings of despair and, tellingly, didn’t think his doctors could do anything to help him. “He said, ‘I don’t need to take my medication,’ which can be a sign of depression,” she recalled.
Elizabeth couldn’t force him to take his medications, but she wanted to keep him connected to care. She contacted his adult children and, with their involvement, arranged for him to receive behavioral counseling and also got his doctor to re-evaluate his medications. The gentleman was soon on the path to better health, and the family — and the health plan member himself — became immediately integral to his care team.
After more than two years of delivering care at home in a pandemic, nurses continue to make a difference every day in the lives of the people they care for. While the environment has certainly been difficult, Fatima finds a silver lining in the “new normal.”
“One thing I do now is breathe a little more calmly, walk a little more slowly,” she says. “Wearing a mask draws your attention to that, and it’s a good thing to remember. We can’t change reality, we can’t see the future, but we can do our best every day.”