Exploring Home Health Nurse Decision Making: Development And Implementation Of The Visit Plan

Demand for home health services is increasing due to the growing aging population, increasing rates of chronic conditions, and advances in health care that support the provision of many health-related services in patients’ homes. Home health agencies must adapt care delivery procedures to meet the needs of diverse and complex patients in order to keep them in their homes for as long as possible. However, it is unknown how home health nurses decide on visit patterns and implement their visit plans within the dynamic and unpredictable home health setting. This qualitative descriptive study was guided by an adapted nurse decision-making model with a superimposed socio-ecological lens and explored the processes that home health nurses use to decide on visit patterns and implement their visit plans for newly admitted patients. Semi-structured interviews were conducted with twenty-six home health nurses from three different agencies and analyzed using directed content analysis. Nurses reviewed the referral information but did not make any visit plan decisions before assessing the patient because the information was often incomplete and inaccurate. Following a multifactorial assessment of the patient and their post-discharge environment, nurses relied on their experience and clinical judgment and referred to their agency’s protocols to create the visit plan. Agencies had varying levels of oversight and different practices that influenced nurses’ final decisions. Nurses planned their daily itinerary based on patient acuity, preferences, and geographic location then adjusted as needed. During the care episode, nurses modified their visit plans based on changes in the patient’s clinical condition, engagement, and caregiver availability. Nurses faced challenges related to home health policy constraints; they were expected to justify patient needs and provide matched condensed care to assist patients in reaching their maximum potential. These findings suggest strategies to improve visit planning through the use of health information technology that can facilitate the standardized transfer of patient information across care settings and support nurses in their decisions as they develop and update visit plans. By providing targeted skilled nursing visits, home health nurses can positively influence outcomes by promptly intervening to decrease hospital readmissions and optimize patient wellbeing.