The Importance of Dedicated One on One Orientation in Home Health Nursing

July 26,2011

Medicare has decreased the amount of PPS (Prospective Payment System) in home health by 4.74% effective January 1, 2014. The reason was this decrease was twofold. Home health Agencies had not put into place the Face-to-Face requirement and they could not prove that their patients overall health and well-being had improved. One way to improve on showing Medicare patient improvement is to have staff who are knowledgeable in Medicare guidelines and are performing every task, from use of point of care to wound care the same way, every time. One way to achieve that goal is by dedicated one on one instruction or orientation for all staff, from old to new. This article will talk briefly of a new home health nurses orientation.

Orientation should provide the new nurse more than a copy of the agency dress code and when will the next payday begin. Of course, all of the things that Human Resources does on the nurses first and second day is important and must be done before the new nurse is able to accomplish anything else. That is why it should never be considered as part of orientation. Human Resources (HR) manages all these tasks for every employee in the home health agency; HR is not just for nurses. Do not count the two or three days it takes for the new nurse to accomplish all the paperwork, fingerprinting, drug tests, W-2 and CPR requirements.

Once all the tasks for HR are completed, greet your new nurse and tell her “Now you’re orientation begins!” Orientation can take anywhere from a two to six months depending on how much experience the nurse has, if the nurse is familiar with Medicare and home health, if the nurse is competent in instruction of medical surgical disease, if the nurse is self assured and well organized. If the nurse does have organizational skills or needs a lot of reassurance then the orientation period may take longer but this in no means is a reason to give up or not hire the nurse in the first place. All it means is the clinical educator or the supervisor will continue to keep close tabs on that nurse for a longer period of time.

It is easier to write out a timeline and tasks for a brand new home health nurse than it is to try to teach an experience home health nurse Medicare guidelines and nursing for home health patients. Obviously, this is because the clinical educator will be able to impress upon a nurse who has never done home health the importance of following Medicare Guidelines as well as the way the particular agency expects their nurses to perform. The use of the internet for verifying information on the cms.gov website is a crucial part of orientation and should be used from the first day of “true” orientation to home health. It is always more impressive to use the Medicare website because that makes your orientation date current.

Timelines can be re-written and tasks moved around; home health is never the same way two days in a row. This is one of the most important reasons to have a clinical educator or even a consultant who can dedicate every moment of the day to nothing but orientation of all new staff members, although today we are concentrating only on the nurse. With one dedicated person for orientation the new nurse will receive the same instruction, in the same way, without variation or contradictions that sometimes occurs when a new nurse is shuffled from one supervisor to another or one field staff RN (registered nurse) to another.

Regardless of how talented and competent your field RN’s are, wait a long time before sending the new nurse with them out on the road. The Clinical Educator needs to be the one to go into the field with the new nurse, do the tasks and have the new nurse give return demonstrations on every task as well as on the point of care. The Clinical Educator needs to be the one responsible for “imprinting” the agencies policies and procedures and Medicare guidelines on every new home health nurse.  It is the dedicated one on one instruction from the best home health educator to the new nurse that will ensure success and retention of the home health staff forever.

A template for orientation will follow along on a calendar. The new nurse will be on a Monday through Friday schedule until competency and confidence is achieved. The home health agency can use their own policy and procedure book to get a return demonstration on every skill or task and several will eventually be done in a single day as the orientation progresses. Orientation should if possible always be done in the field, not in a lab; home health is not nursing school.

The Clinical Educator will be the one to perform a skill or a task, and then at then at the next patient home the new nurse will perform the same skill or task. Sometimes it may be more efficient if the Clinical Educator also have a current number of patients, as this will be less stressful on the other nurses whenever a new nurse is hired. This is especially important if the home health agency is still paying nurses per visit instead of salary. It will also make acceptance of the new nurse easier within the circle of nurses already employed by the agency, as they will not feel threatened.

In summary, orientation should never take a specific amount of time. The new home health nurse can become a valued team member if given the proper start. Although it may sound comical to talk of “imprinting” the new nurse like a Mother Goose with her goslings, this is not far from the truth. When the home health agency is dedicated to providing quality patient care within the budgets and guidelines of Medicare; this leads to another dedication. That new dedication becomes to provide all of their nurses the tools, knowledge and the support from Medicare and the home health management itself.  When the staff see their Clinical Educator or supervisor out in the field, instructing and assisting instead of sitting in the office having “tea and crumpets” attitudes will changes and improved outcomes will be the end result.  Improvement in outcomes will mean only one thing; the patient will improve and the home health agency will be able to show they were the cause for the patient improvement!

barbara bethard