The nursing shortage places a burden on patients who need home care and the recruiters who work to fill their positions.

This is because the home care nursing shortage is widespread. However, some locations have been hit harder than others.

Complex pediatric patients and their families, for example, are often on the receiving end of its devastating effects, said Garey Noritz, MD, internist and pediatrician, section and division chief of the Complex Health Care Program, and director of the Comprehensive Cerebral Palsy Program at Nationwide Children’s Hospital.

Factors contributing to the home care nursing shortage

There are several reasons why the home care nursing shortage is severe, according to Nortiz, who also is a professor of pediatrics at Ohio State University.

  1. Significant pay disparities between hospital-based versus home care nursing jobs (hospitals pay more).
  2. A shortage of nurses overall and the availability of higher paying positions elsewhere.
  3. Home care nursing can be isolating due to lack of socialization with colleagues.
  4. Complex pediatric patients are hospitalized frequently and, when they are admitted, their assigned home care nurse is temporarily out of work (loss of income).

“It’s not difficult to hire RNs, but it can be challenging to find experienced RNs to care for children with special needs,” said Nick Provost, president of New Jersey Total Care of Paramus, N.J. “Many nurses don’t stay in home care — it can be a revolving door. The pay rates are lower in home health due to the lower reimbursement rates that kicked in since 2014 in New Jersey with the Affordable Care Act.”

In-home nursing shortage for pediatric patients

Noritz said the shortage of home care nurses typically leads to longer hospital lengths of stay for medically complex children. “It impacts our ability to get these kids home,” he said.

The home care nursing shortage affects pediatric patients.Researchers found some key findings from a 12-month multi-site study conducted in Minnesota of children with medical complexity, who were discharged with home health.

“The average child going home for the first time with an order for in-home nursing care spent nearly 54 additional days on average in the hospital due to the lack of in-home nurses to provide care after discharge,” said Roy Maynard, MD, FAAP, medical director at Pediatric Home Service based in Roseville, Minn., a provider of high-tech home care for children with medical complexities in Minnesota and Wisconsin.

A cost analysis conducted in this study also revealed “delayed discharge resulted in an added cost of approximately $170,000 per patient and an overall increased cost of $5 million to the healthcare system in Minnesota alone,” said Maynard, who also is a former executive committee member for the American Academy of Pediatrics Section for Home Care, and a retired neonatologist and pediatric pulmonologist from Children’s Hospital in Minneapolis, Minn.

Findings of this same study — conducted by Maynard and his colleagues — also discovered the pediatric population with tracheotomies and ventilators is increasing.

“One reason for the increased number of children with medical complexity is better cardiac surgical techniques for children,” the study stated. “More kids are saved. However, they’re dependent on tracheotomies and ventilators. Their survival rates have increased, they’re living longer and their quality of life has improved — but they’re not liberated from their dependence on medical technologies.”

Getting in-home nursing care approved by a patient’s insurance and in a timely manner can be challenging, as well.

“Once approved, the second hurdle is finding nurses available to staff all of the hours that have been approved,” Noritz said.

The lack of approved hours by insurance along with the shortage of in-home nurses requires parents pick up the slack.

“The typical number of hours approved for patients on a ventilator is only eight hours per day,” Nortiz said. “This requires us to always train the parents.”

The impact on the families of children with medical complexity also is significant.

“This causes increased stress on the family as they try to provide care to their child,” Maynard said. “Many parents are unable to work. A parent cannot work if they have to be home providing care. This decreases their earnings and increases financial burdens.”

The elderly are negatively impacted too

The lack of in-home nurses also adversely affects the elderly, said Ron Ordona, DNP, FNP-BC, chairman of the Gerontological Advanced Practice Nurses Association’s House Calls Special Interest Group and a primary care medical house call provider for home-bound seniors with Senior Care Clinic House Calls, based in Lincoln, Calif.

Ordona, who is board certified in gerontology and family practice, said in addition to the demand for nurses in general to work in home care, there is a great need for home-based primary care providers for home-bound elderly patients.

“A 2018 report prepared for the Association of American Medical Colleges, projected a primary care shortage of between 14,800 and 49,300 physicians by 2030. Nurse practitioners can help fill the gaps as primary care providers, including the provision of home-based primary care for home-bound elderly patients,” said Ordon, clinical faculty at Boise State University and volunteer clinical faculty and founding donor at UC Davis Betty Irene Moore School of Nursing.

The shortage of in-home nurses and home-based primary care providers for the elderly leads to the exacerbation of chronic conditions, said Ordona.

“This creates stress for family members and assisted living staff, and results in an increased use of the emergency department for primary care access, costing an average of $2,500 to $5,000 per visit,” Ordona said.

Strategies to resolve the home care nursing shortage

Ordona suggests three ideas to address the home care nursing shortage:

  • Expose undergraduate nurses and graduate/advanced practice nursing students to community-based care.
  • Allow full practice authority for APRNs.
  • Remove barriers for NPs for signing home health orders (NPs are not allowed to order home health, which delays care for patients.).

Maynard proposed recognizing home care nursing as a specialty, paying nurses for what they do, and not where they work.

“Home-based nurses provide complex care to patients with ventilators for example, just like ICU nurses do,” Maynard said.

Additional suggestions from Maynard include offering flexible scheduling and if a patient is hospitalized, finding another place for their nurse to work so they can make ends meet.

There is a critical need to increase salary rates for home care nurses.

“The competition from hospitals is stiff — they can pay nurses more,” Nortiz said. “Also, finding ways for in-home nurses to connect with each other is important, so they don’t feel so isolated.”

Provost said increasing reimbursement rates for in-home nursing care from Medicaid, Medicare and private insurance would help increase pay rates for nurses.

Despite the challenges for nurses providing in-home care, it’s very rewarding work, agreed Noritz and Ordona.