What Does a Home Care Rehabilitation Nurse Do?

Introduction

The purpose of this role description is to identify and clarify the role of rehabilitation nurses practicing in home care settings and to promote a high degree of professionalism in keeping with the established scope and standards of rehabilitation nursing practice published by the Association of Rehabilitation Nurses.

Throughout this document, the term client refers to a person with an injury or an illness who is receiving healthcare services. The term family refers to significant others as well as to relatives. The term caregiver refers to all paid and unpaid persons providing care.

Rehabilitation nursing is a specialty practice that is committed to improving the quality of life for individuals with a disability or a chronic illness. The rehabilitation nurses mission is to improve the optimal level of functioning of individuals with a disability or a chronic illness at home and in the community. The goal of the rehabilitation process is to provide, in collaboration with an interdisciplinary healthcare team that includes the client, a holistic approach to nursing care that maximizes the client’s independence and mastery of self-care activities. Physical, emotional, social, cultural, educational, developmental, and spiritual dimensions are considered when team members establish goals for the client.

The Home Care Rehabilitation Nurse

The home care rehabilitation nurse acts as an advocate for clients and their families during the re-entry process from the hospital into the home and the community.

The home care rehabilitation nurse coordinates the services provided by the interdisciplinary team and enacts the plan of care that has been developed by the client, the physician, and the rehabilitation team. In this role, the home care rehabilitation nurse functions as a clinical resource, a care coordinator, an advocate, a primary care provider, a teacher, a consultant, and a team member. The home care nurse, using rehabilitation expertise, develops an individualized program for the client and the client's family or caregiver.

The rehabilitation nurse in the home setting provides client-driven care as part of a continuum between other healthcare settings and the client’s home. The goals are to safely implement the client's self-management skills in the home setting and to restore the client's relationships with family members and others in the community.

The Association of Rehabilitation Nurses believes that the role of the rehabilitation nurse in the home care setting is an essential one in the continuum of care. The value of the rehabilitation nurse can be demonstrated by improved cost-effectiveness of client care, specialized rehabilitation nursing clinical knowledge and skill, reduction in the frequency of complications and re-hospitalizations experienced by rehabilitation clients, increased quality of nursing care, and reduced costs because of the presence of a resident expert to provide consultation services.

Rehabilitation nursing in home care is highly specialized; however, rehabilitation nurses in this setting serve a diverse population. Infants, children, adolescents, young adults, middle-aged adults, and older adults with disabling conditions may receive specialized home care nursing support from rehabilitation nurses in settings that include alternative living situations and their own home. Home care rehabilitation nurses may also serve in a case management role after transition to community is completed.

RESTART Recovery Website

Developed for consumers, the restartrecovery.org website provides more thorough and definitive key information for patients, their families and caregivers, who are on the rehab journey. It is a good resource for rehab nurses to direct patients and caregivers to during the start of rehabilitation discussions, so they may find information surrounding expectations during rehab, transitions of care, and financial and legal implications that should be considered.

Roles of the home care rehabilitation nurse

The roles of the home care rehabilitation nurse include, but are not limited to, those outlined below.

Practitioner

• Serves as a clinical resource for those involved in rehabilitation nursing practice
• Serves as a clinical resource in the care of clients with a complex chronic illness, and disabling conditions.
• Acts as a resource during a crisis that is aggravated by a chronic illness or a disabling condition
• Assesses the appropriateness of a client's admission to, and the delivery of rehabilitation services in, the home environment
• Provides assistance with discharge planning to ensure a smooth transition into the community or, when appropriate, to help clients who are hiring private attendants
• Collaborates with the interdisciplinary team in the management of the team function in the home environment; is responsible for ensuring that the client is involved as a significant member of the team
• Helps the client, the client's family and caregivers safely adapt to changes in lifestyle necessitated by the disabling condition
• Implements rehabilitation nursing care based on scientific knowledge, home care standards, and rehabilitation principles that are safe and appropriate to the home care environment

Care coordinator

• Acts as a member of the interdisciplinary healthcare team and promotes the coordination of client care
• Coordinates the activities of rehabilitation professionals; integrates the knowledge and skills of various rehabilitation disciplines into a comprehensive continuum of care
• Facilitates the design and implementation of the plan of care for clients who are chronically ill or who have disabling conditions

Advocate

• Advocates for clients, their families and caregivers
• Teaches clients and their families or caregivers to advocate for themselves
• Facilitates the client’s transition from the hospital to the home and the community
• Furthers an understanding of home care-based rehabilitation issues among people in the community and among those in government who are in a position to deal with issues related to this patient population
• Supports clients and their families with end of life decisions

Educator

• Provides education for clients, their families and other caregivers
• Provides staff orientation and guides staff development, both at the professional and the paraprofessional levels, in the area of rehabilitation home care
• Provides education and training for the client, family and caregivers on safe use of new and existing adaptive equipment
• Provides rehabilitation-focused continuing education programs
• Develops policies and procedures that are specific to rehabilitation home care
• Develops educational materials designed to help clients and their family members and other caregivers become knowledgeable consumers in the healthcare arena

Consultant

• Identifies clients and families who could benefit from rehabilitation home care services
• Provides case management expertise within the home care environment
• Serves as a liaison with third-party payers and justifies the use of funds for rehabilitation home care services
• Serves as a resource for home care nurses and as a process consultant to all staff in the home care setting
• Promotes rehabilitation nursing services to community health professionals and to the community at large

Researcher

• Participates in research involving home care clients and their families
• Participates in the analysis and dissemination of evaluative data that may have an impact on clients, their families and other caregivers
• Incorporates evaluative data into nursing practice

Functions of the home care rehabilitation nurse

The home care rehabilitation nurse uses the principles of rehabilitation nursing as defined within the established scope of rehabilitation nursing practice and standards developed by the Association of Rehabilitation Nurses and the American Nurses Association. The functions of the home care rehabilitation nurse can be divided into several categories, which are outlined below.

Assessment

• Reviews and analyzes referral information in consultation with the client, as well as with the client’s rehabilitation team members, employers, the family’s legal representative, and claims or insurance personnel, as appropriate
• Assesses the client’s current personal and functional health status, diagnosis, prognosis, and treatment plan, as well as the caregiver’s level of expertise
• Assesses the home environment for potential safety concerns for the client and caregivers
• Identifies the client’s learning needs, vocational rehabilitation requirements, and potential related to his or her functional impairment, medical diagnosis and prognosis, treatment providers, treatment options, financial resources, psychosocial adjustment, and coping mechanisms
• Identifies needs for adaptive equipment to maintain client and caregiver safety

Data analysis and formulation of a nursing diagnosis

• Identifies temporary or permanent alterations in function that have resulted from the client’s injury or illness
• Identifies potential challenges or complications in the client’s physiological and/or psychosocial functioning that may have an impact on the client’s successful functioning in the home or community
• Identifies potential difficulties that the client may have in being reintegrated into the community
• Identifies the learning needs of the client, the client’s family and other caregivers related to successful reintegration into the home or the community

Establishment of goals and plan of care

• Works with the client to establish realistic goals for achieving optimal outcomes by collaborating with the client and the client’s family and by using available resources
• Helps the client, the client’s family and other caregivers identify the variables that can influence the achievement of goals
• Develops a comprehensive plan that includes treatment measures to prevent disability; identifies alternatives for the client’s treatments, when appropriate
• Establishes target dates for achieving goals
• Integrates rehabilitation goals consistent with the realities of the client’s family system and home environment

Implementation

• Facilitates and collaborates with the healthcare team and the client for timely discharge planning from the hospital to an alternative level of care, when appropriate
• Coordinates the discharge plan with the client, the healthcare team, and the client’s care providers
• Uses rehabilitation principles to promote optimal outcomes for the client
• Provides ongoing assessment of the client, the family, and other caregivers
• Coordinates access to accelerated care options, alternative care options, or both, when appropriate
• Coordinates the client’s access to appropriate government and community programs and resources
• Coordinates and evaluates in a quality-conscious, cost-effective and safe manner the client’s, the family’s and the caregiver’s use of medical equipment, supplies, medications and available services
• Provides instruction, based on identified learning needs, to the client, the client’s family and other caregivers
• Coordinates referrals for instruction or counselling that are agreeable to the client, the client’s family and other caregivers that are based on identified learning needs
• Intervenes promptly, when necessary, to promote optimal functioning and to prevent complications

Collaboration

• Collaborates with the healthcare team, payers, community agencies, providers, and legal representatives to ensure the client’s care throughout the healthcare continuum
• Promotes effective communication between the client, the client’s family, and payers
• Participates in team meetings, when appropriate
• Incorporates the interdisciplinary team’s recommendations and services into the plan of care

Reference

Jacelon, Cynthia S. (Ed.). (2011). The Specialty Practice of Rehabilitation Nursing: A Core Curriculum (6th ed.), Glenview, IL: Association of Rehabilitation Nurses.

Association of Rehabilitation Nurses (2014). ARN Competency Model for Professional Rehabilitation Nursing. Chicago, IL.

Association of Rehabilitation Nurses (2014). Standards & Scope of Rehabilitation Nursing Practice, (6th ed.). Chicago, IL.

This role description was originally developed by the Home Health Care Special Interest Group of the Association of Rehabilitation Nurses. Revisions were made in 2011, 2015, 2018.