What Does A Home Health RN Do?

WHAT DOES A HOME HEALTH RN DO?

Updated: Oct 03, 2025 - The Home Health Registered Nurse (RN) oversees and delivers patient-centered care in the home, acting as both clinical case manager and team leader. This role develops individualized care plans, supervises Licensed Practical Nurses, Home Health Aides, and students, and ensures the timely completion of assessments and documentation. The nurse also collaborates with families, providers, and community partners to coordinate services and support continuity of care.

A Review of Professional Skills and Functions for Home Health Registered Nurse

1. Home Health RN Duties

Home-Based Nursing: Provides nursing care to patients in homes
Case Management: Responsible for the case management of patients
Service Coordination: Responsible for the implementation of services to meet client needs
Clinical Standards Compliance: Follows current nursing professional standards of practice and agency-approved protocols for home health
Client Assessment: Provides ongoing assessment of clients, assuring an accurate evaluation of client needs
Referral Management: Identifies when clients need or qualify for additional services and makes a referral to the appropriate SI manager or other community resource
Caregiver Education: Assesses client and caregiver needs, provides client and caregiver education
Health Documentation: Maintains current and accurate client records through the use of laptop computers and paper/chart documentation in accordance with corporate policies, federal, state, and local guidelines
Preventive Care: Conducts wellness clinics
Team Supervision: Supervises and monitors the performance and skills of Home Health Aides and LPNs
Interdisciplinary Collaboration: Collaborates with other disciplines and performs nursing activities within the plan of care
Regulatory Compliance Knowledge: Maintains knowledge of requirements of regulatory agencies, accrediting bodies, and third-party payers
After-Hours Support: Completes home visits and on-call duties after normal business hours, on weekends, holidays, and in other temporary positions

2. Home Health Registered Nurse Responsibilities

Nursing Care Delivery: Provides comprehensive nursing care to clients based on assessment of their needs and results of ongoing evaluation within the framework of Community Health Nursing Practice
Care Plan Setup: Formulates and implements a home health care plan for the client, which is based on physician orders, the therapeutic plan of other members of the health care team and nursing assessment
Holistic Assessment: Considers all factors which affect client health status, e.g., lifestyle alterations, self-care deficits, critical events, pathophysiology and support network
Caseload Management: Assumes accountability and responsibility for a client caseload, within the accepted standards of Community Health Nursing practice
Skilled Nursing Services: Provides those services requiring substantial and specialized nursing skills
Plan Reevaluation: Reevaluates the client’s nursing needs and makes necessary revisions to the plan of care
Preventive Care: Initiates appropriate preventive and rehabilitative nursing procedures
Health Teaching: Counsels/teaches the client and family in meeting nursing and related needs
Self-Care Coaching: Assists/teaches client/family and/or significant other in learning appropriate self-care techniques
Team Participation: Participates in interdisciplinary case conferences, record reviews and continuing education offerings
Case Management: Acts as a case manager and resource person for professional and support staff

3. Home Health RN Details and Accountabilities

Clinical Documentation: Maintains clinical records, submits statistical data and other required paperwork on a timely basis
Care Referrals: Initiates referrals to other disciplines and community resources
Care Coordination: Prepares clinical and progress notes, coordinates services, and informs the physician and other personnel of changes in the client’s condition and needs
Safety Assessment: Assesses all aspects of client safety in determining what specific activities of the client’s plan of care can be safely delegated to the home health aide and delegates those aspects of care to the home health aide
Aide Care Planning: Develops a plan of care for home health aides
Aide Training: Responsible for demonstrating, teaching, and evaluating the care provided by home health aides according to the agency's policy
Aide Supervision: Arranges for supervision of the home health aide
Safety Compliance: Ensures safety, infection control, and maintenance of equipment in the office area and clients’ homes
On-Call Support: Provides on-call coverage
Clinical Development: Enhances clinical skills through participation in in-service, continuing education, and research review of current literature
Education Participation: Participates in department/hospital/community educational activities
Quality Improvement: Assists with Performance Improvement activities within the departments/hospital to improve client/staff and quality of client care, etc

4. Home Health RN Overview

Professional Involvement: Serves on an agency council or committee, as a clinical coach, or in another professional role as defined by the Home Health Manager or Director
Medication Administration: Administers medications and performs planned interventions safely, competently, and efficiently by following hospital policies, procedures, and protocols
Physician Communication: Communicates with the physician, changes in the patient's condition and advocates for patient needs in a collegial manner and using the SBAR format
Care Coordination: Coordinates patient care by effective collaboration with other healthcare team members and facilities
Healthcare Adaptability: Understanding of the dynamics of health care, adapting to change in a positive and professional manner
Point-of-Care Documentation: Documents accurately and appropriately patient care activities at the point of care, including assessments, interventions, care plans, and physician communication in the patient's medical record, using electronic screens and fields appropriately
Progress Evaluation: Evaluates the progress the patient has made towards goals and updates the care plan accordingly
Care Plan Development: Initiates an age-appropriate, patient-focused care plan upon admission and with patient/family involvement
Patient Education: Provides and coordinates patient and family education pertinent to the patient's needs, level of education, and cultural background
Performance Reflection: Self reflects on performance by turning mistakes and successes into learning opportunities
Critical Thinking: Uses critical thinking skills when assessing patients' needs, planning care, and preparing for discharge
Evidence-Based Practice: Utilizes evidence-based practice, keeping knowledge and skills up to date related to the clinical setting

5. Home Health RN Roles

Team Collaboration: Collaboratively with interdisciplinary teams to ensure patient safety, positive patient experience, and delivery of quality care
Patient Respect: Extend dignity, caring, and respect to all patients, physicians and family members
Effective Communication: Communicating effectively both verbally and in writing
EMR Proficiency: Proficiency, efficiency, and thoroughness using electronic medical records
Confidentiality Commitment: Commitment to patient confidentiality
Regulatory Knowledge: Maintain knowledge of changes governing Home Health Agencies in accreditation, State and Federal Regulations, third-party payors, and patient care needs
Flexible Scheduling: Enjoy working a flexible schedule and be willing to work overtime for the provision of quality patient care
Field Nursing: Field nursing care, as patients will span throughout Yolo, Sutter, Yuba, and Solano Counties

6. Home Health RN Additional Details

Plan Care: Provides care and services in accordance with the physician-ordered plan of care
Initial Evaluation: Makes the initial evaluation visit, evaluates patient risk for preventive and rehabilitative nursing procedures, and regularly reevaluates the patient’s nursing needs
Care Plan Updates: Initiates the plan of care, makes revisions, and updates
Goal Tracking: Documents patient progression towards clinical goals for each patient, plans care conferences on his/her patients, and conducts discharge planning promptly as per Agency policy
Order Processing: Processes orders and notifies the physician of patient needs and changes in condition
Certification Forms: Completes certification/recertification orders and discharge summaries
Service Coordination: Coordinates services with interdisciplinary care team and makes appropriate referrals to Physical Therapist, Speech Language Pathologist, Occupational Therapist and Medical Social Worker for those patients requiring their specialized skills
Home Education: Educates and empowers the patient and family/significant others for safe home management and discharge
Meeting Participation: Participates in staff meetings, in-service programs, and adheres to established Agency policies and procedures
Case Conferencing: Conducts patient care conferences on patients assigned to his/her care
Nurse Onboarding: Participates in onboarding other nursing personnel, peer reviews, and Quality Assessment and Performance Improvement activities

7. Home Health Registered Nurse Roles and Details

Policy Compliance: Implement and maintain established department, unit, administrative, and clinical policies/procedures for patient care, safety, and infection control
Performance Improvement: Participate in improving organizational performance activities
Comprehensive Assessment: Conduct initial and ongoing patient assessment with attention to the patient's physical, emotional, psychosocial, functional, home environment, and spiritual needs
Care Planning: Develop and implement an individualized plan of care for each patient
Patient Education: Develop and teach individualized patient education according to assessed learning needs
In-Home Care: Provide care to patients in the home and consult with other specialists
Condition Monitoring: Assess each patient's clinical condition per unit/dept standards and report changes
Medication Administration: Administer prescribed medications and treatments according to physician orders and/or approved protocols
Team Collaboration: Collaborate and communicate with other personnel and physicians to optimize patient care according to the plan of care

8. Home Health RN Responsibilities and Key Tasks

Equipment Coordination: Coordinate and provide the necessary equipment/supplies needed for patient care
Accurate Documentation: Document in a clear, concise, and organized manner to ensure the accuracy of the medical record to include updating the patient plan of care and medication profile
Care Direction: Provide direction to team members to coordinate care of assigned patients and problem-solve patient care issues
Discharge Planning: Assist patient/family in discharge planning and continuity of care after home health, i.e., how/where to obtain supplies, services from community resources, outpatient clinics
Staff Orientation: Orient and educate new employees and students
Procedure Assistance: Prepare patients for scheduled procedures and assist physicians
Patient Sensitivity: Understand sensitivity to each patient's comfort, safety, and privacy needs
Issue Escalation: Activate the chain of command and follow through on complaints, incidents, ethical concerns, or unusual occurrences
Professional Engagement: Participate in meetings, case conferences, educational events, license/certification renewals, and professional associations in the nursing specialty

9. Home Health RN Duties and Roles

Initial Assessment: Complete an initial health assessment of the patient and family to determine home care needs
Health History: Provide a complete physical assessment and history of current and previous illnesses
Home Visit Care: Conduct home visits, assessing the patient’s condition, progress toward goals, providing patient care, teaching and other skilled interventions
Needs Reevaluation: Regularly re-evaluate patient nursing needs as part of a nursing visit
Preventive Procedures: Initiate appropriate preventive and rehabilitative nursing procedures
Medication Administration: Administer medications and treatments as prescribed by the physician
Patient Instruction: Provide health care instructions to the patient per assessment and plan of care
Discharge Planning: Identify discharge planning needs during nursing visits
Team Communication: Communicate needs to the team as part of the care plan development, and assist in implementing prior to discharge of the patient
Record Maintenance: Assure proper maintenance of EHR/Clinical Records in compliance with local, state and federal laws
Self-Care Education: Educate patients and families in self-care and health management