Home health caseload: deciding which client to visit first and which last

Unstable clients first, emergencies to emergency services

Prioritising a home caseload starts with the same question as on a ward: who has a new, acute change in airway, breathing, circulation or mental status? A client who phones with new breathlessness or chest discomfort is not slotted into the route. The nurse directs them to call emergency services, because a home visit cannot provide the urgent care they may need.

Next come clients whose condition is changing but not immediately life-threatening, such as a recently discharged client with heart failure reporting weight gain and ankle swelling, or a wound that has become hot and painful. These clients may deteriorate if seen late in the day. Stable routine visits, such as a monthly injection, can be placed later.

Infection control shapes the visit order

The CDC isolation guideline notes that the main transmission risks in home care come from an infectious healthcare worker or contaminated equipment carried between patients. Although published spread of resistant organisms between home care clients is not documented, it is theoretically possible if contaminated equipment is moved from one home to another.

That is why stable clients who are immunosuppressed, such as those receiving chemotherapy, are generally visited early, and clients on contact precautions for organisms such as MRSA or C. difficile are generally visited last. This sequence reduces the chance of carrying organisms toward the most vulnerable clients. It never overrides an acute change, which is still seen first.

Equipment and precautions inside the home

CDC guidance for home care advises limiting the amount of non-disposable equipment taken into the home of a client on contact precautions and, where possible, leaving equipment there until discharge. If an item such as a stethoscope must leave, it is cleaned and disinfected before leaving or bagged for later cleaning.

Contact precautions themselves involve gloves and gown for interactions that may involve contact with the client or their surroundings, and dedicated or disposable equipment. Hand hygiene on arrival and departure from every home is basic. The guideline also notes that barriers between the nursing bag and household surfaces are common practice but their evidence is debated.

What the nurse handles by phone and what can be delegated

Some caseload problems are best handled before setting off. A morning phone call to the client with heart failure can confirm whether symptoms are mild enough for a visit or severe enough for emergency services. Calls to the prescriber about abnormal readings can also happen early, so orders are ready when the nurse arrives.

Home health aides can provide personal care, help with meals and report changes, but they do not perform the nursing assessment of a client whose condition is changing. Document each phone triage decision, the reason for the visit order and any instructions given, especially when an acute client is advised to seek emergency care instead of waiting for the visit.

Worked example and distractors

In a hypothetical caseload, four clients are scheduled: a client with a MRSA leg wound needing a dressing change, a client receiving chemotherapy due a routine assessment, a client with diabetes needing a monthly vitamin B12 injection, and a client with heart failure who called reporting a weight gain of several pounds and swollen ankles. The heart failure client is seen first.

The chemotherapy client follows, then the routine injection, and the MRSA wound last. Choosing the MRSA client first because the dressing seems the most involved, or the injection because it is quickest, ignores acuity and transmission risk. Tasks such as bathing or meal help can be assigned to a home health aide, but assessment of the heart failure client stays with the registered nurse.

Sources and further reading

CDC: Guideline for isolation precautions in healthcare settings (2007, updated 2024). Transmission risks in home care, theoretical MDRO spread via contaminated equipment, leaving equipment in the home and the nursing bag barrier debate.

CDC: Transmission-based precautions. Contact precautions with gown and gloves and use of dedicated or disposable equipment.

CDC: About heart attack and symptoms. Calling emergency services immediately for heart attack warning signs.