Why Home Health Documentation Is Driving Your Best Nurses Out the Door

My bachelor’s degree had 10 weeks of training in home health, which is very unusual. Most nursing students get a day or two. I got an entire semester, and from that point on, I was hooked. I’ve spent the last 30-plus years carrying a bag, supervising nurses, running agencies, building specialty programs, and, more recently, helping technology teams understand what clinicians actually need. And after all that time, the thing I keep coming back to is that home health was designed to do something very specific, and we’ve buried that purpose under so much documentation that we can barely see it anymore.

People Heal Better at Home

We know from research that patients recover faster when they’re in their own environment. Patients with dementia have significantly less confusion when they’re cared for at home versus being moved to a hospital, where everything is unfamiliar, and the schedule revolves around clinical convenience rather than the patient’s needs. Infection rates drop. Outcomes improve. And the cost difference is dramatic: a day in the hospital runs roughly $3,100, while a day of home-based care is around $1,100.

Why? Because at home you’re not paying for the building, the 24-hour nursing staff, the housekeeping, the kitchens, the lab staff, and all the support infrastructure that keeps a hospital running even when an individual patient doesn’t need most of it on any given day. For lower-acuity patients who are past the acute phase, there’s no clinical reason to keep them in that environment. The powers that be want to move care into the home. But if we’re going to do that, we have to figure out a much better way to deliver it.

The Bridge That Became a Bottleneck

When Medicare funded home health care in the 1960s, the concept was beautifully simple: a short-term bridge between being completely cared for in the hospital and being completely independent at home. It was designed to be intermittent, not daily. You’d see someone several times a week for 30 to 60 days, teach the patient and family what they need to do, and then you’d leave. The whole point was a finite, predictable ending. When we walk in the door, we’re already supposed to be thinking about when we’re going to stop.

And that’s a really big misconception, because when patients get discharged, the discharge planner says "Home health will be there to take care of you," and the family practically wants to show us to the spare bedroom. They’re thinking someone is going to be there making meals and cleaning the house. That’s not what home health is. That’s not what CMS pays for. Home health is a skilled nursing intervention to get you back on your feet, and the moment we walk in, we should be building a plan to walk out.

They Moved the Troublemakers to Home Care

Early in my career, I was working at a teaching hospital in Los Angeles, and the hospital was forming its own home health agency. They took all of us who were considered the troublemakers, the nurses who really wanted to sit down and talk with patients rather than rush through rounds, and moved us to home care. Because in home care, you have to be autonomous. You have to be a critical thinker. You’re walking into someone’s home by yourself, and you have to figure things out on the spot.

I’ve taken care of patients in every walk of life. People with a lot of money, people who didn’t have any, people struggling to figure out which medications they could afford and which ones they’d skip this month. And what I learned very early is that sick people are sick people. How someone responds to illness is how they respond to illness, regardless of their circumstances. My job is to help them get back to the level they want to be at or can be at in terms of their health, and figure out how to make that happen. That hasn’t changed in 30 years. What has changed is how much time I actually get to do it.

Documentation Is the Dissatisfier

We have a limited nursing workforce in general, and an even more limited one in home care. We haven’t figured out a way to see patients except one at a time in their own homes, which means we are fundamentally constrained by how long it takes to get to the home and how long we spend once we’re there. So if we’re going to be in that home, we want to minimize the time spent on documentation and maximize the time actually taking care of the patient.

But that’s not what’s happening. The start of care visit, which was supposed to take two hours takes six. There are over 150 OASIS questions. There’s the skilled nursing assessment on top of that. And the paperwork doesn’t just eat time, it actively pulls the nurse’s attention away from the patient. Documentation in home care is a significant dissatisfier for clinicians, and it’s one of the biggest reasons we lose good nurses from the field.

The Real Problem With OASIS Isn’t Fraud

People hear about inaccurate OASIS coding, and they jump to fraud. That’s almost never what’s actually happening. In my experience, the overwhelming majority of assessment errors come from one of three things:

• The nurse didn’t understand the parameters of the question. OASIS developers had very specific thinking about how each question should be answered. Some questions ask about the last 14 days. Some ask about this moment. Some ask about what the patient usually does. If you don’t know which framework the question is using, you’re going to get it wrong.

  
  

• The nurse was rushing. There are 200-plus questions. When you’re trying to get everything done so you can actually spend time with the patient, it’s easy to say one thing in one section and contradict it in another without realizing.

  
  

• Nurses tend to over-assess. This is the one that surprises people. Nurses consistently rate patients as more functional than they actually are. A PT will evaluate the same patient and document significantly less ambulation ability and range of motion, because the PT is trained to catch those nuances. The nurse asks, "Can you go from sitting to standing?" and the patient says, "Sure," and struggles through it. But the nurse writes down that they’re independent.

  
  

This is why the clinical story so often doesn’t make sense. When the nurse’s admission assessment says the patient is at one level and the PT documents something completely different four days later, it looks like someone is lying. But usually, nobody is lying. Someone just didn’t understand the question, or didn’t take the time to really watch the patient do the thing they said they could do, or didn’t know what the OASIS developers were actually asking for.

And here’s the downstream problem: if we over-assess on admission, marking the patient healthier than they are, then the reimbursement doesn’t match the actual acuity. The agency gets paid less than what’s needed to provide appropriate care. And when the patient is reassessed at discharge and hasn’t improved much on paper, it looks like we didn’t do anything, even though we did a lot. The inaccuracy on admission poisons the entire episode.

Is the Home Safe? 

One of the most important assessments we make, and one that doesn’t get enough attention, is whether the home is actually a safe environment for the patient to recover in. Sometimes we walk in, and there’s no family, no caregiver support, no one who can help with medications or meals or bathing, and we have to make the hard call that home is not the right place right now. That patient may have come from the home to the hospital, but the home they’re going back to may not be the right environment to recover in.

Can the family learn to manage the dressing changes? Can we work with the physician to change the IV antibiotic from three times a day to once, so that home health can cover it? Can we put a home health aide in temporarily for bathing? We try everything we can to keep people in their homes, because that’s where they want to be and that’s where outcomes are better. But the threshold question is always safety, and if the intake process isn’t capturing that context accurately, then we’re making clinical decisions on incomplete information.

What I Want Technology to Actually Do

I’ve been working with technology in home health for about 15 years now, starting with remote patient monitoring and moving into how we use digital tools to improve care delivery. And when I spoke at the National Alliance for Care at Home conference about the future of the EMR, the point I kept making was this: you have to include clinicians in the build. Don’t build something in a room full of engineers who’ve never been in a patient’s living room and then hand it to nurses and say, "Use this."

What I want technology to do is give me back the time that documentation steals. There is so much information that already exists before the nurse walks through the door: the H&P from the referral, administrative details like emergency contacts and living situation, and medication lists. Why does the clinician have to re-enter all of that? And after the visit, the nurse should be able to give her clinical observations, her assessment of the patient’s mental status, mood, and functional ability, and then let the system handle the translation into OASIS answers, flagging the five or ten questions where it genuinely needs the clinician’s judgment.

That’s what drew me to Copper Digital. The approach isn’t to replace the clinician’s thinking. It’s to handle everything that doesn’t require clinical judgment, so the nurse can focus on what does. Because remember what home health is supposed to be: a bridge. And the faster we can get the nurse’s attention off the paperwork and onto the patient, the faster that patient is going to get across it.

Your Nurses Aren’t Coding Inaccurately Because They Don’t Care. They’re Doing It Because the System Set Them Up to Fail.

The Start of Care assessment has over 150 questions, and most nurses are rushing through them to get back to the patient. Copper AI pre-fills administrative data, answers what can be answered from existing documentation, and flags only the questions that require clinical judgment, so your nurses can focus on accurate assessment instead of data entry.

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