Key Responsibilities and Required Skills for Home Nurse

🎯 Role Definition

A Home Nurse (Home Health Nurse / Private Duty Nurse) provides skilled clinical care and holistic nursing services to patients in their homes. The role focuses on patient assessment, development and implementation of individualized care plans, medication administration and reconciliation, wound and IV therapy, patient and caregiver education, coordination with interdisciplinary teams, and accurate clinical documentation in electronic health records (EHR). Home Nurses ensure safe, high-quality, patient-centered care while reducing hospital readmissions and supporting independence in the community.

📈 Career Progression

Typical Career Path

Entry Point From:

Staff Nurse (Hospital, Clinic, or Rehab)
Licensed Practical Nurse (LPN/LVN) transitioning to home care
Home Health Aide or Certified Nursing Assistant with nursing licensure

Advancement To:

Senior Home Health Nurse / Lead Clinician
Case Manager / Clinical Coordinator
Home Health Nurse Supervisor or Manager
Clinical Educator or Quality Improvement Specialist
Palliative Care or Hospice Nurse Specialist

Lateral Moves:

Telehealth Nurse / Remote Care Nurse
Community Health Nurse
Private Duty Pediatric/Adult RN

Core Responsibilities

Primary Functions

Conduct comprehensive initial and ongoing patient assessments in the home environment, including full physical exam, functional status, psychosocial screening, and home safety evaluation to identify risks and establish baseline metrics for care.
Develop, implement and revise individualized nursing care plans that reflect patient goals, physician orders, family preferences and evidence-based practice, ensuring continuity of care across interdisciplinary teams.
Provide skilled clinical treatments such as wound assessment and advanced wound care management (debridement, dressing selection, negative pressure therapy where applicable) with documentation of progress and escalation if healing is not advancing.
Administer and manage complex medication regimens safely, including oral, subcutaneous, intramuscular and intravenous medications; perform medication reconciliation at transitions of care and educate patients/families on proper administration and side effect monitoring.
Initiate, maintain and troubleshoot peripheral IVs, central lines, and PICC lines when within scope, perform IV push and infusion nursing procedures, and coordinate with pharmacy for home infusion therapies.
Manage ostomy, catheter, tracheostomy and ventilator-dependent patients per orders and protocols, including routine care, emergency troubleshooting, and caregiver training to ensure safety and reduce complications.
Perform chronic disease management for patients with diabetes, COPD, heart failure, renal disease and other long-term conditions by monitoring vitals, labs, weights and symptoms, titrating nursing interventions and reporting changes to the physician.
Monitor and document vital signs, intake/output, pain scores, wound measurements and other clinical parameters; escalate clinical deterioration immediately following agency protocol and provider instructions.
Provide post-operative and post-discharge skilled nursing care to prevent hospital readmissions, including drain and wound care, suture/staple removal, and patient education on activity restrictions and signs of infection.
Deliver palliative, comfort-focused and end-of-life nursing care that supports symptom control, family counseling and coordination with hospice teams when appropriate.
Coordinate care with physicians, therapists (PT/OT/Speech), social workers, home health aides and community resources to ensure comprehensive services and to address social determinants of health (transportation, housing, nutrition).
Maintain accurate, timely and compliant documentation in the electronic health record (EHR), including visit notes, care plan updates, assessments, medication records and billing information to meet regulatory and agency quality standards.
Conduct patient and caregiver education sessions focused on disease processes, medication safety, wound and device care, fall prevention, and self-management strategies to empower families and improve adherence.
Perform infection control practices and teach family members best practices for PPE, hand hygiene and environmental cleaning to reduce home-acquired infections and protect vulnerable patients.
Execute formal care transitions: communicate clear handoffs at hospital discharge, skilled nursing facility discharge, or provider change to support medication reconciliation and follow-up appointments.
Complete pre-visit planning and post-visit follow-up including ordering necessary supplies and equipment (DME), arranging home therapies, and confirming appointments to ensure smooth patient care flow.
Conduct routine quality audits and participate in performance improvement initiatives by collecting data on key metrics (readmission rates, wound healing outcomes, patient satisfaction) and implementing corrective actions.
Respond to on-call clinical issues and emergencies with professional assessment and stabilization measures until higher-level emergency care is available or provider direction is obtained.
Support telehealth visits by conducting virtual assessments, documenting remote findings, and coordinating hybrid in-person and telemedicine care to expand access for homebound patients.
Ensure compliance with federal, state and agency regulations, including HIPAA, Medicare/Medicaid documentation, and professional licensure requirements.
Mentor and precept new home care nurses and aides, providing clinical oversight, training on home visit workflows and modeling best practices to raise team competency.

Secondary Functions

Assist with scheduling, triage and prioritization of patient visits in collaboration with clinical coordinators to optimize workload and response times.
Participate in interdisciplinary case conferences, utilization reviews and care coordination meetings to identify gaps and recommend resource allocation.
Support agency quality assurance programs by reporting incidents, participating in root-cause analyses and implementing corrective action plans when necessary.
Maintain and track inventory of nursing supplies and medications for assigned patients, coordinate delivery of DME and liaise with vendors to ensure timely equipment setup.
Contribute to community outreach and patient education programs that promote preventive healthcare, chronic disease self-management and vaccination awareness.
Prepare clear and professional discharge summaries and transfer paperwork for other care settings, ensuring accurate problem lists, medication lists and pending orders.
Assist with billing documentation and coding accuracy by ensuring clinical notes include necessary elements for reimbursement and regulatory compliance.
Promote patient satisfaction and retention by responding to family concerns, escalating unresolved issues to supervisors, and following up after care episodes for feedback.
Participate in continuing education, mandatory in-service training and competency validations to maintain licensure, certifications and clinical skills.
Support telephonic nursing triage by providing evidence-based advice, determining need for in-person visit or emergency referral, and documenting guidance per policy.

Required Skills & Competencies

Hard Skills (Technical)

Licensed RN (Registered Nurse) or LPN/LVN with active state license; strong clinical assessment and physical exam skills in home settings.
Advanced wound care knowledge including staging, dressing selection, negative pressure therapy familiarity and documentation of wound measurements.
Intravenous (IV) therapy skills: peripheral IV insertion/maintenance, PICC/central line care, infusion pump management and home infusion coordination.
Medication management expertise: safe administration, medication reconciliation, dose titration per orders and identification of adverse drug events.
Experience with EHR systems and accurate clinical documentation for home care billing and regulatory compliance.
Competence in managing durable medical equipment (DME) — oxygen therapy, suction, feeding tubes, ostomy supplies and basic ventilator support when applicable.
Telehealth and remote monitoring proficiency: conducting virtual assessments, using remote vitals technology and documenting telemedicine encounters.
Infection prevention and aseptic technique knowledge consistent with home-based infection control protocols.
Basic life support (BLS) certification required; Advanced Cardiac Life Support (ACLS) or Pediatric Advanced Life Support (PALS) preferred where indicated.
Familiarity with Medicare/Medicaid home health requirements, physician orders, care plan development and OASIS/Outcome reporting for agencies that use OASIS assessments.

Soft Skills

Excellent verbal and written communication to clearly explain clinical issues to patients, families and provider teams.
Strong clinical judgment and critical thinking with ability to triage complex situations independently in the field.
Empathy and patient-centered approach to support patients and families through illness, recovery and end-of-life care.
Time management and organizational skills to prioritize visits, manage caseloads and meet documentation deadlines.
Problem-solving ability to adapt nursing interventions to varied home environments and limited resources.
Cultural sensitivity and competency in working with diverse populations and communicating across language barriers when needed.
Collaboration and teamwork when coordinating with interdisciplinary providers, home health aides and external agencies.
Dependability and professional accountability for maintaining licensure, certifications and agency standards.
Conflict resolution and de-escalation skills for handling family stressors or emotionally charged situations.
Continuous learning mindset to stay current with best practices in home health care and clinical protocols.

Education & Experience

Educational Background

Minimum Education:

Current and active Registered Nurse (RN) license OR Licensed Practical/Vocational Nurse (LPN/LVN) depending on role requirements.

Preferred Education:

Bachelor of Science in Nursing (BSN) preferred for clinical advancement and leadership tracks.
Certifications such as Wound Care Certification (WCC), IV Therapy Certification, Certified Home Health Nurse (if applicable), or specialty certifications (e.g., CHF, COPD management) are a plus.

Relevant Fields of Study:

Nursing (ADN, BSN)
Community Health Nursing
Geriatric/Chronic Disease Nursing
Pediatric Nursing (for pediatric home care roles)

Experience Requirements

Typical Experience Range: 1–5+ years of clinical nursing experience; many employers prefer at least 1 year of acute care experience plus 6–12 months in home health or community nursing.

Preferred: 2+ years of direct home health or community-based nursing experience, demonstrated competency in wound care, IV therapy and care of medically complex patients; previous experience with EHR-based documentation and working independently in patient homes.