Q&A with Margarite Alvarez, CEO of Choice Home Health Care interviews Margarite Alvarez, the owner and CEO of Monterey, California-based Choice Home Health Care, a Medicare-Certified home health agency and winner of the "Home Care Elite" award. She is also co-author of the book "Hidden Shame: The Shocking Story of America's Elderly Ill." In addition to Choice Home Health Care, Margarite Alvarez is the owner of Community Caregivers, a provider of agency-employed caregivers and personal attendants, and Care Solutions, a problem-solving resource for senior transitions and elderly care.

Below she shares what it takes to be a home health nurse and the future of the field.

Q: Can you tell us about your current position?

I'm the CEO of Care Solutions, Choice Home Health Care in Monterey, California. We are a Medicare-certified, state-licensed agency providing skilled nursing care, therapies, and medical social work in the home for people that qualify as homebound with doctor's orders. We also have Community Caregivers with which we provide private-duty, caregiver care with private pay insurance and long-term care insurance.

We've won the CMS Home Care Elite award twice in our county, and we're the only ones that have ever done that.

Q: How did you become involved in home health care?

I started in the business not as a nurse, but actually as a businesswoman. I had a degree in political science from UC Davis and almost finished my master's in communications at the University of Nevada. I really didn't have a background in anything related to nursing. But, I knew with the baby boomers growing that this was the type of business that was going to be going up for a long time.

Q: What can a nurse expect from a home health care position?

We have a lot of paper work. At least 50 percent of what nurses in our business do is paperwork, which is a negative. The positive side of home care for the nurses is that they get to go out and really be the liaison between the patient and the doctor. When most patients leave a hospital or facility, they might not see a doctor for another six or eight weeks. Basically, we're right there when the doctor gives the order for home care. If skilled nursing or dementia care are needed, we can go in and try to qualify [the patient] for Medicare or Medi-Cal. We can keep the doctor informed of what's going on. If we see a problem, we can attack it immediately.

A typical day may start with a nurse knowing that she has five visits. Then, all of a sudden, we may say we have an opening for her, so she has to take two of those [five] visits and reschedule them for the next day. There has to be a lot of flexibility in the nurse's thinking. She has to think on her feet.

Q: What preparation/skills are needed for this career?

If people are looking toward a home care career-which they should be-though a lot of it is paperwork, the reality is that [it really involves] taking care of the patient. What an aspiring home care nurse wants to do is to go to a school that really has a separate home care program. Home care skills are very different [from the skills needed for some other types of nursing]. The other thing that nurses should realize is that to get into home care now, they have to have at least one year of acute care experience. They can't just come out of school and get into home care.

In home care, we really have to be observant; we have to be working independently; we have to be very [aware of] the family situation. We often have to call in a psych nurse or a medical social worker. We need to know how to handle oncology, recognize schizophrenia, know what to do with diabetes patients, and more.

Now, our nurses have to have an oncology and psychology background. They have to have an understanding of case management. They have to do medication checks and check in with the doctors on a regular basis. [In addition], they need to know [how to handle] emergency situations. Most importantly, they have to be able to work independently even though they have a team behind them and doctors to contact.

Q: Are any other skills needed?

One of the questions that comes up for patients in home health care is, "What is your pain ratio and how much pain did you have before you started care and after?" Often, a person will have taken a pain pill right before [the home health nurse] got there and so when the nurse says to them, "How is your pain level today," [the patient responds], "Oh, it's a two."

Actually, 15 minutes before it was a 10. So, a nurse has to start thinking about different ways of asking those questions to really get at the heart of what's going on with that patient. That's something we're all learning today.

Also, time management is extremely important. If you're not a good time manager, you're not going to make it in this field.

Q: What are some of the challenges nurses in this field face?

Nurses may deal with emotional issues, psychosocial issues, family issues and with the patient's physical and mental state. It's not just a matter of going with the doctor's plan of care. A nurse may get out to the home and see a number of other things like that the patient has three flights of steps to get up to his bedroom and absolutely wants to use it. Nurses may see that patients have medications in their closets, which may be months or even years expired.

Q: Is home care nursing the right choice for everyone?

I would say do a trial situation. Once [you're done with your] years of acute experience, and you think home care nursing is something you want to do, go in very honestly. Say, "I want to spend three months or even a few weeks going out with a home care nurse and seeing what it's like before I decide what I'm going to do."

Even two weeks driving around with a home care nurse will give someone a good feeling of just how much is involved. Instead of being in one place, home care nurses are driving from one place to another, especially in rural areas like our area. [Potential home care nurses] have to realize that they are going to be driving and sitting in their cars at various times. For some nurses, that's great-it gives them time to think and to evaluate. For other nurses who just want to park in the lot and go to work in their hospital, it's not the [right choice].

Q: How has home health nursing changed in recent years?

People [used to think that home care] was just people in little white hats who went out and took blood pressure, had tea and entertained people. In 2000, things really started to change and the Centers for Medicare and Medicaid in Washington realized that home care was the future of nursing and the future of health care.

Q: What do you see for the future of home health care?

Right now, there are less than 10,000 home care agencies throughout the United States. There are large groups of them in places like Los Angeles and San Francisco. The reality is that there are a lot of places throughout this country that don't have home health agencies, and I think in the next 10 years we're going to see a doubling, if not a tripling of them. Medicare wants home care and they want community-based care. It's much more cost-effective, and it's much more patient-friendly. Plus, it's what the patients want.

We're going to have telehealth medicine, which is going to be able to monitor people at home really well. We're going to have chronic care and long-term care reimbursement. The nurses that are going to be going into home care in the future are going to have the brightest future possible because in the next few years, Medicare will be paying for long-term care, chronic disease management, and disease management overall. They've been doing trial tests throughout the United States now that have shown positively that disease management programs run by home care are much more effective than programs through the hospitals in which patients get a brochure and maybe a class.