By Frank Otto and Alex Gardner
Carolyn Coladonato, BSN, RN
The American “cowboy” image evokes someone who is unapologetically free, unpredictable, and cool under pressure as they roam across the open range. But, to be successful, cowboys needed practicality and pragmatism.
When a Penn Medicine home care nurse talks about how they handle their jobs as they ride the road, they sound a little like that mythical “cowboy.”
“You need to know a little about everything, and we see everything: Orthopaedic patients, surgeries, a lot of heart issues, sometimes dementia,” said Carolyn Coladonato, BSN, RN, a Penn Medicine At Home nurse. “One day it will be heart failure and all of the devices people have to manage that, and the next will be focused on cancer and IVs and infusions.”
Coladonato said this in the late afternoon of a recent Tuesday, sitting in her sedan, the “horse” she rides from job to job. When the suggestion of cowboys came up, she laughed, but then took a second to consider it.
“There is some autonomy to what we do,” she mused. “We’re basically nurse case managers, so it’s a lot of responsibility. And we do have to rely on our feelings—if something seems off or wrong, you have to investigate.”
Coladonato is early in her career as a registered nurse, but she is a home care nurse as a result of a recent initiative from Penn Medicine At Home, the home health care arm of the University of Pennsylvania Health System. In late 2020, amid the continued COVID-19 pandemic and its accompanying and enduring push to move more care to home settings, Penn Medicine launched the Nurse Residency At-Home program. Typically, residency programs—the months-long training periods for recent nursing school graduates—place nurses in hospitals or clinics. Only after these nurses have experience in traditional facilities are they considered for home care jobs, and that is often years down the line. But for those in the new program, day 1 puts them on the road to tend to patients in their homes.
Creative Recruiting and Retention
Recruiting nurses, for home care settings and at hospitals, has been a difficult proposition as of late, dating even before the COVID-19 pandemic strained health care workers. In light of this, Penn Medicine has targeted new ways to bring early-career nurses into the fold, including investing in the new ASPIRE pipeline program that supports local high school and college students interested in the profession.
But when it comes to home care nursing specifically, early-career nurses represent an untapped talent pool, according to Danielle Flynn, MSN, the director of Penn Medicine Home Health and a nurse herself.
“We thought that, if we build a residency program out the right way, we can help these early-career nurses make the transition to home care and do it safely for everyone involved,” Flynn said.
The first cohort of the program three years ago consisted of four nurses. Since then, more than two dozen people have enrolled, and Flynn said there is room—and demand—for growth.
“This program is about recruiting new nurses into a specialty area of practice that was traditionally held for later-career nurses. We needed to be creative to adapt to increasing demands in at-home care and responsive to a national trend of an aging workforce,” Flynn said. “But it’s also about providing support to new graduates and ensuring that we meet their needs and retain them in what is a growing and specialized field.”
Articulating a Unique Path at Penn Medicine
Nurses in this residency program are partnered with an experienced home care nurse, called a preceptor in this program, over several months. They learn and master specific types of home nursing skills like wound care, phlebotomy, infusion, chronic-disease management, and others. For many early career nurses, this is a giant leap toward what they hoped to do for the rest of their careers, and a chance to learn the craft on the road.
Coladonato said she has been especially happy with all of the support she gets through the program, ranging from her preceptor, Marie Morrison, BSN, RN, to her manager Jessica Michielli, MSN, RN, and her residency educator, Jill Rachild, MSN, RN.
“I know this kind of support isn’t available in programs elsewhere,” Coladonato said.
Significant training for the residents includes clinical management, which is an important aspect of home health and a place where at-home nurses have an opportunity to take the lead in managing their patients’ care.
“When you’re in a patient’s home, you’re privy to information that other providers aren’t,” said Flynn. “You see what’s in your patients’ cabinets, where they are sleeping. You can make a better call on their overall condition and what interventions would both help them and would be added easily into their lives.”
After roughly six months, the nurse residents are given more independence, and advance to making home visits without their preceptors. They also complete a residency project around nine months into the program to explore and display their knowledge on some specific aspects of their work. The participants continue learning on the job and through trainings for an additional nine months, then “graduate” from the program at about 18 months.
Opening the Door
Coladonato is more than a year into her residency. She’s thrilled.
“I’m so happy to finally be doing this, moving from patient to patient,” she said. “You get to know them really well in a way you might not on a floor at a hospital.”
When Coladonato decided to move on from her initial career in teaching, she became a home care-based certified nursing assistant. That often entailed spending 8 to 12 hours with the same patient every day and there wasn’t much variety; the position usually only encompassed elder care.
So Coladonato went to nursing school in San Diego hoping to go directly into home care. She found out she likely couldn’t pursue that side of nursing right away. But after graduating and moving to the Philadelphia area with her husband, she discovered the Penn Medicine At Home residency program.
“I figured that was right up my alley,” she said.
Coladonato was hired in May 2022 and now covers a range that runs between Chester and Delaware counties. In October, she’ll wrap up her residency. But that won’t be the end of her learning or her career advancement. Early on, Coladonato thought she wanted to be a home-hospice nurse, but she has since realized that may not be for her. What is?
“I love wound care,” Coladonato said. “It’s so funny to me because we had one person in my program a while ago say she wanted to do that, and I was like, ‘Why?’”
Now, with the wound care portion of residency behind her, Coladonato sees that as engaging and important work. She plans to receive her wound care nursing certification down the line at Penn.
At-Home Nursing in the Future
As the United States moved into the 20th century the American cowboy became nearly extinct, owing to mechanization of ranching.
The opposite holds true for at-home nurses. In the world brought forth by COVID-19, health care welcomed advancements in technology—such as telemedicine and connected devices like digital blood pressure monitors and pulse oximeters. This jump in technology appears poised to increasingly push more care outside of a traditional clinical environment. That bodes well for home care nurses and the training they received in adaptation and calling their own shots.
“Home health care is projected to grow at a breathtaking pace over the next decade,” Flynn said.
“According to the US Bureau of Labor Statistics, employment in the sector will grow by 25 percent, adding roughly 700,000 jobs each year on average. The average industry growth rate is just 7 percent, so you can see why we’re hoping to be on the cutting edge when it comes to bringing these nurses in and supporting them.”
Hospitals and the armies of clinicians that run them and their specialized departments will likely never go the way of the mythical Old West. But moving forward, care seems destined to look a lot more like what Coladonato and her fellow nurse residents deliver: Riding from home to home, jacks of all trades.
“Out here, it’s just fascinating,” Coladonato said. “You definitely get to know your patients, see them as the whole person. And I’m just so happy to be doing this now, to have this independence, and to care for people in the way that I do.”