The Home Health Care Team: Better Relationships, Better Care

1. The Home Health Care Team: Better Relationships, Better Care Applying a Learning Collaborative Approach to Optimize the Role of Home Health Aide Teleconference April 25, 2007

2. Session Content Discuss the importance of creating a culture within the Home Health Agency that supports inclusion of the Home Health Aide (HHA) as part of the care management team Identify the interventions, including the Five Promises, that optimize the role of the HHA to improve patient outcomes Describe the HHA perspective of the benefits of role change to patient care and care management Discuss the current working environment of the HHA and describe ways to improve HHA recruitment and retention

3. Creating a Culture within an Agency that Supports Inclusion of the Home Health Aide as Part of the Care Management Team

4. What We Learned in the HHA Partnering Collaborative Video “Better Relationships, Better Care”

5. Interventions that Optimize the Role of the Home Health Aide

6. “The Five Promises” • Every time you are in a patient’s home together, take 5 minutes for the following interaction: • Introduce yourself and show your I.D. • Discuss the progress the patient is making toward achieving his/her functional health goals. • Review together, any changes in Paraprofessional Plan of Care (PPOC) and/or duty sheets. • Discuss any observations or concerns about the patient you have today. • Thank each other. Make sure you communicate about the next Nursing visit and the ongoing or changing HHA schedule and/or assignment. Make sure contact numbers are in the home.

7. Best Practices that lead to a Change in the Role of the Home Health Aide • Implement the “Five Promises” on each visit • Instruct HHA on each Plan of Care item • Keep Plan of Care updated and accessible to the HHA • Utilize a log , flow sheet or ADL tool for documenting interventions and /or patient responses • Elicit information from Patient and HHA to update the PPOC • Listen and value what the HHAs have to say • Supervise the HHA on every visit • Encourage HHA to contact Visiting Nurse for changes in patient’s condition • Respond promptly to HHA telephone calls • Work with the vendor to stabilize the number of HHAs on a case • Provide feedback to HHA and vendor

8. Best Practices to Promote Licensed Agency and Care Team Partnering • Establish “Core” team HHAs • Work closely with Manager and Visiting Nurse to cluster short hour cases • Pre-work with HHA before assigning • Review “Five Promises” & ADL tool • Review role change from doer to supporter • Inform HHA of any special projects the team may be working on • Support from Leadership

9. Integrating the HHA and Licensed Agency into the Team • Create an atmosphere of inclusiveness • Licensed Agency coordinators attend team meetings and /or participates in the bimonthly conference call • Licensed Agency participates in scheduling needs of the teams • HHA participates in the home visit • Contributes to the updating of the PPOC • Patient sees HHA as a care partner

10. Purpose: Patients should use this form to write and watch their progress as they try to reach their goals. Home health aides should use this form to support the patient’s goals. Date: Date: Date: I hope to get better at, be more independent in, or accomplish this goal:

11. The HHA Perspective

12. What Home Health Aides are saying about their role change…. • “I find out what the patient is capable of doing for his/herself and I supervise for safety.” • “If the PPOC requires assisting, I encourage patients to do what they can for themselves and I assist.” • “Now we are able to speak to the nurses and managers and communicate important information about the patient.” • “I can finally do my job….I assist the patient to improve.” • “At the start of care, I am thinking aboutgetting patients more independent and that hours will be tapered.”

13. What the HHA Needs from the Clinician… • Always introduce yourself and have your IDs visible. • Therapists and nurses include me in discussions about patient progress toward becoming more independent. • Ask the HHAs about the patient and what their concerns are. • Nurses and Therapists tell me when you will make the next visit and an approximate time of arrival. • Give me phone numbers so that I can call them if I need to.

14. More About What the HHA Needs from the Clinician… • Set the patient’s expectation up front as to what the HHAs role is in their care. • Ask me about the patient. I have important information to share. • Update the plan of care as the patient makes progress. • Request HHAs by name. It’s a better understanding when you work with the same nurse. We do not mind hours being tapered if our cases can be clustered.

15. Changing the Work Environment

16. Transforming Patient Expectations • Elicit patient’s expectations, self management goals and support system • Introduce the HHAS as a partner in care • Educate pt on the role of HHA as a care partner. • Include HHA in all patient teaching • Patient views the clinicians and HHA as a team speaking with the same voice.

17. Transforming Relationships toPromote Licensed Agency and Care Team Partnering • Coordinators of Care keep promises during every HHA interaction – making it a team standard • The HHA is included in all patient teaching sessions • Copies of the promises are posted in the elevator and at strategic places throughout the region. • Team members have presented the five promises at the regional staff meeting.

18. Transforming Relationships with Licensed Agency Coordinator, Patient Service Manager and Care Team Relationship • Attending team meetings to get started I don’t wait for an invitation, I get the schedule and I call to be sure there are no changes. • Ongoing team meetings First part of agenda includes time to address Licensed Agency issues • Contact list I have all of the Coordinators of Care cell phone numbers and know them, so I am comfortable calling them. No matter how busy they are, I get immediate responses. • Coordinators of Care call me directly and I respond fast.

19. More Practices to Transform Relationships… • LHCSA schedules bi-monthly proactive teleconference calls for 20 minutes with Coach, Primary Coordinator, and Back-Up Coordinator • Use team data and standard worksheet for preparing for these scheduled calls. • Conference calls can also address a specific area that needs improvement. The “theme” call can focus team members on the plan for improvement and outcomes to be achieved. • Best practices folded into the orientation and in-service of both the LHCSA and the CHHA

20. Questions and Answers….