Penny Feldman, Ph.D. Robert Rosati, Ph.D. Gail Quets, M.A. Gil Maduro, Ph.D.

1. Linking Work Life Changes to Worker & Patient Outcomes: Evaluating the VNSNY Home Health Aide Partnering Collaborative Penny Feldman, Ph.D. Robert Rosati, Ph.D. Gail Quets, M.A. Gil Maduro, Ph.D. Theresa Schwartz, B.A. Visiting Nurse Service of New York Penny.feldman@vnsny.org Funded by US HHS Office of Disability, Aging and Long-Term Care Policy Contract #HHSP23320044304EC

2. Today’s Objectives • Describe a multi-faceted work life/“culture change” intervention in home health care • Outline the evaluation • Discuss evaluation strategies & challenges

3. Intervention Objectives “Optimize the role of the HHA” …. • Strengthen ties to agencies that employ HHAs • Improve nurse supervision & support of HHAs • Promote common goal setting– patient, HHA & nurse • Transform HHA from “doer” to “supporter” Resulting in…. • Better nurse/HHA/patient communication • Improved HHA satisfaction • Reduced HHA turnover • Improved patient function (bathing, transfer, ambulation) • Services “matched” to needs

4. Intervention • Modified “Learning Collaborative” model • Senior leadership • 4-month “spread” process • Teams undertake common goal: “Everybody teaches. Everybody learns.” • Formal plans & accountability • Rapid implementation of change concepts • Focus on data – goals & measures • Group learning sessions, team meetings, content experts, coaching, theme calls, web site • Tools • ADL/Functional Health Improvement Tool • “Five Promises” • HHA Partnering “Best Practices” • HHA video/skills – reinforce training

5. ADL Progress Report

6. 1. Introduce yourself and show your VNSNY I.D. 2. Discuss progress patient is making toward achieving their functional health goals. 3. Review any changes in PPOC and/or duty sheets. 4. Ask HHA if there are any other observations or concerns they have today. 5. Thank the HHA. Let him/her know when your next visit will be and how to reach you. The Five Promises Tool EVERY interaction with a HHA, takes 5 minutes to……

7. HHA Partnering Collaborative: Goals & Measures

8. Conceptual Model • Organizational/Structural Characteristics • Communication Processes • Governance • Information Technology • Leadership • Values • Style • Strategy Core Structural Domains Process Domains • Work Design • Staffing • Resources/Training • Measurement/Rewards • Autonomy • Supervision • Communication • Support • Recognition, respect • Group Behavior • Collaboration • Consensus • Quality Emphasis • Patient Centeredness • Safety • Innovation • Outcome Measurement • Evidence-based Practice • Healthcare Worker Outcomes • Satisfaction • Health and Safety • Organizational Identification • Turnover • Patient Outcomes • Satisfaction • Safety • Self-care • Health and Function Outcomes

9. Challenges in Implementing the Intervention • “Culture”: values, beliefs, expectations: • Nurses re patients and HHAs • HHAs re patients and nurses • Patients & families re services & goals • Organizational structure: • Aides employed by separate agencies • “Interdisciplinary” meetings: competing priorities, limited aide participation • Work design: • Isolation & dispersion of aides • High ratios of HHAs to nurses, HHAs to licensed agency coordinators

10. Objectives of the Evaluation Assess impact of the HHA Collaborative: • HHA perceptions, satisfaction, turnover • Patient service use and costs • Patient discharge disposition & outcomes Examine implementation challenges & strategies: • Perceptions/attitudes – “culture change” • Usefulness of tools • Use of data • Matching services to patient needs

11. Evaluation Products: To “make the case” for the intervention and facilitate replication • Usual suspects: final report, articles • Intervention Guide – main audience: potential adopters • Policy/Practice Brief – main audience: federal and state policy makers, professional associations, union leaders, workforce experts, other stakeholders *Six-person TEP review

12. Evaluation Design Overall design • Random assignment of 42 service teams to “intervention” (21 teams) or “control” (21 teams); stratification by borough • Bronx, Brooklyn, Manhattan, Queens • Repeated measurement – before, during and post-intervention (see next slide) • Summative analysis – quantitative • Units of analysis: team, HHA, patient • Formative analysis – qualitative/quantitative

13. Intervention & Evaluation Timeline

14. Evaluation: Analytic Approach Impact analysis – quantitative* • Comparison of intervention and control groups: HHA perceptions, HHA outcomes, Patient service use, Patient outcomes • Use of appropriate multivariate regression models (e.g., ordinary least squares, ordered logit) • Case-mix adjustment for baseline patient differences and/or propensity score matching Implementation analysis – multi-faceted (qualitative, some quantitative) • Focus on intervention group & stakeholders • Observation (learning sessions, meetings, theme calls) • Interviews & focus groups (participants, stakeholders) • Document analysis (e.g., team plans, reports, ADL tool documentation) • *No Primary Data Collection

15. Questions to HHAs • How often • Do the nurses and therapists you work with give you the help you need to do a good job? • Do the nurses and therapists you work with treat you as an important member of the care team? • Are your opinions about patients heard and appreciated by the nurses and therapists you work with? • Do you discuss patients’ progress walking, bathing, and getting out of bed with the nurses and therapists you work with? • Do you talk to patients themselves about the progress they are making walking, bathing, and getting out of bed? • Do you agree or disagree : Overall, I am a satisfied employee

18. Challenges in Conducting the Evaluation • Complexity of the intervention – multiple components, multiple teams, emphasis on team “buy-in” via adaptive practices – a moving target • Variations in implementation – how to document “fidelity” / “intensity” • Fluidity of the HHA workforce – across teams & over time • Reliance on existing data • Outcome measures (worker and patient) – are they sufficiently sensitive

19. Conundrum of Applied “Real World” Research • If intervention impact demonstrated – to which component/s can it be attributed? • If no impact demonstrated – why not? • Poorly designed intervention? • Poorly implemented intervention? • Poorly designed evaluation? • Response • Employ conceptual & logic models at design phase • Document components • Measure fidelity • Randomize • Identify and analyze “pure” intervention & control aides & associated patients

20. Conclusions: Benefits [or Risks] of the Research • Understand benefits/costs of the intervention • Show linkage between organizational change and patient outcomes • Build a business case for work life investment • Document change strategies • Create a toolbox for diffusion of intervention • [Undermine support for future change if costs exceed benefits (due either to externalities or weak/no effect)]