The final report’s executive summary
A research brief outlining the study’s findings (pdf)
The implementation manual (pdf)

Home health agencies that want to improve staff retention and client outcomes will find some unexpected results and useful lessons in a report recently posted to the US HHS/ASPE Office of Disability, Aging and Long-Term Care Policy website.

Home Health Aide (HHA) Partnering Collaborative Evaluation: Final Report (pdf) assesses the impact of an effort to truly incorporate home health aides into care teams. The initiative was implemented in 2003 by the Visiting Nurse Service of New York (VNSNY) and several of its licensed agency partners.

“It’s working because the aides feel more involved in the team, and they appreciate that,” says Daisy Diaz, supervising coordinator for Cooperative Home Care Associates (CHCA), one of the participating agencies. “They work hard, and it’s good for them to get acknowledged.”

It’s also good for the agency and its clients to get more regular and immediate input from the aides, Diaz adds. “They call us right away now to let us know about any issues with the patients. They also call the nurse.”

The Five Promises

One of the main tools for improving relationships between nurses and aides is The Five Promises. A set of five activities that the nurse and HHA working on a case promise to go over every time they are together, they start with “Introduce yourself and show your I.D.” and include “Discuss any observations or concerns about the patient that you have today.” The Five Promises were conceived as “reminders to everyone involved – particularly the nurses, but the aides as well – to have a face to face interaction when they’re in the home together, to share observations and to troubleshoot,” says Miriam Ryvicker, VNSNY research associate and the project manager for the HHA Partnering Collaborative.

That may sound obvious, says Sally Sobolewski, director of practice improvement for VNSNY, but most agency staff need to start with the basics in improving their communication, whether they realize it or not. “Most care team members assume there is little or no dissatisfaction on their immediate team,” she says. “Recognizing how communication and inclusion is perceived is the first step to improving the process.”

Lessons Learned

In addition to improving relationships between nurses and HHAs to incorporate the aides more fully into the care team, the initiative was aimed at getting aides more involved in helping the people they assist become more functionally independent. “We did see some modest improvement in patients’ ability to walk and get in and out of bed, but I want to emphasize the ‘modest’ part of that statement,” says Ryvicker. “The impact wasn’t quite enough to be clinically meaningful, but we did learn a lot from it.”

One of main lessons learned, she says, was the importance of communication – not just between nurses and aides but among the nurses and supervisors involved in the project. “As the initiative grew, it became more of a challenge to maintain the peer-to-peer communication that was driving the process,” she says. “This is a very large agency. A group of nurses and aides had become champions of the initiative early on. They communicated regularly for a while with their peers on other teams, but as the initiative grew, that was difficult to maintain.”

Another important finding was that best way to improve retention was to work on scheduling in order to give HHAs full-time work, or close to it. “It was a powerful finding: having enough hours contributed much more than any of the other things we looked at in explaining whether people stayed on the job,” says Ryvicker. “We found there was a jump in retention at something close to full-time hours – around 35 hours a week, I think, but we’re still doing the analysis, so I’m not sure. So there’s been a lot of talk about scheduling, and the structural issues that keep aides form getting a full workload.”

“Change Does Not Occur through Implementing Best Practices”

Another important lesson learned, says Sobolewski, is that “change does not occur through implementating best practices. Best practices are just the beginning tools to introduce a change in the process of how teams and licensed agencies, or clinicians and HHAs, will work together.”

In order to tend that process, she says, organizations need to answer questions like “How will we check in to see how these changes are holding? What is working well? And when things break down (and they will!), do we treat that as a failure or an opportunity?”

VNSNY “incorporated the process into the fabric of the organization,” Sobolewski says, by making one of its staff members responsible for providing feedback to teams, managers, and clinical directors. Participating coordinators like Diaz also provide peer-to-peer support, holding conference calls every two weeks to share progress reports and help each other solve problems as they arise.

Significant progress has been made, all agree, but there’s more work to be done before HHAs are fully integrated into the care team and the quality improvement process. One of the main challenges, Ryvicker notes, is the nature of home care work. “It can be difficult to integrate people into the team when, by definition, it’s a very dispersed workforce.”

Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org