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A new joint publication of PHI and the Pioneer Network details how Partners in Care (PIC), the country’s largest home health agency, changed its culture, increased staff morale, and lowered turnover.

The profile (pdf) explains how PIC’s decision to participate in the PHI Center for Coaching Supervision and Leadership (CCSL) affected the entire agency.

“Coaching Supervision has transformed the culture of this organization,” said PIC president Marki Flannery. “Relationships between office-based supervisors and home health aides are much more positive.”

Based in New York City, PIC employs more than 9,500 home health aides and serves more than 20,000 clients each year.

Coaching Training Gets Results

PIC’s culture-change journey began in 2006, when it agreed to participate in CCSL. Several managers were trained in the core skills of PHI Coaching Supervision^SM, which include active listening, collaborative problem solving, and nonjudgmental communication.

Later, those managers trained several hundred of PIC’s supervisors, instilling the lessons of coaching throughout the organization. Currently, PIC is trying to train all 9,500 of its home health aides in the communication skills involved in the PHI Coaching Approach^SM.

The infusion of PHI Coaching Supervision into the organization has produced clear benefits, detailed in the case study.

Supervisory staff turnover has dropped dramatically to around 14 percent, down from more than 32 percent in 2006, the year PIC began its involvement with CCSL.

Home health aides are also experiencing stronger relationships with their supervisors, according to both survey data and anecdotal evidence. “Supervisors now listen to you more,” said Pauline Smith, a home health aide who has been at PIC for 12 years. “You’ll have a complaint, and the supervisors are more attentive to you and what you have to say. That way, we get better results.”

Supervisors at PIC also say that aides have been able to deliver better care to clients, due to both their enhanced communication skills and the newfound sense that they are truly valued by PIC management. “If the aides feel more valued…their whole approach with their clients is going to be [changed], and the clients are probably having a better experience,” Flannery said.

– by Matthew Ozga

Sen. Robert Casey (D-PA)

Senator Robert Casey (D-PA) has introduced a bill that would expand the role of direct-care workers across the country.

The Improving Care for Vulnerable Older Citizens through Workforce Advancement Act (pdf) would establish demonstration projects focusing on care coordination and service delivery redesign for older adults with chronic illnesses, or those at risk of institutional placement.

“Direct-care workers are key to providing services that improve the health of older Americans and reduce re-hospitalizations, vastly improving the quality of life for our older citizens and reducing costs and strain on the entire healthcare industry,” Casey said.

“My legislation will help to better train and utilize direct-care workers to lower the cost and improve the quality of healthcare provided to older Americans,” he continued.

Demonstration Projects Detailed

The bill would create six three-year demonstration projects:

• Two would incorporate direct-care workers into interdisciplinary care coordination teams to promote smooth care transitions and prevent unnecessary re-hospitalizations;
• Two would have direct-care workers take on a greater role in monitoring, maintaining, and improving their consumers’ health status; and
• Two would train direct-care workers to care for specific diseases and afflictions, including dementia, diabetes, and congestive heart failure.

“With adequate training, compensation, and support, a newly created ‘advanced aide’ position could support health promotion, better chronic care management, and care transitions, resulting in less institutionalization and fewer re-hospitalizations,” PHI President Steven Dawson said.

Partnerships of health service providers, including at least one long-term care facility or home and personal care service provider, are encouraged to apply for demonstration funding if the bill passes into law.

PHI has published a one-page backgrounder (pdf) capturing the highlights of Casey’s bill.

– by Matthew Ozga

Direct-care workers in training

A new PHI analysis found that only 15 states require home health aides to have more training hours than are federally mandated, yet 30 states and the District of Columbia require certified nurse aides (CNAs) to have more training hours than the federal requirements.

In 1987, the federal government set a training standard of 75 hours, including a minimum of 16 hours of clinical training, for both home health aides and CNAs who are employed by Medicare-certified nursing homes or home care agencies.

“Our analysis shows that state home health aide training requirements have not kept pace with their nursing home aide training requirements, even though these direct-care workers provide essentially the same care and services,” said Steve Edelstein, PHI national policy director.

“Although it is clearly time to revisit the federal standards, having states move ahead on their own to upgrade training requirements is a step in the right direction.”

In Retooling for an Aging America, a 2008 report, the Institute of Medicine (IOM) recommends that the federal minimum training requirement be raised to at least 120 hours for both CNAs and home health aides and that competency in elder care be demonstrated as a criterion for certification.

Other Findings

The PHI analysis also found that:

• 4 states meet the IOM recommended training standard for home health aides;
• 14 states meet the IOM recommended training standards for CNAs;
• 13 states require more than 16 hours of clinical training for home health aides — the federal minimum training requirement; and
• of the states that exceed the federal training standard, 9 require home health aides to be CNAs, and 4 allow CNAs to become home health aides with supplementary training.

Trend Toward Home and Community-Based Care

Today, the majority of direct-care workers, including personal care aides, are employed in home and community-based settings (pdf).

By 2018, home and community-based direct-care workers are likely to outnumber facility workers by nearly two to one.

“Current federal training standards have not kept pace with changes in public policy and services delivery and do not adequately prepare the direct-care workers who provide the lion’s share of paid hands-on long-term care,” Edelstein said.

“The federal government must modernize training requirements for direct-care workers to help them gain the skills and knowledge they need to help elders with chronic and complex medical conditions live as independently as possible where they prefer — in their homes and communities.”

To compare the training requirements for home health aides and certified nurse assistants in each state, visit the PHI PolicyWorks website.

– by Deane Beebe

In recent weeks, numerous media outlets — from daily newspapers to trade publications — have reported on issues relevant to the direct-care workforce.

San Antonio Paper Covers Looming Care Gap

On October 29, the San Antonio Express-News reported on the rising demand for direct-care workers, particularly home health aides.

However, most jobs in the direct-care field are of such low quality, it will be difficult to attract the estimated 1.1 million additional workers needed to meet that demand, wrote reporter Melissa Fletcher Stoeltje, who quotes PHI National Policy Director Steve Edelstein and Public Education and Media Relations Director Deane Beebe in the article.

In a letter to the Express-News, Beebe wrote that Stoeltje devoted a disproportionate amount of attention on the tiny number of direct-care workers who are unscrupulous.

The article “may have left an impression that because of low wages, home-care workers can be unreliable or, worse, thieves,” Beebe wrote. On the contrary, the vast majority are “dedicated, compassionate people,” she added.

Washington State Ballot Initiative Debated

An October 23 article in the Olympian reported on Ballot Initiative 1163, a measure to establish more rigorous training standards for home and residential care workers, which passed last week.

The initiative also requires that home and residential care workers undergo background checks and become certified. State certification for home care aides is “pretty uncommon at this point,” Edelstein is quoted as saying.

PHI Featured in Trade Publications

The October 10 issue of ADVANCE for Long-Term Care Management featured an article on cross-functional teams by PHI Regional Policy Specialist Alexandra Olins.

Cross-functional teams, which engage employees at all levels of an organization, are an effective means of directing culture change efforts in long-term care facilities, Olins wrote. This is a unique approach that PHI has tested with multiple clients.

Meanwhile, Long-Term Living on November 2 published the latest in a series of blog posts by PHI Training and Organizational Development National Director Susan Misiorski.

Misiorski’s newest post describes an evaluation of the PHI Coaching Approach^SM, which found that the coaching helps to improve job satisfaction among workers and frees up more time for supervisors, who no longer have to concentrate on resolving minor daily disputes.

In another article published online in September and in the October issue, Long-Term Living noted the debut of the PHI State Data Center.

The State Data Center compiles comprehensive workforce data for all 50 states, including trends in wages, health insurance rates, and legislative and policy developments pertinent to the direct-care workforce.

– by Matthew Ozga

Suzanne Mintz

In recognition of National Family Caregivers Month, PHI interviewed Suzanne Mintz, president and CEO of the National Family Caregivers Association (NFCA), about the interconnection between family caregivers and direct-care workers.

Suzanne co-founded the NFCA in 1993, nearly 20 years after her husband Steven was diagnosed with multiple sclerosis.

Getting the diagnosis was “a huge wallop for us,” said Suzanne, who has been a caregiver to her husband ever since.

Over time, Steven has become increasingly disabled and is doing less for himself.

Suzanne says that she clearly remembers the day about seven years ago when they moved back into their home after six months of renovations to make it more accessible. She was transferring Steven from one chair to another when she “just lost it” and said “I cannot do this anymore. We have got to find help.”

Since then, Suzanne — like many family caregivers — has supplemented her caregiving for her husband with the long-term services and supports that home care workers provide.

_________

PHI: November is Family Caregiving Month, both a celebration of the hard work done by family caregivers and an effort to increase awareness and supports. I understand that there are a number of supports that family caregivers need, but can you talk specifically about the role of paid home care workers?

SM: Home care aides are critical players in the lives of family caregivers because when you are dealing with somebody with multiple chronic conditions and they need help with ADLs [activities of daily living], it’s really, really hard to do it on your own. The services of home care aides are really, really valuable for family caregivers.

November Is National Family Caregivers Month

 
President Obama has proclaimed November to be National Family Caregivers Month, a time to “pay tribute to the individuals throughout America who ensure the health and well-being of their relatives and loved ones.”

A recent NFCA survey of our members found that they are “higher burden” family caregivers, meaning that our members are the ones who really need help and are more likely to be using the services of home care aides.

We also found that spouses are the least likely group to get help. This is not new news; it’s been known for a while, but it was definitely corroborated with our findings.

PHI: What do you hear about home care aides from these “higher burden” caregivers?

SM: When people have aides whom they really like — who are doing a wonderful job — they can’t say enough good things about them. But there are a lot of times when the situation doesn’t work out and very often you hear family caregivers say, “I wish that that we could get high-quality aides on a regular basis and that these services could be covered — at least in part — by insurance.”

Of course in some states there is actually no training required for home care aides so it is not surprising that it runs the gamut. Quality across the board is not consistent.

PHI: You mentioned that there is widespread concern over insurance coverage.

SM: Yes, one thing that came up a lot in our survey was the concern about the lack of coverage for paid home care support. From a family caregiver’s perspective, we definitely need help with all of the activities that aides provide.

Yet the kinds of services that home care aides provide are not covered by Medicare or private insurance, unless associated with a hospital stay, and then it is only short-term coverage. So in order for family caregivers to utilize the services of home care aides or personal care attendants, it’s an out-of-pocket expense. Unfortunately, it’s not affordable for everybody.

Medicaid, which covers care for the very poor, only affects a small proportion of the population. Medicare and private insurance affect a lot more people. To help the majority of family caregivers, coverage would need to be provided through Medicare.

PHI: Do you find that family caregivers and the people for whom they care have a preference as to whether they want to hire a home care aide themselves or through an agency?

SM: It really depends on the family and the individual situation. Some families prefer one thing and some prefer the other. Each is different.

The help my husband gets is from outside the agency system. We are actually forced to do that — whether we want to or not. The help that Steven needs is provided through traditional home care aide services, but he also requires intermittent catheterization, which legally is not allowed to be provided by an aide. If you need both skilled and unskilled services, you have to create your own support team.

PHI: In your personal and professional experience through the years, are you hearing more about direct-care workers being included and acknowledged as integral members of the care team? For example, have you seen home care aides being consulted about the person they are caring for — not just by the family but by medical professionals themselves?

SM: I don’t think there is any question that an aide who spends time with her client has the opportunity to witness changes or altered behavior. Yet I think it is still difficult for aides to be formally considered a part of the health care team. We are still fighting for the family caregivers to be considered a part of the team. People talk about “person-centered” care, but we prefer “family-centered” care.

In some cases the aides have an intimate relationship with the patient. Their reporting should definitely be made available to the health care professionals. More likely than not, their reporting would be through the family caregiver.

If the family caregiver is working and the aide is with Mom or a spouse all day long, the aide knows a considerable amount and can see changes from day to day, and that information needs to be gathered. Part of the responsibility of the family caregiver is to gather that information in a way that can be presented when reporting changes about the patient. The home care aide knows about things from bowel movements to when her client has more difficulty feeding him or herself.

PHI: Do you think that better reporting — knowing what to look for, how to report observations, and who to report them to — is an area where home care aides could benefit from more training?

SM: Yes, more training would help. Family caregivers need to be trained, too. For instance, family caregivers need to learn to communicate effectively with health care professionals so that they are taken seriously. “Communicating Effectively” is actually the name of one of our training programs.

The aides require some type of communication training (pdf) as well. Not everyone has the same level of communication ability, from how to gather information and then report it both on paper and orally. I don’t think there is any question that they need training, but as you know there are some states that don’t require any training. That of course is where PHI comes in. You are doing great work.

PHI: Other thoughts?

SM: Aides, like everyone else, need access to health care. People need a living wage. The difficulties come in figuring out how to make the service affordable for the majority of Americans and providing the service provider — an aide or personal care attendant — with sufficient wages, training, and benefits.

– by Deane Beebe

On November 8, voters in Washington State overwhelmingly passed a ballot initiative that strengthens training requirements for most newly hired long-term care workers there.

Workers will now undergo 75 hours of state-mandated training, a significant increase from the previously required total of 34 hours.

PHI first wrote about the ballot initiative last month.

– by Matthew Ozga