ICS has refined its model of care over the past 13 years. The new Interdisciplinary Care Management Team embodies their person-centered approach, in which the central focus is the member. Each ICS member is supported by a team that includes nurses, social workers, and a member-services coordinator, along with resource specialists in behavioral health, wound care, and rehabilitation. The team also includes a senior home health aide, who provides guidance in addressing issues with personal care services and supports aides in the field to deal with challenging situations.

In many care settings, the aspiration is to have staff from different disciplines work together. More often than not, however, each discipline contributes from its own vantage point, but remains isolated in their separate silo. Sometimes, their different ways of seeing provoke tension — a classic one being between the nurse’s focus on clinical concerns and the social worker’s focus on the social/emotional. At ICS, there was a strong desire to move to a new norm, one where team members could develop a shared lens, informed by these different but complementary ways of thinking.

Working to Achieve Teamwork

ICS sought PHI’s help to make this happen. In a pilot program, PHI Organizational Change Consultant MariaElena Del Valle worked with senior staff to develop the vision, design, and goals for the Interdisciplinary Care Management Team. Once the group was formed, she helped guide members toward functioning as a team, rather than as discrete individuals representing their respective departments. The team then moved on to interdisciplinary care planning, case conferences, home visits, and other aspects of care coordination. It was sometimes challenging: people had strong and often discordant views about what was in the best interest of ICS members. But over time, they learned that it was OK, even beneficial, to have diverse interests — the key was managing these differences.

I had the remarkable experience of observing this team at a meeting, after they had been working together for about eight months. They were doing case conferences, discussing members in crisis. I didn’t know peoples’ roles on the team, and, based on the discussion, it was difficult to tell. A nurse sounded like she could have been a social worker, given her expressed concern about the isolation and emotional state of a particular member; a social worker indicated strong interest in another member’s health status and disease progression; and the member-services coordinator asked insightful questions about a member’s family situation. At other times, their input was more specific to their disciplines.

The team showed a great deal of fluidity between roles, people listened closely to one another, and everyone in the room contributed. Together they developed strategies for fixing problems that were far more creative and effective than they could have individually.

Lessons Learned

Later, I interviewed team members, as part of a Lessons Learned process, to determine how to roll this team model out to the rest of the organization. All were very positive and enthusiastic, though some admitted they were doubtful at first. All talked about how hard they had to work to hear others’ perspectives, how at first each thought only they knew best what to do, and how they were “fixers,” wanting to jump to an immediate solution. But now they could see how much more insight they had into members’ needs — that the multiple perspectives formed a more complete picture, making it easier to come to a solution that actually addressed the underlying problems.

They were also more easily able to work productively with people in other disciplines. For example, the nurses and social workers better understood all the steps involved in repairing wheelchairs, and the rehab specialist understood more clearly why these repairs should be prioritized.

What made it possible to get to that point, they said, was the relationships and trust developed through the initial team-building exercises (which many resisted), their intentional use of the PHI Coaching skills, and their clear focus on ICS members. And though they were pleased with their process, they were much happier with the results. Without a doubt, they said, the members’ health had improved through the pilot program.

ICS is preparing for significant expansion, developing the infrastructure and partnerships to manage the care of approximately 4,000 people by the end of the year. The Interdisciplinary Team model is a key element of their growth strategy. After seeing the success of the pilot, ICS staff believe that, as they roll this model out, they will be able to continue to provide highly individualized, high-quality person-directed care.

– by Sara Joffe, PHI Organizational and Executive Coach

The video features interviews with administrators, direct-care workers, and residents at three Michigan long-term care facilities:

• The Sanctuary at Bellbrook, in Rochester Hills;
• Lakeview Manor, in Tawas City; and
• Jackson County Medical Care Facility, in Jackson.

Each of these facilities has introduced consistent assignment within the last few years, generally as part of broader culture-change efforts.

They’ve all seen immediate positive results, including increased family satisfaction and better clinical outcomes. At the Jackson County facility, for example, there has been a marked decrease in pressure ulcers, according to administrator Sandra Place.

Residents also greatly prefer seeing the same caregivers each day. Erin Leutermann, a certified nursing assistant at the Sanctuary, says in the video that residents “count on us to come in every day. They don’t have any surprises. They look forward to us coming in. They know how they’re going to be treated…. We know them so well, everything just goes real smooth.”

In 2010, Joanne Robinson, PVM’s Senior Vice President of Operations, was tasked with implementing “customer service training” throughout the organization. Robinson, however, had seen similar strategic initiatives at PVM fail due to lack of sustainability. She recognized that it would not be enough to merely teach good customer service skills — it was more important to “create a culture of service excellence in the organization,” she said.

Robinson also knew that creating such a culture would require a strong team effort. In August 2010, she convened an interdisciplinary team of about a dozen PVM employees from across the state, and asked them to identify the basic “core values” that define PVM as an organization. Through much hard work and debate, the team decided on four values:

• Accountability
• Listening
• Relationships
• Respect

Some of these core values were decided on easily. For example, “relationships” is a natural fit for PVM because the organization has a “very relational culture,” Robinson says. Other values demanded more refinement. Initially, “communication” was deemed a core value, but the team eventually decided that “listening” is more important. “PVM is such a fast-paced culture, so we decided ‘listening’ is more appropriate because it would encourage people to slow down and really listen to what others have to say,” Robinson said.

The interdisciplinary group also studied three key resources to help shape their thinking: Quint Studer’s book Hardwiring Excellence, which describes the tools necessary to maintain culture change in health care organizations; Walt Disney’s concept of “making magical moments”; and Nordstrom’s famous “strong service culture.” PVM wanted to strive for a similar service-oriented culture that could deliver magical moments for its residents.

PHI Develops Training

With the four core values decided, Robinson contacted PHI to create a training centered on them. PHI Midwest Organizational Culture Change Consultant Cean Eppelheimer responded, developing a day-long “Service Excellence” training that teaches skills related to each value. For example, the value “respect” is conveyed to trainees with a role play highlighting the differences between a respectful exchange and a disrespectful one.

The training is designed to be accessible to everyone in PVM, from caregivers to administrators. “That way,” Eppelheimer explains, “the core values presented in the training become the driver for behavior and a litmus test for organizational practices — everyone has to know these values.”

To support the behavior changes necessary to fully live the PVM core values, Eppelheimer included PHI Coaching Approach^SM skills in the training. “The PHI Coaching Approach fits perfectly with the goals that PVM has set,” she said. “In the trainings, I integrated several key components of the Coaching Approach, including the value of clear communication skills and how to give feedback constructively. The result is a one-day training that highlights the PHI Coaching skills, yet remains uniquely tailored to PVM and its emerging value-based culture.”

The roll-out of the Service Excellence initiative began earlier this year with a train-the-trainer session preparing 14 Service Excellence educators. These trainers will work with RaShonna Crosby, a newly hired training specialist, to share the one-day training across the entire organization. By the end of the year, all 650 PVM employees will have received the training.

To promote sustainability, the concept of Service Excellence will be “hardwired” into PVM’s culture. Performance evaluation criteria have been adapted to reflect the Service Excellence values. Additionally, potential employees are asked Service Excellence-related questions during the interview process, and new hires will go through the day-long training as part of their orientation. “You can contaminate a work team when someone comes in and doesn’t embrace the culture,” Robinson notes.

Overall, PVM administrators say they are excited about the direction their organization is going. “The core values of accountability, relationships, respect, and listening are so crucial to maintaining the high quality eldercare that we want to deliver,” Robinson said. “With PHI’s help, we are certain that we can maintain that high standard of care for years to come.”

The conference, entitled Navigating the Way Home: Guiding Change Along the Continuum of Care, will feature:

• Eden Alternative co-founder and Green House Project founder Dr. Bill Thomas;
• nationally acclaimed writer and former NPR host Connie Goldman;
• Senior Vice President of the American Health Care Association‘s Quality and Regulatory Affairs David Gifford;
• family advocate and speaker Sarah Rowan; and
• culture change specialist and author Carmen Bowman.

The Eden Alternative is pleased to highlight this international conference as one that consciously acknowledges culture change as a movement that impacts the full care continuum — not just the organizational development of nursing homes.

In addition to the line-up of featured speakers, the conference also offers more than 30 break-out sessions, designated by interest track and culture change milestones, as they are detailed in the Eden Alternative’s implementation roadmap, The Path to Mastery^TM.

A local Michigan Steering Committee of five individuals — including PHI Organizational Change Consultant Cean Eppelheimer — is partnering with the Eden Alternative to make this a rich conference experience.

Additionally, PHI National Director of Coaching and Consulting Services Susan Misiorski and PHI Organizational Change Consultant Kathy McCollett are pleased to present Self-Managed Work Teams: Getting Started on Thursday of the conference.

Please join us there and gather tools and inspiration from culture change leaders with experience in creating home — wherever home may be.

Register online, or, for more information, download the registration brochure (pdf).

An affiliate of the Visiting Nurse Service of New York, Partners in Care is the largest licensed home care agency in the country, employing 9,500 home health aides and providing services to 20,000 clients annually.

The profile explains how Partners in Care — where growth had outpaced the ability of supervisors to effectively support the frontline staff — set about transforming its culture using the PHI Coaching Approach to Supervision^SM.

Training in Coaching and Communication Skills

Partners in Care’s culture-change journey began in 2006, when several managers were trained in the core skills of PHI Coaching Supervision^SM, including active listening, nonjudgmental communication, self-awareness and self-management, and collaborative problem solving. Those managers in turn trained several hundred of Partners in Care’s supervisory staff.

These skills resulted in improved relationships between coordinators and the aides they supervised, according to CEO Marki Flannery. But the impact went deeper. Partners in Care’s aides are more comfortable approaching their supervisors with suggestions or concerns. Supervisors, meanwhile, have been far more active in soliciting their aides’ opinions. Consequently, clients have noticed a positive difference in the quality of care they have received since Partners in Care implemented PHI Coaching. “Coaching Supervision has transformed the culture of this organization,” Flannery says.

To sustain that change, Partners in Care decided to train all 9,500 of its home health aides in the same communication skills taught to supervisors. These skills, which underlie the ability of organizations to implement and sustain change, are what the PHI Coaching Approach is all about.

Quantifiable Benefits

The infusion of the PHI Coaching Approach into Partners in Care 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 Partners in Care 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 Partners in Care 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.”

Flannery believes that the PHI Coaching Approach has prepared Partners in Care for its next expansion, into the private pay market. With improved communication skills, the entire staff is working together to provide quality person-centered services that truly meet the needs of each individual client. Flannery notes, “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.” That gives Partners in Care a competitive edge in the marketplace.

Dawson argued that home care aides, because of their daily role in clients’ lives and their relationships with family members, have a crucial role to play on care teams:

We all can debate differing definitions of “care coordination,” but what we should agree on is that any successful design will require the rapid flow of accurate information — so that the right services can be provided to the client, by the right person, in a timely manner….

And so, from the perspective of home-based care coordination, the role of the aide becomes plainly visible — not in isolation, but as an essential actor within the care coordination model. No other paid member of the care system is present in the home on a regular basis, to notice changes in condition over time; no other paid member has the same type of daily relationship of trust with the client and family members; no other member holds such intimate knowledge of what is “really” happening in the home.

Discussing the benefits and the challenges, Dawson ended optimistically, noting there is a real opportunity today, with the move away from fee-for-service models to capitated payments, to create more valued roles for home care aides. Rather than define one such role, he called for “a thousand experiments to bloom.”

Read Dawson’s full remarks here (pdf).

PHI President Steven Dawson will give the keynote address.

The forum will be held on March 30 from 8:00 a.m.-12:30 p.m. Pre-registration is required and space is limited. For more information, visit the ASA website.

The conference will take place from 8:30 a.m. to 5:30 p.m. at 1825 Connecticut Ave., N.W.

Co-sponsored by PHI, panelists include PHI Government Affairs Director Carol Regan. Register online.

PHI has recently completed a project to refine and strengthen the way we present our consulting services to the eldercare and disability services community. As a result, I am proud to announce our new team name and tagline:

PHI Coaching & Consulting Services
Building Skills. Strengthening Teams. Managing Change.

The new name captures both what we do (consulting services) and how we do it (using the PHI Coaching Approach^SM). And the tagline succinctly states the heart of our approach:

• Building skills amongst all staff in the organization to provide exceptional person-directed care
• Strengthening teams so that staff are able to communicate and collaborate effectively in achieving organizational and client goals
• Helping provider organizations manage the rapid changes in today’s long-term care and disability service markets

Our website has also been updated and new resources are now available including case studies, client stories, and video clips of coaching in action. Please stop by and check them out.

I would like to thank the Taproot Foundation, a nonprofit that provides pro bono consultants to organizations working to improve society, for leading us through this process and providing a top-notch team of marketing and branding experts to work with. PHI is fortunate to have had their assistance and strongly recommends their services.

Please visit our website often, as new content will be added regularly. If you would like to contribute a story or content, contact me at smisiorski@phinational.org.

Kathy McCollett

By Kathy McCollett

Kathy is a Change Management Consultant with PHI’s Coaching and Consulting Services team.

In order to create the feeling of “home,” many nursing homes are changing the look and feel of their facilities, removing the objects and other artifacts that scream “institutional.” Perhaps taking their culture change efforts a step further, they have implemented consistent assignment, with the same staff supporting and caring for a specific group of elders. Having made these initial changes, these organizations want to know what to do next.

Culture change is not a task that lends itself to checklists. If we think of it that way, we will be waiting to check each aspect of the change process off our list. Rather, it is a process of making the needs and desires of each person living and working there more important than what has been dictated by institutional history. It’s about creating communities of people in relationship with each other, those who live there as well as those who work there.

Many providers have made changes to their physical environments and operational procedures that support culture change, but these changes aren’t always enough to have actually changed the culture. It is not uncommon to hear, “We did everything we thought we were supposed to do, but the culture still feels the same.” That’s because a culture doesn’t change by moving through a series of tasks.

Cultures change when our way of being with other people is altered from one that focuses on staff or organizational needs first to one that focuses on the needs of the elders first. According to Webster’s, changing a culture means making “the sum total of ways of living built up by a group of people and transmitted from one generation to another something different from what it is or from what it would be if left alone.” This takes an intentional process that is applied consistently and persistently.

Let’s take changing dining services as an example. If a home decides to eliminate tray service and go to family-style dining, that home is often intending this change to shift the culture. However, if staff and elders are “told” this is what they will now be doing — rather than being involved in the decision making — the result may fall short of the goal. Tensions between dietary and nursing may escalate, and staff may even plate the food without asking the elders what they want to eat.

In this instance the home could “check off” that they implemented family-style dining, but they would not have moved decision-making to the elders and those working most closely with them and, therefore, would not have shifted cultural norms.

If you are looking for more information on how to move beyond tasks to a relationship-centered culture, check out Getting Started, a guide to implementing culture change available through the Pioneer Network. In addition to providing guidance on the change process, this handbook includes multiple staff education tools that invite involvement in thinking about the why, what, and how of culture change.