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PHI Celebration Honors “Care Connections” Senior Aides

March 4, 2016

PHI recently celebrated the accomplishments of the Senior Aides who participated in the “Care Connections Project” (CCP), a pilot funded by the New York State Department of Health that aimed to reduce preventable re-hospitalizations among members of Independence Care System (ICS), PHI’s affiliate managed-care organization.

The Senior Aides’ role in the pilot was to support ICS members’ home care workers in attending to and reporting unusual signs, symptoms or behaviors whose early detection could prevent a decline in health or the need for acute care. The Senior Aides also worked with both members and home care workers in the home in situations where unidentified or unaddressed issues threatened to “destabilize” the case.

The pilot officially ended in December 2015, and the clinical outcomes related to the pilot’s interventions are still under analysis. In the meantime, the Senior Aides themselves are ready to share stories of how they witnessed their impact firsthand.

Before the New Year began, PHI gathered them together to hear about how they had improved the lives of ICS members, and the lives of the home care workers who support them.

One Senior Aide recalled receiving a call at 3 PM on the Friday of Labor Day weekend. “The home care worker on this case was new, and she didn’t know how to use the Hoyer Lift in the member’s home or how to help the member sit up safely,” said June Jack. “I went to the member’s home right away, and spent three hours teaching the home care worker what she needed to know.”

Another Senior Aide recalled being in a member’s home to train the home care worker how to use a telehealth device, when she happened to notice that there was grit in the member’s catheter. “I asked about it,” said Marisol Rivera, “and learned that the member couldn’t get to her appointment to get the catheter changed because the elevator was broken in her building. I informed my Clinical Manager, who was able arrange to have someone come to her home to change the catheter, and this might have prevented a hospitalization for her down the road.”

In some cases, Senior Aides worked with members and their assigned home health aides to ensure that the aides could provide stable, on-going support. In one case, Beverley Harriott coached a member to communicate more effectively with her assigned aides, which resulted in significantly less aide turnover.

Another Senior Aide, Rokhaya Sarr, discovered that one home health aide who had become chronically late to her case was at risk for becoming homeless. The Senior Aide was able to work with the agency to link the aide with supportive services that helped her secure more stable housing, thus enabling her to get to work on time.

Not only have ICS members and their home health aides benefited, but so have the Senior Aides themselves. Some of them took time at the December celebration to share what it has meant to them to take on this new professional role.

“This has opened up my eyes and taught me to be more ambitious,” said Venessa Morgan.

Beverley Harriott agreed. “In a lot of jobs, you have a fear to be open. Now I feel I can be open. You have poured so much into training us, more than we ever could have imagined was possible. I feel like I’m soaring, and I have PHI to thank for that.”

— by Renya Larson, PHI Organizational Change Consultant

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