SummaryA collaborative, team-building initiative in the country's largest home care agency effectively integrated home health aides into health care teams by increasing clinician support of the aides; improving communication among clinicians, aides, and patients; and educating home health aides to promote patient self-care. The program resulted in more patients successfully transferring (i.e., independently moving from a bed to a wheelchair or chair) and walking indoors and outdoors without support.Strong: The evidence consists of an RCT in which 45 acute and congregate care service teams from Visiting Nurse Service of New York were randomly assigned to control and intervention groups.
Developing OrganizationsVisiting Nurse Service of New York
Date First Implemented2003
Age > Aged adult (80 + years); Vulnerable Populations > Disabled (physically); Frail elderly; Age > Senior adult (65-79 years)
Problem AddressedMore than 800,000 home health aides provide services to home health patients in the United States.1 Typically, patients are seen by home health aides as care recipients, whereas home health aides are viewed as unskilled workers who merely perform tasks for the patient. Aides often have high rates of job dissatisfaction and turnover, and rarely are their observations and capabilities fully utilized to improve patient outcomes and promote self-care.2
- Many challenges in delivering home health care: The complex structure of home health services, with widely dispersed patient populations and workforces, and heavy reliance on contractor-provided aides in urban areas, poses numerous challenges to improving patient care. Home health patients often have multiple and complex health conditions, and many providers are involved in their management and care.
- Challenges in coordinating nurse and home health aides visits: Visiting Nurse Service of New York, the largest not-for-profit home care agency in the United States, faced challenges integrating aides into its service delivery teams of clinicians, nurses, therapists, and social workers who provide frontline care under the leadership of patient service managers. Nurse visits to patients' homes often could not be scheduled to coincide with the aides' assigned schedules. Nor was it generally feasible for aides to leave their patients to attend team meetings scheduled at a more central location.2
- Lack of coordination in aide oversight: Most aides at the Visiting Nurse Service of New York are contractors who report to both an aide coordinator or manager at the contracting organization and to a nurse or therapist at the Visiting Nurse Service who is responsible for the patient's overall care plan. This lack of coordination creates barriers to providing high-quality care and achieving high levels of satisfaction among nurses, aides, and patients.2
Description of the Innovative ActivityThe Visiting Nurse Service of New York Home Health Aide Partnering Collaborative was designed to better integrate aides into health care teams by increasing clinician support of aides; improving communication among clinicians, aides, and patients; and educating aides to promote patient self-care and to be proactive members of the team. The overall goal is to support patient improvement in key activities of daily living (ADL), such as allowing a patient to move independently from a bed to chair or wheelchair (transferring) and independent ambulation. Key elements of the program are described below:
- Enhanced communication among the care team: Weekly phone calls, faxes, and other approaches are used to improve communication between patient service managers and agency coordinators. A set of field supervision practices ("Five Promises") was implemented to promote positive and effective communication between all caregivers while in the patient's home. The Five Promises practices require aides to directly provide updates in the patient's care plan, which made aides feel more valued and comfortable communicating with nurses about a patient's condition and progress.
- Education and empowerment of aides: Nurses, therapists, and other clinicians provide direct education and feedback to aides to improve their effectiveness with patients. Because of the diverse locations of the health team members, it was difficult to organize team meetings that could be attended by all members, including aides. As a result, coordinators at the licensed vendor agencies that provide aide services to patients educate aides individually or in small groups about how to use the ADL tool and proper body mechanics for assisting patients with basic ADL so that home health aides can take a more prominent role in patient care.
- Shifting the mission of the home health team and aides' roles: Leaders of the collaborative effort worked to change the culture of health services, stressing the goal of improving patient self-care management instead of having aides and other members simply perform tasks "for" the patient. Instead, the aide is presented as a valued member of the health care team and became more involved in working with patients and their caregivers to set goals for self-care and self-management. For example, aides began using daily activity "What I can do for myself" charts to help patients identify their progress and goals in areas such as moving in and out of bed, walking or using a wheelchair, and bathing. In another example, aides were encouraged to have patients try to complete tasks themselves before assisting.
Context of the InnovationVisiting Nurse Service of New York is the largest not-for-profit home health care agency in the nation, serving an average of 24,000 patients daily throughout New York City and Nassau and Westchester counties. The service has a private home care subsidiary, Partners in Care, that contracts with 21 agencies to provide a workforce of 22,000 aides. They also provide nursing and clinical oversight to the aides, whose average age is 43 years old. Approximately 96 percent are female, 80 percent are African American, 15 percent are Hispanic, 1.3 percent are white, and 2.6 percent are Asian American. The average wage is $7.87 an hour, and the average work week is 30 hours.
More than 60 percent of the patients that aides attend to are elderly, and each patient receives aide services for 1 to 3 months on average. Patients may receive aide services from one Visiting Nurse Service agency or from several, depending on their medical, cultural, and language needs. The home care agency must provide care to many residents who do not speak English—more than 56 percent of the city's population are foreign born or the children of foreign born. Therefore, aides are needed who speak Spanish, Russian, Mandarin, Cantonese, Korean, Tagalog, and other Asian languages and who are trained in the cultures, values, and customs of many different ethnic groups. Like other home care agencies, Visiting Nurse Service of New York has struggled to integrate its widespread aide services into its service delivery teams of nurses, therapists, and social workers who provide frontline care under the leadership of their respective patient service managers.
ResultsA randomized controlled trial (RCT) showed that the program improved the ability of patients to transfer themselves from beds to chairs or wheelchairs and to walk independently; these improvements were sustained over time. The program also made home health aides feel more involved as team members.
Strong: The evidence consists of an RCT in which 45 acute and congregate care service teams from Visiting Nurse Service of New York were randomly assigned to control and intervention groups.
- Enhanced transferring and ambulation: Sixty-one percent of patients in the integration collaborative group showed improvement in transferring themselves from their beds to chairs or wheelchairs, compared with only 53 percent in the nonintervention control group. Although the differences were smaller in ambulation improvements, they were still statistically significant, with 37 percent of patients showing improvement in the integration collaborative group, compared with 36 percent in the control group. The larger impact in transferring is consistent with national data, indicating that it is more difficult to generate improvement in ambulation. Followup analysis showed these improvements were sustained at a 10-month followup point after the end of the randomized trial.
- Little or no additional costs: The improvements in patients' functional outcomes were achieved without any major change in service provision (e.g., home visits by aides) or costs.
- No reduction in intensity of home care: The program did not reduce length of stay in home care, which averaged 55 days for both the intervention group and the control group.
- No impact on aide job perceptions or retention: Aides who responded to a short job perceptions survey reported they were generally treated as important members of the team. There were no significant differences in job perceptions between aides working with the collaborative teams and aides in the control group, however. Moreover, although job retention was relatively high across the board, the initiative did not show a significant impact on retention.
Planning and Development ProcessKey steps in the planning and development process include the following:
- Year-long learning process: The strategies the agency developed emerged from a 12-month learning process modeled after similar learning collaboratives developed and disseminated by the Institute for Healthcare Improvement's Breakthrough Series to promote sustainable change across the health care industry. This model has been increasingly used across health care settings as a means to jump-start improvements by testing new strategies and continuously adapting them to achieve better results.
- Internal team drives the initiative: A leadership team made up of clinical and program directors, quality improvement specialists, and several other key department personnel designed and drove the initiative during the pilot and organization-wide implementation. Staff from Visiting Nurse Service of New York's Center for Home Care Policy and Research conducted the evaluation of the implementation.
- Training: The pilot project targeted training on 7 (out of 45) acute and congregate care service teams that partnered with 3 different licensed vendor agencies that provided aide services. Training included improving coordination and communication between team members, aide supervision best practices, aide use of ADL tools, how to shape patient expectations, and integration of aides into the care plan.
- Initial pilot and rollout: The program was pilot tested between 2003 and 2004. The initial success of the pilot led to a decision to roll out the program in two phases, first the randomized trial with 22 intervention teams and 23 control teams, and then the agency-wide spread February and July 2006.
Resources Used and Skills Needed
- Staffing: Trainers were existing employees of the Visiting Nurse Service's Quality Management Services, which has full-time practice improvement staff. Once the pilot project was completed, home health service team members, who had participated in the pilot project, led the expansion of the collaborative initiative through the organization.
- Costs: No additional funding was required because trainers came from existing quality improvement staff. The formal evaluation was funded by the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.
Funding SourcesVisiting Nurse Service of New York
The initiative was funded internally; a grant from the U.S. Department of Health and Human Services funded a formal evaluation.
Tools and Other ResourcesVisiting Nurse Service of New York made its Home Health Aide Partnering Collaborative Implementation Manual available to any interested organization. The manual is available at the end of http://aspe.hhs.gov/daltcp/reports/2007/HHAPartrb.htm.
Getting Started with This Innovation
- Designate an individual and/or committee to develop a team-building strategy and identify what care management issues must be taught to aides.
- Reeducate the team on the value of aides, including their ability to be contributing members of the care team, by acknowledging the unique contributions of the aide and fostering the concept of the aide as "assisting" the patient rather than "doing" for the patient.
- Clarify the patient's expectations to promote self-management goals.
- Establish best practices that can optimize the role of the aide, including instructing aides on each care plan item, utilizing flow sheets and ADL tools for documenting interventions and patient responses, providing appropriate supervision and feedback to aides, and listening to aides and encouraging them to contact the agency when there are changes in a patient's condition.
- Create an atmosphere of inclusiveness by having aide supervisors attend team meetings and participate in bimonthly or weekly conference calls, have the aide participate in the updating of the patient care plan, and help the patient view the aide as a care partner and an essential part of the health care team.
Sustaining This Innovation
- Regularly review the effectiveness of the initiative by tracking patient self-care improvements, changes in how long patients require home health services, and aide retention rates.
- Periodically survey aides about job satisfaction and where they see the need for improvements in organizational communication, training, and supervision.
- Carefully consider how to spread the use of the ADL tool, which can be challenging. Although aides favored using the tool because it helped them make better use of their skills, clinicians were less open to using it. Some patient service managers were not convinced of the immediate value of the tool and resisted imposing extra work on field nurses who had responsibility for implementing its use. During the agency-wide rollout of this initiative, faculty implemented a revised, patient-centered, user-friendly version of the tool, but still met with resistance. The faculty ultimately decided to pursue a broader initiative to improve both clinician and patient readiness for a self-management approach to care.
- Designate frontline staff to be program champions and teachers, rather than leaders or faculty members. As the collaborative effort spread, the peer-to-peer messages became more diluted.
- The fact that patient outcomes improved even without widespread use of the ADL tool suggests it was not the tool that led to better outcomes, but rather the overall emphasis on collaboration and better communications among the clinician, aides, and patient.
- Several home health agencies could maximize their resources by jointly contracting with a consultant or health care quality improvement organization to spearhead an aide partnering collaborative based on the Visiting Nurse Service's model.
Contact the InnovatorSally Sobolewski
Director, Quality Improvement-Provider Services
Clinical Transformation and Innovation
Visiting Nurse Service of NY
1250 Broadway, 20th Floor
New York, NY 10001
Phone: (212) 609-6351
Fax: (212) 290-3756
Innovator DisclosuresMs. Sobolewski reported having no financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesU.S. Department of Health and Human Services (HHS). HHA partnering collaborative evaluation: practice/research brief. Visiting Nurse Service of New York; Center for Home Care Policy and Research. 2007 September. Available at: http://aspe.hhs.gov/daltcp/reports/2007/HHAPartrb.htm
U.S. Department of Health and Human Services (HHS). HHA partnering collaborative evaluation: practice/research brief. Visiting Nurse Service of New York; Center for Home Care Policy and Research. 2007 September. Available at: http://aspe.hhs.gov/daltcp/reports/2007/HHAPartrb.htm
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Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 23, 2014.
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