Home Health Coordinating Care for Older Adults

They were a simple couple.  They were born and raised in rural America.  As they called it, the country.  They worked hard.  They strived to provide for their children.  They did the best they could for their kids. Their greatest joy was their grandchildren. They were married almost 58 years before she passed away.  He died about two years later.

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The last five years of their marriage were tough for them and their grown children.  Her health began declining, plateauing, declining, plateauing, declining until she made the decision for inpatient hospice.   She was adamant about not going into a nursing home.  Whenever her daughter approached the subject or the case manager at the hospital because she had several readmissions, the answer was a resounding no.  He understood and supported her decision.  While others did not agree with their stance, they held their ground.  They stayed in their apartment until their last hospitalization.

This is where the real story begins amid her discharges to home with home health services.  She always qualified for home health.  Her home health RN, Kathy, was an excellent clinician.  She developed a trusting relationship with Kathy.  She probably told Kathy things she would not tell her daughter. 

Kathy brought in a social worker.  The social worker's role involved conducting an interview with them to determine the assistance they might need or qualify for.  The coupled did not qualify for Medicaid.  Based on the social worker's evaluation, their income exceeded the poverty level for a married couple, even though they had significant medical expenses.  Yet knowing their financial limitations, the social worker urged them to go into a nursing home or residential facility for seniors.

It was at this point, the social worker and home health RN started having conversations with the daughter.  The discussions centered around her mother's needs, nursing home, bedside commode, walker, carpet removal, medication assistance forms completion, etc.  Soon the daughter became the bank and case manager.  Before the numerous requests from the healthcare team, the daughter supplemented the couple's income by about $700/month plus running errands after working more than a full-time job.

From her vantage point, the social worker and home health RN gave up. The team was from a highly respected home health agency.  They were politely professional.  But they did not offer nor try to find equipment or resources to assist the couple.  Instead, the team relied upon the daughter to procure the equipment along with finding the resources.  The daughter could not be just a daughter.

To make matters worse, the couple was embarrassed about the amount of support they received from their daughter.  They wanted to do this for themselves. Or, at most, to have their care providers assist them.

This experience is not unique to this family.  This patient and family's experience were not centric to the healthcare team's ability to implement individualized care, namely, care coordination.  Unfortunately, it occurs within our healthcare system. 

Care coordination is central to patient experience and mitigating health issues.  The Centers for Medicare and Medicaid Services require home health agencies to provide care coordination, specifically:

§ 484.60 - Condition of participation: Care planning, coordination of services, and quality of care, (d) Standard: Coordination of care. The HHA must: (4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities.

When there is a deficit in a team's ability to coordinate care appropriately, it requires probing to discover the etiology.  It, also, requires an action plan (with metrics of success).  The goal is to find the cause and start working on solutions that will elevate the team's ability to coordinate a patient's care.  Integrated Care Strategists recommends starting that journey with an assessment followed by an action plan.

Initially assess

While the action plan ultimately depends upon the assessment findings, there are some endeavors worth exploring and incorporating.

Possible actions

  •      Shadowing team members—This serves several purposes.

o   It assists in gaining a better understanding of the challenges and barriers team members experience, which fosters more focused solutions.

o   It provides opportunities for immediate feedback and guidance.

o   Lastly, it conveys interests and concern for team members.

  •     Connecting with community resources that are meaningful to the team—This is especially important because it goes beyond the typical referrals.

o   This entails scouting for agencies that offer services/equipment that are free or for a nominal fee.

o   It involves cultivating partnerships with traditional and non-traditional resources that can be a source of support for the team and patients. For instance, developing a relationship with the local electric company for patients experiencing difficulties paying their bills.  Or, a secondhand store where patients and families can purchase equipment more economically when it is a non-covered item.  Or, researching for a construction company that will donate their time and resources for small projects.  This takes time but is invaluable. 

o   Ensuring and maintaining competency on local and state resources is vital. 

o   Another method to investigate is purchasing a social determinants of health software platform to assist team members in finding resources and actually coordinating care/services.  An example of this type of software is Unite Us.

o   This is an excellent project for a practicum student.

  •    Developing and implementing a role competency assessment—When team members experience role ambiguity, it increases the possibility of poor clinical outcomes.   Thus, it becomes essential to provide ample orientation and continuing education followed by team members successfully demonstrating their knowledge and skills.

  •  Educating and reviewing the implications of the Home Health Care CAHPS Survey with the team

  •   Applying "Lean" principles" to improve processes— The goal of lean is to eliminate waste in procedures and processes, thereby reducing costs and increasing patient satisfaction. This action will ultimately improve employee engagement.

  •   Providing guidance on family involvement and engagement with patient care—At the heart of care coordination is advocacy.  Home health agencies developing a framework or position on advocacy will assist the team as they work with patients and families.

Most importantly, when on the journey of enhancing care coordination processes, Integrated Care Strategists recommends setting and sharing the vision.  Explain the purpose and value of letting the daughter be the daughter.

Kelly Simunovich