CME-MOC

Time Stamps

  • 02:33 What support do our patients have at home and how does those people play a role in their care?

  • 04:22 What do we gain by providing patients with long term support at home?

  • 06:00 Are there various types of home care workers?

  • 07:25 What role do home attendants play in caring for a patient?

  • 08:31 What tasks do home health aides do?

  • 10:11 What are the types of “skilled care?”

  • 13:17 What can Medicare cover for older adults in terms of home health aides?

  • 15:17 How does Medicare define homebound?

  • 16:03  How does having Medicaid impact access to home care?

  • 19:10 What if a patient isn’t eligible for Medicare or Medicaid?

  • 19:35 What is the cost to use a private agency for home health services?

  • 24:02 What are some challenges that home health aides face?

  • 25:42 What are “plans of care?”

  • 29:58 Who makes up the home care workforce?

  • 31:47 When patients get discharged from the hospital, do they go home to the same home care assistance?

Show Notes

Why is it important for GIM practitioners to learn about home health workers?

  • Your patients use these services; as such, you should become familiar with them. Having a better understanding of what they do and the services they can provide will enable you to work these team members more appropriately both for your patients and the system as a whole.
  • Home health aides serve as eyes and ears in the homes of our patients. They can often provide important collateral information on what’s going on with your patients outside the clinic/office.
  • When home health care is appropriately leveraged, the healthcare system as a whole benefits. There is literature to suggest that patients who use home health care services have lower rates of hospital readmissions and mortality, and cost the healthcare system less money.

What are the different kinds of home health workers your patients might encounter, and how do their scopes of practice differ from one another?

  • Home attendants (AKA: personal care assistants, personal assistants, ISS workers): help with light shopping, groceries, personal care, light housework and meal preparation. Also for some patients, they may provide social support and companionship.
  • Home health aides: 
    • Are trained to do all the personal care tasks that home health assistants do – (bathing, feeding, light housework, light shopping). 
    • Also have some more medically-oriented training (e.g. can do vital signs or routine ostomy care) but cannot administer medications.
    • NB: this training is not standardized between states, and may not include disease-specific training. 
  • Visiting/skilled service: describes a healthcare professional (such as a nurse or PT) who enters the home for a specific patient need (e.g. wound care). This skilled care is intended to be episodic rather than continuous or long term. 

Insurance and home services

  • Medicare 
    • Generally covers home health services for patients who:
      • Need skilled care services.  
      • Are deemed homebound by Medicare criteria. 
        • Note: Medicare’s definition of homebound doesn’t mean the patient can’t leave the home at all but they need to meet the following two criteria: 
          • Need the aid of supportive devices (e.g. crutches, canes, wheelchairs, walkers), the use of special transportation, or the assistance of another person in order to leave their place of residence OR has a medical condition where leaving the home is contraindicated. 
          • There must exist a normal inability to leave home AND leaving home must require a considerable and taxing effort
    • This coverage is short term and often in the post-discharge period (but can be after any change in a patient’s status – for instance, a fall).
  • Medicaid is the primary payer for long-term home health services in most states.
    • In order to receive these long-term support services, patients must:
      • Be enrolled in a managed Medicaid care plan.
      • Receive an evaluation from an interdisciplinary team of providers who will determine the number of hours of home care that will be covered.
    • The process of instituting this care can be time-consuming and it can often be many weeks before a patient receives their Medicaid-covered home health services.
    • In some states (such as NY), Medicaid patients can participate consumer-directed personal assistant programs, which allow family members to receive payment for providing home health services to their relatives.
  • Patients without Medicaid or Medicare coverage may have other forms of insurance that cover their home health care (such as long-term care insurance). If not, they must seek their care from the private market, which includes:
    • Licensed home health agencies: Often more expensive. However, aides are likely to have been vetted/trained and typically will provide substitute aides if someone calls out sick.
    • Gray market (e.g. an unlicensed worker from the community employed directly by a private home/employer): can be cheaper than going through an agency, however less regulated.

Pain points: what makes home health work challenging?

  • Knowledge transmission: home care workers are often not told what diagnosis the patient has before they’re assigned to the job.
  • Incomplete/inadequate care plans: Plans that home care nurses develop and MD/NPs sign often are not what the HHAs see when they walk into the home – instead, the plans home workers receive are much less detailed.
  • Home health aides do not receive formal training in specific diseases that they might frequently encounter (such as heart failure). This may prevent them from being able to identify concerning symptoms that require up-triaged care. Additionally, getting a hold of a supervisor when questions arise can be challenging.
  • Many home health aides are women, immigrants, or both; many do not have consistent employment. They are vulnerable to the dynamics of power present between them and medical professionals/patients/their family members. As such, they might not wish to speak up or contradict their patient due to a desire to avoid losing their jobs.
  • Continuity of care can be challenging to achieve, as aides are often given new assignments if their patient is admitted to the hospital. 

Best practices

  • Get the lay of the land – ask your patients who is helping them with their medications or with travel to/from appointments. Work to bring that person/those people into the room and ask them their perspective.
  • Educate yourself, your colleagues – and your patients – on the different kinds of home health services for which they might be eligible (and from which they might benefit).
  • When initiating home health services, be proactive about looping in/collaborating with your colleagues in social work and case management to help make the process more efficient and actively incorporate their valuable expertise in this area!
  • Consider ways in which to communicate key aspects of the care plan with home health aides, as this may provide them with important medical details relevant to the care they will be providing. 
  • Lastly,  don’t put all the pressure on yourself. This is why you have a team. The more you understand the concepts and terms, the more effective you’ll be at working with your social workers and care managers to formulate the best plan. It’s a team sport; leverage your team members. It’s not all on you as the practitioner. 

Transcript

Shreya: Hi everyone! This is Dr. Shreya Trivedi. I am so excited to be kicking off our series on interprofessional education! We see snapshots of our patients in the clinic and in the hospital and now with a growing emphasis on team-based care, it fascinates me how little we know about the larger healthcare team, how little we get a chance to interact and to understand about other team players in our patients health. I think that’s where the beauty of podcasts can come in. Podcasts can help us go places where we can’t necessarily go to in our day to day. And today we will be exploring home care working with a focus on home health aides! And helping me today on the podcast is Gaby Mayer — She does a lot behind the scenes graphic bytes for Core IM and you may remember her from the Stories of Women in Medicine episode!

Gaby: Thanks for having me join you, Shreya. Talking about an equally important – but very different – topic. I think this is gonna be very practical and maybe even an eye-opening episode for some.

Shreya: Agreed. Thank you to the ACP for sponsoring this episode for CME. Particularly a shout out to Dr. Davoren Chick for believing in this mission and a huge kudos to the work she has already done with interprofessional education on Compassionate Care Curriculum. We’ve linked to it in the transcript for this episode, which you can find on our website.

Gaby: Let’s set the agenda for today’s episode: we’re going to go over why all clinicians learn about home care workers? What is actually their different scopes of practice? How does the insurance that your patient has play a role? And what are the challenges that home health aides face and how does it impact how you communicate with your patient and HHA?

Shreya: Just a heads up: parts of this episode will be focusing on the American healthcare system. For our friends in Canada, Australia or other countries, listen in and we’d love to hear from you on how  home care/health systems are similar or different. And with that, let’s dive in!

The Why 

Maddie Sterling: Despite kind of being eyes and ears in the home,  most of the time home care workers, which include home health aides, personal care, attendants, I find that actually they’re actually invisible to the rest of the medical team.

Shreya: That’s Dr. Maddie Sterling, a general internist and health services researcher at Weill Cornell Medical College. 

Maddie Sterling: I was taking care of patients as a primary care doctor. I was studying, um, heart failure, readmissions and trying to understand, you know, what was driving this, you know, a few years ago along with everyone else. And patient after patient, you know, would talk to me about, you know, relying on caregivers in the home and, you know, Doctor Sterling, why are you asking me about my medications? My daughter is helping me with that or what do you mean, you know… cook a meal with low salt. Like my aide is taking care of that. And I think those questions are, those statements from patients really made me as a researcher think really hard because I thought, you know, that’s fascinating. I had never bothered to ask about who is helping you at home. And a second point is I had never bothered to ask the person in the waiting room to come join us.

Gaby: You know, at first, I felt a little guilty. Had I been making a basic error with patient after patient by not checking in about whether they’d left a home health aide or paid caregiver in the waiting room? But with a little more reflection, I decided to let myself off the hook – because quite frankly, I can’t remember a time that I was taught anything about this.

Anne Meara: I don’t think it’s the type of thing that gets covered in medical school or quite frankly in nursing school. I think there is a knowledge gap in terms of the types of services the home health aide can provide. The difference between the skilled care that can be provided in the home through Medicare or not, the wealth of information that home health aides can provide. They are such an untapped resource.

Shreya: That’s Anne Meara. She has been a case manager for the last 30 years or so, working in large health systems and is now serving as senior leadership at the New Jewish Home, which handles a lot of  community-based programs, such as with home health aides!

Anne Meara: The idea is that you’re trying to maintain this person in the community and either delay or avert the need for institutional care. The goal of providing these long term support services in the home is really to avoid the need for, uh, having to go into a nursing home.

Gaby: And keeping people in the home helps the larger healthcare system. There’s some evidence to suggest that home health care can save health systems money. A 2017 study that randomized patients to either be discharged with or without home health services. Those WITH  saved the system about $6,000, decreased readmissions (HR 0.82, p < 0.0001) and even death (HR 0.08, p < 0.0001) in comparison to similar matched control patients who did not receive these services.  I’ll add that this study was performed in a large/diverse patient population (n of 65,000). 

Shreya: It is a nice bonus!

Scope of Practice: What do different Home Health Workers do?

Shreya: So the larger health system is benefiting from these services, our patients are using these home services and so we should probably become familiar with them.

Gaby: Just like, when I was on my psych rotation, I was required to attend AA meetings so that I would know what it was like should I ever recommend it to my patients. 

Shreya: Right, we can’t even begin to navigate this if we don’t know who are the different health workers in the home are and how their roles differ. 

Maddie Sterling: There’s many different types of home care workers. There’s many different types of home care workers. Those types involve home health aides, personal care aides, home health, attendants, nurses, aides. Sometimes people include, um, a nurse anesthetist. And this model, there’s all different, different types of workers. 

Shreya: Yikes, there are so many! The titles can get quite confusing – for instance, two home care workers may have different titles but very similar scopes of practice and on the flip side, two home care workers can have the same title but their comfort with tasks  may differ depending on the agency or state they trained. It doesn’t help that terminology is often regional – for instance, what we call a “home attendant” in New York state goes by the title in-home support services, or an “IHSS worker,” in California.

Gaby: What helped me was thinking about it from the perspective of the tasks done by homecare workers. I’d say this generally falls into three buckets of jobs they do for their patients. Let’s start with the group who has the narrowest scope of practice. This group is generally  referred to as the personal care assistants or home health attendants.

Anne Meara: Those are people who are doing maybe a little bit of shopping, a little bit of housekeeping. They, they are providing the personal care, the bathing, the feeding, uh, you know, sort of help with range of motion exercises and that type of thing. But generally it’s personal care, I mean, there and companionship, which I think is, is important. Um, you know, they become, often, the link to the outside world. The, uh, you know, they, they are part of relieving the social isolation.

Gaby: Well said –  you can’t forget that these people can also serve as company for some of our patients. I could also use some company on my weekly grocery shopping trips, that would materially impact my quality of life.

Shreya: That’s probably what  my spouse is doing for me! Next up is home health aides. Home health aides are trained to do all the personal care tasks that home health assistants do – so again, that’s bathing, feeding, etc. But home health aides have a little bit more medically-oriented education:

Maddie Sterling: Home health aides usually typically have, um, sort of a larger scope of care. So they can do vital signs, they can do a little bit higher level.

Shreya: For instance, they’re trained in blood pressure readings or routine ostomy care. But there in talking to some home health aides in preparation for this episode, this varies between agencies and  states. For ex, with fingersticks – not home health aides were comfortable doing fingersticks. Despite those variations, there are some definite limits to know on to their scope of practice:

Anne Meara: Generally they do not administer medications. I think there’s been a lot of discussion about expanding the scope of practice of home health aides to maybe encompass, um, more of that type of care, uh, since they are in the home. 

Shreya: Just to reiterate that common misconception: it would actually be incorrect for me to instruct a home care attendant or home health aide to give a patient medications — that’s not within their scope of care. Sure they can remind the patient about their medications. 

Gaby: And if the patient is self-directing (meaning, essentially, that they have capacity), HHAs can actually remove pills from a bottle if the patient directs them to. 

Shreya: So takeaway is that HHA cannot actually take over the process of administering the medications from start to finish. Similar thing with foleys, HHA can change foley bags but cannot insert or remove the foley. 

Gaby: So what happens when your patient needs help performing a skill like administering medications or inserting foleys? 

Shreya: That’s when you consider referring the patient to skilled care.

Anne Meara: Skilled care, encompasses nursing, physical therapy, and speech therapy. But again, that’s episodic. It, uh, the goal of it is really to address a short term issue or to provide the education and skills to either the client that’s being served or their caregivers to be able to, to continue the care on a longer term basis.

Shreya: I know, I know it may sound weird hearing “client,” but that is how patients are referred to in certain training programs!  But what I took away from this was, reflecting on all the times I’ve discharged patients with a “safe” plan but don’t think I fully realized that skilled nursing services or therapy were only for just a couple of visits and not necessarily a good long-term solution for my patient. 

Gaby: Well that’s what podcasts are like this are for! So now we’ve got the who’s who down. 

  • Attendants: smallest scope of practice, handle IADLs and company
  • Aides: a little more medical training, can things like BPs and help with basic dressing changes with cavet its super dependent on where you are in the country
  • Skilled nursing and PT: for everything beyond that

Nuts & Bolts: How insurance plays a role in the delivery of home health services

Gaby: For the remainder of this episode, we are going to focus on home health aides. First question: which of our patients can actually get home health aides? And how does insurance factor into this?

Shreya: Ugh insurance! After researching this, I finally understand why the social worker – who I love – gives me a deep sigh when I ask for a HHA on rounds for say for a patient who is “older comes in for recurrent hypoglycemia from trouble eating from his esophageal CA and I think could use some help with his puree diet and groceries!” 

Gaby: Hmm – because he has Medicare, and not Medicaid?!

Shreya: Yes, you got it. I feel like I have this whole new depth of understanding of the back and forth of multidisciplinary rounds now that I know the basics of what insurance covers for home health aides. 

Gaby: And a lot less deep sighs?!

Shreya: Yes! Let’s go insurance by insurance and start with Medicare… what are home health aide options are there for your patient who has Medicare?

Anne Meara: Medicare generally covers older adults, uh, of, of the 65 years and older, uh, and younger disabled Medicare, uh, pays for what we call skilled nursing care in the home. Um, so this is episodic care. Uh, it does not pay for longterm home health care. Uh, so if somebody is leaving the hospital and requires wound care or um, ongoing, uh, but short term medication management or physical therapy, speech therapy. So it’s a pretty limited benefit. During that episode, uh, the home care agency can determine that there’s a need, for a home health aide, uh, the hours that get approved generally don’t extend beyond 20 hours a week. Once that episode of skilled nursing care ends the coverage for the home health aid ends also. 

Shreya: So that’s why so many older patients say they have a HHA for 3 hours x 6 days/weeks or 4 hours x 5 days/week. 

Gaby: The caveat here is that this stuff is always changing. To recap: With MediCARE, home health aides are provided for patients who have demonstrated a need for skilled care. This means that under Medicare, you can’t get a solo home health aide, the aide needs to come alongside skilled nursing like for IV abx, injections, wound vac care or skilled therapy. Once your patient’s skilled need ends, so does the home health aide.  

One important thing to mention – there’s a SECOND criterion. Not all Medicare patients who need skilled services are eligible for home health care.  To get covered, your patient must be considered homebound. 

Shreya:  And to that point, I think I’ve signed off many forms without fully understanding how homebound is defined by medicare. homebound doesn’t mean that the patient cant confined to the home but it’s just that they require some kind of assistance so they can still go to dialysis or to church if that’s important to them but  its considerable and taxing effort. The exact definition will be in the infographic and in our show notes.

Gaby: This is so counterintuitive! Really makes me appreciate all the social workers and case managers who are able to navigate this so deftly.

Let’s move on to MedicAID, Medicaid you usually have to meet income requirement below the federal poverty line- and so the thing to know about Medicaid, is that unlike Medicare, Medicaid actually covers home health aide for more patients for longer periods of time.

Anne Meara: Medicaid becomes the primary payer for that long-term care  in the home that are provided by home health aides.

Gaby: However, to receive long term home health services, you can’t just have plain old Medicaid…a patient has to be enrolled in a particular form of Medicaid called a managed long-term care plan which in the biz sometimes referred to as “MLTC.”

Shreya: Drop that on rounds!

Anne Meara: People now who require a long-term support services in the home are required to enroll in what’s called a managed long-term care plan. There’s an enrollment process that somebody has to go through to get into a managed long-term care plan, uh, which could take several weeks. So once a person gets into the managed long term care plan it then they are assigned an interdisciplinary care team, which includes a nurse and a social worker. Um, and that the plan will make the determination, uh, as to how many hours need to be authorized.

Gaby: Let’s recap this confusing (and also dynamic) process so far.

Your patient wants a home health aide. They’re gonna have to enroll in a special insurance long term care plan.

  • Once you have your insurance on board, you can submit a request for home health care. At that point, a Certified Home Health Agency (also known as CHHA) that evaluates the patient in the home and justifies the need for home health to the insurance plan
  • This determines whether the patient will qualify for any home care or not.  

That’s a lot of form-filling and red tape to get an aide at home. 

Shreya: A lot! Also small aside, I actually didn’t know what CHHA was! I had heard social workers say on rounds that they referred Mr. J to CHHA or read that in their notes but now it makes sense they made a referral to the certified home health agency to assess the patient’s needs.

Gaby: Have I mentioned that I’m grateful to social workers yet?

We haven’t covered all our patients – remember, Medicare is for the elderly and Medicaid is for those under a certain income (plus a few other populations e.g. pregnant folks, disabled folks). 

Which begs the question – what if a patient isn’t eligible for Medicare or Medicaid?

Anne Meara: If the person does not have Medicaid and does qualify for Medicaid, then the options become, uh, does this person have a longterm care insurance policy or can they privately pay?

Gaby: In other words – if there’s no way to get Medicaid on board, then some proactive patients have already paid into a special type of insurance called private long-term care insurance. If they don’t have the ability to do that – meaning no insurance coverage at all – your patient will have to turn to paying out of pocket to the private home health care market. 

Anne Meara: If you are going to go through a licensed agency to hire a home health aide, it would probably cost you in the neighborhood of about $28 an hour. Um, if you’re going to hire, uh, you know, through what’s called the gray market, which is people who you know, are in the community and do this work. Uh, if, you know, you might be paying something like $15 an hour. The benefit of going through a licensed agency is that the home health aide that you would be, that would be coming into your home has been, uh, you know, their background has been checked. They are required to receive certain levels of training and ongoing training. Um, they’re supervised by a nurse. Um, and in the event that that person can come today, the agency, you know, can dip into their, their staffing and supply somebody else that you have coverage.

Shreya: Ok – so the MedEd person in me thinks we should solidify all of this. Gaby, will you be play along in a little socratic method?

Gaby: I’m the only person in the room, so I think I’m obligated to say yes.

Shreya: (Shout out to Dr. Hadas Riech and Dr Irene Swanenberg for the inspiration behind this). So let’s say we have a 72 y/o who has family living on the other side of the country who has progressively worsening vision and is now deemed blind and requires 5 pills/day, and is asking for a HHA. Is it allowable by a HHA or does he require skilled home care nurse?

Gaby: A HHA sounds like a good idea. But an HHA usually can’t administer medications. If he’s self-directing and has capacity, the aide can remind him and give him pills and he can then put the meds into his mouth. 

Shreya: Great! And what if this was self-directing but the same patient’s insurance is Medicare?

Gaby: That is tricky. Remember that for Medicare  you need to meet 2 criteria: homebound and skilled need. His blindness may be considered “homebound” because he may require special assistance to leave the home. But he doesn’t have a skilling need so Medicare might not approve of a home health aide.   

Shreya: Right. So what would be the patient’s other options?

Gaby: So he can apply for some type of Medicaid long-term care plan – the caveat being that his income needs to meet criteria and it will probably take weeks. If Medicaid is not an option, he is left with privately paying for help from a home health agency or gray market. 

HHA: Pain Points

Shreya: So let’s say we jump through all the logistical hoops to get our patient a home health aide covered by insurance.

Gaby: Yay! 

Shreya: Well – yes, yay, but that’s not the end of the story.  Many of the home health aides we spoke to in preparation for this episode talked about how much they love their jobs, but they were also really honest about the struggles. I think it’s really important to openly talk about these “pain points” in our healthcare system. Dr. Sterling has done extensive research talking to many home health aides. She was surprised to learn that often, home health aides don’t know what kind of medical or psychosocial issues that are going to be on the other side of the door:

Maddie Sterling: Home care workers are actually not told what diagnosis the patient has before they’re assigned to the job, which I find fascinating and scary, um, for both the worker and the patient. So imagine walking into a home in the Bronx and you’re going to take care of somebody and you don’t know what disease they have or why you’re being assigned to them. And um, you’re then in the home trying to figure that out in that patient may be cognitively impaired. There may or may not be a family member around. Um, and some of this is because of HIPAA and older policies where that information wasn’t shared with the worker. But it’s sort of ironic because this person is now going to be involved in some of the most intimate details of this patient, bathing them, showering them, getting their meals cooked and, and actually they have no clue what disease from the get go.

Gaby: “Hidden diagnosis” feels like such a wacky way to practice any form of healthcare! 

Shreya: Agreed – some aides have told stories about arriving at patients’ homes to find they did not have lifts or other necessary equipment, suffered from dementia, or were physically or sexually aggressive. 

Gaby: That’s heavy stuff. Does the home health aide have any information on what’s going on medically with their patient?

Shreya: Sort of. If you’ve ever helped a patient initiate home health services, you might recall that clinicians are required to sign off on “ plans of care,” which have been created by a nurse who evaluates the patient in the home. These are unfortunately long documents that some insurances require to fill out but what Dr. Sterling tells us from her research is that parts of these plans get lost in translation. 

Maddie Sterling: As a primary care doctor, we’re often signing home care forms, right? These need to be the visiting nurse goes into that home when, uh, when it’s deemed that a patient has a need, skilled need, um, we as the doctor sign the form, the form that we sign isn’t very different. That care plan is very, very different in appearance in detail than the one that actually ends up in the home. Medications or their indications aren’t always on there. So if a patient has a side effect, you know, how are you supposed to know what that’s for? Why? And so it’s very interesting because the level of detail actually never makes it into the person that’s supposed to be overseeing what’s happening. So we asked in one of our studies for the aides from all different agencies across the city to bring in the care plan that they see on the refrigerator. And actually if I had to use that care plan, I would not know what to do for a patient, even with my medical background.

Shreya:  Where does this information get lost in the system? The experts – including some home health aides themselves – weren’t entirely sure. Dr. Sterling gives us her best guess:

Maddie Sterling: It could vary by agency… but often what happens is that this sort of generic, more generic sort of called care plan or plan of care ends up in the home. And so I imagine that more detailed plan is sitting at the home care agency as it should. But as you’d imagine when an aide is in the field, they don’t always have access to what’s at the agency, which may be in a different borough or different location.

Shreya: And on top of that, if the home health aide has a question or runs into a problem, sometimes they can’t hold of their nursing supervisor or someone at the agency.  This is both cited in a bunch of studies and also in the HHA say that they often have to call 3 or 4 times before they get an answer. 

Gaby: Now, even if a home health aide has access to the detailed care plan, their training isn’t standardized. Most hover at the federal requirement of ~75 hours and a lot of that focuses on more general information like infection control, transferring patients, how to deal with  harassment:

Maddie Sterling: A lack of disease specific training has been shocking to me. And more recently there have been programs to train, um, home care workers in certain conditions. I study congestive heart failure and, um, here in New York City. This is a condition where, um, home care workers are utilized frequently. Um, there really have not been formalized training programs on the disease. And so if you think about a scenario where an aide may be placed in a home and not know what condition the patient has and then they also haven’t received formal training, that could be a problem. Um, you might not be able to observe what you’re supposed to be observing, um, triage, uh, how you might, if you were trained.

Shreya: Some of HHA did say that they received training on some things like signs of hypoglycemia and stroke. On hearing this, I thought maybe some of things can be addressed during clinic visits, asking the patient if they’re okay if the HHA comes in the room too. 

Gaby: A lot of HHA say when they hear the doctor/nurse educate pt, they are also educate the HHA and he or she can then reinforce with the patient at home.

Shreya: But, one thing to keep in mind if you do bring the home health aide into the room that they  may not always feel comfortable speaking up and there could be quite a large power dynamic implicitly present in the room:

Maddie Sterling: I think what I’ve learned from the home care workforce is it’s, it’s a really vulnerable population. And so, um, you know, majority women, minorities, foreign born, um, may have erratic employment, by um, minimum wages. And so, uh, something to note is that sometimes these like family, you’ll see this in the exam room if you bring in, we, we see this all the time. You bring in a patient and you have a failing caregiver or an aide or whatever and you’re asking a patient, no, are you taking your blood pressure medicine and the AA and the patients saying like, yes, of course. And then the aide is like behind them whispers, no, but they don’t want to just, they don’t rate, they don’t want to look. They don’t want, a lot of the times we see they don’t want to have a conflict with someone who’s kind of employing them, not really employing them. It’s the agency who is. But um, you can imagine that to avoid conflict, like they’re not going to want to always go against the patient for fear of maybe losing a job. So there’s like these very delicate dynamics going on that are different from family dynamics.

Shreya: It’s PCP gold when the collateral information you need is right there in the room to help you!

Gaby: But I’m a really big fan of naming unseen/unspoken forces in the room. How to navigate that is a whole other convo for a whole other podcast episode, but at least I’m now thinking about these things and their clinical impact.

Shreya: Those power dynamics actually came up when talking with home health aides for episode. While they were happy to share information with us, they were afraid of the implications of  having their voices and names on air. And the last pain point that Dr. Sterling pointed out is that HHA don’t have agency over the continuity of care they have for patients. 

Maddie Sterling: When patients get hospitalized, it’s not guaranteed that they’re going to go home and get the same caregiver they had before.

Shreya: for this reason, some home health aides feel like they are interchangeable, low-skilled employees, rather than essential members of the care team.  From a logistical level, it’s understandable – depending on the duration of the patient’s hospitalization, an aide may be without work for days or weeks while waiting for their patient to leave the hospital. 

Gaby: But continuity of care perspective, I can imagine that knowing and working with a patient for a long period of time means the home health aide to pick up on subtle important changes, especially in a patient with, say, cognitive impairment.

HHA “Pearls for better collaboration”

Gaby: There are still some kinks to work out to allow us to optimize the environment in which we deliver home health to our patients. But there’s hope! Let’s close this episode by giving you a few “pearls” so that we can all better collaborate with our home health aides.

The first pearl? Education. You’ve already done some work towards that goal by listening to this podcast (hopefully). But don’t just educate yourself…educate your front desk staff, educate the other members of your practice…and educate your patients! Because they may not actually know what kind of a role home health aides can play in their care.

Anne Meara: There is a knowledge gap … because of the knowledge gap and you know, because of the pressures that people are under when they’re operating, uh, you know, providing care in the community, sometimes the conversations just don’t happen. Being able to explain the kinds of things that a home health aide or, or help in the home could provide. 

Gaby: Anne also reminds us to be proactive when considering whether a patient may need these services:

Anne Meara: To actually become enrolled in a managed longterm care plan, it could take several weeks, um, you know, four to six weeks, somebody has to come and do an assessment. Really be sort of anticipating, uh, in advance, you know, sort of be thinking about these things proactively. Somebody’s functional status is declining if their cognitive status is declining. If you can see the stress that family members who might be bringing, you know, their, their mother, their father or their, their family member in for services. 

Gaby: I acknowledge, this is so much more easily said than done, which is why Anne highlights the importance of leaning on our interprofessional colleagues who might be able to do some of this lifting alongside us. And I think one of the most valuable pieces of advice Dr. Sterling gave was simply to remember the fact that our patients are not islands – they probably have people supporting them at home:

Maddie Sterling: I think the first step for any clinician would be to simply acknowledge the fact that there are probably a number of people in the home that are helping the patient, um, whether that’s with personal care or medically oriented care and, and just ask them and it take the time. It’s a simple question that could be incorporated into the social history. You know, who is, who is helping you at home. Um, is there anyone that helps you get your medications? Is there anyone that it brought you here today? Um, is there someone I should bring into the exam room?

Gaby: Of course – when you do get that home health aide in the room, make sure to check in with them to see what additional perspective they might be able to provide.

Anne Meara: These are people, uh, once they are in place who are with this person all the time, every day, you know, able to pick up on, uh, you know, cognitive decline, functional decline, uh, depression, uh, non-adherence to the care plan. Um, you know, and I, I don’t know how often that treasure trove of information has really tapped into.

Shreya: Yes, treasure troves of information. To  round out the episode, it seems like medical world and home health world operate in silos that  rarely interact in a meaningful way which is to everyone’s disadvantage. Bridging these worlds is complicated and involves spending time (everyone’s most precious resource during the day), and a thoughtful system has yet to help the two worlds collaborate. There are no silver bullets, and we won’t solve these long-standing issues on our podcast today, but recognize that similar to patient care, the better we ‘handoff’ patients to home care and similarly create a communication channel to homecare back to us, the better the system will work for patients. And lastly: this is a team sport. Lets work to better communicate and leverage our interprofessional team.


References

 

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