Description

The Visiting Nurse Service of New York (VNSNY) used the breakthrough collaborative model developed by the Institute for Healthcare Improvement (IHI) to foster a better understanding of the role of home health aides (HHAs) in the delivery of care and to engage HHAs in identifying and disseminating related best practices and new approaches. The initiative -the Home Health Aide Partnering Collaborative- involved working intensively with a small number of high-performing teams.

Sponsoring Organization

VNSNY, a New York City-based organization with a long history of addressing the needs of direct-care workers, is the largest freestanding not-for-profit provider of home health care in the United States. Its other HHA job improvement initiatives include a 2004 agreement to bring thousands of HHAs to a $10-per-hour starting wage by 2007, provision of pension benefits and health insurance with family coverage at no cost to those employed by Partners in Care, and opportunities for advanced skill training accompanied by related wage increases.

Setting

VNSNY delivers the entire range of home health care services including nursing care, rehabilitation therapy, nutrition counseling, social work services, and allied professional services as well as home health aide, home attendant, and housekeeping services. These services are provided through a range of short-and long-term care and specialty programs. VNSNY serves the greater New York City area including Manhattan, Bronx, Brooklyn, Queens, Staten Island, Nassau County and Westchester County. VNSNY caregivers see an average of 25,000 patients each day. To provide these services, VNSNY contracts with a number of home health agencies.

Target Group

The HHA Partnering Collaborative and a number of earlier related initiatives have focused on the role of HHAs, nurses and other members of the service delivery team in providing quality patient care and addressing related challenges. Partners In Care, a licensed agency that is a for-profit subsidiary of VNSNY, employs over 4,000 HHAs. Home health aide service is also provided on behalf of VNSNY by HHAs employed by several outside licensed home care service agency 'partners.'

Start Date

June 2003

Objectives

Objectives of the HHA Partnering Collaborative are:

• To optimize the role of the home health aide as a member of the VNSNY care team.
  
• To improve patients' functional independence and self-management capabilities.
  
• To improve field support of HHAs.
  
• To facilitate partnering between licensed agencies that supply VNSNY with paraprofessionals.
  
• To increase the satisfaction of patients, HHAs, and other direct-care staff.

Key Components

Collaboration The collaborative was launched with the help of a panel of experts, who identified challenges and discussed solutions. They included representatives from three licensed home health agencies and seven acute and congregate care teams. Participants included HHAs, nurses, rehabilitation specialists, managers, and senior leaders from VNSNY and licensed agencies.

About 20 VNSNY clinical directors and quality-management staff acted as collaborative leaders, or faculty. Teams varied in the number of members, with at least three HHAs serving on each.

A structured approach The learning collaborative followed the 'plan, do, study, act' model set out by IHI. An initial learning session for VNSNY and licensed agency staff set the stage, teaching participants about a rapid-cycle approach to quality improvement. Two subsequent learning sessions allowed teams to share data gathered during action periods. HHAs and other team members had opportunities to voice their concerns and opinions and to present data in these highly interactive sessions. During action periods, team members used conference calls, e-mails, and listservs to enhance communication.

A relatively short period of intensive focus on change
The HHA Partnering Collaborative ran from June 2003 through May 2004. During this time, teams tested ways to make HHAs integral players on the care team. 'Change concepts' were identified, implemented, and tested. During these 12 months, HHAs also received special training for diabetes and other conditions.

Together, the teams considered ways to address four key themes related to the initiative's objectives:

• How to better match workforce to patient needs
  
• How to improve field support for HHAs
  
• How to increase functional health care
  
• How to bolster patients' self-management skills.

Results, Outcomes, Evaluation

VNSNY has not released a formal report on the findings of the collaborative, although the U.S. Department of Health and Human Services' Office of the Assistant Secretary for Planning and Evaluation has indicated its intent to grant VNSNY a contract to conduct an evaluation.

In the meantime, VNSNY has reported several preliminary findings. A pilot test of a tool created to document progress in activities of daily living (ADLs) over a four-week period with 114 patients demonstrated a decrease in the degree of assistance and support HHAs provided to patients in the activities of bathing, ambulation, and transferring. These results were correlated on those patients' aggregate functional status scores, as measured by the OASIS assessment instrument. Improvement in all three ADL areas between two assessment time points during which the ADL tool was used indicated a decrease in patient dependence. There was an increase in HHA satisfaction, with a greater percentage of the participating HHAs strongly agreeing that they were treated as members of the care team (59 percent after participation in the collaboration, compared to 45 percent before.) In addition, the percent of participating HHAs who strongly agreed that their opinions were heard and appreciated by team members rose from 45 percent to 65 percent over the course of six months. Another significant finding was the percent of professional staff who strongly agreed that the primary partnering licensed agency was responsive to services concerns and issues, which increased from 69 percent to 97 percent.

VNSNY is working to disseminate some of the practices that proved helpful during the collaborative. These include the adoption of a communications tool called 'The Five Promises,' which guides HHA and supervising clinicians through essential steps in communicating upon entering a patient's home. VNSNY is also disseminating the ADL forms, which double as coaching tools for HHAs who want additional guidance from their supervisors.

Lessons Learned

Though the collaborative has led to gains in HHA satisfaction and care outcomes, it has also underscored the complexity of the problems facing the nation's largest home health care provider, according to a collaborative co-director. The broad challenge remaining is how VNSNY can best meet the sometimes conflicting scheduling and staffing needs of the many licensed agencies it contracts with while delivering care seamlessly to patients.

As it works toward that goal, VNSNY will continue to eye its success in continuity of scheduling for HHAs (that is, assigning an aide to a certain team or group of teams so he or she gets to know visiting nurses and patients), scheduling HHAs for a consistent number of hours each week, and improving overall team and HHA satisfaction.

Costs and Funding

VNSNY funded collaborative planning, learning session planning, coordination and delivery as well as faculty support and staff participation. Each licensed agency involved funded the participation of its own administrative and supervisory staff. A Health Workforce Retraining Initiative grant from the New York State Department of Health supported the participation of HHAs.

Contact Information

Sally Sobolewski
Director of practice improvement and collaborative co-director
107 East 70th Street
New York, NY 10021

t: 888-867-1225
Website: www.vnsny.org

Other Resources

For more information on the Breakthrough Collaborative Model, contact:
Institute for Healthcare Improvement
375 Longwood Avenue, 4th Floor
Boston, MA 02215 USA
Phone: (617) 754-4800
Fax: (617) 754-4848
www.ihi.org