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Advanced Training for Home Health Aides Is Changing the Way Americans Age in Place

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When Mary, a longtime home health aide, was asked to fill in for one of her colleagues recently, she found that her new client wasn't even attempting to follow the vegetable-rich diet prescribed by her physician. "I began digging deeper to find out why she wasn't eating in a healthier way," Mary recalls. "When she told me she didn't really know how to prepare vegetables in a way she liked, I offered to cook some dishes for her. She ended up loving them, and today her entire diet has changed for the better!"

Mary's story reflects the expanding role of home health aides (HHAs) today. While their responsibilities have traditionally entailed helping clients with daily activities such as bathing and dressing, maintaining a safe, clean household and shopping for groceries, they are becoming increasingly involved in hands-on health care, as well. In Mary's case, she has benefited from a program offered by my organization, Visiting Nurse Service of New York, that trains HHAs to act as "health coaches." The program, supported by a grant from New York State, teaches HHAs with Partners in Care, our private-pay division, how to motivate clients to eat better, stop smoking, take their medications as prescribed, and follow other healthy behaviors.

These types of programs reflect a growing realization that HHAs have the potential to be one of America's most valuable health care resources. As America's baby boom generation reaches retirement age, there is an increasing need for support systems that enable elderly individuals to live safely and comfortably in their own homes. Effective home health care is often a key part of "aging in place" successfully -- and for many clients, an HHA is an essential member of their home health care team. Because HHAs are typically in their clients' homes several days a week for hours at a time, they are also uniquely attuned to their patients' day-to-day health status.

Health care experts are now connecting these dots, and looking for ways to take advantage of this close relationship by having HHAs become directly involved in supporting clients' medical plan of care. While this doesn't mean the kind of clinical medical care provided by a nurse, it does mean coaching and support for the plan designed by a physician and supervised by a nurse. This evolutionary step is dramatically moving the HHA away from just being an observer and custodial companion.

In their health coach training, our HHAs learn to use a powerful technique called "motivational interviewing" to help patients manage chronic medical conditions or make important lifestyle changes. "Our aides don't tell clients what to do. Instead we teach them to offer suggestions and ask questions, digging down into what might be stopping clients from doing what they're supposed to do," says Sheniqua Johnson, RN, who runs the health coach training program for Partners in Care. "A coach might say, 'I know you're not eating the right things, but why do you think that is? Is it a financial issue, or what you're used to eating?' Once we understand what the issue is, we can begin to address it."

Several hundred of our HHAs have now gone through Sheniqua's one-week health coach training course. Other tools they learn include reflecting back what the client is saying, having the client summarize the key points of the conversation, and providing regular affirmations -- or "pats on the back" -- for a job well done. To guide these discussions, the HHAs are also taught about specific diseases and their effects on the body. As Sheniqua explains, this coaching is all aimed at enhancing the clients' own self-efficacy. "They're at the center of everything. We want to empower our clients, and make them want to do the right thing."

At VNSNY, we are also training HHAs to assist clients in carrying out physical therapy protocols, and training them as hospice aides who provide specialized care to the terminally ill. In addition, we are beginning to actively evaluate the benefits of these new HHA roles -- an important step toward gaining widespread acceptance for this approach. For example, we recently teamed with NYU Langone Medical Center on a six-month evaluation project to see whether HHA health coaching can help patients with congestive heart failure (CHF) do a better job of managing their condition in a home setting. A number of our HHAs provided coaching to 40 (CHF) patients who were treated at NYU Langone for acute symptoms and then discharged home. Each patient had five sessions with their HHA health coach, in which they were encouraged to take their medications as prescribed, weight themselves daily, and follow a low-sodium diet. The study then compared the outcomes of these patients to another group of heart failure patients who went home with standard physician and nursing care, but no additional health coaching.

"While both groups had similar hospital readmission rates, those who received health coaching from HHAs went longer before readmission on average, and also showed significant improvements in their overall symptom management," reports Senior Evaluation Scientist David Russell, VNSNY's lead evaluator on the project. NYU Langone staff provided very positive feedback on the initiative as well. "It's clearly an approach that merits further study," noted David.

Just as important, our HHAs are finding their new roles both satisfying and empowering. "Our HHAs come out of my course very excited with the skills they've learned," says Sheniqua. "They enjoy the chance to do something different, and welcome the chance to advance their careers. Some are so engaged that they go on to become nurses or social workers, and some already have advanced degrees that they've earned in other countries. We're seeing a new kind of HHA workforce take shape and it operates with a new level of sophistication and pride in the important role it fills in our changing health care system."

Even when our HHAs aren't officially employed as health coaches, we encourage them to use their coaching skills with the clients they serve. As Jennifer Leeflang, head of our Partners in Care division, notes, "Health coaching is a wonderful and cost-effective way to reinforce and build on the information that clients receive from their doctors and nurses. One of the most important takeaways from our HHA health coaching initiative is that it's helping so many of our patients feel more confident about managing their health and keeping their symptoms under control. That's one of our main goals in home health care -- to enhance our clients' ability to carry out self-care -- so there's a real value there."