Millions of older Americans have a home health aide (HHA) come into their home on a daily basis to assist with essential activities such as bathing, dressing and preparing meals, and to help keep them connected in their communities. But what if that HHA is also trained to check on any changes in her client's medical condition, and uses a pre-programmed computer tablet that automatically notifies a clinical manager whenever a change occurs? And what if that same HHA goes over all prescribed medications with the client as well, makes sure doctors' appointments are scheduled and kept, and works with the client and their home care agency to identify effective alternatives to the hospital emergency room, should pain or other worrisome symptoms suddenly arise? That's exactly what's been happening these days where I work.
A recently concluded pilot program trained HHAs to do exactly these things for their managed care clients -- and it found that this additional training significantly improved these clients' health outcomes. The 18-month study, funded by a $1.9 million grant from New York State's Department of Health, was implemented by the Bronx-based Paraprofessional Healthcare Institute (PHI) in collaboration with Independence Care System (ICS), a New York City-based nonprofit that coordinates home-based care for seniors and people with disabilities, as well as three local home care agencies. The study tracked 1,100 home care clients who were cared for by HHAs with advanced training, and found that this group had 24% fewer visits to the emergency room compared to those clients whose HHAs did not receive advanced training.
This is exciting news for those of us in the home care industry who believe that expanding the skill sets of our nation's HHAs is one of the keys to helping America's growing population of seniors age in place successfully. Since HHAs are in their clients' homes for multiple hours each day, they can play a critical role in protecting clients' health -- provided we give them the right tools. Last year, for example, I described in this column how my own organization, Visiting Nurse Service of New York (VNSNY), is training our HHAs to serve as health coaches so they can help their clients adopt better diets and healthier lifestyles. We've also developed specialized HHA training programs in rehabilitation support and hospice care.
The recent PHI pilot pioneered several other important innovations designed to help empower HHAs and expand their skill sets. Perhaps the most important of these was the creation of a new, salaried "senior aide" position. Senior aides are experienced home health aides who in the pilot program received extensive education that prepared them to coach other HHAs to carry out medication review, physician appointment oversight and symptom monitoring with clients in the home. The senior aides then served as an ongoing resource for the HHAs in case they had questions or ran into difficulties carrying out these tasks -- a role that included mediated any issues that might arise between the HHA and the client.
"One of the chief goals of the pilot was to demonstrate the value of this new senior aide position," says Sara Joffe, PHI's Vice President for Organizational Learning, who oversaw the study. "Besides the value of senior aides as trainers, we found from interviewing HHAs in the field that they were much more comfortable sharing their problems with their supervising senior aide, as opposed to an agency manager, because they saw the senior aides as peers rather than agency superiors. The quality of compassion we saw in these senior aides was absolutely remarkable. They truly were on everybody's side."
The computer tablets used by the HHAs in the pilot program are another interesting innovation. The tablets' software, developed by the firm Practice Unite, employs a simple and highly effective approach: Near the start of each day's visit, the HHA uses the tablet to tick through 12 "yes-no" questions related to the client's primary medical conditions, all intended to detect any changes in health status -- whether any skin breakdown has occurred, for example, or whether the client is experiencing increased fatigue or confusion. If one or more "yes" answers are recorded, the tablet sends an automatic alert to a clinical manager at the HHA's agency, who then contacts a physician or other clinician -- enabling emerging health problems to be caught as early as possible, before they result in an emergency.
"The tablets included a function that lets the HHA directly phone or text their clinical manager if they felt a need to elaborate on the 'yes-no' questions," adds Joffe. "This was very important in terms of the study -- the fact that HHAs had the capacity to quickly get someone's attention."
The pilot was also able to reduce clients' reliance on the ER for relatively minor complaints, by bringing senior aides together with the HHAs and their clients to talk through various scenarios that might have triggered a trip to the ER in the past. "For instance, an HHA may say 'We go to the hospital a lot,' and the senior aide will then suggest trying a local urgent care center or clinic instead," says Joffe. "Afterwards, we've had clients tell us, 'I don't know why I was using the ER before.' Simply being able to discuss the matter with the senior aide allowed HHAs and their clients to change their paradigm."
On the heels of the PHI pilot, the concept of a senior aide position -- including how this new category of employees might be paid for -- is now getting a serious look from home care organizations. At the same time, other approaches to expanding the role of HHAs are being actively explored across the U.S. In New York, for example, a Medicaid workgroup has proposed that HHAs be allowed to take on additional responsibilities under a nurse's supervision, including administering routine medications. New Jersey has carried out a demonstration program testing a similar option. In addition, the federal Centers for Medicare and Medicaid Services (CMS) has funded pilot programs that are providing enhanced training for HHAs in Arkansas and training HHAs in California to serve as health monitors, coaches and navigators.
Besides their direct impact on the health of home care customers, these advanced HHA training initiatives have another important potential benefit: By offering an enhanced career path for our nation's one million HHAs, they should help reduce turnover, enabling home care agencies to retain our most experienced HHAs as a vital resource. That, together with the increasing embrace of advanced training for the nation's home health aide workforce, adds up to a major win for the well-being of older Americans.