U.S. Department of Health and Human Services

The Home Health Aide Partnering Collaborative: Implementation Manual

Miriam Ryvicker, Ph.D., Theresa Schwartz, B.A., Sally Sobolewski, M.S.N., Terese Acampora, M.A., R.N., Marki Flannery, M.A., Elizabeth Buff, R.N., B.S.N., M.S., Ann Marie Hess, M.S.N., M.S., Robert Rosati, Ph.D., and Penny Feldman, Ph.D.

Visiting Nurse Service of New York
Center for Home Care Policy and Research

August 2007

PDF Version: http://aspe.hhs.gov/daltcp/reports/2007/HHAPartmnl.pdf (74 PDF pages)

This report was prepared under contract #HHSP23320044304EC between the U.S. Department of Health and the Center for Home Care Policy and Research. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Marie Squillace, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail address is: Marie.Squillace@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

TABLE OF CONTENTS

ACKNOWLEDGEMENTS

ABOUT THIS MANUAL

FOR SENIOR LEADERS

Introduction to the Home Health Aide Partnering Collaborative

FOR MANAGERS IMPLEMENTING THE COLLABORATIVE

Why We Need to Improve Teamwork in Home Health Care

How a Collaborative Works

Overview of Collaborative Goals and Strategies

The Importance of Gaining Buy-In

Using the PDSA Cycle to Set Goals, Test Changes, and Adapt Ideas

Goal 1: Improving Support to Home Health Aides

Goal 2: Improving Patients' Functional Independence

FOR SENIOR LEADERS AND MANAGERS

Celebrating Success and Planning for Spread

Sustaining the Gains

NOTES

LIST OF FIGURES

FIGURE 1: Who Participates

FIGURE 2: Learning Collaborative Model

FIGURE 3: PDSA Cycle

FIGURE 4: Percentage of Patients Showing Improvement in Bathing at Discharge

FIGURE 5: Tests of Change

LIST OF EXHIBITS

HHA Job Perceptions Survey

Clinician Survey

Items for Measuring Patients' Functional Outcomes

Nurse-Aide Interaction: The “Five Promises”

Paraprofessional Manager Tool for Partnering Collaborative Conference Calls

Paraprofessional Manager Tool for Partnering Collaborative Team Meetings

Activities of Daily Living (ADL) Tool

"What I Can Do for Myself" Tool

Role-Play Script for Introducing the Functional Improvement Tool

HHA Partnering Collaborative: Tasks and Timeline

ACKNOWLEDGEMENTS

Many individuals and organizations contributed to the development of the Home Health Aide (HHA) Partnering Collaborative and this Implementation Manual.

The HHA Partnering Collaborative adapted the Breakthrough Series model of collaborative learning developed by the Institute for Healthcare Improvement (IHI), including the “Plan, Do, Study, Act” methodology developed by Associates in Process Improvement.

Under the guidance of Sally Sobolewski and several of the manual’s co-authors, the Collaborative Faculty at the Visiting Nurse Service of New York (VNSNY) -- comprised of clinical directors, quality improvement (QI) specialists, and administrators -- worked with managers and field staff throughout the agency to develop the tools and strategies presented in this manual.

The Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services, funded an evaluation of the HHA Partnering Collaborative developed and implemented at VNSNY (Contract No. HHSP23320044304EC). The development of this manual was funded by ASPE as a product of the evaluation. As the federal project officer for the project, Marie Squillace provided direction to and feedback on drafts of the manual as it developed.

Several individuals reviewed a draft of the manual and provided valuable feedback that informed the final set of revisions. The reviewers were: Donna Locurto (Visiting Nurse Association of America), Laura Peterson (independent health care consulting practice), Adele Pike (Visiting Nurse Association of Boston), Maureen Schnider (Partners Home Care in Boston, Massachusetts), Vicky Agramonte and Christine Stegel (both from IPRO, New York State’s QI Organization). 

ABOUT THIS MANUAL

The HHA Partnering Collaborative is a quality improvement (QI) project developed and implemented at the Visiting Nurse Service of New York. The primary purpose of the Collaborative was to enhance the quality of work life for home health aides while improving outcomes for home health patients. This Implementation Manual emerged out of the lessons learned from an evaluation of the agency-wide spread of the Collaborative’s tools and strategies. For more information on the results of the evaluation, see “HHA Partnering Collaborative Evaluation: Practice/Research Brief” at http://aspe.hhs.gov/daltcp/reports/2007/HHAPartrb.htm.

The beginning of the manual includes an introduction to the Collaborative’s framework, goals, and methods, geared specifically toward senior leaders in home health agencies, QI organizations, or other settings who wish to adapt the Collaborative’s methods and strategies.

The remaining sections of the manual are geared primarily toward managers and other key personnel responsible for implementing the Collaborative within their organizations. These sections describe the purpose of the Collaborative, offer guidelines for implementing and testing the Collaborative’s strategies, and provide instructions for carrying out tests of change in the context of this intervention.

The final two sections -- "Celebrating Success and Planning for Spread” and “Sustaining the Gains” -- offer suggestions and resources of use to both managers implementing the Collaborative and senior leaders in home health agencies.

In addition to adopting and adapting the tools presented here, we encourage senior leaders and managers to use any language from the manual that may be helpful for presentations, project materials, and Collaborative activities.

INTRODUCTION TO THE HOME HEALTH AIDE PARTNERING COLLABORATIVE

As leaders in home health care, you almost certainly have grappled with the question of how to get everyone -- patients, nurses, home health aides (HHAs), family members, and therapists -- to work together toward common goals. You probably also have found that, given the complexity of home health services, this is not easy to achieve. The overarching goal of the Home Health Aide (HHA) Partnering Collaborative is to foster positive relationships among patients, families, HHAs, nurses, and other home care clinicians to create an effective care team that works together toward patients’ well-being. In particular, the HHA Partnering Collaborative aims to create opportunities for both patients and HHAs to become more actively involved in managing the patient’s care and moving the patient toward greater independence.

You may ask -- how realistic is it to expect that increasing collaboration among HHAs, clinicians and patients will actually lead to measurable improvements in patient outcomes? Two prominent researchers from Yale University found that when clinicians and aides worked with their patients to establish and track functional health goals that were meaningful to the patient, there was a significant, measurable improvement in patients’ functional outcomes, along with a significant reduction in patient hospitalizations.¹

Moreover, an evaluation of the HHA Partnering Collaborative implemented at the Visiting Nurse Service of New York (VNSNY) found that a similar approach yielded a significant improvement in two of three targeted activities of daily living (ADLs) -- transferring and ambulation. The impact was strongest in transferring, where the randomized trial conducted at VNSNY showed that 61% of patients in the intervention group experienced improvement from the start of care to discharge, compared to only 53% in the control group. Smaller, though statistically significant, differences were also found in ambulation.²

An emerging body of literature, including the two home care studies described above, provides evidence that collaboration improves the quality of patients’ care and the quality of employees’ work life. This manual offers strategies for achieving a “healthy work organization.” A healthy workplace is defined as one that integrates the goals of performance improvement with the goal of promoting employee health and well-being.³ Such an organization is one that will employ established principles of quality improvement (QI) to integrate professional and paraprofessional services, establish effective cross-disciplinary learning, and yield positive changes in employee, organizational, and patient outcomes.

Promoting Culture Change and Workforce Sustainability

The HHA Partnering Collaborative addresses two key issues that hinder the capacity of home health providers to deliver the best possible care. First, the Collaborative serves as a catalyst for change in the culture of health services, moving away from a purely professional model of care and toward self-care management. In the traditional, professional model of health services, patients, family members, and paraprofessionals have limited roles in decision-making about important aspects of a patient’s care. Typically, patients are seen as care “recipients,” and HHAs as “unskilled” workers who “do for” the patient. The self-care management model is centered on patients and informal caregivers as active participants in decision-making and goal-setting, with HHAs playing a key supportive role. The tools introduced in the HHA Partnering Collaborative manual provide an opportunity for moving toward a self-care management model of home health services.

Secondly, the Collaborative offers useful strategies for improving the sustainability of the paraprofessional workforce. In the United States, over 600,000 HHAs provide supportive services and personal assistance to patients receiving home health care. Although aide services are essential to the health and well-being of home care patients who receive them, the nurses and therapists who comprise the professional home care workforce all too often treat HHAs as “unskilled” workers with little potential to enhance the overall effectiveness of patient care. The devaluing of aide services has, in turn, been cited as a contributor to aide dissatisfaction, aide turnover and less than optimal patient outcomes. The HHA Partnering Collaborative addresses growing public interest in strategies to develop the capacity of the aide workforce and better integrate these paraprofessionals into care delivery.

What Is a Collaborative?

The HHA Partnering Collaborative adapts the Institute for Healthcare Improvement (IHI) Breakthrough Series model of collaborative learning.⁴ In this model, organizations convene a core team that commits to making continuous and measurable improvement toward a specific goal. The team utilizes the Plan, Do, Study, Act (PDSA) Cycle to make rapid, testable changes that inform each step in the improvement process. Health care providers in a wide range of organizational settings throughout the United States -- including hospitals, home care agencies, primary care practices, nursing homes, and community-based health centers -- have employed the collaborative model and PDSA Cycle to achieve improvement in a variety of areas. These areas include disease-specific clinical practices, patient safety, access to care, efficiency of care, and other organizational issues. (See IHI, 2003, for a “sampler” of Breakthrough Series Collaboratives and their results.)

Depending on the changes being sought, collaborative teams have been constituted in multiple ways, drawing on participants from across different disciplines, provider settings, and sectors within the health care industry. For example, a collaborative may consist of: clinicians from different disciplines within a hospital; staff from eight home care agencies within a geographic region; or personnel coming together from primary care practices, a local hospital, a home care agency, and a community health center.

The Structure of this Collaborative

The HHA Partnering Collaborative brings together HHAs, nurses, therapists and patients to improve teamwork toward common goals that promote patients’ well-being. Since the integration of paraprofessional and professional services is a key element of this collaborative, the leadership team consists of personnel who manage both aspects of home health services. In some smaller agencies, managers may be responsible for coordinating the services of HHAs and clinicians simultaneously, whereas larger agencies may rely on separate divisions for managing the two, or they may contract with external agencies for paraprofessional services. Whatever the size or structure of your agency, the tools and strategies of the HHA Partnering Collaborative can be adapted to promote teamwork among all members of the home care team.

Your collaborative may be organized in a variety of ways. You may choose to launch your own internal collaborative, engaging multiple teams or branches within your agency. Alternatively, you may choose to collaborate with leaders of other agencies within your geographic region, or to work with your state’s QI Organization as part of a wide-scale effort. Working across organizations may be valuable for pooling resources and sharing ideas to promote large-scale change in a cost-effective manner.

The Importance of Buy-In

As in any performance improvement project, change does not happen overnight. As senior leaders, make sure that you provide full support to the project. The more fully you integrate the change objective into the organization’s overall goals and strategies, the more effective the Collaborative will be. This includes not only verbal support and endorsement, but also a commitment to protecting the project’s resources and staffing needs when other pressing priorities arise within the agency. If you have quantifiable measures that you use for performance more broadly, integrating the Collaborative’s measures into that broader set of performance goals can be another powerful indicator of your support.

Moreover, the active participation of field staff and patients throughout the entire change process is key to a successful Collaborative. The PDSA Cycle is integral to this process, as it allows you to gain ongoing feedback from those on the front-line. This is your key to adapting the Collaborative’s tools and strategies to best suit the needs of your agency and to gaining buy-in from staff members and patients alike. To guide you through this, we have included a set of tips in each section of this manual to address issues you might encounter related to buy-in. As leaders, the more you listen and adapt to the needs of staff members and patients, the better your chances for creating positive, wide-spread, and sustainable change. More tips on gaining buy-in are included in Setting Aims and Defining Strategies.

What You Will Need to Implement This Collaborative

A successful Collaborative involves the full participation of individuals from a range of disciplines and with a variety of roles throughout your organization. As you begin the initiative, you will need to convene a core Collaborative Leadership group who will provide support and guidance throughout the project. This group includes:

• A designated chair (or two co-chairs) of the Collaborative responsible for coaching participants and providing ongoing leadership and support.

• A planning group, consisting of 2-5 individuals who will share the responsibility of planning Collaborative meetings and events.

• Senior leaders in your organization.

• QI specialists, staff education personnel, and/or expert consultants, if available.

Make sure you have the support of senior leaders in your organization (e.g., the chief operating officer) who can authorize the allocation of time and resources to the project. The Collaborative chair will need to dedicate time to lead the team in preparing “Learning Sessions” (described in later sections), reviewing data, and guiding the team through multiple tests of change. Generally, the chair should be able to commit about 12-16 hours per week during the first few months of the Collaborative and then gradually decrease his or her time commitment to about two days per month after the sixth month. Each member of the planning group should be able to commit roughly two days per month to the project, with the greatest time commitment in the beginning of the project.

If your agency has dedicated QI specialists or staff education personnel, their technical support may be valuable throughout the project. Or, if resources allow, you may wish to hire an external consultant who can provide guidance and expertise in QI methods related to the project’s goals. You may also choose to allocate some time for an administrative assistant to provide support, including scheduling meetings, creating and copying forms, tabulating data, and creating data displays.

The Collaborative Leadership is at the core of the larger Collaborative Team, which includes clinicians, HHAs, and field managers who can serve as champions of the project and motivate change throughout your organization. All members of the Team will need to devote 6-15 months to the project. Although members of the team may play different roles, it is important that everyone is able to follow the project through to facilitate collaborative learning. The Collaborative will rely on the backing of senior leaders in adjusting the workload expectations of team members, as well as participating field staff who will not always be involved but will devote time to carrying out tests of change. (For an illustration of who is involved in the Collaborative, see Figure 1.)

Finally, you will need to ensure a mechanism for collecting data and feeding back results to team members and field staff who carry out tests of change on the front-line. Reporting back results to front-line staff in an efficient, “real-time” fashion is key to motivating and sustaining improvement. If such an infrastructure is not already in place, senior leaders should make sure that the team has access to the technical expertise of a QI specialist or consultant who can guide team members in developing a feasible mechanism for data collection and reporting.

A high-level task list for the HHA Partnering Collaborative, including a suggested schedule for the project, is shown as "HHA Partnering Collaborative: Tasks and Timeline." See illustration of the IHI’s Learning Collaborative model (Figure 2).

You may also find these references helpful for background on the Learning Collaborative model, the PDSA Cycle, and other aspects of performance improvement:

• http://www.ihi.org.

• Langley, G.J., Nolan K.M., Nolan T.W., Norman, C.L., Provost, L.P. (1996). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers.

• IHI (2003). The Breakthrough Series. IHI's Collaborative Model for Achieving Breakthrough Improvement. Available at http://www.ihi.org.

• Plsek, P. (2000). Spreading Good Ideas for Better Healthcare: A Practical Toolkit. VHA.

WHY WE NEED TO IMPROVE TEAMWORK IN HOME HEALTH CARE

HHAs play a vital role in the care, therapy, and well-being of home care patients. They work within a service delivery team consisting of nurses, therapists and other professionals, and are typically in the patient’s home on a more frequent basis than other members of the team. HHAs act as clinicians’ “eyes and ears” in evaluating patients’ progress. However, all too often aide services are not well integrated into the home care team, creating barriers to aide job satisfaction, aide retention, and improvement in patient outcomes.

Enhancing teamwork in home health services is important for aides’ quality of work life, as well as patient satisfaction and well-being. The following scenarios illustrate some of the dilemmas that arise without a well integrated home care team.

Do these scenarios sound familiar?

All of these situations could have turned out better with positive communication, support, and common understandings among all members of the home care team.

In this manual you will find a guide to adopting and adapting the tools and practices of the HHA Partnering Collaborative, which was developed by and implemented at the VNSNY. The HHA Partnering Collaborative provides tools and strategies for addressing the issues depicted in the scenes above. Through this effort, your agency can work to improve teamwork so that…

• patients are supported in setting goals and moving toward greater independence;
• aides become valued members of the team;
• clinicians are prepared to work effectively with everyone involved in the patient's care;
• patients, aides, family members, and clinicians all feel that their voices are heard.

HOW A COLLABORATIVE WORKS

The HHA Partnering Collaborative adapts the IHI Breakthrough Series model of collaborative learning.⁵ The purpose of a Collaborative is to go beyond traditional educational approaches in order to accelerate improvement. IHI’s model provides a structure for learning and action that enables participants to jumpstart improvement by making real, ongoing changes on the front-line.

A successful Collaborative involves the full participation of individuals from a range of disciplines and with a variety of roles throughout your organization. A group of leaders is responsible for developing a framework for change, planning Collaborative meetings and events, and providing ongoing support and guidance to everyone involved in the project. The Collaborative Leadership consists of a designated chair and planning group, senior leaders in your organization, QI or staff education specialists, and, at times, expert consultants. The leadership is at the core of the larger Collaborative Team, which includes clinicians, HHAs, and field managers of both clinical and paraprofessional services who serve as champions of the project and motivate change throughout your organization. The Collaborative Team brings together individuals who can authorize the allocation of resources and staff time to the project, offer clinical and technical expertise, and provide day-to-day leadership.⁶

In forming the team, be sure to involve field staff and managers who can serve as champions of the Collaborative. Try to identify individuals who are:

• Opinion-leaders among their peers.

• Willing to take risks in promoting new ideas.

• Able to commit to the project for a period of 6-15 months.

With the guidance of the Collaborative leaders, team members commit to making continuous and measurable changes toward a well-defined goal. When planning for specific tests of change, the Collaborative Team also recruits volunteers among the field staff to carry out the tests and provide feedback on their experiences with the Collaborative strategies when implemented on the front-line. Although these volunteers are not formally members of the Collaborative Team, their participation and input are integral to the improvement process. Be sure to recruit willing volunteers who are already motivated to make changes.

Who Participates in the Collaborative?

The figure below illustrates the different groups that comprise the Collaborative. Clinicians’ and HHAs’ full participation -- both as members of the Collaborative Team and as volunteers who implement specific tests of change -- is key to a successful Collaborative.

FIGURE 1: Who Participates

The Timeline for Learning and Action

Underlying every successful Collaborative is a clear problem statement, a framework for addressing it, a measurement strategy, and evidence that helps identify relevant change strategies. This is why many organizations consult with an outside organization like IHI, work with an expert consultant, or join with other providers in order to do this “pre-work” for their Collaboratives.⁷ In this manual, we provide a general framework outlining goals and strategies that can serve as a starting point for your improvement project.

With a framework already established, the Collaborative Team alternates between “Learning Sessions” and “Action Periods."⁸ The Learning Sessions provide an opportunity for team members to meet face-to-face and discuss improvement strategies with the guidance of senior leaders and experts in the field. Team members engage in dialogue about their methods, results, and lessons learned from their tests of change. A typical Collaborative includes three Learning Sessions, over the course of 6-15 months. These sessions often bring together participants from different sites for a full day of presentations, workshops, and informal dialogue. Depending on how your Collaborative is organized, you may decide to conduct shorter or more frequent sessions.

In between Learning Sessions, the Collaborative Team engages in an Action Period, carrying out multiple tests of change using the “PDSA Cycle." The PDSA Cycle is a method for continuously testing changes and adapting them to their environment to obtain better outcomes (described in the sections to follow). During the Action Periods, team members implement and test improvement strategies and collect data to measure their progress. Team members continue to communicate with one another by participating in conference calls, sharing monthly progress reports, peer-to-peer site visits, and other mechanisms. In the collaborative model, peer-to-peer support is key for motivating change, so it is critical to keep communication going during the Action Periods.

At the end of the Collaborative, the team documents the results and lessons learned throughout the project. Team members present their results to non-participants, either within their organization or at external meetings and conferences.

Figure 2 illustrates the IHI’s Learning Collaborative model. For more information on the model, visit http://www.ihi.org.

FIGURE 2: Learning Collaborative Model

Adapted from: IHI (2003). The Breakthrough Series. IHI's Collaborative Model for Achieving Breakthrough Improvement. Retrieved February 22, 2007, from http://www.ihi.org/ihi.

OVERVIEW OF GOALS AND STRATEGIES

Goals

The ultimate goal of the HHA Partnering Collaborative is to (1) improve aide quality of work life and job retention, and (2) improve home care for patients with functional dependencies in bathing, transferring, and ambulation. Participants will adopt and adapt tools and strategies to optimize the role of the aide as a member of the care team. As part of the Partnering Collaborative, participants will focus on the following goals:

Process Goals:

• Improve teamwork among nurses, aides, therapists, and patients.

• Identify patients’ needs and support patients as they gain functional independence.

Outcome Goals:

• Improve HHA quality of work life and retention.

• Increase patients’ functional independence at discharge in ambulation, bathing, and transferring.

Strategies

A core team of approximately 12-15 Collaborative participants, consisting of a chair or two co-chairs to serve as Collaborative leaders, selected clinical managers, field staff and other personnel, will commit to a continuing improvement process over the course of 6-15 months. This team will work together to set goals related to improving collaboration among patients, aides and nurses. The Collaborative Team will initiate small-scale tests of change that will allow you to adopt and adapt the Collaborative’s practices to best suit the needs of your agency. Learning sessions will provide a venue for participants to become familiar with the Collaborative’s tools and strategies and develop a plan for implementing and testing them “on the ground.”

The VNSNY Collaborative engaged in four main strategies, bulleted below. Your Collaborative might want to start with adapting or adopting these or experimenting with other strategies through a series of PDSA Cycles.

• The ADL Tool, a functional health improvement tool that structures common goal-setting among nurses, patients, and aides.

• The Five Promises, a guideline for communication designed to foster positive interaction between nurses and aides.

• Phone conferences and in-person meetings between managers of paraprofessional and professional services.

• Strategies for improving clinical supervision of aides, such as changing documentation in order to make nurses and therapists more aware of their interactions with aides and to hold them accountable for face-to-face supervision

The Collaborative team will track results using the PDSA Cycle, described in more detail in the sections that follow.

Expectations

The Collaborative Leadership will:

• Convene a core team of participants, including clinicians, aides, field managers, and other personnel.

• Plan Collaborative learning sessions.

• Identify team members who can be champions of change.

• Work with participating team members to develop plans for implementing Collaborative practices on the front-line.

• Offer coaching to the Collaborative Team.

• Ensure appropriate mechanisms for collecting, analyzing, and reviewing data through the PDSA Cycle.

• Ensure mechanisms for ongoing communication among team members, such as listservs, teleconferences, and face-to-face meetings.

• Provide participants with feedback using data that measure their progress toward well-defined goals

Members of the Collaborative Team will work together to:

• Develop quantifiable goals for improving performance by adapting Collaborative tools and practices.

• Plan and implement tests of change using the PDSA Cycle.

• Designate a “scribe” to record the team’s decisions pertaining to PDSA Cycles and issues discussed during Collaborative meetings and events.

• Recruit volunteers to help carry out tests of change.

• Develop and implement a plan for spreading Collaborative practices among all members of the home care team.

• Measure performance at baseline and monthly.

• Share information with the Collaborative Leadership, including details of changes made and data to evaluate these changes.

• Keep communication going within the team to facilitate collaborative learning, using listservs, teleconferences, and/or face-to-face meetings.

THE IMPORTANCE OF GAINING BUY-IN

Positive change does not happen overnight. The challenges of spreading good ideas have driven experts from a variety of disciplines to investigate the many factors that influence the success of a performance improvement effort. Even some of the best ideas do not catch on right away. The more prepared you are to address the challenges of buy-in, the more potential you will have to achieve your goals through the HHA Partnering Collaborative. Throughout this manual you will find a variety of tips and strategies for accelerating progress and getting participants on board.

Here are a few key points to keep in mind, drawing from the research on performance improvement.⁹

1. Mobilize Opinion-Leaders to be Champions of Change.

   In his seminal work on the diffusion of innovation, Everett Rogers¹⁰ points out that innovations tend to spread slowly and small, beginning with the efforts of leaders who actively promote the new ideas. A certain proportion of people -- usually between 10% and 20% -- enthusiastically embrace innovation early in the spread process. This group, referred to as “early adopters,” is essential for generating momentum and making change visible to the rest of the organization. As early adopters begin to achieve their goals, the spread accelerates dramatically, and individuals or groups who are somewhat more risk-averse begin to adopt the change ideas. Finally, the new ideas spread to the “laggards,” who are generally skeptical of all types of change. Based on this model, it is important that you begin by identifying opinion-leaders throughout your organization who can become early adopters of Collaborative practices. Aim for an initial 10%-20% adoption point, and make sure that others can observe the progress made by the early adopters. Encourage the early adopters to talk to their peers -- they are your champions of change!

2. Be Open to Reinvention.

   Experts on performance improvement have underscored the importance of adaptation in creating positive and sustainable change. Since members of any organization are part of a complex social network, a good idea will not always fulfill its potential if implemented in the same exact way from one setting to the next. This is why leaders should be open to reinvention so that the change idea is spread in a way that best fits the environment. It is critical that, as leaders, you send a clear message about the core concept of the change idea, but remain flexible about the details of how it is implemented. Leave some room for experimentation, and encourage participants to offer their input about what works and what does not.¹¹

3. Tailor your Message to Your Audience.

   Researchers have pointed out that everyone has a different threshold for change -- some people are more ready for change than others.¹² As leaders, make sure you “keep the finger on the pulse” so that you are aware of your audiences’ readiness for change.¹³ You may find that readiness varies from one part of an agency to another, so be sure that your message speaks to the needs of your audience.

USING THE PDSA CYCLE TO SET GOALS, TEST CHANGES, AND ADAPT IDEAS

As you begin the Collaborative process, you may find yourself asking these questions:

• How will we experiment with selected strategies and develop useful adaptations?

• How will we go about getting feedback from participants?

• How will we know if the change is working?

• How will we develop useful adaptations?

• How will we make our progress visible throughout the organization?

• How will we sustain the changes once we have made them?

To address these concerns, the HHA Partnering Collaborative utilizes the PDSA Cycle, a method for accelerating improvement by continuously testing changes and adapting them to their environment to obtain better outcomes. The PDSA Cycle provides a structured approach to assessing agencies’ progress toward improvement goals.

The PDSA Cycle was developed by Associates in Process Improvement¹⁴ and adapted by the IHI. IHI integrated the PDSA Cycle into their Breakthrough Series model of collaborative learning, in which team members commit to making continuous and measurable improvement toward a specific goal. The HHA Partnering Collaborative adapts this model for improvement. The suggestions and diagrams in the next several pages are adaptations of the IHI’s guidelines for using the PDSA method. For further tips, tools, and examples of the PDSA Cycle, visit http://www.ihi.org.

The PDSA Cycle will enable you to:

• Start small and learn before expanding.

• Study what has happened.

• Learn from participants throughout your organization.

• Act quickly on what you have learned by:

  • Adjusting the plan.
  • Abandoning the idea.

• Experiment with adaptations of the idea.

• Minimize resistance to change by testing new ideas and creating opportunities for adaptation.

What Happens in a PDSA Cycle?

The PDSA Cycle is based on three main questions, as shown in the diagram below.¹⁵ These questions are integral to any improvement effort, as they focus our attention toward clearly defining our goals, strategies, and method for testing change.

FIGURE 3: The PDSA Cycle

Diagram adapted from: Langley G.J., Nolan K.M., Nolan T.W., Norman C.L., Provost L.P. (1996). The Improvement Guide. San Francisco, CA: Jossey-Bass Publishers, Inc.

In any PDSA Cycle, the team sets an objective for a specific, measurable, and feasible change that can be implemented quickly. In the beginning of a performance improvement project, changes are tested on a small scale, allowing participants to measure and study their results over a short period of time -- anywhere from a few days to a few weeks. Through this learning process, team members take stock of the successes and challenges of the change, and decide on how to act on the lessons learned. This leads the team into the planning phase of the next PDSA Cycle, allowing participants to engage in a continuous improvement process.

Below we describe the steps in the PDSA Cycle. In the pages that follow, we provide some examples specific to the HHA Partnering Collaborative.

Step 1: Plan

• Define the objective of the test cycle.

• Develop a plan for implementing the change: Who? What? When? Where?

• Decide on what measures will be collected and how participants will collect the data.

• Make predictions about the potential successes and challenges of the test.

Step 2: Do

• Implement the plan on a small scale.

• Observe and document what did and did not work.

• Collect and begin to analyze data.

Step 3: Study

• Finish analyzing the data.

• Study the results and compare them to your predictions.

• Summarize and take stock of what was learned.

Step 4: Act

• Based on what was learned in the test, decide on to do next: Adopt the ideas and expand the scope? Adapt them? Abandon them?

• Prepare a plan for the next test.

The PDSA Cycle is an essential tool for gaining buy-in among participants. To be clear, you do not need consensus from the beginning -- rather, you can use the PDSA Cycle to gain buy-in over time. Engaging in continuous tests of change will allow you to adapt and modify change ideas to best suit the needs of your environment. As you find out what does and does not work, you can refine the improvement strategies and enhance your potential to achieve better results. Seeing your measures improve can motivate you to try out more, aim higher, and adopt changes we might otherwise have resisted.

Setting Aims and Defining Strategies

At the beginning of your improvement project, it is crucial that the Collaborative Team agrees upon specific, measurable aims. These aims are your overarching goals over the long term. Each PDSA Cycle is based on a shorter-term objective that helps you take steps toward your long-term aims.

For example, you might set an overarching aim in the area of patients’ self-management of specific ADLs:

Aim: Increase the percentage of patients with improvement in ambulation by 30% within nine months.

Although the team’s aim is long-term and wide in scope, within each PDSA Cycle you will set objectives on a smaller scale. Keep these tips in mind when setting the aim of a test cycle:

• Your aim should be specific and concrete.

• Set a numerical target with a clearly defined measure and a specific timeframe for achieving your target.

• Continually remind team members of the aim throughout the improvement process.

• If necessary, refocus the aim or redefine its scope.

• Clearly define who is carrying out the test and the role of each team member and volunteer who may be participating in the test cycle.

The team should also clearly define the strategies to be tested, whether you are experimenting with a simple change on a small scale or implementing a change agency-wide. To work toward the example above (improvement in ambulation), the team would plan multiple sequential PDSA Cycles. For example:

Cycle 1: Five nurses pilot the practice of talking with patients about setting ADL goals. Each nurse speaks with two patients (ten patients total) with dependency in ambulation within one week. The nurses report back to the Collaborative Team on the outcomes of their conversations with patients.

Cycle 2: The Collaborative Team develops a tool for setting specific ADL goals and involving HHAs and family members to support patients in working toward their goals.

Cycle 3: Over the course of four weeks, five nurses each test the protocol with two patients (ten patients total) who have dependency in ambulation. Each nurse gives the patient’s HHA instructions on how to support the patient in using the tool. Each nurse collects data on the patient’s progress in ambulation and receives feedback from patients, family members, and HHAs. Participating nurses and HHAs report their experiences to the Collaborative Team. The team studies the data on patients’ progress in ambulation.

Cycle 4: The Collaborative Team revises the tool and expands the test. Within four weeks, 20 nurses each test the tool on two patients (40 patients total). Each nurse collects data on the patient’s progress in ambulation and receives feedback from patients, family members, and HHAs. Participants report back to the team. The team studies the data on patients’ outcomes in ambulation.

Cycle 5: The Collaborative Team concludes that the tool is a success and works with the agency’s operations staff to implement the protocol throughout the entire agency. In addition, plans are implemented to establish an ongoing monitoring and feedback system to collect data on patients’ functional outcomes and make the data widely available on a regular basis.

Similarly, the team should plan for a sequence of test cycles to improve aides’ quality of work life alongside the changes to increase patients’ functional improvement. For example, the team may set the following aim and plan PDSA Cycles accordingly:

Aim: Increase the percentage of HHAs who agree that they are treated as an important member of the care team by 30%.

Cycle 1: The Collaborative Team administers a brief survey to HHAs about their perceptions on whether or not they are treated as an important member of the care team and on their communication with nurses and patients. The survey may be administered either to all aides in the agency or, if the Collaborative is targeting a particular part of your agency (e.g., a geographic region), to a smaller group of aides. The team analyzes and studies the data to learn about aides’ perceptions at baseline.

Cycle 2: Five nurses pilot the practice of talking with HHAs about tasks the aide can engage in to support the patient’s progress toward his or her functional goals. Each nurse speaks with one HHA (five HHAs total) within one week. The nurses report back to the Collaborative Team on their conversations with aides.

Cycle 3: The Collaborative Team develops a guide for nurse-aide communication related to the patient’s functional progress. The team identifies a small group of nurses (e.g., ten nurses) who volunteer to try the new strategy.

Cycle 4: Over the course of four weeks, ten nurses each implement the communication guide with one HHA (ten HHAs total). Each nurse asks for feedback from the aide on what helps or hinders his or her communication with nurses and feelings of being integrated into the care team. Each nurse invites the aide to share this input at a Collaborative Team meeting. If the aide chooses not to, the nurse reports on the conversation to the Collaborative Team.

Cycle 5: The Team modifies the communication guide based on the feedback received from aides and nurses. The team expands the test, involving 30 nurses who each follow the guide with two aides (60 HHAs total). The test takes place within four weeks. The HHA survey is administered to the 60 aides involved in the test. Participants report back to the team. The team studies the data on aides’ perceptions of their integration into the care team and their communication with nurses and patients.

Cycle 6: The Collaborative Team concludes that the communication guide is a success and works with the agency’s operations staff to implement the guidelines throughout the entire agency. The Team also works with operations staff and senior leaders in the agency to make sure that a long-term plan is in place to regularly collect data on HHAs’ job perceptions and feed back the data to managers and front-line staff.

Although the test cycles described above incorporate the basic principles of PDSA, they use the PDSA method for different purposes. The PDSA method is designed to be very flexible. Some test cycles may focus on developing a new mode of communication or designing a new tool and getting preliminary feedback from the people who are affected (e.g., patients, aides, clinicians, etc.). Other tests may focus on conducting a baseline survey or record review and studying the data before testing new improvement strategies. The PDSA method can be adapted to the context and realities of your agency and the needs of the Collaborative Team.

Example of a PDSA Cycle

Improving Patient Involvement in Self-Management of Functional Health

Plan

• Develop an aim statement: Increase patients’ involvement in setting functional improvement goals (e.g. regain ability to dress lower body).

• Make predictions: Patients will be receptive to talking about setting goals.

• Define strategy for improvement: Five nurses will each engage one patient in a conversation about their goals for ADL improvement.

• Define measure: Number of patients who set functional health goals, as reported by nurses who are assigned to conduct the experiment.

Do

• Over the course of two weeks, each of the five nurses engages a patient in a conversation about their functional goals.

• Each nurse documents the conversation and any goals the patient set.

Study

• Team members and participating volunteers meet to discuss the test.

• How many patients set a goal? Did the conversations facilitate goal-setting?

• Were patients receptive to talking about ADL improvement?

• Did clinicians encounter any barriers?

Act

• Should we try the change with more patients?

• Should we modify or further develop the change?

• Should we address any barriers encountered during the test?

• These decisions will be the basis of the next PDSA Cycle.

Tips for Testing Change Ideas

• Start with changes that are easy to implement.

• Plan for multiple, sequential tests of change.

• Designate a scribe to document plans for upcoming tests of change, action taken, and feedback from team members and volunteers carrying out tests of change.

• Test proven or new ideas on a small scale. For example, three nurses, three HHAs, one physical therapist, and five patients on bathing tasks.

• Move quickly to test changes. Rather than testing changes over a year or quarter, complete tests over the course of a month, week or day.

• Work with willing volunteers.

• Listen to feedback from field staff carrying out tests of change and collect data during each test cycle.

Measuring Your Progress

Measuring progress is an integral part of continuous improvement. The PDSA Cycle calls for collecting and analyzing well-defined measures over time, allowing the Collaborative Team to track its progress toward selected goals.

Two types of measures play a role in the improvement process.

• Outcome measures indicate the results of your team’s performance from the patient’s or staff member’s perspective. For example, a project aimed at improving integration of HHAs into the care team might administer a survey asking HHAs about the extent to which they feel they are treated as an important member of the team. The survey could be administered at multiple points throughout the Collaborative to track how aides’ job perceptions change over time.

• Process measures indicate whether staff practices are being carried out as planned. For example, a team focused on improving communication between nurses and aides might track the percentage of patients with bi-weekly documentation of aide supervision.

It is important to collect both types of measures in any improvement project. When choosing what measures you will collect in a test of change, consider these tips:

• Make sure your measures directly relate to your goals. Ask yourselves, “Will these measures help us understand whether we have achieved our goals?”

• Do not worry about acquiring new resources for data collection. If you do not have the latest technology for collecting and analyzing data, plot your measures with a pencil and paper.

• Your measures should be easy to analyze. Most of your measures will be analyzed in terms of percentages, such as the percentage of patients who improve in transferring, or the percentage of patients with bi-weekly documentation of HHA supervision.

• Clearly define your target population. This will determine the denominator in your calculation. For example, when calculating the percentage of patients with improvement in transferring, do you want to know the percentage of all patients, or just the percentage of those who had a dependency in transferring at the start of care?

• Make sure that you can quickly feed back data to participants. Rapid turnaround is key to keeping up the momentum for continuous improvement.

Example: Plotting Outcomes Over Time

By charting your results over time, you can see how your improvement efforts move you toward your goals. In the example below, the team sets a target of 60% improvement in bathing over a nine-month period among patients needing assistance in bathing at the start of care. Through multiple PDSA Cycles, the team refines its strategies and ultimately reaches its goal. With the target of 60% plotted on the chart during the entire effort, team members are continually reminded of their goals and see how they get closer to it with each test of change.

FIGURE 4: Percentage of Patients Showing Improvement in Bathing at Discharge

Multiple, Continuous Tests of Change

Tests of change are not only continuous, they also happen alongside other changes simultaneously. For example, the team may choose to focus on improving patients’ functional self-management, while also focusing on improving field support for HHAs.

FIGURE 5: Tests of Change

Diagram adapted from http://www.ihi.org/ihi.

Measuring Progress toward HHA Partnering Collaborative Goals

In working toward the goals of the HHA Partnering Collaborative, you will need to collect a variety of measures. The table below suggests several measures and data sources for assessing your progress toward each goal. For some of the measures, participants will need to conduct surveys on staff members’ opinions about their work relationships. Other measures draw on the Outcomes and Assessment Information Set (OASIS) and information from administrative records. The OASIS is a core set of screening and assessment items, including standardized definitions and coding categories that form the foundation of a comprehensive assessment for all clients of home health agencies certified to participate in Medicare or Medicaid.¹⁶

The table also indicates some of the strategies the team may test throughout the Collaborative process. The strategies are meant to be flexible; with an enthusiastic team, you might arrive at new innovations for achieving Collaborative goals.

The pages that follow include additional suggestions on how to collect and analyze your measures.

Suggestions for Data Collection and Measurement

The key to assessing a Collaborative’s progress is to collect basic measures that are easily interpreted and understood by everyone involved in the project. Data analyses should remain simple and to the point to assure that results are fed back to all members of the Collaborative Team and participating field staff in a timely manner. The following describes key measures used in the VNSNY Collaborative and different approaches to collecting the data. The measures and methods may be adapted as appropriate for your agency.

HHA Retention

At VNSNY, the evaluation team defined HHA job retention as whether or not an aide provided at least one visit in the pay period following a designated point from the start of the Collaborative. You may decide to measure retention as your Human Resources department defines it. Be sure to choose the measure and timeframe that is most relevant to your agency.

HHA Job Perceptions Survey

To measure HHA job perceptions and quality of work life, you may choose to administer a brief survey. Depending on the size of your agency and resources available, you may decide to create a pen-and-paper, phone or web-based survey. You can calculate simple percentages to determine the distribution of responses to each question. There are sample questions in the HHA Job Perceptions Survey (below) which can be adapted as you find appropriate.

Clinician Survey

The VNSNY Collaborative developed a short survey to learn about clinicians’ self report of practices related to the Collaborative’s goals and strategies. The eight-question survey (below) addresses key themes such as communication between clinicians and aides, and the usefulness of the functional health improvement tool tested during the course of the Collaborative. Field managers administered the survey to clinicians on paper during routine monthly meetings. The survey was kept anonymous to encourage candid responses. As with the HHA Job Perceptions Survey, you may choose a different method of data collection based on the resources available to you. Simple percentages were calculated to determine the distribution of responses to each of the questions.

Patients’ Functional Outcomes

To measure patients’ functional outcomes, you may use items from the start of care and discharge in the OASIS. At VNSNY, we compared the Activities of Daily Living Measures for Ambulation (M0700), Transferring (M0690), and Bathing (M0670) from admission to discharge to determine patients’ progress. If you do not have the OASIS readily available for analyses, functional scores can be collected as you wish during admission and discharge for comparison. The OASIS items are shown below (Items for Measuring Patients’ Functional Outcomes). You might choose to measure improvement in patient function for a selected period of time in either of two ways: (1) the percentage of patients in categories 1-5 below who reduced their score at least one point between admission and discharge; or (2) the average change in total ADL “score” (categories 0-5) for all patients between admission and discharge.

GOAL 1: IMPROVING SUPPORT TO HOME HEALTH AIDES

HHA Support -- Part I: Improving Nurse-Aide Interactions in the Field

Rationale: Surveys show that a key predictor of turnover is employees’ dissatisfaction with their supervisors.¹⁷ For this reason, clinical supervisors can have a major impact on HHA retention rates. Positive communication can prevent aides from feeling under-utilized or under-appreciated, which could negatively affect their work and overall patient outcomes. Patient outcomes have been shown to improve when aides serve as the clinicians’ “eyes and ears” and clinical and paraprofessional staffs work together to address a patient’s health care needs.¹⁸

Expectation: Clinicians and aides show recognition to one another and actively discuss all aspects of patient care. Clinicians supervise aides at each visit, encouraging them to openly discuss patient progress and goals.

Change Concept: A guideline for interaction between clinicians and aides can promote productive discussion of patient’s goals and increased staff satisfaction.

Aims:

• Increase HHA perception of appreciation by their clinical supervisors (nurses/therapists) by x%.

• Increase clinicians’ satisfaction with HHA competency in the tasks required to care for patients by x%.

• Increase HHA job retention by x% or reduce HHA turnover by x%.

Measures:

• Percentage of HHAs who strongly agree that they are treated as an important member of the care team.

• Percentage of clinicians who strongly agree that HHAs are competent in tasks required to care for patient.

• Percentage of patients with bi-weekly documentation of HHA supervision.

• Percentage of HHAs who continued to work at the agency over a specified period of time.

Changes:

• Clinicians and aides will integrate a tool called the “Five Promises” into everyday home care practice. Positive and regular communication will become the standard practice among HHAs and clinicians. (Nurse-Aide Interaction: The “Five Promises” can be found below).

• Clinicians will document their supervision of aides through a paper or electronic supervision form, allowing the Collaborative Team to track its progress toward improving nurse-aide interactions.

Promoting Staff Buy-In and Support

Use the PDSA Cycle to overcome resistance: Based on our experiences at VNSNY, you might find that some clinicians resist adapting the Five Promises, while others respond with enthusiasm. Those who resist might feel that the Five Promises reflect what is already being done in the field and simply state the obvious. Although the guidelines may seem straightforward, we discovered at VNSNY that they were not necessarily standard practice before the Collaborative.

The PDSA Cycle is your key to overcoming resistance. Involving field staff with opportunities to give feedback on their experiences with the Five Promises can give clinicians and aides a sense of ownership over the changes being made, which may help to achieve buy-in. Starting out with small tests of change will allow the Collaborative Team to modify aspects of the new strategy that may be a source of resistance. As your measures begin to show improvement, those who have previously resisted adopting the practice may become convinced that it is worthwhile. Alternatively, you may decide to abandon the Five Promises or substitute it with another strategy, depending on what you hear from field staff carrying out tests of change on the front-line.

Raise the bar: You may also find it helpful to remind field staff that even if many staff members already engage in positive, open communication in the patient’s home, you want to make it the gold standard. Having a guideline that reminds people of this expectation can make a big difference in moving toward your goal. Members of the Collaborative Team -- especially clinicians and aides -- play an important role in motivating their peers to make the Five Promises common practice.

Use friendly reminders: Clinicians are often bogged down with paper work and new tasks being asked of them. Ongoing reinforcement of your goals can prevent the Five Promises from being tossed aside and forgotten. Encourage field staff to carry the Five Promises tool with them at each visit as a reminder that positive communication is now a top priority.

Tips for Testing Changes in HHA Field Support

• A job perceptions survey for HHAs is an excellent way to assess whether they feel they are appreciated and treated as an important member of the team. See earlier section -- “Suggestions for Data Collection and Measurement” -- for more information on administering a survey.

• A clinician survey can provide the team with feedback on HHA competency and communication in the patient’s home. See section on data collection for suggestions on administering a clinician survey.

• Engage staff members in establishing a work plan for documenting HHA supervision. Set a specific target for the frequency of HHA supervision that will motivate clinicians to make it a priority.

• Use a standardized form for documenting supervision that is easy to complete and use consistently. In addition to noting the aide’s performance on tasks related to the service plan, you may choose to include a few key questions:

  • What is the quality of the aide’s relationship with the patient’s family (i.e., good, fair, or poor)?
  • Does the aide follow the plan of care?
  • Has the plan of care been revised recently?

HHA Support -- Part II: Improving Communication Among Managers

Rationale: In all home health agencies, a skilled nurse or therapist provides clinical supervision to the aide in the patient’s home. In addition, most agencies have separate managers who provide general oversight of professional and paraprofessional services. Sometimes these are the same person, while sometimes they are different individuals. No matter how aide services are structured, however, nurses and aides often receive different messages from their managers. Mixed messages and a lack of coordination between clinical and aide services create barriers to providing high quality care and achieving high levels of satisfaction among nurses, aides, and patients. Setting standard expectations for partnering and communication can help solve problems efficiently and reduce confusion about the aide’s assigned tasks, schedule, and role.

Expectation: The Collaborative Team will work to improve partnering relationships among field staff and their managers, and to make proactive communication standard practice.

Change Concept: Setting an expectation for clear, regular communication between clinical and paraprofessional supervisors and for consistent messages to front-line clinical and paraprofessional staffs will facilitate positive work relationships between clinicians, aides, and patients.

Aims:

• Increase clinicians’ satisfaction with HHA competency in the tasks required to care for patients by x%.

• Increase HHA perception of appreciation by their clinical supervisors (nurses/therapists) by x%.

Measures:

• Percentage of clinicians who strongly agree that aide services respond to their concerns.

• Percentage of aides who strongly agree that they are treated as an important member of the care team.

Changes:

• Managers will participate in monthly phone conferences to discuss issues related to aide services. You can find a tool in this manual for these calls (Paraprofessional Manager Tool for Partnering Collaborative Conference Calls).

• If management of aides and nurses is divided among different staff in your agency -- or if multiple managers are responsible for aide services -- managers will meet regularly (e.g., bi-weekly or monthly) by phone or in person to discuss issues related to the supervision and delivery of aide services. An additional tool for in-person meetings can be found in this manual (Paraprofessional Manager Tool for Partnering Collaborative Team Meeting).

• The team will designate a scribe to circulate meeting agendas, summarize issues covered and document agreed upon solutions.

Promoting Staff Buy-In and Support

Remember that proactive communication saves time. Depending on workload and staffing issues, some managers may be resistant to participating in regular conference calls or meetings. However, establishing a regular schedule for communication will eventually save time by preventing problems and reducing more round-about means of communication. As participating managers become accustomed to regular meetings and more comfortable raising issues, they will become more efficient at trouble-shooting. Building managers’ support for regular communication is an area where use of PDSA Cycles may be an important vehicle for gaining managers’ buy-in.

Use the PDSA Cycle to figure out what works best. Carrying out continuous PDSA Cycles can help the Collaborative Team figure out how to implement proactive communication strategies in a way that is both feasible for managers and effective at preventing and solving problems. You may wish to experiment with different meeting schedules (e.g., every week, bi-weekly, etc.) or different modes of communication (e.g., face-to-face meeting vs. phone conference). Whatever your approach, be sure to listen to feedback from managers implementing the new strategies.

Tips for Testing Changes in Partnering

• You may decide to test different kinds of logs and follow-up sheets. You may adapt either of the tools as a guide for conducting phone conferences or in-person meetings. The first tool -- “Paraprofessional Manager Tool for Partnering Collaborative Conference Calls” -- provides a general guide of how to plan for and organize a conference call, with room to document general issues related to Collaborative practices, aide scheduling, and service problems. The second tool -- “Paraprofessional Manager Tool for Partnering Collaborative Team Meeting” -- provides a more detailed list of questions that managers may wish to address on a regular basis. Either tool may be modified to address the issues most relevant to your agency.

• Depending on the structure of your agency, you may find it useful to develop a daily communication log that managers can use (by fax or email) to inform one another about current aide assignments, hours, and any special concerns. Take advantage of the PDSA Cycle to experiment with different approaches to proactive communication.

• No matter what the mode or frequency, encourage participating managers to use the conference calls or in-person meetings as an opportunity to share information and solve problems.

NURSE-AIDE INTERACTION: THE "FIVE PROMISES"
EVERY TIME you are in a patient’s home together, take five minutes for the following interaction:
1.	Introduce yourself and show your I.D.
2.	Discuss the progress the patient is making toward achieving his/her functional health goals.
3.	Review together, any changes in the service plan and/or duty sheets.
4.	Discuss any observations or concerns about the patient that you have today.
5.	Thank each other. Make sure you communicate about the next nursing visit and the ongoing or changing home health aide schedule and/or assignment. Make sure contact phone numbers are in the home.

GOAL 2: IMPROVING PATIENTS’ FUNCTIONAL INDEPENDENCE

Rationale: When home care staff and caregivers are not present, patients have to engage in ADLs on their own. Patients often will avoid performing a task because they are afraid their attempt will result in a fall or injury. In some cases patients resort to unsafe methods of bathing, walking, or transferring. By setting functional health goals at the start of care, patients can become better prepared to manage their own health care needs and less reliant on home care staff. Working toward specified goals is a team effort that strengthens the relationship between patients, clinicians and HHAs. Two prominent researchers from Yale University found that using this type of collaborative approach to establishing and tracking functional health goals led to a significant improvement in the functional outcomes of home health patients and to a reduction in patient hospitalizations.¹⁹

Expectation: Patients and all members of