Introduction and Overview
I have been practicing physical therapy for the last twenty years. I have a great passion for what we do as home health care therapists and the value we provide. There are changes on the horizon for home health care. There will be new and exciting opportunities for which we will need to prepare ourselves.
One of the key elements that will be vital to achieve success in this post-acute world, specifically as it relates to home health care, is communication. Not merely communication – effective communication. What does it mean to be an effective communicator? The definition of effective is “to be successful in producing a desired or intended result.” We need to analyze our communication skills to determine if we are being effective, in terms of how we interact with patients, referral sources and each other.
Currently, there are changes occurring with regard to home health care. We are seeing a greater level of physician engagement with our patients. There are emerging technological advances, which will allow us to obtain information and integrate it into usable resources for better care management. We're also going to take some time today to talk about patient-centeredness, because everything we do revolves around the patient. We have an obligation to elevate the quality of care we provide, while at the same time being mindful of ways to reduce costs.
- The participant will be able to accurately identify at least three key stakeholders in the successful management of the home health patient.
- The participant will be able to independently list two strategies to create an interdisciplinary approach to case management.
- The participant will be able to identify at least two ways effective communication and agency success are linked together.
Where I live in Northwest Pennsylvania, old silos are readily visible, scattered across the landscape. The silo was an ingenious invention during the development of dairy production. Silos stored nutritious grain for dairy cattle, which they consumed when the growing season was over. This allowed for greater production, as the cattle could continue to produce milk during the winter. Silos also allowed for improved value and better product quality.
From an agricultural perspective, there are good aspects about silos of the past. Many of them were made of concrete and were very rigid. However, farmers have found more effective and more efficient ways to produce their outcomes. My brother-in-law is a dairy farmer, and he has transitioned from a traditional silo, to more of a bunker-style, plastic-wrapped silage, that is more accessible, more economical and more efficient.
As therapists, we need to follow a similar model: we need to move away from a using a barricaded approach to caring for our patients, to using more effective methods to convey information. One of the biggest obstacles we face is a lack of interdisciplinary communication and coordination of care. According to Patrick Lencioni, author of Silos, Politics and Turfwars, a silo mentality will “devastate organizations, waste resources, kill productivity and jeopardize the achievement of goals.” Furthermore, in an article by Driscoll et al (2015), they state that within an organizational structure, “silos do not support communication and collaboration beyond that specialty and often contribute to communication breakdowns between disciplines as well as process inefficiencies.”
We need to put some screen doors in our silos, to allow communication to flow freely. When we look across the landscape, we can see that many of the ancient silos are not torn down; they simply crumble from age and disuse. The silos may still be present, but we have to work around them…and move beyond them.
Identify the Key Stakeholders
To begin moving beyond the silos, we need to determine who our stakeholders are. With whom should we be partnering? Who do we need to identify as our team? When we think of our stakeholders, we need to look outside, but we also need to look inside.
When we look inside, everything centers around our patient; helping them achieve an optimal outcome. When we look outside of our immediate structure, those stakeholders can include our referral sources (hospitals, outpatient centers); it might be our durable medical equipment suppliers. The community and its resources are also in that outer ring of stakeholders.
What are some barriers to communication that we may encounter when we are networking with our stakeholders? Often, it is due to individual differences. As therapists, we all have a different metric that we use to create success. In order to break down the differences, we need to agree that the commonality in the center of everything is the patient. We have to look out for the patient, and for each other. That's going to be a critical component to success as we move forward, as a home health industry.
In an article by Kitson and her group (2012), they completed a narrative review and synthesis of literature from health policy, medicine and nursing. In all of the literature they analyzed, they found three common themes that are critical elements in patient-centered care:
- Patient participation and involvement: If the patient participates and is engaged, they will benefit more from therapy.
- Relationship building between the patient and the health care professional: If the patient likes you, they will respond to you and have better outcomes.
- Context where care is delivered: As an organizational system, how do we distribute information? How cohesive are we as a team in administering treatments and interventions? How can we meet our requirements while keeping the patient in the center?
Furthermore, to perform excellent and consistent patient-centered care, we need to keep in mind the following nine components (Kitson, et.al):
- Respect for patients
- Coordination and integration of care
- Physical comfort
- Emotional comfort/alleviation of fear and anxiety
- Involvement of family and friends
- Transition and continuity
Community Care Network
In Meadville, Pennsylvania, we have what's called the Community Care Network. The Community Care Network was originally founded with grant money from Highmark, Blue Cross, Blue Shield. It has been subsequently subsidized through the hospital, which funds nursing care. It is comprised of a team of clinicians who work with patients, and they coordinate with the patient’s physicians, health care providers and other agencies to help them manage chronic disease conditions. Their focus is on meeting the patient’s health and wellness goals. The Community Care Network team consists of a medical director, physicians, registered nurses, dietitians, social workers, counselors and health coaches. Coordination of services provided by the program aims to assist in the following areas: appointment adherence, nutritional support, medical reconciliation, prevention and risk, emotional support, accessing community resources, challenges of daily living, and education on health and well-being.
The Community Care Network has a partnership with the local college (Allegheny College) and their pre-Med program, where the students take part in a “health coaching” course. They are assigned to a resident; there are over 500 residents in the Community Care Network. They can go out and support them, and encourage them. They don’t have to be homebound to receive community care. The health coaches can follow-up to see if a patient is following through with a prescribed exercise regimen, or that they are taking their medicine properly. This program has resulted in a significant reduction in our readmission percentage. A good share of the population in the Community Care Network are those high risk, problem-prone patients (i.e., treatment resistive patients). They have a very difficult time adhering to the program. They are repeatedly discharged and readmitted. Using Community Care services, we see a more longitudinal effect and stabilization of patients.
Community Care also collaborates with our local hospice group, to work with patients who have chronic diseases. Often, the cause of admissions and destabilization is ineffective symptom management. Our palliative program is involved as well. We've been looking at utilizing Part B Nurse Practitioner Billing in our chronic disease state conditions and patients, because we want a little bit more sophistication that might help in dealing with this particular population.
The nice thing about this program is that through the hospital, through the Community Care Network and the palliative and hospice programs, we are integrating communication. We also are networked with assisted and extended care facilities, as part of our partnership. We have programs in place to assist patients who are struggling at home. It may be that a patient is destabilizing in their home, or perhaps their needs are beyond being able to be independent in their home. Once we see that the patient is having difficulty at home, or the caregivers are having greater difficulty, we can fast track them into the assisted living or extended care programming. We are following the patient over a longer period of time. Through collaboration with other disciplines and services – which historically had operated as separate “silos” -- we have been successful at helping manage this particular population.
Another term frequently used in healthcare is interoperability. Often used in relation to technology systems and software applications, this term can also be used to describe communication between health care professionals. It is defined as the ability of a system or product to work with other systems or products, without special effort on the part of the consumer. The “without special effort” portion is where things are often lost in translation. In the past, it has been difficult to exchange information between groups, and this slows things down. We want to improve interoperability. That's just one example of how we're trying to move forward in looking at patient-centered care.