Linking Work Life Changes to Worker & Patient Outcomes: Evaluating the VNSNY

Home Health Aide Partnering Collaborative

Penny Feldman, Ph.D.

Robert Rosati, Ph.D.

Gail Quets, M.A.

Gil Maduro, Ph.D.

Theresa Schwartz, B.A.

Visiting Nurse Service of New YorkPenny.feldman@vnsny.org

Funded by US HHS Office of Disability, Aging and Long-Term Care Policy Contract #HHSP23320044304EC

Today’s Objectives

• Describe a multi-faceted work life/“culture change” intervention in home health care

• Outline the evaluation

• Discuss evaluation strategies & challenges

Intervention Objectives

“Optimize the role of the HHA” ….– Strengthen ties to agencies that employ HHAs– Improve nurse supervision & support of HHAs– Promote common goal setting– patient, HHA & nurse– Transform HHA from “doer” to “supporter”

Resulting in….• Better nurse/HHA/patient communication• Improved HHA satisfaction • Reduced HHA turnover• Improved patient function (bathing, transfer, ambulation)• Services “matched” to needs

Intervention • Modified “Learning Collaborative” model

– Senior leadership– 4-month “spread” process – Teams undertake common goal: “Everybody teaches. Everybody

learns.”– Formal plans & accountability– Rapid implementation of change concepts– Focus on data – goals & measures – Group learning sessions, team meetings, content experts, coaching,

theme calls, web site

• Tools– ADL/Functional Health Improvement Tool – “Five Promises” – HHA Partnering “Best Practices”– HHA video/skills – reinforce training

ADL Progress Report

Patient Name:__________________________________________ Coordinator of Care (Nurse or Physical Therapist):__________________________________________________________

PATIENT ACTIVITIES OF DAILY LIVING WEEKLY PROGRESS REPORT PATIENT DIRECTIONS: Check INDEPENDENT in the areas that you feel you can perform ALONE, SAFELY & WITHOUT help. Check NEEDS ASSISTANCE in the areas that you need someone to assist you with OR you feel UNSAFE in performing alone. Once you complete these areas your Nurse &/or Therapist will review these items with you and together we will design a PLAN OF CARE to help promote your independence at home. Your Home Health Aide is an important member of your Home Health Care Team and will be working closely with you, your Nurse and/or Therapist to help you regain your independence. Each week we will reevaluate your progress and identify strategies to help promote your independence at home. Activity of Daily Living Component Week One Patient Response.

Date:__/__/__ Week 2 Date:__/__/__

Week 3 Date:__/__/__

Week 4 Date:__/__/__

I can do this alone

I need help to do this

Independent Needs Assistance

Independent Needs Assistance

Independent Needs Assistance

Bed mobility and transfers 1. Rolls from side to side 2. Moves from lying to sitting up 3. Can get walker, cane or crutches 4. Can get in and out of bed 5. Sets self up safely to get up 6. Can get up from all surfaces safely 7. Can maintain standing

Ambulation 1. Can walk to and from the bathroom 2. Knows safety precautions/techniques 3. Can move walking device 4. Can move legs (to take steps) 5. Can change directions

Bathing 1. Can get in & out of bathing location (tub,

shower, etc)

2. Washes upper body 3. Washes chest, trunk, and private areas 4. Washes legs 5. Washes hair 6. Adequately dries skin

Goals Week 1 Goals Week 2 Goals Week 3 Goals Week 4

The Five Promises ToolThe Five Promises ToolEVERY interaction with a HHA, takes 5 minutes to……EVERY interaction with a HHA, takes 5 minutes to……

1. Introduce yourself and show your VNSNY I.D.

2. Discuss progress patient is making toward achieving their functional health goals.

3. Review any changes in PPOC and/or duty sheets.

4. Ask HHA if there are any other observations or concerns they have today.

5. Thank the HHA. Let him/her know when your next visit will be and how to reach you.

HHA Partnering Collaborative: Goals & Measures

GOAL MEASURE

Improved HHA Field Support

•HHA satisfaction

•HHA Supervision

•Team Satisfaction

Increased Functional Improvement at Discharge

•Functional Outcome at Discharge: Bathing, Ambulation, & Transfer

•# of HHA Assisted Activities ADL tools

CHANGE IDEAS

•Five Promises tool

•Supervision Every Visit

•Supervision Six Documentation Points

•ADL Weekly Progress Tool

Organizational/Structural Characteristics• Communication Processes• Governance• Information Technology

Group Behavior• Collaboration• Consensus

Supervision• Communication• Support• Recognition, respect

Quality Emphasis• Patient Centeredness• Safety• Innovation• Outcome Measurement• Evidence-based Practice

Work Design• Staffing• Resources/Training• Measurement/Rewards• Autonomy

Healthcare Worker Outcomes• Satisfaction• Health and Safety• Organizational Identification• Turnover

Patient Outcomes• Satisfaction• Safety• Self-care• Health and Function

Leadership• Values• Style• Strategy

Conceptual ModelConceptual ModelCore

Structural

Domains

Process

Domains

Outcomes

Challenges in Implementing the Intervention

• “Culture”: values, beliefs, expectations:– Nurses re patients and HHAs– HHAs re patients and nurses– Patients & families re services & goals

• Organizational structure:– Aides employed by separate agencies– “Interdisciplinary” meetings: competing priorities, limited

aide participation

• Work design:– Isolation & dispersion of aides– High ratios of HHAs to nurses, HHAs to licensed agency

coordinators

Objectives of the Evaluation

Assess impact of the HHA Collaborative:– HHA perceptions, satisfaction, turnover– Patient service use and costs – Patient discharge disposition & outcomes

Examine implementation challenges &strategies:

– Perceptions/attitudes – “culture change”– Usefulness of tools– Use of data– Matching services to patient needs

Evaluation Products: To “make the case” for the intervention and facilitate replication

• Usual suspects: final report, articles

• Intervention Guide – main audience: potential adopters

• Policy/Practice Brief – main audience: federal and state policy makers, professional associations, union leaders, workforce experts, other stakeholders

*Six-person TEP review

Evaluation Design

Overall design– Random assignment of 42 service teams to

“intervention” (21 teams) or “control” (21 teams); stratification by borough

• Bronx, Brooklyn, Manhattan, Queens– Repeated measurement – before, during and

post-intervention (see next slide)– Summative analysis – quantitative

• Units of analysis: team, HHA, patient– Formative analysis – qualitative/quantitative

Intervention & Evaluation Timeline

Feb May Sept

Intervention R O1 X O2 O3

Control R O1 O2 O3 X

Measurement Measurement MeasurementHHA Satisfaction HHA Satisfaction

HHA turnover HHA turnoverPatient SOC Patient Outcomes Patient Outcomes

Service Use Service UseR=randomization; X = observation

(n=21)Bronx Brooklyn Manhattan

(n=21)Bronx Brooklyn Manhattan

Evaluation: Analytic ApproachImpact analysis – quantitative*

– Comparison of intervention and control groups: HHA perceptions, HHA outcomes, Patient service use, Patient outcomes

– Use of appropriate multivariate regression models (e.g., ordinary least squares, ordered logit)

– Case-mix adjustment for baseline patient differences and/or propensity score matching

Implementation analysis – multi-faceted (qualitative, some quantitative)– Focus on intervention group & stakeholders

• Observation (learning sessions, meetings, theme calls)• Interviews & focus groups (participants, stakeholders)• Document analysis (e.g., team plans, reports, ADL tool documentation)

*No Primary Data Collection

Questions to HHAs• How often

– Do the nurses and therapists you work with give you the help you need to do a good job?

– Do the nurses and therapists you work with treat you as an important member of the care team?

– Are your opinions about patients heard and appreciated by the nurses and therapists you work with?

– Do you discuss patients’ progress walking, bathing, and getting out of bed with the nurses and therapists you work with?

– Do you talk to patients themselves about the progress they are making walking, bathing, and getting out of bed?

• Do you agree or disagree : Overall, I am a satisfied employee

HHA Job Perceptions -- All Regions

0

10

20

30

40

50

60

70

Help ImpMember

Apprec Prog-RN Prog-Patient

Per

cen

t

Never Sometimes Usually Always

N= 811MEAN=3.23STDEV= 0.92

N= 808MEAN= 3.36STDEV= 0.85

N= 809MEAN= 3.28STDEV=0.84

N= 786MEAN= 3.18STDEV= 0.93

N=790MEAN= 3.48STDEV= 0.77

HHA Satisfaction -- All Regions

0

5

10

15

20

25

30

35

40

45

50

Job Satisfaction

Survey Question

Per

cen

t

Strongly Disagree Disagree Not Sure Agree Strongly Agree

N= 747 MEAN= 3.93 STDEV= 1.04

Challenges in Conducting the Evaluation

• Complexity of the intervention – multiple components, multiple teams, emphasis on team “buy-in” via adaptive practices – a moving target

• Variations in implementation – how to document “fidelity” / “intensity”

• Fluidity of the HHA workforce – across teams & over time

• Reliance on existing data• Outcome measures (worker and patient) – are

they sufficiently sensitive

Conundrum of Applied “Real World” Research

• If intervention impact demonstrated – to which component/s can it be attributed?

• If no impact demonstrated – why not?– Poorly designed intervention?– Poorly implemented intervention? – Poorly designed evaluation?

• Response– Employ conceptual & logic models at design phase– Document components– Measure fidelity– Randomize– Identify and analyze “pure” intervention & control aides &

associated patients

Conclusions: Benefits [or Risks] of the Research

• Understand benefits/costs of the intervention• Show linkage between organizational change and patient

outcomes• Build a business case for work life investment• Document change strategies• Create a toolbox for diffusion of intervention• [Undermine support for future change if costs exceed

benefits (due either to externalities or weak/no effect)]