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The Design and Implementation of a Restorative Care Model for Home Care

^a Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, CT
^b Department of Rehabilitation Services, Yale New Haven Hospital, CT
^c New Haven, CT
^d Department of Internal Medicine, Yale School of Medicine, New Haven, CT

Correspondence: Dorothy I. Baker, PhD, RN–CS, RN–CS, Department of Epidemiology and Public Health, Yale School of Medicine, 129 York Street, Suite 1N, New Haven, CT 06511. E-mail: dorothy.baker{at}yale.edu.

Eleanor S. McConnell, RN, PhD

	Abstract

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Purpose: The increasing demand for geriatric home-based care makes it timely to examine how the existing system can become most effective and efficient in promoting the functional outcomes of older patients. Design and Methods: A multidisciplinary work group identified home care agency policies, misconceptions of older adults and their caregivers, and practice patterns of nurses, therapists, and home health aides that can impede patients' progress toward functional independence. This article describes the process that one home care agency used to remove these obstacles. Results and Implications: The work group developed and implemented a restorative model of care that integrates the medical treatments for acute disease processes and the personal care and rehabilitative interventions directed toward chronic disabilities, to improve the functional outcomes of older adults receiving home care.

Key Words: Coordinated care • Functional outcomes • Patient goals

Home health is the most rapidly expanding segment of U.S. health care. Its growth has been fueled by (a) increasing longevity, with more frail, older persons living at home (Haupt 1998); (b) the introduction of the hospital Prospective Payment System, resulting in more older patients discharged home in an early stage of recovery (Haupt 1998); and (c) financial incentives that Health Care Financing Administration (HCFA) regulations have created for care providers (Bishop, Kerwin, and Wallack 1999; Medicare Home Health Agencies 1998). Little attention, however, has focused on the optimal structure, process, and outcomes for home health services (Welch, Wennberg, and Welch 1996). Instead, home care has been defined by reimbursement policies that direct the provision of clinical care. Medicare covers services to treat acute conditions, but other funding sources are needed for visits to manage chronic illness (Vladeck and Miller 1994).

Direct care providers can inadvertently be working at cross purposes in their efforts to simultaneously manage disease, provide personal care, and rehabilitate older adults while trying to comply with regulations regarding which funder pays for which visits. Without careful communication, providers can find themselves giving conflicting advice to older patients. We identified this as a widespread problem while working with patients in 27 home care agencies in a home-based rehabilitation clinical trial designed to help participants gain independence in activities of daily living (ADLs) through behavioral or environmental changes (Tinetti et al. 1999). For example, a nurse might assign a home health aide (HHA) to bathe and dress an older woman post stroke at the same time as the rehabilitation therapists are encouraging her to build endurance and regain independence by performing those self-care tasks. Some patients did not want to perform their own ADLs for fear of losing their HHAs; others stated they would start learning self-care only when HHA care was ending (Tinetti et al. 1997). These attitudes and behaviors proved counterproductive to effective and efficient rehabilitation.

The HCFA recently implemented the Outcome and Assessment Information Set (OASIS) for prospective Medicare reimbursement of home care. This system quantifies the effect of home care by comparing patients' baseline and discharge functional abilities (Shaughnessy et al. 1994). Yet, the experiences described above and those of other researchers suggest that home care has not focused on altering functional outcomes (Penrod, Kane, Finch, and Kane 1998; Weissert 1988). This article describes the development of a restorative model of home care designed to integrate medical treatments for acute conditions with personal care and rehabilitation for chronic disabilities in order to improve older adults' functional outcomes.

	Methods

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To develop this model we chose a demonstration site at a geographically distinct branch of a typical nonprofit home care agency (HCA). The agency is the oldest and largest in the state, averaging 800 employees who serve more than 12,000 patients a year, 75% of whom are aged 65 years or older. A multidisciplinary work group, experienced in home care, comprised the principal investigator (PhD, RN), a research physical therapist (PT), and HCA staff (2 RNs and 2 PTs). The group initially scheduled weekly meetings, lasting an average of 1.5 hours, but during the 18-month development and implementation process the meetings tapered to monthly. As needed, the work group expanded to include two HHAs experienced in working with older adults. To include consumer opinion, regular attendees at the area senior center, including the center director, a senior social worker, and seven community-dwelling older persons, four of whom had received home care services, were invited and volunteered to participate in a focus group. All work group participants were asked to share insights on how HCA staff might be more effective and efficient in helping older adults achieve functional goals.

To facilitate eventual implementation of our model we periodically met with HCA supervisors and administrators for their suggestions and to keep them updated regarding our plans. To prepare for any reactions from patients or families perceiving a change in practice, we also met with staff who monitor patient satisfaction. They explained that most patient complaints involved scheduling—rarely staff skills or care—but that patients are sensitive to behaviors they interpret as impersonal. We requested that any patient complaints that could possibly be a result of project activities be brought to the attention of work group members.

Testing followed the Plan-Do-Study-Act cycles suggested by Berwick 1998 wherein small, local, short-cycle changes in clinical practice are observed and adjustments made as data and experience accumulate. We followed four steps to develop and test the restorative care model: (1) operationalize the concept of assessing and maximizing functional independence within episodes of home care; (2) identify structural, process, and attitudinal barriers that impede maximizing functional independence; (3) identify and test solutions to these barriers; and (4) implement and test the model with all staff in a designated branch of the HCA.

	Results

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Operationalizing Assessment and Maximization of Function
The HCA nurses identified "managing disease" as the traditional goal of nursing services and reported they did not specifically focus their interventions on achieving functional independence. A new paradigm for thinking about home care goals emerged, with disease management viewed as essential, but as an intermediate outcome in a course of care aimed at optimizing functional abilities (Table 1 ). The work group recognized that we did not have a system for objectively assessing and quantifying the type and amount of assistance required for ADLs. The OASIS tool was not sensitive to tracking the incremental changes in ADL abilities. For example, unless patients bathe in the tub or shower unassisted, OASIS does not classify them as independent in bathing—even if they progress from a bed bath to a pattern of safely and effectively sponge bathing at the sink. Protocols developed for a rehabilitation trial, in which each ADL is divided into specific, observable subtasks (described in Tinetti et al. 1997), were adapted by the HCA staff to create the Self-care Progress Report (see Table A1 1). It includes the items tracked by OASIS and (a) records recent (previous 2–4 weeks) and admission functional abilities; (b) tracks the evolving subtasks of each ADL for which the patient needs assistance; and (c) identifies who will provide each type of assistance, including that of non-HCA caregivers. The Self-care Progress Report is started at the time of admission and left in the home as a means of communicating one consistent plan of care among the patient, home care staff, and any other caregivers.

Nurses and therapists described the challenge of making clinical decisions with limited referral information combined with constant pressure to keep home visits brief and infrequent. Some patients were too sick to be managed at home with available resources or had been promised care that was inappropriate or not feasible. Referral information that was incomplete or contradictory and prescribed drug regimens that were unclear, unsafe, too complicated, or too expensive were time consuming and created impediments to patient progress. The pressures faced by professional staff created incentives to place HHAs and confusion about the goals for such placements.

Nurses and therapists reported that their primary method of ensuring patient stability and averting unplanned trips back to the hospital was to place an HHA. To be reimbursed, HHA placement requires that the patient need help with ADLs. Patients, however, were typically more interested in receiving help with instrumental ADLS such as shopping or cleaning, rather than personal care such as bathing. Sometimes patients were encouraged to let the HHA help with ADLs in exchange for having the HHA also perform the instrumental activities of daily living (IADLs), which were of more interest to the patient. As the aide's role expanded, there was potential for the patient to become more sedentary and ultimately to lose function.

Home health aides can play a key role in fostering independence once they learn that "doing for" a patient, while efficient in the short term, results in lost confidence, physical deconditioning, and increasing dependence. However, HHAs explained that they were neither trained nor authorized to orchestrate the gradual transition of activity that would increase the patient's participation in self-care. The typical HHA care plan lists tasks the aide will perform rather than outlining steps for the HHA and patient to take to gradually assign more responsibility to the patient as physical abilities improve. The nurses and HHAs reported that HHAs did most of the work for patients right up to the day of discharge. Visit frequency decreased, but changing the content of the HHA care plan takes time and is especially complicated if multiple HHAs are involved in a case. Discussions of discharging the HHA were often met with resistance as patients expressed anxiety about being able to care for themselves. HHAs worried they would be reported to their supervisors if they exerted less physical effort than the patient. The HCA policy of placing HHAs for standardized blocks of time, although efficient for scheduling, inadvertently fostered patient dependence and complicated setting limits on HHA activities. HHAs reported performing inappropriate tasks because they and their patients believed they should stay busy. All HHAs with whom we met described how unclear expectations resulted in their assuming inappropriate household chores. For example, a patient's daughter left the HHA written instructions to wash the entire family's dishes left from the previous evening. Male HHAs described pressure to perform such handyman services as moving furniture and seasonal cleaning. When we explored this issue with the older adults in the focus group, they reported the term "home health aide" implied help with housework. They described uncertainty about lines of authority regarding the HHA and feeling obligated to find tasks to "keep her busy."

The work group discovered that many caregivers and patients do not realize that remaining sedentary is hazardous, not recuperative. Staff reported meeting resistance when they suggested increasing physical activity or functional independence. It was evident that many gauged how "good" a staff member was by their performance of physical tasks. Staff reported that attempts to teach patients safer methods for ADL performance were met with resistance, effectively saying, "Let the aide do it if I can't do it like I always did." Time constraints tempt staff to comply rather than investing the energy needed to overcome such resistance.

In the past, HCAs cleaned and repaired donated durable medical equipment, such as walkers or tub benches, for temporary loan to patients. Because accreditation standards now discourage this practice, delayed acquisition of equipment also slowed progress toward independent function. HHAs described assisting patients for extended periods because caregivers and professionals failed to acquire needed equipment.

Identifying and Pilot Testing Solutions
The work group agreed that having a specific stated goal of care was essential and that—depending on the type and severity of the event—it was generally realistic to expect patients to regain the functional abilities they had just prior to the event that precipitated home care (Table 3 ). Chronically "deconditioned" patients might even improve above that baseline. The work group discussed engaging patients in goal setting, realizing that too often goals are set for, rather than with, patients. Review of the literature (Bradley, Bogardus, Tinetti, and Inouye 1999; Kiresuk and Sherman 1968; Molde and Baker 1985; Prochaska 1991; Rodin and Langer 1977) led to agreement to specifically ask patients what they hoped to achieve during home care and precisely what help was needed to reach that goal. Patient goals were recorded on the Self-care Progress Report, and staff explained their interventions in relation to goal achievement. Discussing goals with patients taught clinicians the importance of assessing recent (2–4 weeks) functional abilities, identifying existing systems for meeting needs, and developing a shared definition of when goals had been met. The work group identified the importance of patients, family, and HCA staff sharing the ultimate goal of achieving functional independence.

Having the Self-care Progress Report better prepared the nurses to effectively handle instances where patient expectations exceeded the amount or type of service considered justified. The report provides the nurses with the needed objective data to explain their decisions regarding HHA placement, making negotiations less arbitrary. Some patients, usually those who received significant amounts of care in the past, did not agree with our care plans and asked their physicians to refer them to other agencies, but the volume of such cases was no greater than usual. There were no complaints to staff monitoring patient satisfaction as a result of implementing the Restorative Care model.

Use of the Self-care Progress Report was central because it clarified goals, established the baseline, standardized the assessment for HHA placement, clarified care responsibilities across the multiple providers, and tracked patients' incremental progress toward functional independence. It provided the staff with a framework for describing the purpose of home care. After the admitting clinician started the Self-care Progress Report it remained in the home as a guide, updated as the patient progressed. Often the nurse and patient agreed that an HHA was not needed. When assessment indicated the patient did not have or was not expected to regain function for a particular task, the staff immediately pursued non-HCA sources for ongoing assistance. The goal of HHA care was to help the patient safely practice regaining function. Use of the report authorized HHAs to expect patients to become more active in ADLs and IADLs and protected them against unrealistic expectations. The report specified the ADL subtasks the HHA performed initially and clarified that, to foster independence, as the patient could do more the HHA would do less. The HHA hours would gradually decrease to avoid abrupt changes in the pattern of care. It was also found helpful to stop HHA care before stopping professional visits, to reassure patients that help was still available should issues arise during the adjustment time after the HHAs were withdrawn.

The nurses learned to explain and reiterate the functional goals of care, especially for patients who previously had "do-for" home care. By objectively assessing and documenting those tasks the patient could perform without help, staff were better able to differentiate between necessary help and care that the patient, family, or physician desired. During pilot testing we identified patients already receiving home care services who, although apparently physically capable of more self-care, resisted attempts to alter their functional status. We used these situations—for which any change would require extraordinary, united, clinical, and administrative efforts—as case studies to learn how HCA staff might avoid creating similar dependency in the future.

To hasten patient progress, therapists and nurses were cross-trained in screening assessments of impairments that can impede function: mental status, depression, and gait and balance deficits. After this training, staff reported heightened awareness for early referral to other disciplines to increase patient mobility and participation in self-care. Identifying the need to broaden HHA training, a group of eight HHAs were paid to attend an all-day restorative care conference specifically designed for our project and held at a rehabilitation hospital. Conference faculty were physical and occupational therapists, rehabilitation aides, and a behavioral psychologist. The curriculum, based on a Rehabilitation Hospital Aide Program, addressed basic rehabilitation services including coaching patients on ADL subtasks, mobility activities, and use of assistive devices. HHAs were trained to help patients follow through on prescribed exercises and gait and transfer training. HCA nurses and therapists participated in role playing and discussions with the HHAs. This conference broadened HHA training and highlighted the unique wisdom and ability that experienced HHAs contribute to improving function in older patients. Several HHAs noted they had never before been invited to a multidisciplinary education session, paid to spend a day talking about their work, and treated to lunch.

Our philosophy of dissemination was that those who were expected to implement the change needed to have the time to help develop the process. After a year of incrementally testing and refining our methods, work group members and their supervisors were enthusiastic about disseminating the restorative care model to all clinicians (11 nurses, 12 physical therapists, and 1 occupational therapist) in the demonstration branch. Educational sessions, small group discussions, and individual case reviews were used to describe the restorative care model, constantly inviting staff critique and integrating their suggestions. Monthly multidisciplinary staff meetings were instituted for staff to seek assistance with cases deemed to be especially challenging or resource intensive. Because we had trained a small cadre of HHAs, scheduling conflicts commonly prevented assignment of the specifically trained HHAs. To overcome this problem, nurses learned to explain the Self-care Progress Report simultaneously to the HHA, patient, and other caregivers. In addition to being efficient, staff described increased teamwork and camaraderie based on these joint meetings and working toward common goals. Our ideal model would be for all HHAs to have the additional training and then to start each patient placement with a brief joint meeting. When the focus of care became function, nurses reported that they were quicker to involve physical and occupational therapists and to instruct the HHAs to get patients up as soon as possible. HCA supervisors, chart review, and supervisory conversations noted that demonstration branch staff were unique in their emphasis on "getting patients moving." The HHAs' response to the restorative model was particularly positive. They reported feeling more support from professional staff and for recognition of their expertise.

	Discussion

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This small-scale, short-cycle project was designed to engage clinicians in changing the culture of clinical home care, moving beyond disease management to focus on functional independence. We learned that many routines common throughout the home care industry create barriers to the functional independence of older patients. We acknowledge that the characteristics of project participants and this one HCA may have influenced our results, potentially limiting generalization to other HCAs. It is hoped, however, that others will benefit from review of our methods of engaging clinicians and consumers in the design and implementation of change in home care. The central premise is that, for effective dissemination of information, those who implement change must have a hand in developing the process. The project successfully assembled clinicians who developed a practical method—the Self-care Progress Report—for setting goals and measuring increments of functional change in busy home care practice. The HCA staff participated in a process to change their practice patterns. Patients and their caregivers participated in developing care plans to reach their personal goals. Agency-wide adoption of the model awaits objective evidence to substantiate the subjective reports of improved patient outcomes, as reported by HCA staff at every level. Analyses of OASIS data to compare outcomes of patients at the experimental branch to those of case-matched patients receiving usual care in the other HCA branches are underway.

	Acknowledgments

 
This work was made possible by grant support from an anonymous donor to Gaylord Hospital in Wallingford, Connecticut; from the American Association of Retired Persons, Andrus Fund to Dr. Tinetti; and by grant AG10469 (Claude D. Pepper Older Americans Independence Center) from the National Institute on Aging.

Received for publication July 11, 2000. Accepted for publication November 3, 2000.

	Appendix

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	References

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