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 York
Penny.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.
Week 2
Week 3
Week 4
Date:__/__/__
Date:__/__/__
Date:__/__/__
Date:__/__/__
I can do this
I need help to
Independent Needs
Independent Needs
Independent Needs
alone
do this
Assistance
Assistance
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 Tool
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
CHANGE IDEAS
Improved HHA
Field Support
•HHA satisfaction
•HHA Supervision
•Team Satisfaction
•Five Promises tool
•Supervision Every
Visit
•Supervision Six
Documentation Points
Increased
Functional
Improvement at
Discharge
•Functional Outcome at
Discharge: Bathing,
Ambulation, & Transfer
•# of HHA Assisted Activities
ADL tools
•ADL Weekly
Progress Tool
Conceptual Model
Core
Structural
Domains
Organizational/Structural Characteristics
• Communication Processes
• Governance
• Information Technology
Leadership
• Values
• Style
• Strategy
Process
Domains
Supervision
• Communication
• Support
• Recognition, respect
Work Design
• Staffing
• Resources/Training
• Measurement/Rewards
• Autonomy
Group Behavior
• Collaboration
• Consensus
Quality Emphasis
• Patient Centeredness
• Safety
• Innovation
• Outcome Measurement
• Evidence-based Practice
Outcomes
Healthcare Worker Outcomes
• Satisfaction
• Health and Safety
• Organizational Identification
• Turnover
Patient Outcomes
• Satisfaction
• Safety
• Self-care
• Health and Function
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
X
May
Sept
O2
O3
Intervention
(n=21)
Bronx
Brooklyn
Manhattan
R
O1
Control
(n=21)
Bronx
Brooklyn
Manhattan
R
O1
O2
O3
Measurement
Measurement
Measurement
HHA Satisfaction
HHA Satisfaction
HHA turnover
Patient Outcomes
Service Use
HHA turnover
Patient Outcomes
Service Use
Patient SOC
R=randomization; X = observation
X
Evaluation: Analytic Approach
Impact 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
70
60
Percent
50
40
30
20
10
0
Help
Imp
Member
N= 811
MEAN=3.23
STDEV= 0.92
N= 808
MEAN= 3.36
STDEV= 0.85
Never
Sometimes
Apprec
N= 809
MEAN= 3.28
STDEV=0.84
Prog-RN
N= 786
MEAN= 3.18
STDEV= 0.93
Usually
Prog-Patient
N=790
MEAN= 3.48
STDEV= 0.77
Always
HHA Satisfaction -- All Regions
Percent
50
45
40
35
30
25
20
15
10
5
0
Job Satisfaction
N= 747 MEAN= 3.93 STDEV= 1.04
Survey Question
Strongly Disagree
Disagree
Not Sure
Agree
Strongly Agree
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)]