Understanding the Structures of Home-Based Care Delivery: Developing a Picture of the Home Care Team. Research Team and Funder

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1 Understanding the Structures of Home-Based Care Delivery: Developing a Picture of the Home Care Team Margaret Saari PhD Candidate & Erin Patterson PhD Candidate CHCA 2015 Home Care Summit Research Team and Funder Ann Tourangeau PhD, Principal Investigator Michael Villeneuve MN, Co-principal Investigator Audrey Laporte PhD, Co-investigator Whitney Berta PhD, Co-investigator Margaret Saari PhD Candidate; Research Manager Erin Patterson PhD Candidate; Lead Research Analyst Funded by the Government of Ontario without express permission 1

2 Overview Study context and overview Home care team members Structures of care Home care patient outcomes Over the next 20 minutes we will provide you with an overview of the study, we will describe the members of the home care team and structures of care. Finally, we will discuss home care patient outcomes and the implications of this work. without express permission 2

3 Home Care Sector: Ontario 14 Community Care Access Centers Single point of entry Service allocation 160 service provider organizations Contracted to provide care by CCACs Direct care provision In the province of Ontario, Canada home care is organized by 14 Community Care Access Centers or CCACs. CCACs are the single entry point to home and long term care. Care coordinators, employed by CCACs are responsible for allocating home care services including nursing, personal support and allied health services to patients in need across the province. Direct care is delivered by regulated and unregulated health providers employed by 160 service provider organizations. These organizations are contracted by the CCACs to provide direct patient care. without express permission 3

4 Context Aging population with more complex health issues Increasing demand for home care services Nursing Personal Care Allied Health (physiotherapy, occupational therapy, etc.) To accommodate increased need, care traditionally delivered by health care professionals is often delivered by family caregivers and personal support workers As we all know, the population is aging. People are living longer and as a result experience more complex health issues. Patients most often prefer to remain living in their homes despite complex health issues and challenges with physical and cognitive functioning. This has increased the demand for home based nursing and supportive care. In addition, the provision of acute and post acute care has moved in to community and home care settings with nurses providing the majority of this care. Combined, this has resulted in more and more care being provided by family caregivers and personal support workers. Care provision by unregulated care providers is becoming a more important component of the structure of home based care. without express permission 4

5 Context Task-shifting: the transfer of tasks traditionally performed by nurses and other health professionals to unregulated care providers Core versus added skills Limited research describing task-shifting in the context of the home care team The transfer of tasks traditionally performed by nurses and other health professionals to unregulated care providers is known as task shifting. Personal support workers are trained to deliver a set of core skills for example bathing, medication cueing etc. Added skills are skills that go beyond PSW basic training. Limited research exists examining task shifting in the context of the home care team. As a result, little is known about what care tasks are commonly transferred to unregulated care providers, how this varied group of providers are trained and monitored, and how the shifting of tasks affects patient care outcomes. without express permission 5

6 Study Aim To examine the structures of home-based care teams in relation to patient outcomes. To address this gap in knowledge, this study aimed to examine the structures of home based care teams in relation to patient outcomes. We were particularly interested in understanding how and when care traditionally performed by nurses and other health professions is delegated or taught and assigned to personal support workers. without express permission 6

7 METHODS In this phase we employed two data collection methods, focus group sessions and chart reviews to examine the structures and outcomes of home based patient care. without express permission 7

8 Methods: Focus Groups 13 focus groups conducted over 2 Community Care Access Centers & 6 home care service provider agencies 23 personal support workers 18 personal support services supervisors 17 home care nurses (RNs & RPNs) 12 care coordinators Purpose: to develop an understanding of care team roles and to describe the process for delegating, teaching and assigning care tasks to unregulated care proivders 13 focus group sessions were conducted across 2 CCACs and 6 home care service provider organizations. Service provider specific focus groups involved 23 personal support workers, 18 personal support services supervisors, 17 home care nurses, and 12 care coordinators. Through these focus group sessions we were able to more clearly understand the role of each provider type and to describe the process for delegating, teaching and assigning care tasks traditionally performed by nurses and other health professionals to unregulated care providers. without express permission 8

9 Methods: Chart Reviews Charts belonging to 790 patients were reviewed in 6 service provider organizations across 4 CCACs Sociodemographic, clinical, caregiver, service utilization and outcomes data were abstracted To better understand the structures of home based care chart reviews were undertaken. This allowed us to identify who was providing care and the care activities performed by each provider type. We also sought to understand which care activities were delegated to personal support workers and how often they were providing delegated care. without express permission 9

10 Methods: Sample Selection Randomized list of 310 client episodes meeting study criteria identified at each CCAC (total of 930 charts identified) Inclusion criteria: Home care referral Discharged between Jan 1, 2014 and Dec 31st, 2014 Admitted after April 1, 2009 Classified as long term maintenance patients Older than 18 at time of admission Receiving PSW care At each CCAC a randomized list of 310 client episodes were identified. We chose to over identify charts meeting study criteria as rates of retrieval for paperbased service provider charts are low. Further, some referred home care clients never receive service due to service refusals, hospitalizations or relocation to long term care. Client episodes were identified if they were 1) discharged between Jan 1 st, 2014 and Dec 31 st, 2014, 2) were admitted after April 1 st, 2009, 3) were classified as long term maintenance patients, and 4) older than 18 at the time of admission and received PSW care. Half the sample received only PSW care while the other half received PSW plus nursing care. without express permission 10

11 Methods: Data Sources Administrative data related to identified client episodes referral, admit and discharge dates, costs of care, selected clinical variables Care coordinator notes in CHRIS (Client Health & Related Information System) Service provider charts Nursing charts Personal support charts As patient records are not shared between organizations, multiple sources of data were reviewed for each patient and synthesized into one study chart. Data sources included: 1) administrative data related to the identified client episodes including referral, admission and discharge dates, costs of care and selected clinical variables from the RAI HC, 2) care coordinator notes and 3) nursing and personal support charts at the service provider organizations. without express permission 11

12 PRELIMINARY RESULTS Home Care Team Members without express permission 12

13 Home Care Delivery Process Map Through focus groups sessions we were able to better understand the roles of care coordinators, frontline nurses, personal support services supervisors and personal support workers. The findings of the focus group sessions were synthesized and a process map was developed illustrating the interplay of provider roles across the home care episode. The following slides break down the process by provider role highlighting the responsibilities of each provider group. without express permission 13

14 70 66 Referral Source PSW alone PSW and nursing Percentage of Referrals Patients are referred from numerous sources in both acute and community settings. Patients included in the chart reviews were referred to home care from hospitals, emergency departments, primary care practices, retirement homes (community other), family, and through self referral. Note that as expected, patients receiving PSW plus nursing care were more often referred by hospitals. without express permission 14

15 Care Coordinator Employed by the CCAC Responsible for service allocation and care coordination Big picture understanding of patient status and care delivery In this first step of the process, Care Coordinators employed by Community Care Access Centers are responsible for allocating types and amounts of home care services. Through patient assessment, care coordinators determine which care provider or group of care providers is most appropriate to provide care. Based on the findings of our chart review, it was evident that in the current service delivery model, care coordinators have the most complete understanding of the client s situation including health events, social situations and services utilized allowing them to coordinate care across service provider organizations. without express permission 15

16 Care Coordinator Designation Registered Nurse Social Worker Physiotherapist Occupational Therapist 76.6 Registered Dietician Care coordinators are often nurses but can also be physiotherapists, occupational therapists, social workers or dieticians. In this study, case managers were most often registered nurses. without express permission 16

17 Nursing and Allied Health Employed by the service provider organizations Plan and provide direct patient care Identify opportunity for transfer of skills Provide training for delegated tasks Front line nurses and allied health providers are most often employed by home care service provider organizations and in some cases by the CCAC. These care providers are responsible for the planning and delivery of direct patient care and often identify the opportunity for the transfer of skills to PSWs. In the case where skills are transferred to support workers, nurses often stay involved with patient care to continue monitoring the patient and to order necessary supplies. However, it is the responsibility of the PSS Supervisor to monitor the PSW and assess the care they provide. without express permission 17

18 Personal Support Services (PSS) Supervisor Nurses employed by service provider organizations Train, supervise and manage Assess patients and plan day-to-day care Assess if delegation is appropriate Delegate nursing care when appropriate Participate in delegation Provide on-going support Monitor the need for and delivery of added skills PSS supervisors are nurses employed by service provider organizations and are responsible for managing and supervising personal support workers. PSS supervisors assess patients requiring supportive care and develop care plans. They are responsible for determining whether or not it is appropriate to shift care activities to PSWs. When it is determined that a PSW will perform an added skill, the PSS supervisor participates in delegation or trains the PSW directly in performing the added skill. They are then responsible for ongoing monitoring of the need for and delivery of added skills. without express permission 18

19 Personal Support Workers Employed by service provider organizations Provide day-to-day care (e.g. personal care and added skills) Task Compression therapy Transfers Physiotherapy Medications Urinary catheters Diabetes care Ostomy care Assessment & monitoring Bowel management Examples Compression stockings and wraps Mechanical lifts, two person transfers and transfers with special equipment Range of motion exercises Cueing and administration of oral medications, eye drops, ear drops, medicated creams Emptying bag, bag changes and intermittent catheterization Blood glucose monitoring and insulin administration Bag and appliance change Skin assessment, blood pressure monitoring Digital disimpaction and suppositories Other Enteral nutrition, oral suctioning Personal support workers are employed by service provider organizations and provide direct patient care. The majority of care provided by personal support workers involves support for activities of daily living such as bathing, dressing, meal preparation and medication reminders. However, more and more support workers are being asked to perform care traditionally provided by registered health professionals such as nurses and physiotherapists. In addition to personal care, home support workers are currently applying compression stocking, performing transfers and lifts, assisting patients with range of motion exercises, cueing and administering medications, providing catheter care, assisting patients with diabetes care including blood glucose monitoring and insulin administration, performing ostomy care, assessing and monitoring skin integrity and vital signs, performing bowel management such as disimpaction and suppository administration, and providing enteral nutrition and oral suctioning. without express permission 19

20 PRELIMINARY RESULTS Structures of Care and Home Care Patient Outcomes Next we will describe the structures of care and outcomes experienced by our study sample. The data from 725 patient records was included in this analysis. While data were abstracted from 790 patient records, the data from one region was not included due to poor data quality. Therefore the sample included in this analysis was drawn from 6 service provider organizations in 3 CCACs. without express permission 20

21 Sample Characteristics Mean age is 80.5 years 60.1% are female 39% are married 87.9% have a caregiver The mean age of the sample is 80.5 years, 60.1 % are female, 39% are married and 87.9% have a caregiver. without express permission 21

22 Living Arrangement 22.8% Live Alone 25.4% Live with Spouse 22% Live with Family 29.3% Live in Congregate Living Settings 22.8% live alone, 25.4% live with a spouse, 22 % live with family, and 29.3% live in congregate living settings like retirement homes or group homes. without express permission 22

23 Primary Diagnosis Percentage of Sample PSW alone PSW and nursing The group receiving PSW and nursing services had higher rates of cancer and skin integrity issues as their primary diagnosis. Those receiving PSW services more often had a primary diagnosis of neurological conditions like dementia or Parkinson's, musculoskeletal issues like fractures or arthritis, or functional deficits. without express permission 23

24 Types of Care Received Service PSW Alone PSW and Nursing Physiotherapy 46.6% 51.1% Occupational Therapy 50.4% 67.4% SLP 4.6% 5.1% Social Work 3.1% 8.3% Primary Care Visits 1.4% 4% Other 7.7% 17.9% Community Support 17.7% 12.3% Services Rapid Response Nursing 6.8% 12.6% Specialist Nursing Enterostomal Therapy Continence Nursing Wound Care Specialist 0.3% 2.6% 0.3% 5.6% 2.1% 7.2% Palliative Care 1.1% 25.1% Those receiving PSW and nursing together tend to receive more types of service. This may be because they have more health issues and require more care or this may be as a result of nurses identifying and communicating the need for additional services. Some of this variation is logical based on differences in the primary diagnoses in the two populations, specifically skin integrity and cancer. However, variation in other services, including occupational therapy and physiotherapy, is contrary to what would be expected clinically for the dominant diagnosis groups in the PSW only population (functional deficits, neurological disorders and musculoskeletal issues). without express permission 24

25 Service Provider Organizations Number of service provider organizations ranged from 1-7 with an average of Percentage of Sample Provider 2 Providers 3 Providers 4 or more PSW alone PSW and Nursing Providers On average patients received care from 2.5 different service provider organizations. Only 5.6% of individuals receiving PSW and nursing care received that care from the same agency. Given the current structure of home care service delivery, it is not surprising that the more types of services you receive, the more care provider organizations you will have. However, those receiving multiples types of service are likely more complex and would benefit from more integrated care. without express permission 25

26 Personal Support Visit Pattern Mean length of stay = 429 days (Range: 11 to 1996 days) Percentage of PSW only patients with a service escalation = 23.4% Percentage of PSW plus nursing patients with a service escalation = 39.3% Percentage of Sample x per week 3-6x per week PSW alone Daily 2x per day 3x per day or more PSW and Nursing The average length of stay for home care patients in our sample was 429 days. For those receiving PSW services only, visit patterns were more likely to be one to two times per week. Those receiving PSW plus nursing care had more regular PSW visits, the majority receiving PSW visits either daily or more than once per day. Additionally, a larger proportion of patients receiving personal support plus nursing had an escalation in PSW services over time when compared to individuals receiving PSW care alone. without express permission 26

27 Number of PSWs in 3 months x per week 3-6x per week daily 2x per day 3x or more per day This slide illustrates the number of PSW care providers for the five most frequently occurring visit patterns over a 3 month period. As expected, due to scheduling, visit patterns with more frequent service require more service providers. However the range highlights variation in continuity of care within patterns. Patients receiving 1 2 visits per week had between 1 and 25 different PSWs with an average of 2.3. Those receiving 3 to 6 visits per week had between 1 and 21 different PSWs with an average of 3.9. Those receiving visits daily had a range of 1 to 25 different providers with an average of 6.8. Those receiving visits twice a day had a range of 1 to 30 providers with an average of Finally those receiving 3 or mover visits a day had a range of 3 to 34 different PSWs with an average of without express permission 27

28 Intermediate Outcome Variables % at Risk Who Experienced Event Data on outcome measures were abstracted from the final year of the care episode from CCAC and provider charts and then synthesized across charts to ensure each outcome was a unique event. These preliminary descriptive results reflect the percentage of patients in the sample who experienced an event when they were identified as being at risk for the event. For example, only those with a catheter can experience a catheter obstruction. Similarly, only those with an existing application for long term can be designated a crisis application. Patients were identified as at risk for medication errors when the patient was on service for medication administration, management, or reminders. 39% reported experiencing a fall, 21% developed a new wound, 3% of those at risk for a medication error experienced a documented event, 29% developed a new infection, 18% of those with a catheter developed catheter obstructions, 19% of those with a caregiver experienced documented caregiver burnout, and 70% of those applying for LTC were designated crisis. without express permission 28

29 Outcome Variables ED visits Hospital admissions LTC admission Death The entire sample was considered at risk for this next set of outcomes. Admissions to long term care were considered negative outcomes when the admission was unplanned or crisis. 65% of the sample had at least one emergency department visit, 59% had at least one hospitalization, 17.7% were admitted to long term care and 18% died either unexpectedly at home or in hospital. This death rate does not capture those who were admitted to hospital for longer than 14 days who subsequently died. In addition, multiple emergency department visits (n=244) and multiple hospitalizations (n=150) were common among our sample. without express permission 29

30 Summary of Findings Providers work in isolation and there is really no home care team Home care team roles are fairly well defined, although interaction between care team members is limited The role of personal support workers is expanding to include tasks traditionally performed by health professionals, however, support for appropriate documentation and communication vary across service provider organization Care coordinators often have the most complete picture of the clients health and social situation Home care patients are complex and experience multiple negative outcomes during their episodes of care In home based care, providers work in isolation, there really is no home care team. While home care provider roles are fairly well defined, limited interaction occurs between care provider types. PSWs spend the most time with patients and as a result are often more aware of changes in patient status. PSWs are required to report any patient issues to their supervisor, however, they are not consistently supported to appropriately document and communicate their observations. Because care coordinators are the central point of contact for all service providers, they often have the most complete understanding of the patients health and social situation. However, care coordinators are only aware of issues if they are reported by formal care providers, patients or families. Continuity of care can also impact care providers ability to recognize and act on changes in patient status. Patients being care for in the community are complex, receive multiple types of services and frequently experience multiple negative outcomes. without express permission 30

31 Study Implications PSWs have the most patient contact and need to be supported to appropriately communicate and report changes in patient status Reporting of negative patient outcomes differed across CCAC and provider charts, highlighting the need for a common chart available to all service providers involved in the patient s care Sharing of outcomes data between the CCAC and home care service provider organizations, could facilitate the identification of areas for improvement and motivate the development of targeted quality improvement plans. PSWs spend the most time with patients. Through more extensive education, training and the implementation of structured communication processes PSWs can be supported to consistently and effectively communicate patient issues and changes in status to other members of the home care team. Reporting of negative outcomes varied across patient charts. Often what was documented in the provider chart was not documented in the CCAC chart. Intermediate outcomes were most often documented in provider charts while long term outcomes such as ED visits and hospitalizations were most often documented in CCAC charts. This highlights the need for a common home care chart. By making all patient information available to all service providers, patient issues and changes in status could be identified and addressed earlier. A common chart could also foster a more team based approach to home care. More extensive reporting of relevant, modifiable home care patient outcomes may help to identify opportunities for improvement. Providing home care organizations with access to and support for understanding their patients RAI HC data could facilitate the identification of areas for improvement, motivating the development of targeted quality improvement plans. without express permission 31

32 For study updates visit: THANK YOU! without express permission 32