Home Health Care 101.

Home Health Care 101

Home Care Experience? Home Care Myths

Home Care Myths! Where “old” therapist go to die
Can’t do until you have 1-2 years in a clinic Only works with the patient until they can get out to clinic for real therapy All home care patients are bed bound No one does it full time No equipment to do “cool” stuff Not able to specialize Agencies are run by nurses No research /evidence-based practice in home care Home Care Myths

The Whole Truth New Grads Welcomed!
Many Therapists work in Home Care Full Time Many Therapists decide to have specialization in Home Care Therapists play in integral role in the leadership of home care agencies EBP is alive and well in Home Care Home Care Myths

Home Care Agency Structure
Certified Certified by Centers For Medicare & Medicaid (CMS) HMOs and Private Insurance Licensed Private Duty Hospital-Based Hospital Discharges Are Primary Focus Independent All Referral Sources Hospitals SNFs Assisted Living Physician Office Certified by State = all services available by or through the provider organization (required to be able to serve Medicare Beneficiaries) Licensed: A dscipline or group of disciplines. Often sub-contract to certified agencies or treat commercial insurances that piece together providers to provide service to a patient/beneficiary. Profit/not for profit: For profit; revenue goes to shareholders Not for profit “revenue/surplus suppliements other operations and expeditures Hospital based serves their facility first…all types of patients all the time Free standing focuses on the referral sources For-Profit Profits To Owners/Shareholders Pays Taxes Not-For-Proft “Surplus” Must Be Used Within The Organization; Related to Mission Tax Exempt Revenue Remains Important

What Is ‘Certified’ Home Health Care?
Billing Through Major Payers Medicare/Medicaid Private Insurance, HMOs Interdisciplinary Team Skilled Nursing Physical/Occupational/Speech Therapy Medical Social Work Registered Dietician Home Health Aide Regional Structures: From Belle May’s book on home care, the history section: East coast Immigrant & indignent based, urban areas, not for profit (the oldest agencies are in Boston, NYC, Phila, Baltimore) West coast rolled out with city development, part of settlement/ planning, often organizations like united way, city or other population based service.

Skilled Nursing/Inpatient Rehab Facility
Continuum Of Care Hospital - Skilled Nursing/Inpatient Rehab Facility Home Health Care Outpatient Services Case Example Total Knee Replacement Surgery Best Outcomes? Most Cost Effective? Bundled Payment

Patient Populations Pediatrics Adult Early Intervention Acute
Providers Credentialed By New York State Preschool Age Adult Acute Skilled Services Short-Term/Restorative Improvement Anticipated Long-Term Personal Care Assistance Program Funded by Medicaid Maintain Health & Wellness Hospice Palliative Care For Terminally Ill Physical, Emotional, and Psychosocial Needs < 6 Months To Live Early Intervention-0 through 2 year Pediatric children up to 18 or 21, depending on payer/policy Adult Acute: short term restorative phase and goals, traditional home care, the largest part of home care at this time. Hospice: palliative care. Require 6 month prognosis from physician. May have their physician or chose physician with team. Dispell the myth that the patient has to give up their physician…some do change to a physician who is on the team and has a palliative focus. Team usually follows the patient and family for one year after death of patient (Medicare and other insurance policies) Has all disciplines, plus pastoral (multiple religions for the community served), bereavement counselers, volunteers (to sit, talk, read, comfort) Pre-Operative: In a case rate system, sometimes PTs see patient to assess them, their home, set up HEP, ice, bed, bathroom, etc for immediately returning home. Coming directly home post-op day 3-5 for elective joint replacements has the same outcomes (pain, ROM, akmbulation) as SNF and Rehab facilities. Home care costs less, (than SNF or inpatient rehab) and the patient is in their home, family, food and social environment. Health & Wellness: An area to grow in the future, as currently most payors reimburse when there is a patient problem. Some payors are looking at preventative home assessment and exercise programs to keep their elders healthy longer. Example: Aetna on the east coast refers older adults/seniors (do not call them elderly) who have no ongoing medical care/recent hospitalization for a PT and OT program of 6 visits over two months. The PT and OT assess the home, functional level, and exercise routine(s). Safety in lighting, falls risk and other areas are addressed through education, follow-up visits (in frequent over two months). This is a shift for both the patient (I am not sick, why do I need a PT (and not home bound) AND the PTs…what am I treating, as the patient does not have a problem. YOU (the students) have the opportunity to dispell these myths and perceptions…Some PTs are doing it now, mostly self pay referrals, but this service is a great opportunity for us and them

Typical Diagnoses Cardiopulmonary General Medical Falls Prevention
Orthopedics Joint Replacement Surgery Fractures Neurology Stroke Multiple Sclerosis Parkinson’s Disease Amyotrophic Lateral Sclerosis Cardiopulmonary Heart Failure Chronic Obstructive Pulmonary Disease General Medical Frail Elderly Extended Inpatient Care **Medical Management Skills Vital Sign Monitoring Wound Assessment Triage

What Defines “Home”? Patient’s Home Family Member’s Home
Independent Living Facility Assisted Living Facility Group Home

What exactly is HOME? Private Home Mobile Home
Assistive Living Facility Independent Living Facility Apartment Group Home

There’s No Place Like “Home”

Home Health Care Who Qualifies?
Conditions Of Participation (Federal) Acceptance of Patients “Patients are accepted for treatment on the basis of a reasonable expectation that the patients medical, nursing and social needs can be met adequately by the agency in the patient’s place of residence.” Medicare Benefit Manual Homebound Skilled Service Physician Order Direct Access is N/A…unfortunately Reasonable & Necessary Intermittent Acute Change in Condition Rehab Potential Maintenance Therapy Jimmo vs. Sebelius Unique/Individualized Care Plan The gold standard, Many but not all other payors require homebound COP’s (CFR – code of federal regulations) 42 CFR Acceptance of patients “Patients are accepted for treatment on the basis of a reasonable expectation that the patients medical, nursing and social needs can be met adequately by the agency in the patient’s place of residence.”

Payment Medicare: Prospective Payment System (PPS)
Instituted in 2000 Fixed payment for 60-Day Episode Of Care Case Severity Determines Payment Outcomes Assessment Information Set (OASIS) Therapy services **Home health services that meet the guidelines are covered by Medicare at 100%. Medicaid Recent NYS Reductions Episodic Payment Managed Care Fee-For-Service FFS = Fee For service. Every visit or skilled treatment activity is billed. The incentive is to provide more care to earn more money…is that in the best interest of the patient? Case rates: Allow the provider to manage the costs of providing care and the service needs of the patient. Medicare PPS is a tiered case rate, detailed to the clinical function and service needs of the patient. We will talk about the details of PPS later

Home Health Medicare PPS
Base episode rate is $ Responses to specific OASIS questions are organized into 3 domains: Clinical and Functional Severity Each Item Has A Severity-Based Point Value Service Utilization (Therapy) Greater Medical Complexity = More Reimbursement

Clinical Severity Domain
Diagnoses Parenteral/Enteral Nutrition or IV Infusion Vision Pain Wound/Lesion Pressure Ulcer Stasis Ulcer Surgical Wound Dyspnea Urinary Incontinence Bowel Ostomy Behavioral

Clinical OASIS Question

Functional Status Domain
Dressing upper body Dressing lower body Bathing Toileting Transferring Ambulation/Locomotion Ability To Self Manage Injectable Medications

Functional OASIS Question

Service Domain Receipt of Therapy Visits Physical Therapy
Occupational Therapy Speech Therapy Additional Reimbursement >/= 6 Combined Therapy Visits Medicare sees value in Therapy! Falls prevention Re-Hospitalization Functional Mobility

PPS Payment Variations...
Low Utilization Payment Adjustment (LUPA)– Four (4) visits or less are paid on a per visit basis Skilled Nursing $102 Physical Therapy $112 Occupational Therapy $113 Speech Language Pathology $122 Medical Social Work $165 Home Health Aide $47 Typical Reason For A LUPA? Partial Episode Payment (PEP) Patient is admitted to Agency A, then elects to transfer to Agency B. Agency A receives a proportional payment based on length of stay Patient meets treatment goals, is discharged, then subsequently re-admitted during same 60-day episode Don’t need to memorize these, just realize there are variations for when a patient has low or changing needs in healthcare during the 60 days from when they start home care. Most patients do not stay on home care 60 days, but there is fiscal recouperation for money if the patient is rehospitalized or uses another provider for skilled services with in that sixty days. The emphasis is for home health agencies to ensure the patient has learned and integrated the skilled care and able to sustain it. So we do not always discharge immediately when they feel great, expecially if they are frail or inconsistent in their ability to function. We may monitor and mentor along that week or two if unstable history or progress to date.

Face-To-Face Encounter
Direct Meeting Between Patient And Physician/Non-Physician Practitioner Medicare Requirement 60 Days Prior To OR 30 Days Following Home Care Admission Signed Attestation of Qualification For Home Care Services

Home Care Clinical Outcomes
Outcomes Assessment Information Set (OASIS) Centers for Medicare (CMS) system for measuring patient outcomes Therapist can become certified specialist in OASIS: COS-C Clinical specialist HCS-D Coding specialist Outcomes measure for patient care Reported on internet so clients can compare agencies outcomes Many of the measures are related to function Responses to 22 specific OASIS questions are organized into 3 domains: Clinical Severity Functional Status Service Utilization The combination of the three totals creates a Home Health Resource Group (HHRG) OASIS ASSESSMENT (Outcome Assessment Information Set) ADL (activities of daily living) Gait Skin Pain Medication Management Transfers Cognition Caregiver support

Patient Satisfaction Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Home Care Compare

Benefits of Home Care PT Practice: Case Load
1:1 Patient Care 45min-1hr sessions 5-6 patients/day Changing work environment Autonomy and flexible schedule Benefits to Home Care Practice

Benefits of Home Care PT Practice: Clinical Care
Autonomous practice Ideal setting for functional training Opportunity to fully understand patient perspective Interdisciplinary collaboration Must mention that a new grad coming to come care must be independent, organized, and willing to seek assistance/guidance when needed.

Vision 2020: six pillars Autonomy Professionalism Direct Access
The Doctor of Physical Therapy Evidence-Based Practice Practitioner of Choice

Specialization Of Services
Advanced Training Diagnosis Specific Parkinson’s Stroke APTA Board Certification Multiple Areas of Specialization Geriatrics Neurology Orthopaedics Cardiovascular & Pulmonary Pediatrics 2,000 hours of clinical practice in the specialty area

The Challenges Of Home Health Care

Time Management Autonomous Practice Maximize Time With The Patient
Organizational Skills Scheduling/Travel Route Flexibility With Scheduling Patients Sometime Unavailable MD Appointment Hospitalization Integrating Documentation Into The Visit How Good Is Your Memory? Exit Strategy Loquacious

Rural Home Health Distance Between Patients Proximity to Office
Windshield Time Proximity to Office Team Meetings/Ongoing Education Cell Phone Coverage Mentorship

Weather

What Poses The Greatest Safety Risk For Home Care Clinicians?
Safety & Security What Poses The Greatest Safety Risk For Home Care Clinicians?

Safety & Security If Something Doesn’t Feel Right… Security Escort
Pet Policy Needle Sticks Crime If Something Doesn’t Feel Right… Security Escort Off-Duty Police Officers Mandatory For ALL Staff

Variety Of Living Conditions
Home Environment Family Support Abuse APTA Code Of Ethics 4D. Physical therapists shall report suspected cases of abuse involving children or vulnerable adults to the appropriate authority, subject to law. Social Work Adult Protective Services (APS) Child Protective Services (CPS) Community Resources

Physical Therapy Assessment in Home Care
PMH and previous level of functioning Gait ADL & IADL Cognitive/mental status Cardiopulmonary status (Vital Signs) Integumentary Neurological Musculoskeletal PROM AROM Strength Social Support/Caregiver Involvement Environmental/Home

Home & environmental assessment DME: Present, ordered, needed Living space: Functional & Quality of life Home Safety Assessment Proper lighting Assess the appropriateness of a “Lifeline Alert System.” Safe stairway/hallway entrances Removal of throw rugs, cords Recommendation for bathroom grab bars, tub seat, other DME

What are your home safety recommendations?

How do we meet our patient’s needs, while still keeping staff safe?

Evidence Based Assessment in Home Care
Assessing Strength 5 Times Sit to Stand 30 Second Sit to Stand Assessing Upper Extremity Gross Function Functional Reach Assessing Cardiovascular Endurance 2 Minute Step Test 2, 4, 6 Minute Walk Test Assessing Agility 4 Square Test Reassessment requirements

Evidence Based Assessment in Home Care
Assessing Balance Berg Balance Scale Dynamic Gait Index Tinetti Assessing Cognition Mini-mental status exam Montreal Cognitive Assessment (MoCA) Assessing Functional Activities Barthel Index

Timed-Up-And-Go Before & After

30-Second Chair Stand Test2,3,27
Measures Endurance, Strength, Transfers Purpose Measure number of stands completed in 30 seconds. Time to Administer 30 seconds Equipment Required Chair and stopwatch Norms Age Male (norm) Female (norm) 60-64 14-19 12-17 65-79 12-18 11-16 70-74 10-15 75-79 11-17 80-84 9-14 85-90 8-14 8-13 90-95 7-12 4-11 The procedure for the 30 second sit to stand is the same and you count the number of times the patient comes to a full standing position. If the timer runs up while they are ½ to a full stand, you count that as one. So, lets get the blood flowing and have everyone perform this one. The 30 second sit to stand is the same activity as the 5x sit to stand but now we are measuring the amount of reps that can be completed in 30 seconds. This tool will be more useful in two circumstances, If your patient will not have sufficient strength or endurance to complete 5 stands. If you are looking more at endurance and power in a higher functioning patient. This is obviously as great measure of functional performance of transfers. So if you have goals for transfer training, this would be a good tool to measure progress. You can see there are some normative data based on the patient’s age and sex that you can use as justification for therapy treatment.

Two Minute Step Test Measures
Muscular endurance, cardiovascular endurance, balance and strength. Purpose Tests functional fitness in seniors. Equipment needed Stopwatch Procedure Pre test vitals signs. Mark midway between iliac crest and patella. Have patient march for 2 minutes. Knee must rise above marker. Count the number of times the right knee rises above the marker. Post test vital signs. The Two Minute Step Test is another simple tool that can be administered quickly and with minimal to no supplies. Essentially, you will be having your patient march in place for 2 minutes. The procedure for this test is to have the patient standing, you will take a measure at the midway between the iliac crest and the patella. This is the point where the patient must elevate their knee with each march. You will be counting the number of times the right knee rises above the marker. Since this will certainly elevate the HR and BP of your patient, you should be monitoring vital signs and instructing them to stop if they have any chest pain during the testing.

Two Minute Step Test Male Norms
Age % Rank 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95% 135 139 133 126 114 112 75% 115 116 110 109 103 91 86 55% 104 98 95 90 78 72 35% 93 92 80 66 59 15% 79 77 71 63 62 50 42 5% 67 47 48 36 26 Here are the norms. Now this shows the percentile ranking by age. So you can se to be in the 95th percentile a male years old should be completing 135 marches with the right leg. Jones CJ, Rikli RE. Measuring functional fitness of older adults. Journal on Active Aging. 2002: 24-30

Two Minute Step Test: Female Norms
Age % Rank 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95% 130 133 125 123 113 106 92 75% 107 101 100 90 85 72 55% 94 93 87 78 73 61 35% 82 80 74 75 66 50 15% 63 58 59 51 47 36 5% 52 43 45 37 39 24 Here are the female reference norms. Again, this type of data helps give you perspective on how your patient faires compared to their age norms, but also helps justify your plan of care. Jones CJ, Rikli RE. Measuring functional fitness of older adults. Journal on Active Aging. 2002: 24-30

Physical Therapist’s Role
What is the overall “plan” for the patient, and how do your PT goals help to meet the plan? Develop goals WITH the patient. What were you able to do a month ago that you would like to be able to do again? Develop goals WITH the TEAM. Provide cost-effective care, while meeting the functional needs of the patient. 3 49 49

Developing Goals Who are the goals derived for? Measurable
Function related Achievable Patient/caregiver Agreement Participation

Communication and Collaboration
The Clinical Team Coordinator of Care Physician and other services Patient, family, & caregivers Payers: managed care Durable medical equipment (DME)

PT Intervention in Home Care
Strengthening ROM/stretching Gait/Stair training Transfer/Bed Mobility Training Balance training DME training Coordination & proprioceptive training Motor learning Orthotic/Prosthetic Training Modalities Moist and dry heat Ice Electrical Stimulation Ultrasound Wound Care Edema management Pain management Sensory retraining Breathing/respiratory training Falls prevention/education

Discharge planning Establish role and goals from day 1
Avoid learned helplessness Link to patient goals Other team members Community resources Continuum of care

Where Do We Discharge? Discharge with home exercise program
Discharge with caregiver to assist Discharge to outpatient PT Discharge to day program

Technology I Remember The Day….

Point Of Care 7” or 10” Samsung Galaxy Tablet 99% Electronic
Documentation Efficiency Portability Average In-Home Time= 43.2 minutes Average Documentation Time After Visit= 11.7 minutes Visits= 72% of documentation completed in-home Work-Life Balance

Virtual Meetings Multi-Branch Agencies Shared Education & Updates
Common Goals ‘Connection’ To Team

Telehealth

Telehealth Telecommunications Technology For Remote Patient Monitoring
Complex Medical Conditions Heart Failure, Uncontrolled HTN, COPD High Risk For Emergent Care or Re-Hospitalization Cost-Savings Quality of Care Monitors Blood Pressure, Pulse, Oxygen Saturation, Weight, And Blood Glucose Data Analyzed By Registered Nurse Alert By Exception Coach Patient To Self Manage Alert Home Care Staff and Physician

Stretch Break

Diversity Diversity is a collection of individuals bringing together varied demographic, cultural, intellectual, and philosophical differences. Our conversation is going to dive into a the topic of diversity for the second half of this session. If time allows, after we get through all the content of the slides, we will be breaking out into groups to complete case studies. The case examples we will be talking about are specific to home care, however, the concepts can be applied to almost every setting. So, Diversity…

Diversity How do we differ? Age Gender Culture Sexuality
Socioeconomics Education Physical abilities Religious beliefs Political beliefs Ideologies Here is a list of all the ways we, as individuals, can differ. I guarantee everyone in this room varies from one another in at least on of these items. You can imaging that the patient’s you will be working with likely vary even more. We have vary in our age, gender, culture, sexuality….

Diversity We need to provide care that:
Accepts, respects and understands that each individual has an uniqueness that can be in the dimensions of race, ethnicity, gender, sexual orientation, socio-economic status, age, physical abilities, religious beliefs, political beliefs, or other ideologies. As health care professionals it is our responsibility to provide care that:

Diversity: Education Health Literacy
Average American reads at an 8th grade level. 1/5 Americans are functionally illiterate. 21% cannot read the front cover of a newspaper People with low health literacy utilize health care services more often regardless of socio-economic status One of the ways our patient’s will vary is in their level of education, and particularly, their reading capabilities. Who has heard of the term Health Literacy? Health Literacy is defined as the ability of an individual to read, understand, and use healthcare information. Now you have all been in college for a long time, and it can sometimes be easy to forget that level in which you can read, write and verbally communicate is well above the level of much of the American population- and the majority of your like future patients. I’m going to show a video developed by the AMA Foundation that discusses this topic. Did anyone have any thoughts about the video?

Diversity: Education Speak in lay terms
Have your patient repeat or return demonstration to ensure understanding Provide images with minimal written instructions Don’t assume all patient’s have health literacy Acknowledge the challenges of reading medication instructions When working with patient’s in home care, or any clinical setting, it is important to always speak in lay terms. We should use caution when you use any technical language. Remember that your language should adjust for your audience. If you are talking to your CI, use technical language like Ambulation and gait, but when you are talking to your patients you should be saying “Walking.” You should be verifying the patient understands the information you provided by allowing them to ask questions and paraphrase so you can know what they have learned. For example, I will provide information, then ask if the patient has any questions immediately after providing the information. I always acknowledge that the information is complex and that I’m happy to answer any questions they have to create that environment where they feel like I won’t judge them if they need further clarification. When providing written materials I will use forms that maximize use of images or pictures. When I’m first introducing the handout, I will read it aloud with them in a position so they can read it as well. Later in the session I may have them demonstrate using the sheet to see how well they can use it as a tool. If their literacy is really low, then repetition of the information is key to retention and understanding.

Case Study #1 Linda Robinson is a 55 year old female you have been seeing s/p BKA. Your plan is for her to continue with a HEP after discharge. The Social Worker on the case has informed you that the pt is functionally illiterate and quite embarrassed by it. What strategies would you utilize to provide the comprehensive HEP she can complete properly, while being sensitive to her reading level? Be empathetic to her situation. Acknowledge that your goal is to provide an exercise program that she is familiar with and can complete without written instructions. Start working on the HEP each session. Help the patient become familiar with all the exercises that will be included. Provide HEP with pictures only. Have the patient return demonstration of the HEP using the handout provided or my memory. Have her demonstrate the program more than once over multiple sessions. Involve a family member.

Diversity: Age & Generation
Multi generational challenges What is a generation A group of people of the same age range who tend to hold shared interest and attitudes. These shared values are the product of witnessing historical and cultural events in one’s formative years. Communication Between Generations Video Now everyone in this room has probably encountered age and generational diversity just in regular daily life. I’m sure everyone has family or friends who are from different generations. Generation is defined as… I’m going to show a video that showcases how different generations case be and how communication between individuals from different generations can be difficult. Does anyone feel like they can relate? This is obviously designed to be humorous, but considering you will be working with patient’s of all generations, it is important to understand each generational group so you can be more sensitive when you are communicating and trying to create trusting therapist-patient relationships. Gen Y vs boomer

Traditionalist Born (70-89 years old) World War II, Great Depression era Family members and gender roles, religion, rituals, and friends and enemies clearly defined Intercultural relationships were almost non-existent Never jump the chain of command Respect authority Limited exposure to technology So I’m going briefly going to reviewing they main generational groupings. The Tranditionalist Generation was born from so they are years old. In home care this is a large portion of our patient population. This Generation was a live during world war I and the Great Depression. They saw America through some very trying times but then through some very prosperous times like the 50’s and 60’s. That generation was raised in a segregated world where there was little integration of race or religion. This was just the norm during that time. Whether it is right or wrong, you may still encounter some racism or feelings of discrimination among this generation. When they were growing up they were raised to respect their elders, so they expect the same now that they are elderly. They tend to have always respected authority, and particularly relevant to you, is their respect for their physician. This generation has had little exposure to technology.

Boomers Born between 1943 and 1965 (48-69 years old) Raised in suburbia with many home conveniences Most lived in two parent homes where mom stayed home “Leave it to Beaver” values Can be demanding and self-motivated The Baby Boomers are between the ages of They were raised by the Traditionalists, so some of those values of the traditionalists have carried over to the boomers. America has really prospered throughout their lives, so it is their expectations that that will continue. They have tended to be very hard working people who the media now jokes will just not retire. Their strong work ethic and desire to accomplish comes out when you are treating them in as a physical therapists because they tend to be driven and may come across as demanding.

Gen- X Born between 1965 and 1977 (36-48 years old) Raised in era of outstanding technology Schools became more integrated Working mothers became the norm Computers were introduced in schools Generation X is years old. They were the first generation to really have a lot of exposure to technology. Their youth and adulthood has been fully integrated, so some of that discrimination is much gone with this generation and the subsequent generation. This generation which was originally considered the “wasteland generation” because it included people like Kurt Cobain, has really proved to be motivated much like the boomers.

Gen –Y Born between 1977 and 1999 (12-35 years old) Extensive knowledge of technology Schools fully integrated and students experiment with cross cultural clothing, music, language and relationships Because of multi-levels of activity they are good time managers and multi-taskers Finally, there is generation Y which are those between the ages of How many of you are Gen Y? This generation was practically raised immersed in technology. Now only is everything integrated legally and socially, but there is more cross cultural integrating. It was the norm for this generation to be involved in many different intercurricular activities and when coupled with the immersion in technology you end up with a generation that is excellent at multi-tasking. Giving most of you are gen Y, consider how different this generation is from the Traditionalist. As a health care provider, particularly in the home, you will likely need to adapt to your Traditionalist patient’s to meet their needs completely.

Case Study #2 You enter the home of 90 yo Jack McGuire for your evaluation s/p a hospitalization for a CHF exacerbation. He is confused when you introduce yourself as Doctor stating, “I already have a doctor, plus you are too young to be a doctor.” You notice pictures on his walls of fighter planes from WWII and he goes on to tell you he was a fighter pilot in the war and how much he hates the “japs.” As you begin documenting on your tablet he becomes irritated stating “Why are you wasting my time?” What strategies could you use to have a better outcome?

Diversity: Language & Culture
CLAS standards: Federal Guidelines 14 standards that call for National Standards for Culturally and Linguistically Appropriate Services in Health Care 4 Standards address Translation All Health Care providers who participate in Medicare and Medicaid programs must incorporate these standards There are Federal Guidelines for standards of care that are culturally and linguistically comprehensive. These guidelines address the need to provide transition services in health care.

Diversity: Language & Culture
Using an Interpreter Be cautious if using family to Interpret Interpreter should stand next to you You should always speak to the patient, NOT the interpreter. Speak slowly Avoid slang Avoid idioms In home care it is common to need to utilize a Translator when you work in urban areas such as Rochester. So I want to cover some pointers for using an interpreter when you are in home care. We have two interpretive services available in home care. One is the Language line which is a phone line a clinician can call where an interpreter can be put on speaker phone to translation to the patient. The challenge to using a language line is the inability to effectively navigate the home while utilizing the translator. For example, if I’m trying to show a patient how to complete some standing exercises I have to verbally describe the exercise to the translator then have the translator attempt to explain the exercise to the patient without actually seeing what I’m doing. So you can imagine how much can get lost in translation. So, ideally we will utilize an actual interpreter who can make home visits with myself or the clinician. Some pointers for using an interpreter are to have the interpreter stand next to you. You want the patient to be looking to you when they answer. You should always be talking to the patient versus the interpreter. You want to avoid doing things like this, “Chris, can you tell Ms. Chamberlain to stand up?” You should always speak slowly, not so the patient can understand you, but so the interpreter doesn’t miss anything. Don’t speak loudly..unless your patient is legitimately HOH. Avoid slang and avoid idioms like: “I’m pulling your leg” “We’ll keep an eye out for that”

Diversity: Language and Culture
Provide care that fits the culture Be willing to learn Learn to count, say hello, and thank you Ask about their customs Therapists must be able to abide by cultural needs and Rules and Regulations mandated by our health care system When it comes to language and culture you should always be providing care that fits their culture. I recommend showing initive to understanding you patient’s language or culture or customs. However, you must always provide care that still meets the rules and regulations of the health care setting you are working in.

Diversity: Language & Culture Hispanic
HCR Home Care Transcultural Nursing Overweight= sign of health/wealth Declining hospitality is viewed as disrespectful Outward signs of faith should be acknowledged Family is very involved Respect for elders Proud and my not admit inability to understand due to language barrier So we are going to talk about 3 large cultural groups for which HCR has Transcultural Clinical Teams: Hispanic, African American, and Russian/Ukranian. In the following video the concepts of Transcultural Nursing are highlighted, but it is very important for everyone to realize that the concepts are the same no matter what discipline you are.

Case Study #3 You arrive with an Interpreter to see Juanita Rodriguez for balance training s/p multiple falls in the home. She is an 80 yo Spanish-speaking Puerto Rican woman who lives with 3 generations of family. The extended family tends to congregate in her home which made it difficult for the patient to follow your instructions last time. The daughter has offered you and the Interpreter tea and an empanada when you enter. You have 45 minutes to complete your session before your next appointment. What actions will you take to provide culturally competent care?

Diversity: Language & Culture African American
Tuskeegee Project Building a trusting relationship is key Respect for elders Extended family and clergy are important especially in times of illness Female head of household=competing priorities Who is familiar with the Tuskeegee Project? This was a research study conducted from on impoverished, rural, African American men who were infected with syphilis. Essentially these men were entered into the study told they would receive free health care, meals, and free funeral insurance. They were never told they had syphilis, and they were never treated even when penicillin was validated as a medication to cure the disease in During the course of the study many of the men died from complications related to the syphilis and many infected their partners. The study was discontinued only after the ethical issues were widely publicized. This created a culture African American mistrust in the health care system. So knowing this piece of history, it is important to acknowledge the possibility of mistrust and take steps to create a trusting relationship with your African American patients. The African American culture tends to focus around family. Elders and clergy are respected. Extended family and clergy tend to be involved when individuals are ill. There is a tendency for women to be the head of household who are not only responsible for managing the household and children, but also to work. This creates competing priorities, so whether you are treating the mother, the grandmother, or the children, the effects of these over extended women can impact health care compliance or adherence. Acknowledging these struggles is very important.

Case Study #4 Elsa Johnson is a 50 year old morbidly obese (350#) woman who lives in a 2 bedroom apartment with her adult daughter and 3 grandchildren (ages 2,4,6). Her daughter works the C shift and sleeps during the day so Elsa is responsible for watching the children. You are referred for a home safety assessment, pressure ulcer prevention/education, and proper equipment for pressure relief d/t pressure ulcers. The nurse is doing the dressing changes. The patient already had to reschedule your evaluation 2x because the “children were out of control.” She lets you in the apartment and says “lets make this fast.” You find the patient has no pressure relieving equipment and the home has limited space for her walker to navigate especially in the bedroom d/t many totes and trash bags of clothing. How can you do the meet the patient’s medical needs while considering her cultural and socioeconomic?

Diversity: Language & Culture Russian/Ukrainian
Totalitarian societal background Notorious for non-compliance d/t societies that place low value on self-reliance Difficulty answering questions about themselves directly Medical care is “crisis related” Limited focus on preventative care In Rochester we have a large Russian and Ukrainian Immigrant population. For that reasons HCR has a Russian/Ukrainian Clinical team. Many of the immigrants are elderly and were raised in Totalitarian societies like Communist Russia. So it is important to remember that this type of governmental structure deemphasized self reliance and individualism. All citizens of Communist Russia were reliant on the government for many aspects of life. So for that reason, this population is notoriously labeled “non-complaint” but with understanding their governmental structure, it is easier to understand and address. They individuals tend to come from societies where medical care is only provided during crisis so there is a lack of focus on preventative care. It is common that instead of taking medications on a regular basis to control or prevent disease they will take the medication PRN, however that is not the intention. The same concept applies to Physical Therapy. It is important acknowledge that their exposure to health care may have been different in Russia or Ukraine, much like the Hispanish culture.

Diversity: Language & Culture Russian/Ukrainian
Family is typically told about terminal illness first Punctuality is important Removing shoes in the home is customary Guests are offered food, coffee or tea Some nuiances of beign in the home of a traditional Russian or Ukrainian indivudal is punctuality is very important. If I was 5 minutes late to a therapy appointment, it was very offensive. A simple phone call when you are running late can go a long way to repair the situation. This is much different than the Hispanic culture where punctuality doesn’t matter much. Removing shoes in the home is customary. And guests are offered food or coffee or tea when visiting. Again, it is offensive to deny this offer.

Case Study #5 You are re-visting Alexandiy Vsyokovic for PD exacerbation. Your co-worker completed the evaluation. He was a Physician when he lived in Russia but retired and moved to the US to be close to his son. They live in subsidized housing in a Russian/Ukranian neighborhood. You arrive 15 minutes late with the Interpreter. You enter the home and the pt’s wife seems anxious and asks you to remove your shoes. Your companies policy says you cannot walk in socks in a home. Upon questioning the wife says (via the Interpreter) “His blood pressure was good yesterday so I didn’t give him any medication, today it was up so I gave him an extra dose of the lisinopril.” Your BP reading is 90/50. You ask how the HEP is going since it was provided last visit. The patient and wife report he hasn’t done the exercises and they would like you to come more often to “give him exercise.” His insurance covers PT 2x/wk. What are the cultural considerations and how would you address them?

Diversity: Sexuality Lesbian, Gay, Bisexual, Transgendered (LGBT)
Gen Silent Trailer – YouTube Less likely to be partnered More likely to live alone Fear discrimination Don’t assume all people are heterosexual Avoid using traditional role labels The final diversity group I would like to talk about is the LGBT group. LGBT stands for Lesbian, Gay Bisexual and Transgendered. This is a group that is still discriminated against in many areas. Just to put it in perspective, in % of MD’s reported being uncomfortable providing care to gay patients. As you are enter the healthcare workforce shortly, there will be more research about how to provide sensitive and comprehensive care for this population. Just to have some perspective, this is actually a trailer for a documentary that is used for training health care professionals. This population is less likely to be partnered and more likley to live alone when they are elderly. They fear discrimination, so creating a warm and trusting environment will serve you well as a treating PT. So some things to consider when treating is to never assume all your patient’s are heterosexual. You will have patients with varying levels of “outness” so you need to be considerate and respectfully ask for clarification when appropriate. Avoid using traditional role labels. Don’t ask if the patient has a husband or wife, ask if they have a partner. Ask questions like, ”do you live with anyone?” And follow your patient’s lead.

Case Study #6 You are evaluating an 70 yo male patient in who has moved into a handicap accessible senior living facility after a fall with incomplete C4 SCI. You arrive to the patient’s apartment to find the patient in a power w/c. The medical record indicates he is single and his emergency contact is Larry. The patient’s goal is to return to his multi-story home. How would you question to collect information that is sensitive to his sexuality?

Diversity in Home Care HOME CARE IS CHALLENGING AND REWARDING
Generational diversity is only one factor in Home Care Cultural diversity adds another layer to the puzzle Therapist must be able to know customs and traditions Therapists must be able to know traditional gender roles Therapists must be able to abide by cultural needs and Rules and Regulations mandated by our health care system All while being a guest in someone’s home Home care is a very diverse setting, not only because of the patient population but it is inherent in the actual work environment of patient homes. There are a lot of things to consider to provide quality health care that is culturally sensitive in the home environment, but I speak from personal experience, that is an extremely rewarding setting to work in.

Why Should YOU Consider A Clinical Affiliation In Home Health?
1:1 Time With Clinical Instructor Drive Time = Uninterrupted Mentorship Learn Diverse Set of Skills Interdisciplinary Collaboration Triage Medical Management Continuum of Care Autonomy Vision 2020

New Graduates Myth: New grads can’t work in home health
Fact: New grads are welcome! NYS PT Practice Act Some states have restrictions Florida- PTs must have a minimum of 1 year experience MUST be the right fit! Student Home Care Agency Orientation & Mentorship Clinical Affiliation

Considering A Job In Home Health?

Entry-Level Employment
What To Consider… Clinical Mentorship! Well-Developed New Hire Orientation Program Growth Opportunity Ongoing Education Culture of Team Work and Support Employment Stability

Question, Answer & Feedback

Additional Resources National Association Home Care (NAHC.org)
Visiting Nurse Association of America (VNAA.org) Home Care Association of America (HCAA.org) Center for Medicare and Medicaid (CMS.gov) Home Health Section of APTA (homehealthsection.org) State chapter of APTA, state home care association Industry groups, publications, and list serves

Acknowledgments Thanks to a number of individuals who have contributed over the years to the development of this presentation. Chris Chimenti, PT, MS Director of Therapeutic Services, HCR Home Care Jeanette Brown, PT, DPT, NCS, COS-C Therapy Educator, HCR Home Care Tonya Miller, PT, DPT, COS-C Eastern Regional Vice President, Celtic Healthcare Roger A. Herr, PT, MPA, COS-C APTA Board of Directors

Home Health Care 101.

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