Kenyon HomeCare ConsultingChronic Disease Education Archives - Kenyon HomeCare Consulting (206) 721-5091

Kenyon Connects

Chronic Disease Education

I Know I Need To Educate My Staff For Care In An ACO, But How And Which Employees? I Feel Like I Am Beating My Head Against The Wall Sometimes.

educationWhether you come from a small or large home care agency, preparation for an ACO isn’t easy.   It takes time, resources, and patience.  Let’s take a look at how the proper type of chronic disease education is key for all disciplines involved.

Shift The Paradigm Of Care:

In traditional Medicare models of the past, you see the nurse case manage the patients and other disciplines play a role.  The roles in home health have traditionally been independent of one another.  This was never the intention.  There was always to be a TRUE coordination of care.  All disciplines were to work together to achieve outcomes for the patient.  By ongoing changes to the care plan for all disciplines as coordination took place, the goals should be met and done more efficiently.  Many will read this and think that this can only exist in a perfect world.  Not true.  By shifting the paradigm of care and making it more effective, you can be successful and thrive as an agency independently and part of an ACO.  This begins with education and it is an ongoing process.

Who Should Have Chronic Disease Education?:

The answer is simple; all clinical staff who will touch a patient.  In order to thrive in an ACO environment, you must focus on management of chronic disease.  In order for the team to win the game, you must make sure everyone is on the right play.  Let’s look specifically at some different roles and how they change with a paradigm shift:

1. Nursing:

Nurses are not trained to be task oriented.  Nursing is about critical thinking skills and putting together a whole picture to make the best nursing judgment.  In many cases, the nurse is not able to focus on this because there are so many “tasks” involved in home care.  Chronic disease education doesn’t just consist of pathophysiology of a disease.  That isn’t what chronic disease management is. If the nurse gets to function in true case management, all disciplines take a role in chronic disease management. Chronic disease education is about comprehensive disease management.

2: Physical/ Occupational Therapy:

As healthcare in general has been evolving to a more coordinated approach, therapists have more responsibilities in home care.  Agencies have therapist complete what is within the scope of practice for the discipline.  Physical therapists are looking closer at medication and completing wound care more than ever.  It only makes sense.  You don’t send two nurses to a home to complete what can be done by one.  So, why would the therapist visit be looked at the exact same way.  The point is that many agencies still have nurses complete tasks that can be completed by another discipline.  The skilled physical and occupational therapists are skilled and licensed.  Chronic disease education as part of a paradigm shift for your agency is a must for the rehab staff.

3. Home Health/ Home Care Aides:

Last and certainly not least are the home care aides.  Since aides spend the most time with the patient, then chronic disease education and inclusion is the paradigm shift is most critical .  Because the home health aides can do so much more than give a bath, agencies need to focus on chronic disease education so they can! It was also not the intention for a home health aide visit to mean the employee is a “bath aide” and that is it.  Personal care is so much more than a bath.  However, without chronic disease education and a program that makes the aide a part of the chronic disease management team, an agency can inadvertently silo the role of the aide.

What Is Your Next Step:

Let’s say you have some work to do on your outcomes and re-hospitalization.  Chronic disease education and management programs are your fist step.  You need to look at the size of your agency.  Maybe you want someone to help structure a disease management program for you.  Or, if you have an educational department within your agency, you want that employee to do it.  The first thing is to determine how you want to be educated and what that needs to look like for your agency.  Working with someone who has developed and implemented a successful program makes the process a whole lot easier than re-inventing the wheel yourself.  Development internally often means a lot of trial and error to improve the program and this can be very costly for the agency and frustrating for employees as things continue to change.

You may have a program of education that includes other disciplines, but the home care aides have never been part of the mix.  Chronic disease education for aides is often more difficult to develop because it is new for the agency.  The other disciplines have been educated in the past.  So, this becomes not only teaching about the disease, but also about a shift in the role of the aide.  Conceptually, it requires the aide to see themselves with a different role in care of the patient.  This presents challenges, you know, but it is worth the outcome whether you are part of an ACO or not.

We Can Help!: 

Kenyon Homecare Consulting has extensive chronic disease education.  We can help with the paradigm shift to true disease management.  Call us today at 2o6-721-5091 or contact us online for your free 30 minute consultation and let us show you how to move your agency forward!


Forget About Six degrees Of Kevin Bacon! Become The Kevin Bacon Of Chronic Disease Education

chronic disease education

You have all played the game.  It is fun and everyone how to play six degrees of Kevin Bacon.  Chronic disease management is especially relevant today.  However, chronic disease education is not a priority in many home health agencies.  Let’s take a look at why it is so important.

What is Typically Taught:

There are standards to what must be involved in training home health aides.  Consequently, agencies do what is mandatory and not always what is necessary.  Everyday, you think about re-hospitalizations.  Nurses try to keep patients out of the hospital because it is detrimental for the patient and the agency.  So, it is pushed with the nurses and therapists, but why not the aide staff?  These employees are the front line to the patient.  Home health aides typically spend more time with the patient than the nurse and therapist combined.  Consequently, the home health aide is not trained to recognize early signs of trouble for the patient.

Seeing The Aide As A Key Member Of The Team:

In entering different agencies, often times a home health aide will refer to themselves as the “bath aide”.  Part of seeing the home health aide as a key in chronic disease management is not boxing themselves into a role that includes “just a bath”.  A good home health aide is so much more than that and certainly capable of more.  Consequently, agencies must also look at the home health aide this way.  Do you coordinate chronic disease education between the aides and nurses?

Better And More Specific Care Planning:

By providing specific chronic disease education to home health aides, the care plans for those patients can be more specific.  Any agency that has been through survey understands how much CMS looks at the importance of patient specific aide care plans.  If your aides don’t see a role more than providing a bath, the aide will not recognize how he or she can help prevent a re-hospitalization.  Agencies that provide chronic disease education to aides as part of the chronic disease management program can improve outcomes.  Nurses need to also understand how to incorporate the aide into management of that chronic disease.  The nurses are integral in care planning so the aide is included in the management of the patient.  Coordination of care between your nurse and aide becomes so important in chronic disease education and management.  Use all of your disciplines to be a part of the team effort.

Let Us Help You Transition To An Interdisciplinary Approach to Chronic Disease:

Now, you have decided to move forward with a full team approach to chronic disease education.  However, you aren’t sure how to make it all fit together.  At Kenyon Homecare Consulting, we work with agencies to integrate a comprehensive chronic disease education program that includes your home health aides.  Contact us today online or call 206-721-5091 for your free 30 minute consultation.

Conquering Chronic Disease Education Is A Team Approach

Chronic Disease Education TeamworkHealthcare today is all about increasing patient satisfaction while achieving quality outcomes and decreasing costs.  Chronic disease education is such a big part in doing so.  You team up with other providers.  Have you noticed that sometimes our own disciplines don’t work as a team?  Let’s look at how a “We Are Marshall” approach to a home care team makes a difference.

Current Chronic Disease Education:

How often do your disciplines talk about patient status and care?  If a nurse goes into a home and discovers a change with a patient, does that nurse report to the therapist and aide?  Does the nurse report to the supervisor and then it is reported to the therapist, aide, or social worker?  Maybe, it probably isn’t done all that much.  Too often, disciplines have tunnel vision and do not collectively consider all care.  Is your chronic disease management program doing what you want it to do for patient care?  Here is why chronic disease education needs to be for all staff and not just nursing. Clinicians all need teaching on chronic disease.

1. Home Health Aides Need To Be Key Players

Processes in agencies many times consist of the nurse doing teaching according to a disease management protocol put in place.  The nursing staff are educated on the need to properly manage “The Big 3” as these are the majority of healthcare costs.  However, aides are just as important to that process.  Often times, the home health aide spends more time overall with those patients than the nurse and therapists combined.  Without chronic disease education for aides, a key to catching early signs of trouble is lost.  If a nurse doesn’t hear about changes in patient status until the situation is urgent, it may be too late to avoid an ER visit.  The aide need to know what early signs cause issues to know how quickly to act on it.

2. Rehab Staff Is Not A Separate Entity

After many years in this business, all too often therapy functions independently and from a care plan specific to them.  Although CMS wants care plan interventions to be addressed throughout all disciplines, this often times is not the case.  The goal is rehab staff functioning towards the same goals as nursing and vice versa.  Therapy goals need to address chronic disease where it is appropriate.  However, if chronic disease education is not ongoing with therapy staff, early intervention has a big chance of being missed as well.  The processes must overlap between disciplines.

3. There Is One Patient And Ultimately One Careplan

The one patient, one careplan model is not new.  However, it is not always in practice.  A true case management model should not be nursing, therapy, and aide service as different entities.  In contrast, agencies need to look at is as one patient who we are providing care in multiple different ways.  The goals are the same and the interventions should flow from discipline to discipline as appropriate.  Nursing should run through home exercises while in the patient home for a scheduled nursing visit and address the items therapy reports are of issue.  Therapy should be recording what blood sugar readings have been for the unstable diabetic patient.  Therapy should know what the target goal for that patient is and what should happen if the patient is not within range.  Many times, monitoring isn’t there.  As an industry, we can no longer say that something is the job of the nurse, or therapist, or aide. Ultimately, it is the patient’s careplan and there is only one of them.

Home Care StartupWhere To Go From Here

If you want to look at your chronic disease education and how to improve your process, Kenyon Homecare Consulting can help.  Contact us online or call 206-721-5091 to schedule your 30 minute free consultation today!

How Chronic Disease Education Makes You A Better Home Care Agency

chronic disease managementOur world of healthcare is changing big time.  Chronic Disease Education is on the forefront considering how much these comprise our overall healthcare costs.  Now, let’s look forward and see how home care can truly be the primary care for the patient instead of inpatient facilities.

How to Change Home Care Into Primary Healthcare

15 years ago, a forward thinker in healthcare believed hospitals will only be ERs and ICUs by 2020.  It was thought that all other care would be in the home.  The problem is that care is still provided in the hospital that CAN be at home.  To be the future of healthcare, several things must change.

1. Restructure How We Provide Services

Right now, health care “silos” are the buzzword.  All providers need to eliminate them.  However, even community based care functions this way.  Skilled versus non-skilled services are separate.  Licensed home health versus Medicare home health has to be separate.  And, this doesn’t even consider the completely different ballgame of Hospice.  Moving forward, there must be transparency with once license throughout the continuum.  With CMS granting permission for Medicare Advantage Plans to include hourly services as a benefit, we are moving in the right direction.  This is one step closer to one organizational system delivering all services.

2. The “Team” Needs To Change

Teams in home care currently consist of nurses, aides, social workers and therapists.  The future includes hospitalists, acute care nurses, respiratory therapy and more.  The comprehensive home health team will consist of 3 different parts moving together to manager the patient as follows:

  • The Acute Team: These clinicians accept the patient from the ER or ICU into the home care environment.  Members of this team will be similar inpatient acute care.  MDs, RN Case Managers, LPNs,  PTs, and Aides etc..  The level of care is more intense at this level in the home.
  • The Sub-Acute Team: This team is what we typically see in home health services now.  Nurses, Therapists, Aides, and Social Work provide sub acute care.
  • The Chronic Care Team: This team is so important in the future of home care.  This team consists of an RN Case Manager and aides educated and certified in the chronic diseases seen by the chronic care team.  This is key to moving forward.

3. Chronic Disease Education On All Levels

This is the most important step.  Agencies need to invest heavily in chronic disease education for all caregivers.  Right now, most advanced education is provided to nurses and therapists.  Soon, the aide staff will need that advanced level of understanding to provide chronic care within the home.  This allows the caregiver staff to speak the same language as nursing.  Yes, this is a big investment in education and orientation.  Courses will need to be in-depth and not basic like what is currently in place.

The basic structure of chronic disease education should include, at a minimum, the following:

  • What is the Disease?
  • How is it Diagnosed? (initial testing and routine monitoring)
  • Major Treatments
  • Medication used to Manage the Disease
  • Symptom flags for potential exacerbation

Let Us Help You Move Forward

Webinar Start up agencyWe believe the future of home and community-based services will be from acute to chronic disease management on an ongoing basis.  We need to look at our patients and realize that the aide staff need to part of an elite team of clinicians caring for them.  An elite team of those certified in management of chronic diseases recognizes problems of the patient sooner and understands what wheel in the cog they represent to truly manage the patient.  We truly believe that this will mean your agency will be a partner for the new Medicare Advantage Plans.  The ACO’s will want the ability to achieve cost savings and patient outcomes required today.

To see the results of an organization invested in Certified Chronic Disease Training and the response from referral sources, read the attached white paper.

If you want help moving forward with this process, contact us online or call 206-721-5091 for your free 30 minute consultation today!