Training program keeps homemakers on the job
When the going gets rough, the aides stay put
Case managers of a non-profit, long-term care case management company in Massachusetts were struggling to provide basic services to a small pocket of their clients so difficult that no available homemaker would return for a second visit. Many of these clients appeared to have mental illness or substance abuse problems. Case managers were frustrated by the need to hire new homemakers constantly for this core group, and clients were constantly dissatisfied.
Boston Senior Home Care is one of 27 agencies that receives a capitated fee to provide services, such as homemaking, laundry, and meals, for low-income, frail adults in an effort to prevent premature institutionalization.
"We serve 2,000 clients with case management services. Case managers have so much money per client to purchase services from select vendors. But these few clients were running through every homemaker our vendors had, and we needed to find a solution to turn the situation around," says Marta Frank, RN, MSN, MPA, executive director.
Success with recalcitrant clients
The agency developed a model to train homemakers to work with these difficult clients that has been so successful it has been adopted statewide. "The model enabled us to successfully serve extremely recalcitrant clients. We had one man who had never kept a homemaker for more than one visit prior to the model. After the model, he kept the same homemaker for over two years," says Linda S. George, RN, CNA, MA, CMC, associate director.
Called the care extender model, it’s as simple as it is effective. Boston Senior Home Care first used the model to train homemakers to work with mentally ill clients. The model worked so well it was later applied to clients with substance abuse problems and, more recently, to those with urinary incontinence.
The basic care extender model depends on a clinical specialist, or "expert," to train homemakers and case managers to work more effectively with difficult clients, Frank says. The model remains the same for each program, although the expert changes depending on the program. "For example, the expert used for the psychiatric program is a psychiatric nurse, and the expert used for the substance abuse program is a certified abuse counselor," she says.
Here are the six components of the care extender model:
• Case manager and in-home care extender, or homemaker, receive training from an expert about the problem they are addressing and the intervention technique they will be using.
• Client receives an initial needs assessment and referral to the support/intervention program by the case manager.
• Expert provides comprehensive assessment of the identified problem.
• Care extender works with the client in his or her home a few hours each week to provide support and reinforce and extend the effect of the intervention.
• Ongoing communication between the case manager, the expert, the client, and the care extender helps identify and address problems and acknowledge successes.
• Care extender has an ongoing support mechanism. (For further clarification, see diagram, at left.)
"We contracted with our vendor agencies to supply the clinicians who provide the training and support for these programs," George says. "The vendors are the supervisors of these people. It was more appropriate for the vendor to train and supervise them than for us to do it. We don’t provide direct services other than case management, and case managers often only see clients two to four times a year."
Training for the mental illness program is provided by a psychiatric nurse who developed the curriculum with George’s input and approval. That training covers the following questions:
• What is mental health?
• What is the hierarchy of needs?
• What are developmental tasks of the elderly?
• What are barriers to working with the mentally ill?
• What are the dos and don’ts of working with the mentally ill?
• What are the symptoms and characteristics of the major mental illnesses?
• What are the secondary symptoms sometimes caused by medications commonly prescribed to treat major mental illness?
• How can you take care of yourself when you work with someone who is demanding?
Convey client’s behaviors
"The support group was an important addition to the model. Care extenders needed to talk about the problems and challenges they were facing with each other and the expert," says George.
Care extenders also were told a little about their client’s history, she notes. "We aren’t talking about any issues that would be considered confidential. Care extenders were just told the client’s history in home care," she says. "For example, they might be told that this client has a habit of throwing homemakers out of his house or accusing them of stealing. It helps the care extenders prepare, if they know what behaviors to expect."
The care extenders also learned negotiation skills. For example, they were told, "If you have a very controlling client, allow them identify the time of day you will come. Maybe they want you to come at 8 a.m., but you can’t make it that early. Tell them, OK. I can come in the morning, but I can’t make it 8 a.m. How about 10 a.m.?’" Then care extenders were told that "they must be consistent and always do what they said they would," George says.
Boston Senior Home Care uses a certified substance abuse counselor to provide training and support services for the substance abuse program and a nurse with special training in incontinence for the urinary incontinence program. The experts involved in each program provide Boston Senior Home Care with written reports every month and call if there is a problem.
Suggestions for success
Frank and George say they learned some valuable lessons as they expanded the care extender model to new populations. Here are their suggestions for successfully implementing this type of program:
• Choose vendors you know well.
• Use an appropriate level of clinician to provide training and supervision.
• Allow plenty of start-up time.
• Apply the model to a small number of clients for the first few months and expand the program slowly.
• Maintain frequent and open communication with the vendor and the expert.
• Start with modest goals.
Set modest, attainable goals
"If you start this type of program with high goals, you are bound to be disappointed, as will the client and the homemaker. For example, for the urinary incontinence program, our goal is not 100% continence. We set modest goals like cutting back the number of pads used per day so the client can go shopping again," George says.
Boston Senior Home Care considers the care extender model a complete success. "We have empowered people who were extremely isolated. We’ve given them a second chance by trying a different approach to serving them," she says. "In terms of the homemakers, they receive training and take pride in serving these difficult cases. A few have even been encouraged to go out and receive more formal education."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content