Homemakers get help handling difficult clients
When the going gets rough, homemakers stay put
An aide goes into the home of a client who is mentally ill. Soon the client is making paranoid comments and accuses the aide of taking something off his desk. The aide, frightened of the client or of being accused of stealing, refuses to go back to the client’s home. Another aide replaces him, and the cycle begins again.Difficult clients can result in a revolving door of homemakers and eventually in loss of revenue when the dissatisfied clients jump to another private duty agency. One nonprofit, long-term care case management company in Massachusetts had a small number of clients difficult to serve because of a variety of behaviors. Case managers were frustrated by the need to constantly hire new homemakers for this core group — many of whom appeared to have mental illness or substance abuse problems.
"We had one man who never kept a homemaker for more than one visit," says Linda S. George, RN, CNA, MA, CMC, associate director of Boston Senior Home Care. "He probably went through 30 homemakers over the years."
In response to the problem, the agency developed the "Care Extender Model" to train homemakers to work with these difficult clients. The program, which involves Boston Senior Home Care’s vendor agencies, has been so successful it has been adopted statewide.
Boston Senior Home Care is one of 27 agencies that receives a capitated rate to provide services, such as homemaking, laundry, and meals, for low-income frail elders in a state effort to prevent premature institutionalization. The agency serves about 2,000 clients with case management services, and most of its Medicaid-waiver funding comes from the Commonwealth of Massachusetts.
The care extender model sprang from the agency’s efforts to get funds to provide special assistance for these elders with mental health problems. "We thought we should provide more training and information and more money to the actual caregivers to increase their tolerance for the elders and their problems. And it worked."
After the implementation of the program, the client who could never keep a homemaker for more than one visit kept the same homemaker for more than two years before he died. The model worked so well that it was later applied to clients with substance abuse problems, and, more recently, to clients with urinary incontinence.
The components of the model
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. Boston Senior Home Care contracted with its vendor agencies to supply the experts."It was more appropriate for the vendor to train and supervise them than for us to do it," notes George. "We don’t provide direct services other than case management, and case managers often only see clients two to four times a year."
The agency uses a certified substance abuse counselor to provide training and support services for the substance abuse program and a nurse with special interest and 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. (For more information about the training, see p. 67.)
The six components of the care extender model include:
• 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.
• Case manager performs initial assessment and makes referral.
• Expert performs comprehensive assessment.
• Care extender works with client in his/her home a few hours a week to support the client and to reinforce and extend the effect of the intervention.
• Case manager keeps communication going with the expert, client, and care extender to identify and address problems and acknowledge successes.
• Support groups for care extenders are established.
"The support group, which is led by the expert, 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. "They have to have someone who is their life raft if they get into trouble with the clients."
Boston Senior Home Care considers the Care Extender Model a success. "We have empowered people who were extremely isolated. We’ve given them a second chance by trying a different approach to serving them."
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