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Better Care for Complex, Challenging Clients: Hawaii's Training Program to Improve Residential Long-Term Care a
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Christy M. Nishita PhD , Cullen Hayashida PhD & Emelyn Kim MS a
Center on Aging , University of Hawaii , Honolulu , Hawaii , USA
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Kupuna Education Center, Kapiolani Community College , Honolulu , Hawaii , USA Accepted author version posted online: 24 Jan 2014.Published online: 04 Mar 2014.
To cite this article: Christy M. Nishita PhD , Cullen Hayashida PhD & Emelyn Kim MS (2014) Better Care for Complex, Challenging Clients: Hawaii's Training Program to Improve Residential Long-Term Care, Home Health Care Services Quarterly, 33:1, 1-13, DOI: 10.1080/01621424.2013.870097 To link to this article: http://dx.doi.org/10.1080/01621424.2013.870097
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Home Health Care Services Quarterly, 33:1–13, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0162-1424 print/1545-0856 online DOI: 10.1080/01621424.2013.870097
Better Care for Complex, Challenging Clients: Hawaii’s Training Program to Improve Residential Long-Term Care
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CHRISTY M. NISHITA, PhD Center on Aging, University of Hawaii, Honolulu, Hawaii, USA
CULLEN HAYASHIDA, PhD and EMELYN KIM, MS Kupuna Education Center, Kapiolani Community College, Honolulu, Hawaii, USA
The Kupuna Adult Care Home Project is an innovative training program designed to improve the skills of care home and adult foster home operators in Hawaii. Clients in residential settings are increasingly likely to have complex problems. The project developed nine modules on topics such as dementia care, diabetes, and fall prevention based on stakeholder input and a national scan of best practices. A total of 787 persons were trained. An evaluation indicated that training significantly improved knowledge and that trainees were highly satisfied with the training. A secondary State of the Industry survey indicated that many care home and adult foster home caregivers are aging themselves and their children may not take over the family business. By combining practical knowledge and active learning strategies to work through real-life scenarios, the Kupuna Adult Care Home project is a promising training model. KEYWORDS education service providers, gerontology, long-term care quality of care and evaluation of services, work and occupation
INTRODUCTION In the last few decades, there has been a shift in federal policy toward supporting individual rights for home- and community-based long-term care. Address correspondence to Christy M. Nishita, PhD, Center on Aging, University of Hawaii, 1960 East West Road, Biomedical Sciences T705, Honolulu, HI 96822, USA. E-mail: [email protected] 1
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Both the Supreme Court’s Olmstead Decision which ruled unnecessary institutionalization a violation of the Americans with Disabilities Act, and most recently the Community First Choice Option contained in the Affordable Care Act, reflect this federal policy change toward supporting individual rights for home- and community-based long-term care. These trends parallel the dominant preference of most Americans to age-in-place in one’s own home and community (AARP, 2000), and this preference to return home can remain strong even among those who reside in institutional settings (Nishita, Wilber, Matsumoto, & Schnelle, 2008). There are increasing numbers of older persons and younger persons with disabilities who are transitioning from institutional to community settings and being diverted from costly institutional care. This trend is supported by studies indicating that many nursing facility residents can be supported in alternative, less restrictive settings (Mor et al., 2007; Spector, Reschovsky, & Cohen, 1996). Currently, the need for home- and community-based longterm care is outpacing the supply of knowledgeable and skilled workers able to provide care to older adults and persons with disabilities. Nevertheless, this sector of the workforce is growing. Jobs in the direct care workforce are increasing at a rate of four to five times that of jobs overall in the economy (Seavey & Marquand, 2011). Direct-care jobs (including personal care aides, home health aides, and nursing aides) accounted for 11% of the 10.4 million new jobs produced by economic growth from 1998 to 2008 (Seavey, 2010–2011). Traditionally, the majority of direct care workers are found in nursing facilities but these workers are increasingly employed in home- and community-based settings (Seavey, 2010–2011). With this dramatic shift toward community-based care, direct care workers must be more knowledgeable and skilled to provide a high level of care to clients with challenging, comorbid conditions (Seavey, 2010–2011). Standardized training requirements for the direct care workforce to ensure quality care are of paramount importance. Current strategies employed in the long-term care system by regulators to license or certify the workforce and to keep pace with changes in the field are limited (Stone & Barbarotta, 2010–2011). There are competency-based standards being developed but they have not been widely disseminated or adopted in policy or practice (Stone & Barbarotta, 2010–2011). The Personal and Home Care Aide State Training (PHCAST) Program—Title V, Subtitle F, Section 5507(a)—was funded through the Affordable Care Act and represents a federal effort to create quality standards for training. This program funds six states (California, Iowa, Maine, Massachusetts, Michigan, and North Carolina) to develop core competencies, pilot training curricula, and create certification programs for personal and home care aides. The purpose of this demonstration program is to create training standards that will serve as a “gold standard” for future training of personal and home care workers. These six states are expected to train over 5,100 personal care aides by 2013 (U.S. Department of Health and
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Human Services [U.S. DHHS], 2012). Continuing education and training of personal and home care aides improves not only quality of care and client satisfaction, but can reduce staff turnover and increase retention (Seavey, 2010–2011).
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RESIDENTIAL CARE IN HAWAII Similar to other states, Hawaii’s small residential care home and adult foster home industry is experiencing rapid growth. Adult foster care is an alternative to institutionalization that provides for residents’ high level of care needs in a residential setting (AARP, 2009). According to the Hawaii State Health Planning and Development Agency, in 2010, Hawaii had far more community beds (7,468) in small residential care homes and adult foster homes than institutional beds (4,438). Increasingly these residential long-term care models are providing care to residents that are medically challenging and complex (AARP, 2009). According to a 2010 report by the Hawaii Long-Term Care Commission, key policy makers and community stakeholders in Hawaii have raised concern as to whether caregivers in adult foster homes and care homes have the skills to address their clients’ complex issues (O’Keeffe & Wiener, 2010). This trend of increasingly complex clients is due in part to efforts such as Hawaii’s Going Home Plus project, funded by a Centers for Medicare and Medicaid Services Money Follows the Person grant. The project’s goal is to discharge long-stay, Medicaid residents from institutionalizations to community settings, including adult foster homes. All project participants need nursing facility level of care and have complex, comorbid conditions (Nishita, Johnson, Silverman, Ozaki, & Koller, 2009). Staff in Hawaii’s residential care homes and adult foster homes historically have had limited training in managing the complex health, personal, and social care needs of the frail elder and persons with disabilities. The state’s rules and regulations require a certain number of hours of continuing education each year, but do not require training on topics that pertain to complex clients, such as behavioral health issues and diabetes. In addition, care homes and adult foster homes in Hawaii are licensed by different state departments, Department of Health (DOH) and Department of Human Services (DHS), respectively, and require different training requirements in its rules and regulations, thereby adding another layer of complexity. These regulatory inconsistencies raise questions as to which department is accountable for quality care in community homes (O’Keeffe & Wiener, 2010). The challenges faced by Hawaii’s long-term care industry are not unique. Efforts at improving the quality of residential care are of national importance as well. To respond to a growing need in the long-term care system, Hawaii has developed an innovative, continuing education training program for direct care workers with potential national implications. The
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purpose of this article is to describe and provide data on a comprehensive, culturally responsive training program designed to strengthen the skills of caregivers in care homes and adult foster homes to care for persons with challenging medical conditions. The training responds to a national trend toward utilizing home- and community-based care settings to provide care for increasingly frail and medically complex residents.
DEVELOPMENT OF A RESIDENTIAL CARE HOME TRAINING PROGRAM The Kapiolani Community College’s Kupuna Care Home Training Program was designed for two residential care providers in Hawaii: adult foster home and care home operators (hereafter formal caregivers). Community colleges are well-positioned to develop training given their long-standing focus on paraprofessional workforce development (Hayashida, Faber, & Abushakrah, 2009). The training topics targeted conditions and issues found in an increasingly medically complex residential care population. The training was comprised of nine modules developed through a comprehensive stakeholder involvement by: (a) a project advisory board, (b) discussions with key DHS staff, and (c) guidance from the Hawaii Community Foundation (which provided funding for the training program). The project had three priorities, that: (a) module content was based on best practices in the long-term care field; (b) module topics were developed around common challenging diseases/conditions among clients in care homes and adult foster homes; and (c) modules were culturally responsive to the multicultural formal caregivers and clients in Hawaii (see Table 1). To support the development of quality modules, the project contracted with a California-based consulting firm to scan national best practices and prepare initial drafts of the modules. The project staff and other KCC faculty provided additional expertise and cultural tailoring to Hawaii’s residents. For example, in a training module entitled “Developing Recreational Activities,” examples of local foods and activities common in Hawaii were provided in the handouts. In addition, trainers employed culturally competent strategies during training sessions, including a small discussion group approach to build relationships and trust.
ESSENTIAL FEATURES OF THE TRAINING PROGRAM Training modules were promoted through direct mailings to all adult foster home and care homes on the Island of Oahu (home to 70% of the state’s population). Formal caregivers who work at the home (either the operator or other formal caregiver that works in the home) could register and
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• Module 1. Developing Recreational Activities—Instruction on the importance of providing a range of residential activities. Trainers encouraged caregivers to ask their clients about their interests and provided caregivers with an activity interest assessment form. • Module 2. Fall Prevention—Discussed statistics on falls, risk factors, home safety concerns, and what to do when a resident falls. A Fall Risk Self-Assessment Form was provided to identify fall risks within the home. • Module 3. Dementia Care—Described the symptoms of dementia, compared dementia versus normal aging, discussed treatment for the disease, and explained strategies to communicate and relate to persons with the disease. • Module 4. Challenging Behaviors—Covered the causes of challenging behaviors and presented strategies to respond to these behaviors. The training introduced a One-Week Behavior Tracking Form and a Specific Incident Tracking Form for caregivers to use in their homes. • Module 5. Medications—Provided key guidelines for correctly making medications available to residents, described issues related to safety, disposing of medications, and introduced a Medication Administration Record form. • Module 6. Diabetes Management—Provided knowledge on the types and symptoms of diabetes, outlined skills to monitor clients with diabetes, and discussed healthy diet and exercise strategies. • Module 7. Incontinence Care—Covered the cause and types of incontinence, identified when incontinence symptoms require contacting the primary care physician or case manager, and described guidelines for use of incontinence products. • Module 8. Resident-Centered Care—Described the resident-centered care philosophy, strategies to enhance resident-centered care in daily activities, and the benefits of resident-centered care. • Module 9. Nutrition and Dining—Outlined the benefits of proper nutrition, discussed different types of nutrients, described how to read food labels and how to do a basic nutrition assessment, and explained how to create a pleasant eating environment.
TABLE 1 The Kupuna Care Home Training Modules
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attend any training free of charge and attendance at all trainings in the series was not required. Sessions were held at a time, day of the week, and location convenient to the majority of caregivers on the Island of Oahu. Trainers were faculty in the Kupuna Education Center, Physical Therapy, and Nutrition Departments at the Kapiolani Community College and the College of Nursing at Hawaii Pacific University, both in Honolulu. Each training was comprised of two parts: formal presentation and active learning strategies (small group breakout discussion and case studies). In the latter, trainees met in small groups to discuss specific “scenarios”—problems or issues that are frequently encountered in their own residential facilities. These discussion sessions helped trainees to think about their clients and apply this new knowledge in their own care home or adult foster home.
EVALUATION METHODS Setting and Marketing Training was advertised to all adult foster homes or care homes on the Island of Oahu. In total, marketing flyers were distributed to approximately 1,584 adult foster home operators and 331 care home operators. The operators themselves or another formal caregiver working in the home could attend trainings. Training sessions were held in the evenings at a central location on the island.
Measures The measures can be divided into two parts: (a) evaluation of the training sessions and (b) a survey on the State of the Industry. For the former, three measures were used to evaluate the training. First, a pretest assessed knowledge of the training topic just prior to the training. The posttest, completed following the training, contained the same questions and response categories. The content covered the most important knowledge and take-home messages from the training. The pretest and posttest surveys contained an average of 10 close-ended, multiple choice, and true/false questions. Third, an evaluation survey was completed anonymously at the end of each session and gathered information on the type of home (care home or foster home) and formal caregiver credentials (nurse aide, certified nurse aide, registered nurse, and licensed practical nurse). The survey also contained statements on the effectiveness of the trainer and materials as well as knowledge and skills gained. Likert scale responses to these questions ranged from 1 (strongly disagree) to 5 (strongly agree). Another set of questions asked about the training overall and the Likert scale responses ranged from 1 (poor) to 5 (excellent). Two open-ended questions on the evaluation form were designed to elicit comments about what trainees liked most and suggestions for improvement.
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For Part 2 of the evaluation, the project evaluator and key staff developed a State of the Industry survey for operators that gathered information on motivations for becoming an adult foster home or care home operator, current challenges in the industry, as well as insights into the future of the business. The purpose of the survey was not to gauge the impact of the training, but a complement to the training evaluation to better understand the context in which the training program operates, by examining the needs and future of the residential care industry in Hawaii. The survey was mailed to all adult foster home operators (n = 1584) and care home operators (n = 331) on the Island of Oahu using Kupuna Education Center. Operators were given a 3-week time frame to respond. In total, 89 (5%) homes returned the survey via mail.
Analysis Data (from both Part 1 and Part 2 measures) were entered and analyzed using SPSS version 21 (SPSS, Inc., Chicago, IL, USA). Descriptive statistics (means and frequencies) were used as appropriate to analyze the pretest, posttest, and the evaluation. To assess knowledge gained, the mean number of correct answers on the pretest and the posttest was compared using a paired samples t-test. Among the evaluation forms that contained responses to open-ended questions, content analysis methods were used to identify common themes, broad concepts, and deviations from patterns.
RESULTS Part 1. Evaluation of Training DESCRIPTION
OF TRAINEES
A total of 787 persons attended the 11 training modules that were part of this project (two of the nine module topics were offered as training twice) from April 2010 to November 2011. Attendance at each training ranged from 21 to 105. Training was advertised to all care homes and foster homes in Hawaii. Names were tracked to identify persons who attended more than one training. The majority (71%) of trainees only attended one training, 19% attended two training modules, and the remaining 10% attended three or more. In examining the credentials of trainees, responses indicated that most were certified nurse aides (65%), and the remaining were nurse aides (26%), registered nurses (6%), or licensed practical nurses (3%). IMPACT
OF TRAINING
Six of the 11 training modules collected both pretraining and posttraining data from attendees (n = 394) and were included in the analysis below.
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Analyses examined mean improvement in knowledge scores from pretest to posttest. All training modules had a statistically significant increase in scores (at p < .05 level), based on paired sample t-tests, which indicated increased knowledge. The challenging behaviors training had the largest mean improvement in scores from pretest to posttest (t = −9.5, p < .001). The smallest increase in test scores was in the resident-centered care training (t = 2.21, p = .03; see Figure 1). Satisfaction surveys were given to trainees at all 11 training modules. Analyses indicated that trainees had a high overall satisfaction with all training modules. On a scale of 1 (poor) to 5 (excellent), the nutrition and dining training received the highest rating of overall satisfaction, but all training modules were rated between very good (4) and excellent (5; see Figure 2).
FIGURE 1 Mean Improvement in Scores From Pretest to Posttest.
FIGURE 2 Mean Overall Satisfaction With Training: Range 1 (poor) to 5 (excellent).
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FEEDBACK
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FROM TRAINING
Participants across the 11 training modules provided more than 300 comments in response to open-ended questions about what they gained from the training and suggestions for improvement. In analyzing these qualitative data, we found common themes including a greater understanding of the disease or issue (e.g., “more aware of the symptoms and management of patients with diabetes”), a greater appreciation for the challenges faced by their residents (e.g., “I learned so much about the losses the elderly go through”), and appreciation of the practicality of the training (e.g., “the material provided an excellent review of real life situations”). In examining suggestions to improve the training, the majority of respondents suggested: (a) different and more challenging case study scenarios, (b) more time for small group discussion of scenarios, and (c) more visual aids such as videos and dramatization/skits.
Part 2. Findings From State of the Industry Survey CHARACTERISTICS
AND MOTIVATIONS OF ADULT FOSTER HOME AND CARE
HOME OPERATORS
The State of the Industry survey examined the characteristics and perspectives of operators and the adult foster home and care home industry itself to provide a better understanding of the context of the training program. Over 90% of formal caregivers were female (n = 82) with an average age of 53. Most survey respondents owned their home (90%, n = 79) and homes were in operation for an average of 13 years. Twenty-four percent (n = 19) were in operation for 25 years or more. Two survey questions examined “What do you enjoy most about being a care/foster home operator?” and “What is the most challenging part of being a care/foster home operator?” For the former question, the most common themes were: (a) enjoyment from taking care of elderly and (b) owning own business/working from home. For the latter questions, the biggest challenges were: (a) having to work 24 hours a day; (b) adjusting to and working with challenging clients; and (c) not getting enough sleep. Responses indicated that the most prevalent reason for becoming an operator was to help older persons (34%, n = 40), followed by the ability to own a business (29%, n = 34). The next section of the survey asks formal caregivers whether they have seen changes in the type or amount of help their residents need. The purpose of this section was to reinforce the intent of the training, to provide training that responds to the needs and medical conditions of clients. Eighty-four percent (n = 75) of caregivers stated that they did see a change in the acuity of residents. The next question asked about the type of changes caregivers noticed in their residents. Caregivers could select multiple responses including medical problems, behavioral problems, dementia, comorbidity, more
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help with walking, more help with transferring, and incontinence. The most frequent response was dementia (47%, n = 42) and behavioral problems (47%, n = 42). To understand the future of the residential care industry, the survey examined two issues: (a) whether the children are willing to take over the business and (b) needed changes to support and grow the residential care industry in Hawaii. Over 90% (n = 81) of caregivers who responded to the survey had children (M = 2.5 children). Forty-two percent of caregivers (n = 37) responded that their children would not take over the business whereas 40% (n = 36) stated that their children were interested in taking over. Among those respondents who have children interested in the business, formal caregivers indicated that their children are or are going to school in the nursing or social work field and therefore interested in taking over the business. The State of the Industry survey also poses an open-ended question about needed changes they would like to see in the next 5 years in the residential care industry. The responses fall under the following themes. First, formal caregivers indicated that they would like more training, including more continuing education on compliance with administrative rules and regulations. Another theme was payment. Formal caregivers either wanted to see an increase in pay or parity in rates between care homes (regulated by the Hawaii Department of Health) and adult foster homes (regulated by Hawaii Department of Human Services). Another theme was quality of care within the home. Formal caregivers would like to see additional services such as respite, dietician services, and day care. The final theme related to rules and regulations with wide ranging comments including increasing the number of clients allowed per home, further examination of the qualifications of caregivers, and requiring less paperwork from homes.
SUMMARY AND NEXT STEPS The Kupuna Adult Care Home Training project developed culturally relevant training modules and delivered these modules to adult foster home and care home operators in 2011–2012. Findings indicate a high level of satisfaction and knowledge gained. In addition, project staff fielded a survey to all Oahu adult foster home and care home operators to gain additional insight in four areas: motivations for becoming an adult foster home or care home, the medical acuity and complexity of clients, interest of children in taking over the business, and needed changes in the residential care industry. Findings provide important insight into the perspectives of operators. They are motivated by an interest in owning their own business and caring for older adults. However, operators are seeing an increasing medical complexity in their clients, which is a challenge for operators and validates the need
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for training and continuing education. However, operators have raised regulatory, payment, and quality of care concerns. These need to be addressed to ensure the capacity and growth of the residential care industry, particularly because children of operators are not interested in taking over the business. These findings also complement the work of the training program evaluation by providing a better understanding of the operators who are being trained and the broader adult foster home and care home industry. There are two study limitations. First, trainees were assessed only pretraining and posttraining. A 3-month follow-up survey would have determined whether trainees retained and applied the knowledge learned in the training in practice. Second, the majority of trainees (71%) only attended one training. Although completion for more than one training would be ideal to improve skills in a range of topic areas, it could be that formal caregivers chose which trainings to attend based on need. For example, formal caregivers may have had past or current residents with behavior problems. He/she may have wanted training on this topic before taking another client with challenging behaviors. A second limitation is the small sample size of the State of the Industry survey, which had a response rate of 5% of all formal caregivers on the Island of Oahu. Despite the small sample size and limited generalizability, the findings provide important hints to the future of the industry, and the survey resulted in findings consistent with feedback from key informants in the industry. Furthermore, it is the first survey of its kind in Hawaii to ask formal caregivers about needed changes to improve their industry and explore their perceptions about changes in their clients’ acuity over time. The survey also asked about sustaining the supply of adult foster homes and care homes by asking whether children would take over their parents’ business. The latter is important because the capacity for Hawaii to provide long-term care in community settings will depend upon the recruitment of new homes and retention of the current supply of homes. In the future, resources for a second mailing or telephone survey are needed to improve the return rate and generalizability. Despite a small sample size, the survey findings illuminate important issues that merit further exploration. The next phase of the project is to test an online format for the modules in order to make the training more widely accessible to neighboring islands in the State, which is primarily rural. It will also allow formal caregivers to take trainings at their own pace and convenience for a nominal fee to support its sustainability. The Kupuna Online Training program, a comprehensive package of online training modules, was launched in June 2012. Future research and evaluation should examine the impact of these direct care workforce trainings on quality of care, specifically the trainees’ application of newly gained knowledge in the home. Specifically, future research should examine whether trainings can be linked to fewer adverse events within the home, such as falls or escalation of behavioral health events within the home. The Kupuna Education Center is working with key stakeholders in
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Hawaii to embed these direct care workforce trainings within a larger system of quality assurance and improvement. Efforts at improving the skills and capacity of direct care workers are necessary in a state and federal policy environment that is rebalancing long-term care systems toward residential, community-based care settings. We need to attract a large supply of workers in long-term care, particularly in Hawaii where adult foster home and care home operators are themselves aging and their children may not take over the business. All newly recruited and existing workers will need training and continuing education to prepare direct care workers for the challenging issues and conditions increasingly seen in residential care settings (e.g., diabetes, Alzheimer’s disease, falls, and challenging behaviors). In educating adult foster homes and care homes with practical knowledge and active learning strategies to work through reallife scenarios, the Kupuna Adult Care Home project is a promising training model.
FUNDING This project and its evaluation was supported by the Hawaii Community Foundation from 2010 to 2012.
REFERENCES AARP. (2000). Fixing to stay: A national survey on housing and home modification issues. Washington, DC: Author. AARP. (2009). Building adult foster care: What states can do. Washington, DC: Author. Hayashida, C., Faber, M., & Abushakrah, J. (2009). The role of community colleges in an aging society and the importance of networking. New York, NY: International Longevity Center. Mor, V., Zinn, J., Gozalo, P., Feng, Z., Intrator, O., & Grabowski, D. C. (2007). Prospects for transferring nursing home residents to the community. Health Affairs, 26(6), 1762–1771. Nishita, C. M., Johnson, J., Silverman, M., Ozaki, R., & Koller, L. (2009). Hawaii’s “Going Home Plus” project: A new option to support community living. Hawaii Medical Journal, 68, 156–158. Nishita, C. M., Wilber, K. H., Matsumoto, S., & Schnelle, J. (2008). Transitioning residents from nursing facilities to community living: Who wants to leave? Journal of the American Geriatrics Society, 56, 1–7. O’Keeffe, J., & Wiener, J. (2010). Stakeholder’s views on Hawaii’s long-term care system: Problems, solutions, and barriers to reform. Prepared for Hawaii LongTerm Care Commission. Washington, DC: RTI International. Seavey, D. (2010–2011). Caregivers on the frontline: Building a better direct care workforce. Generations, 34(4), 27–35.
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Seavey, D., & Marquand, A. (2011). Caring in America: A comprehensive analysis of the nation’s fastest-growing jobs: Home health and personal care aides. New York, NY: Paraprofessional Healthcare Institute. Spector, W. D., Reschovsky, J. D., & Cohen, J. W. (1996). Appropriate placement of nursing home residents in lower levels of care. Milbank Quarterly, 74(1), 139–160. Stone, R. I., & Barbarotta, L. (2010–2011). Caring for an aging America in the 21st century. Generations, 34(4), 5–10. U.S. Department of Health and Human Services. (2012). Personal and home care aide state training (PHCAST) demonstration program: Report to Congress on initial implementation. Washington, DC: Author.
Home Health Care Services Quarterly Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/whhc20
Better Care for Complex, Challenging Clients: Hawaii's Training Program to Improve Residential Long-Term Care a
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Christy M. Nishita PhD , Cullen Hayashida PhD & Emelyn Kim MS a
Center on Aging , University of Hawaii , Honolulu , Hawaii , USA
b
Kupuna Education Center, Kapiolani Community College , Honolulu , Hawaii , USA Accepted author version posted online: 24 Jan 2014.Published online: 04 Mar 2014.
To cite this article: Christy M. Nishita PhD , Cullen Hayashida PhD & Emelyn Kim MS (2014) Better Care for Complex, Challenging Clients: Hawaii's Training Program to Improve Residential Long-Term Care, Home Health Care Services Quarterly, 33:1, 1-13, DOI: 10.1080/01621424.2013.870097 To link to this article: http://dx.doi.org/10.1080/01621424.2013.870097
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
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Home Health Care Services Quarterly, 33:1–13, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0162-1424 print/1545-0856 online DOI: 10.1080/01621424.2013.870097
Better Care for Complex, Challenging Clients: Hawaii’s Training Program to Improve Residential Long-Term Care
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CHRISTY M. NISHITA, PhD Center on Aging, University of Hawaii, Honolulu, Hawaii, USA
CULLEN HAYASHIDA, PhD and EMELYN KIM, MS Kupuna Education Center, Kapiolani Community College, Honolulu, Hawaii, USA
The Kupuna Adult Care Home Project is an innovative training program designed to improve the skills of care home and adult foster home operators in Hawaii. Clients in residential settings are increasingly likely to have complex problems. The project developed nine modules on topics such as dementia care, diabetes, and fall prevention based on stakeholder input and a national scan of best practices. A total of 787 persons were trained. An evaluation indicated that training significantly improved knowledge and that trainees were highly satisfied with the training. A secondary State of the Industry survey indicated that many care home and adult foster home caregivers are aging themselves and their children may not take over the family business. By combining practical knowledge and active learning strategies to work through real-life scenarios, the Kupuna Adult Care Home project is a promising training model. KEYWORDS education service providers, gerontology, long-term care quality of care and evaluation of services, work and occupation
INTRODUCTION In the last few decades, there has been a shift in federal policy toward supporting individual rights for home- and community-based long-term care. Address correspondence to Christy M. Nishita, PhD, Center on Aging, University of Hawaii, 1960 East West Road, Biomedical Sciences T705, Honolulu, HI 96822, USA. E-mail: [email protected] 1
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Both the Supreme Court’s Olmstead Decision which ruled unnecessary institutionalization a violation of the Americans with Disabilities Act, and most recently the Community First Choice Option contained in the Affordable Care Act, reflect this federal policy change toward supporting individual rights for home- and community-based long-term care. These trends parallel the dominant preference of most Americans to age-in-place in one’s own home and community (AARP, 2000), and this preference to return home can remain strong even among those who reside in institutional settings (Nishita, Wilber, Matsumoto, & Schnelle, 2008). There are increasing numbers of older persons and younger persons with disabilities who are transitioning from institutional to community settings and being diverted from costly institutional care. This trend is supported by studies indicating that many nursing facility residents can be supported in alternative, less restrictive settings (Mor et al., 2007; Spector, Reschovsky, & Cohen, 1996). Currently, the need for home- and community-based longterm care is outpacing the supply of knowledgeable and skilled workers able to provide care to older adults and persons with disabilities. Nevertheless, this sector of the workforce is growing. Jobs in the direct care workforce are increasing at a rate of four to five times that of jobs overall in the economy (Seavey & Marquand, 2011). Direct-care jobs (including personal care aides, home health aides, and nursing aides) accounted for 11% of the 10.4 million new jobs produced by economic growth from 1998 to 2008 (Seavey, 2010–2011). Traditionally, the majority of direct care workers are found in nursing facilities but these workers are increasingly employed in home- and community-based settings (Seavey, 2010–2011). With this dramatic shift toward community-based care, direct care workers must be more knowledgeable and skilled to provide a high level of care to clients with challenging, comorbid conditions (Seavey, 2010–2011). Standardized training requirements for the direct care workforce to ensure quality care are of paramount importance. Current strategies employed in the long-term care system by regulators to license or certify the workforce and to keep pace with changes in the field are limited (Stone & Barbarotta, 2010–2011). There are competency-based standards being developed but they have not been widely disseminated or adopted in policy or practice (Stone & Barbarotta, 2010–2011). The Personal and Home Care Aide State Training (PHCAST) Program—Title V, Subtitle F, Section 5507(a)—was funded through the Affordable Care Act and represents a federal effort to create quality standards for training. This program funds six states (California, Iowa, Maine, Massachusetts, Michigan, and North Carolina) to develop core competencies, pilot training curricula, and create certification programs for personal and home care aides. The purpose of this demonstration program is to create training standards that will serve as a “gold standard” for future training of personal and home care workers. These six states are expected to train over 5,100 personal care aides by 2013 (U.S. Department of Health and
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Human Services [U.S. DHHS], 2012). Continuing education and training of personal and home care aides improves not only quality of care and client satisfaction, but can reduce staff turnover and increase retention (Seavey, 2010–2011).
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RESIDENTIAL CARE IN HAWAII Similar to other states, Hawaii’s small residential care home and adult foster home industry is experiencing rapid growth. Adult foster care is an alternative to institutionalization that provides for residents’ high level of care needs in a residential setting (AARP, 2009). According to the Hawaii State Health Planning and Development Agency, in 2010, Hawaii had far more community beds (7,468) in small residential care homes and adult foster homes than institutional beds (4,438). Increasingly these residential long-term care models are providing care to residents that are medically challenging and complex (AARP, 2009). According to a 2010 report by the Hawaii Long-Term Care Commission, key policy makers and community stakeholders in Hawaii have raised concern as to whether caregivers in adult foster homes and care homes have the skills to address their clients’ complex issues (O’Keeffe & Wiener, 2010). This trend of increasingly complex clients is due in part to efforts such as Hawaii’s Going Home Plus project, funded by a Centers for Medicare and Medicaid Services Money Follows the Person grant. The project’s goal is to discharge long-stay, Medicaid residents from institutionalizations to community settings, including adult foster homes. All project participants need nursing facility level of care and have complex, comorbid conditions (Nishita, Johnson, Silverman, Ozaki, & Koller, 2009). Staff in Hawaii’s residential care homes and adult foster homes historically have had limited training in managing the complex health, personal, and social care needs of the frail elder and persons with disabilities. The state’s rules and regulations require a certain number of hours of continuing education each year, but do not require training on topics that pertain to complex clients, such as behavioral health issues and diabetes. In addition, care homes and adult foster homes in Hawaii are licensed by different state departments, Department of Health (DOH) and Department of Human Services (DHS), respectively, and require different training requirements in its rules and regulations, thereby adding another layer of complexity. These regulatory inconsistencies raise questions as to which department is accountable for quality care in community homes (O’Keeffe & Wiener, 2010). The challenges faced by Hawaii’s long-term care industry are not unique. Efforts at improving the quality of residential care are of national importance as well. To respond to a growing need in the long-term care system, Hawaii has developed an innovative, continuing education training program for direct care workers with potential national implications. The
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purpose of this article is to describe and provide data on a comprehensive, culturally responsive training program designed to strengthen the skills of caregivers in care homes and adult foster homes to care for persons with challenging medical conditions. The training responds to a national trend toward utilizing home- and community-based care settings to provide care for increasingly frail and medically complex residents.
DEVELOPMENT OF A RESIDENTIAL CARE HOME TRAINING PROGRAM The Kapiolani Community College’s Kupuna Care Home Training Program was designed for two residential care providers in Hawaii: adult foster home and care home operators (hereafter formal caregivers). Community colleges are well-positioned to develop training given their long-standing focus on paraprofessional workforce development (Hayashida, Faber, & Abushakrah, 2009). The training topics targeted conditions and issues found in an increasingly medically complex residential care population. The training was comprised of nine modules developed through a comprehensive stakeholder involvement by: (a) a project advisory board, (b) discussions with key DHS staff, and (c) guidance from the Hawaii Community Foundation (which provided funding for the training program). The project had three priorities, that: (a) module content was based on best practices in the long-term care field; (b) module topics were developed around common challenging diseases/conditions among clients in care homes and adult foster homes; and (c) modules were culturally responsive to the multicultural formal caregivers and clients in Hawaii (see Table 1). To support the development of quality modules, the project contracted with a California-based consulting firm to scan national best practices and prepare initial drafts of the modules. The project staff and other KCC faculty provided additional expertise and cultural tailoring to Hawaii’s residents. For example, in a training module entitled “Developing Recreational Activities,” examples of local foods and activities common in Hawaii were provided in the handouts. In addition, trainers employed culturally competent strategies during training sessions, including a small discussion group approach to build relationships and trust.
ESSENTIAL FEATURES OF THE TRAINING PROGRAM Training modules were promoted through direct mailings to all adult foster home and care homes on the Island of Oahu (home to 70% of the state’s population). Formal caregivers who work at the home (either the operator or other formal caregiver that works in the home) could register and
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• Module 1. Developing Recreational Activities—Instruction on the importance of providing a range of residential activities. Trainers encouraged caregivers to ask their clients about their interests and provided caregivers with an activity interest assessment form. • Module 2. Fall Prevention—Discussed statistics on falls, risk factors, home safety concerns, and what to do when a resident falls. A Fall Risk Self-Assessment Form was provided to identify fall risks within the home. • Module 3. Dementia Care—Described the symptoms of dementia, compared dementia versus normal aging, discussed treatment for the disease, and explained strategies to communicate and relate to persons with the disease. • Module 4. Challenging Behaviors—Covered the causes of challenging behaviors and presented strategies to respond to these behaviors. The training introduced a One-Week Behavior Tracking Form and a Specific Incident Tracking Form for caregivers to use in their homes. • Module 5. Medications—Provided key guidelines for correctly making medications available to residents, described issues related to safety, disposing of medications, and introduced a Medication Administration Record form. • Module 6. Diabetes Management—Provided knowledge on the types and symptoms of diabetes, outlined skills to monitor clients with diabetes, and discussed healthy diet and exercise strategies. • Module 7. Incontinence Care—Covered the cause and types of incontinence, identified when incontinence symptoms require contacting the primary care physician or case manager, and described guidelines for use of incontinence products. • Module 8. Resident-Centered Care—Described the resident-centered care philosophy, strategies to enhance resident-centered care in daily activities, and the benefits of resident-centered care. • Module 9. Nutrition and Dining—Outlined the benefits of proper nutrition, discussed different types of nutrients, described how to read food labels and how to do a basic nutrition assessment, and explained how to create a pleasant eating environment.
TABLE 1 The Kupuna Care Home Training Modules
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attend any training free of charge and attendance at all trainings in the series was not required. Sessions were held at a time, day of the week, and location convenient to the majority of caregivers on the Island of Oahu. Trainers were faculty in the Kupuna Education Center, Physical Therapy, and Nutrition Departments at the Kapiolani Community College and the College of Nursing at Hawaii Pacific University, both in Honolulu. Each training was comprised of two parts: formal presentation and active learning strategies (small group breakout discussion and case studies). In the latter, trainees met in small groups to discuss specific “scenarios”—problems or issues that are frequently encountered in their own residential facilities. These discussion sessions helped trainees to think about their clients and apply this new knowledge in their own care home or adult foster home.
EVALUATION METHODS Setting and Marketing Training was advertised to all adult foster homes or care homes on the Island of Oahu. In total, marketing flyers were distributed to approximately 1,584 adult foster home operators and 331 care home operators. The operators themselves or another formal caregiver working in the home could attend trainings. Training sessions were held in the evenings at a central location on the island.
Measures The measures can be divided into two parts: (a) evaluation of the training sessions and (b) a survey on the State of the Industry. For the former, three measures were used to evaluate the training. First, a pretest assessed knowledge of the training topic just prior to the training. The posttest, completed following the training, contained the same questions and response categories. The content covered the most important knowledge and take-home messages from the training. The pretest and posttest surveys contained an average of 10 close-ended, multiple choice, and true/false questions. Third, an evaluation survey was completed anonymously at the end of each session and gathered information on the type of home (care home or foster home) and formal caregiver credentials (nurse aide, certified nurse aide, registered nurse, and licensed practical nurse). The survey also contained statements on the effectiveness of the trainer and materials as well as knowledge and skills gained. Likert scale responses to these questions ranged from 1 (strongly disagree) to 5 (strongly agree). Another set of questions asked about the training overall and the Likert scale responses ranged from 1 (poor) to 5 (excellent). Two open-ended questions on the evaluation form were designed to elicit comments about what trainees liked most and suggestions for improvement.
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For Part 2 of the evaluation, the project evaluator and key staff developed a State of the Industry survey for operators that gathered information on motivations for becoming an adult foster home or care home operator, current challenges in the industry, as well as insights into the future of the business. The purpose of the survey was not to gauge the impact of the training, but a complement to the training evaluation to better understand the context in which the training program operates, by examining the needs and future of the residential care industry in Hawaii. The survey was mailed to all adult foster home operators (n = 1584) and care home operators (n = 331) on the Island of Oahu using Kupuna Education Center. Operators were given a 3-week time frame to respond. In total, 89 (5%) homes returned the survey via mail.
Analysis Data (from both Part 1 and Part 2 measures) were entered and analyzed using SPSS version 21 (SPSS, Inc., Chicago, IL, USA). Descriptive statistics (means and frequencies) were used as appropriate to analyze the pretest, posttest, and the evaluation. To assess knowledge gained, the mean number of correct answers on the pretest and the posttest was compared using a paired samples t-test. Among the evaluation forms that contained responses to open-ended questions, content analysis methods were used to identify common themes, broad concepts, and deviations from patterns.
RESULTS Part 1. Evaluation of Training DESCRIPTION
OF TRAINEES
A total of 787 persons attended the 11 training modules that were part of this project (two of the nine module topics were offered as training twice) from April 2010 to November 2011. Attendance at each training ranged from 21 to 105. Training was advertised to all care homes and foster homes in Hawaii. Names were tracked to identify persons who attended more than one training. The majority (71%) of trainees only attended one training, 19% attended two training modules, and the remaining 10% attended three or more. In examining the credentials of trainees, responses indicated that most were certified nurse aides (65%), and the remaining were nurse aides (26%), registered nurses (6%), or licensed practical nurses (3%). IMPACT
OF TRAINING
Six of the 11 training modules collected both pretraining and posttraining data from attendees (n = 394) and were included in the analysis below.
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Analyses examined mean improvement in knowledge scores from pretest to posttest. All training modules had a statistically significant increase in scores (at p < .05 level), based on paired sample t-tests, which indicated increased knowledge. The challenging behaviors training had the largest mean improvement in scores from pretest to posttest (t = −9.5, p < .001). The smallest increase in test scores was in the resident-centered care training (t = 2.21, p = .03; see Figure 1). Satisfaction surveys were given to trainees at all 11 training modules. Analyses indicated that trainees had a high overall satisfaction with all training modules. On a scale of 1 (poor) to 5 (excellent), the nutrition and dining training received the highest rating of overall satisfaction, but all training modules were rated between very good (4) and excellent (5; see Figure 2).
FIGURE 1 Mean Improvement in Scores From Pretest to Posttest.
FIGURE 2 Mean Overall Satisfaction With Training: Range 1 (poor) to 5 (excellent).
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FROM TRAINING
Participants across the 11 training modules provided more than 300 comments in response to open-ended questions about what they gained from the training and suggestions for improvement. In analyzing these qualitative data, we found common themes including a greater understanding of the disease or issue (e.g., “more aware of the symptoms and management of patients with diabetes”), a greater appreciation for the challenges faced by their residents (e.g., “I learned so much about the losses the elderly go through”), and appreciation of the practicality of the training (e.g., “the material provided an excellent review of real life situations”). In examining suggestions to improve the training, the majority of respondents suggested: (a) different and more challenging case study scenarios, (b) more time for small group discussion of scenarios, and (c) more visual aids such as videos and dramatization/skits.
Part 2. Findings From State of the Industry Survey CHARACTERISTICS
AND MOTIVATIONS OF ADULT FOSTER HOME AND CARE
HOME OPERATORS
The State of the Industry survey examined the characteristics and perspectives of operators and the adult foster home and care home industry itself to provide a better understanding of the context of the training program. Over 90% of formal caregivers were female (n = 82) with an average age of 53. Most survey respondents owned their home (90%, n = 79) and homes were in operation for an average of 13 years. Twenty-four percent (n = 19) were in operation for 25 years or more. Two survey questions examined “What do you enjoy most about being a care/foster home operator?” and “What is the most challenging part of being a care/foster home operator?” For the former question, the most common themes were: (a) enjoyment from taking care of elderly and (b) owning own business/working from home. For the latter questions, the biggest challenges were: (a) having to work 24 hours a day; (b) adjusting to and working with challenging clients; and (c) not getting enough sleep. Responses indicated that the most prevalent reason for becoming an operator was to help older persons (34%, n = 40), followed by the ability to own a business (29%, n = 34). The next section of the survey asks formal caregivers whether they have seen changes in the type or amount of help their residents need. The purpose of this section was to reinforce the intent of the training, to provide training that responds to the needs and medical conditions of clients. Eighty-four percent (n = 75) of caregivers stated that they did see a change in the acuity of residents. The next question asked about the type of changes caregivers noticed in their residents. Caregivers could select multiple responses including medical problems, behavioral problems, dementia, comorbidity, more
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help with walking, more help with transferring, and incontinence. The most frequent response was dementia (47%, n = 42) and behavioral problems (47%, n = 42). To understand the future of the residential care industry, the survey examined two issues: (a) whether the children are willing to take over the business and (b) needed changes to support and grow the residential care industry in Hawaii. Over 90% (n = 81) of caregivers who responded to the survey had children (M = 2.5 children). Forty-two percent of caregivers (n = 37) responded that their children would not take over the business whereas 40% (n = 36) stated that their children were interested in taking over. Among those respondents who have children interested in the business, formal caregivers indicated that their children are or are going to school in the nursing or social work field and therefore interested in taking over the business. The State of the Industry survey also poses an open-ended question about needed changes they would like to see in the next 5 years in the residential care industry. The responses fall under the following themes. First, formal caregivers indicated that they would like more training, including more continuing education on compliance with administrative rules and regulations. Another theme was payment. Formal caregivers either wanted to see an increase in pay or parity in rates between care homes (regulated by the Hawaii Department of Health) and adult foster homes (regulated by Hawaii Department of Human Services). Another theme was quality of care within the home. Formal caregivers would like to see additional services such as respite, dietician services, and day care. The final theme related to rules and regulations with wide ranging comments including increasing the number of clients allowed per home, further examination of the qualifications of caregivers, and requiring less paperwork from homes.
SUMMARY AND NEXT STEPS The Kupuna Adult Care Home Training project developed culturally relevant training modules and delivered these modules to adult foster home and care home operators in 2011–2012. Findings indicate a high level of satisfaction and knowledge gained. In addition, project staff fielded a survey to all Oahu adult foster home and care home operators to gain additional insight in four areas: motivations for becoming an adult foster home or care home, the medical acuity and complexity of clients, interest of children in taking over the business, and needed changes in the residential care industry. Findings provide important insight into the perspectives of operators. They are motivated by an interest in owning their own business and caring for older adults. However, operators are seeing an increasing medical complexity in their clients, which is a challenge for operators and validates the need
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for training and continuing education. However, operators have raised regulatory, payment, and quality of care concerns. These need to be addressed to ensure the capacity and growth of the residential care industry, particularly because children of operators are not interested in taking over the business. These findings also complement the work of the training program evaluation by providing a better understanding of the operators who are being trained and the broader adult foster home and care home industry. There are two study limitations. First, trainees were assessed only pretraining and posttraining. A 3-month follow-up survey would have determined whether trainees retained and applied the knowledge learned in the training in practice. Second, the majority of trainees (71%) only attended one training. Although completion for more than one training would be ideal to improve skills in a range of topic areas, it could be that formal caregivers chose which trainings to attend based on need. For example, formal caregivers may have had past or current residents with behavior problems. He/she may have wanted training on this topic before taking another client with challenging behaviors. A second limitation is the small sample size of the State of the Industry survey, which had a response rate of 5% of all formal caregivers on the Island of Oahu. Despite the small sample size and limited generalizability, the findings provide important hints to the future of the industry, and the survey resulted in findings consistent with feedback from key informants in the industry. Furthermore, it is the first survey of its kind in Hawaii to ask formal caregivers about needed changes to improve their industry and explore their perceptions about changes in their clients’ acuity over time. The survey also asked about sustaining the supply of adult foster homes and care homes by asking whether children would take over their parents’ business. The latter is important because the capacity for Hawaii to provide long-term care in community settings will depend upon the recruitment of new homes and retention of the current supply of homes. In the future, resources for a second mailing or telephone survey are needed to improve the return rate and generalizability. Despite a small sample size, the survey findings illuminate important issues that merit further exploration. The next phase of the project is to test an online format for the modules in order to make the training more widely accessible to neighboring islands in the State, which is primarily rural. It will also allow formal caregivers to take trainings at their own pace and convenience for a nominal fee to support its sustainability. The Kupuna Online Training program, a comprehensive package of online training modules, was launched in June 2012. Future research and evaluation should examine the impact of these direct care workforce trainings on quality of care, specifically the trainees’ application of newly gained knowledge in the home. Specifically, future research should examine whether trainings can be linked to fewer adverse events within the home, such as falls or escalation of behavioral health events within the home. The Kupuna Education Center is working with key stakeholders in
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Hawaii to embed these direct care workforce trainings within a larger system of quality assurance and improvement. Efforts at improving the skills and capacity of direct care workers are necessary in a state and federal policy environment that is rebalancing long-term care systems toward residential, community-based care settings. We need to attract a large supply of workers in long-term care, particularly in Hawaii where adult foster home and care home operators are themselves aging and their children may not take over the business. All newly recruited and existing workers will need training and continuing education to prepare direct care workers for the challenging issues and conditions increasingly seen in residential care settings (e.g., diabetes, Alzheimer’s disease, falls, and challenging behaviors). In educating adult foster homes and care homes with practical knowledge and active learning strategies to work through reallife scenarios, the Kupuna Adult Care Home project is a promising training model.
FUNDING This project and its evaluation was supported by the Hawaii Community Foundation from 2010 to 2012.
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Seavey, D., & Marquand, A. (2011). Caring in America: A comprehensive analysis of the nation’s fastest-growing jobs: Home health and personal care aides. New York, NY: Paraprofessional Healthcare Institute. Spector, W. D., Reschovsky, J. D., & Cohen, J. W. (1996). Appropriate placement of nursing home residents in lower levels of care. Milbank Quarterly, 74(1), 139–160. Stone, R. I., & Barbarotta, L. (2010–2011). Caring for an aging America in the 21st century. Generations, 34(4), 5–10. U.S. Department of Health and Human Services. (2012). Personal and home care aide state training (PHCAST) demonstration program: Report to Congress on initial implementation. Washington, DC: Author.
