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Your CHAP on-the-go source for news + policy review, innovation, interviews with thought leaders, and the top trends in community-based care.The views expressed by the authors, hosts, and guests are their own, and their appearance on the program does not imply an endorsement of them or any entity they represent. Views and opinions expressed by CHAP employees are those of the employees and do not necessarily reflect the organization's view.
CHAPcast by CHAP - Community Health Accreditation Partner
Homecare Homebase: The Role of Software and Age-Friendly Approaches in Personalizing Healthcare
What if patient care stepped away from mere box-checking and became truly patient-focused? This episode is an eye-opener as we welcome Donnette Threats from Homecare Homebase, whose 30 years of hospice experience bring a profound understanding of software's role in building comprehensive care plans. With Donnette, we shift the focus back to what truly matters - the patient and their family, and how clinicians can utilize software to ask the right questions, thereby making care more personalized.
We discuss person-centric care, dual verification, guidebooks, and the role of EMRs in capturing the four Ms. Tune in to find out how investing in age-friendly care can be a game-changer in delivering quality healthcare.
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Greetings and salutations. I'm Jennifer Kennedy, the lead for Quality at CHAP, and welcome to this month's CHAPCast. Today I'm talking with a double duo here and it's my pleasure to introduce Donnette Threats from Homec are Homeb ase and our very own, Teresa Harbour, to talk about patient-centered care plans and age-friendly care at home. Before we jump into all the good age-friendly stuff, I wanted to welcome Donnette and actually ask you, Donnette, if you could talk a little bit about your organization and your role there.
Donnette Threats:Hi, i'm Donette Threats. I'm with Home Care Home Base and Home Care Home Base has been a leader in EMR that's available to anyone in the hospice space for many, many years now. I recently joined the team back in November and my primary focus is Director of Product Management with a focus on hospice. I have about 30 years in hospice experience so I come with a lot of fun experience from that background and just really get involved with this amazing group of folks where folks focus primarily on building a product that supports hospice and hospice care.
Jennifer Kennedy:Let's do that. I'm glad a fellow hospice person with that many years is on the call to talk about at least which you're helping that sect of the home care continuum do. Teresa, haven't had you on a CHAPCAST before, have we? Well, welcome to CHAPCAST.
Teresa Harbour:So glad to be here.
Jennifer Kennedy:Yeah, so for our listeners, could you tell a little bit about what you do here at CHAP?
Teresa Harbour:All right. Well, I am a registered nurse. I'll give you a little bit of history. I started in hospice in 1990 at our local community hospice here where I live in North Carolina, and just completely fell in love with care in the home and knew that's where I wanted to stay. And so I've been either in home health or hospice ever since. so 33 years now.. q uite sometime. I've been at CHAP for almost four years; Be four years in September. I'm the Chief Operating Officer here at CHAP and get to work with you, Jennifer, and other great people every day.
Jennifer Kennedy:Thanks, theresa. It sounds like all three of us share that passion for community-based, home-based care. So this is going to be an exciting discussion today, and let's get to it. We want to , but we want to frame it in the terms of the patient-centered plan of care, which is really so important, not only to hospice, but to home care, but to any community-based service that is provided at home. But we wanted to talk to this specific topic as it relates to Age-friendly Care . So I'm hoping some of you out there have looked at our Age-friendly Care materials, that you know a little bit about it.
Jennifer Kennedy:What I'd like to do is give you the one minute or less description about , because I really want to give time to Donette and Teresa to talk about the innovation of care planning and applying this particular model to older patients in the home. Age-friendly Vare is specifically for 65, age 65 years and older. We know that that population is exploding into the health care continuum and will continue to be the highest-served population, probably for the next couple of decades. So they need a different approach. They need to be in charge of their care, they need to be partners in their care and they need to have care that's specifically tailored to them being an older adult. So having a good patient-centered care plan is really important.
Jennifer Kennedy:It's individualized, but then when we apply that perspective to someone who's in that older adult category, where I feel like we're pushing patient-centered care to the next level, if you will, in terms of individualizing it, partnering with that patient and their caregiver about what they really want to happen, what matters to them in their space that they occupy today and every day moving forward. So, with that said, that's probably more than one minute of description about Age-friendly Care. Age-friendly Care at home is something that CHAP has taken under our wing as a really interesting project and we're so passionate about pushing it out the door. We developed Age-friendly Care standards and we developed an Age-friendly Care Certification program for those who want to put your toe in the water and be able to provide your older adults with a really wonderful care model as they age out. So, with all of that said, I'm going to swing over to Donnette here, and there are some interesting things that home-care home-base is doing with patient-centered care planning and age-friendly. Is that fair to say?
Donnette Threats:Yes, very, very fair to say.
Donnette Threats:I think it's great when you think about the concept of providing patient-centered care and then you apply the 4M's that are a part of Age-friendly Care, and you think about it and you go in the patient's home and you're like okay, so what do I do with this?
Donnette Threats:One of the great things that a software can do is help to guide that discussion, prompt the user to ask certain questions, to ask what's important to you, what matters right now, what really matters for your life. And as you're completing that assessment and developing that most important plan of care, not only to make it specific, because sometimes the regs say make it specific and you're like, okay, so how do I do that? now, do I say she likes cats? Well, if the cat matters, then yeah, it's important. So it's that ability to help that clinician think through. How do I create that plan of care that focuses on this patient, this family, and also focus on what matters to them, and create that in a way that the rest of the team can come around and support the care that's needed at that point in that patient's life. So Home Care, home Base has built that plan of care to provide that tool to help with that process.
Jennifer Kennedy:Donnette, I gotta tell you I'm so excited that Home Care Home Base did this. I've been out on the road for a couple of months talking about Age-friendly Care at home with both Home Care and Hospice providers and they're slow to warm up to the approach. You know. Once I think that I've got them and that they understand it, the next big thing they say is well, guess what? Our EMR doesn't support it, so it's gonna We feel that it would be a heavier lift in terms of logistics to apply this framework w
Donnette Threats:And they're right, because sometimes, if you have something that is so structured that you can't say what the patient want is da, da, da, da da. What really matters is for me to stay at home, surrounded by my family, and I need you to take care of my medication in a way that allows me to do that. I want you to watch how I'm thinking, to make sure I am alert for when my grandbaby come through the door or that granddaughter you know that granddaughter that you know needs my attention to be able to talk to that person and do what's important to me right now. You need the flexibility in the way that the software is structured to allow you to do that, And the patient- centered care plan allows that clinician to create that plan in a way that is meaningful not only to that patient but also to the care providers.
Jennifer Kennedy:You know, I also think, as I'm listening to you talk, I'm thinking, you know, one of the things I think that H Friendly Care does is sort of push providers out of the things that they've always done and they've, you know, they always do this, we do this, we do this meaning. And here's a good example. And I was talking to a group, I forget which state, but and it was a hospice group and they said oh, we already know what matters to the patient. Well, they might know what matters in a very little space. They're not looking at the broader, the bigger, what matters to that patient.
Donnette Threats:Most definitely, because oftentimes it's given to in your check-in And you know I was having a conversation with someone else and they're saying you know, it's like critical thinking is gone. I don't know, I don't get the opportunity to sit down and think about OK, I've assessed all of this. What is the problem? Well, you don't have to think about it. Ask the patient and family What is important to you right now? What matters? What do you really want to work on?
Donnette Threats:You've been having pain. Is it important to you that that pain get decreased down to zero and that caregiver may say, or that patient may say, not if it means I'm not going to be able to interact, so get me to the point where I can still interact, i can still do what's important to me. That is what care at this point in life is really about to allow that individual to direct their care not just to you know, actively show up, but to actively direct it. And I think that's what's really unique about age-friendly care And when you take it and that old patient-centered care that's been around for eons now, that helps us to build that relationship, to be able to get a framework that's evidence-based that you can then incorporate into software and also help with the quality of care that is provided and make that family feel as if they're living their life to the fullest for as long as they have got.
Jennifer Kennedy:Oh my gosh, well stated. You know the critical thinking. That's a whole other podcast, isn't it? Yes, Just turn it out there, All right. Well, we have another sort of exciting development here with dual verification, Home care Home base. And, Teresa, I want to invite you into this conversation because you know you've had a lot to do with the verification process at CHAP.
Teresa Harbour:Absolutely So. First of all, you know, congratulations on being our first EMR to achieve Age-friendly Care at home CHAP verification. I know that there was a lot of work went into that, you know, and it's definitely going to pay off in regards to the delivery of high quality, patient-centered care. So I just want to provide just a little bit of feedback on what we've been hearing from some of our home care home-based customers in regards to going through our pilot site visits and becoming Age-friendly Care at home certified. You know, in talking about the person-centered care plans, you know the feedback that I have heard from clinicians is that it truly makes it interdisciplinary and it saves so much time. So you know. So here you are, you know, working with clinicians that don't have a lot of time and they're saying that it saves time. So I just wanted to share that with you. That's one of the things that I've heard about the patient-centered care plans. But, yeah, the dual verification and the workbooks, the guidebooks that you know Katherine had developed completely outstanding how she took the four EMS and laid that out and explained through the guidebooks with screenshots and you know where to go and to home care home base to document this, where it's not adding extra work to clinicians. You know this is all part of the workflow. So I mean great, great job with the guidebooks and I believe they're on your customer experience portal for your customers to be able to access. So okay, great, great, yeah.
Teresa Harbour:But the dual verification, you know, not only verifying your home health and hospice platforms to ensure that they meet our CHAP standards, then that additional component, having them verified to make sure it meets our age-related care at home standards.
Teresa Harbour:So kudos to Hump Care Home Base for that. So when you're looking at being able to capture those four EMS, you know part of the pilot site business that we've accomplished is that. You know we don't want extra work added to clinicians and I mentioned before you know, the patient-server care plans. You know saves time does not add additional work, but just the whole approach itself does not add work to clinicians. And you know being able to capture that in the EMR is critical and key being able to identify, just like what you said. You know what matters to that patient and how it's impacting or how medications can impact what matters mobility, mentation and having that captured in your EMR. That's getting pushed in to the plan of care so that every clinician going into the home knows this is what matters. I mean, that's really going to move the needle on patient outcomes.
Jennifer Kennedy:You know I can't agree more and I know you get very passionate, theresa, when you talk about Age-friendly Care in the home. You know you were out there on our pilot. You saw some of the reactions of the clinicians. You know what are they saying. I mean, do they feel like it's really helping them, that this approach is helping them work better with their patients?
Teresa Harbour:Absolutely.
Teresa Harbour:And having worked in many home health and hospices, I can tell you as a case manager, anytime administration brought anything to us clinicians, you know I'd be like here goes the eye-rolling in, and this is going to add so much work and it's not going to have a positive impact on patients.
Teresa Harbour:But with this pilot and the feedback that we've got from clinicians and we heard all of this with our work with the John A. Hartford Foundation and IHI that in the American Hospital Association that you know clinicians like it and we heard that that we actually got to experience that and see that and feel that and hear that from the clinicians in the pilot site visits that the statement was we love this because we get to be clinicians And they're seeing the positive outcome obvious. You know we make home visits during our site visits and during the home visits patients knew their goals. So here you've got clinicians loving something and patients know their goals. That's a huge win. And what more could you ask for? with that? I mean truly looking at you know value-based care models. you know having that, improved patient outcomes, improved patient satisfaction this just goes hand-in-hand with that.
Jennifer Kennedy:Yeah, I believe that too, and I really think it pushes clinicians. Like I said, I think some clinicians get a little bit stagnated when they're in a particular area for a long time, but I feel like this is something that would sort of push them, push their skill set farther than maybe they have been exercising it previously. So I know that, as I said, I've been out and about, and not all clinicians are like on board, but they're like marinating. You could see they're marinating about it, you know. But I do believe it may take just a little bit of time for some to sort of embrace this as a not only is it better quality practice and care, but it's gonna, you know, as you said, move our needle forward in the whole quality space.
Teresa Harbour:Absolutely, absolutely Well, and I think that you know just getting past I mean once again hearing the. You know the conversations that you know this is not a project. I mean it's a framework. You know it's what clinicians have to get to the point They're going through the training. You know that does add a little work to you know to the clinicians and to the team. Just learning about Age-friendly Care.
Teresa Harbour:You know how to have those conversations about. You know what matters to the patient, how to identify some of those high-risk meds that you know older adults should not be taken, and how you know to constantly keep them on the top of your mind. You know mentation and looking at of course, you know during our initial assessments we capture and screen for you know depression, dementia, you know those type of things. But then you know keeping that type of mind during every home visit that you make as well.
Teresa Harbour:And same thing with mobility. We often do screenings on admission for mobility. You know home safety assessments follow risk, those type of things. But once again, just keeping that on top of mind with every visit, that this is truly a framework. So once they understand that this is truly not adding any work, it's changing kind of their mindset and just implementing the framework during the workflow and being then once again able to capture that in home care home base and make an update to that plan of care. When you're talking about, you know, patient-centered care, this completely equals age-friendly care at home.
Jennifer Kennedy:Absolutely, and, and, Donnette, the software approach that you've developed is really going to help to greater individualize that patient's plan of care to a better degree, which CMS always has a problem with the care isn't, doesn't look individualized right. So do you feel like that your, your care plan that you developed here, really helps to accomplish that?
Donnette Threats:It really does. It provides a lot of tools to help that clinician think through those pieces. It allows the clinician even something as simple or complex, i should say, as medication. It gives that medication information to say, hey, you know, these are the side effects, these are interactions You can discuss with the physician And then, as you're developing that plan of care, if the patient goal is to continue to be as mobile as possible, every decision you're making and your documenting as interventions that the teams are going to provide can be aligned to whatever that goal is, because you're able to clearly state what that goal is. It's not a matter of being in a box where you have to stay in this box. You're able to go in and say this patient would like their pain, though we don't like it, they would like their pain to stay at a four, just so that they can be alert for and you may continue to educate on ways you can achieve it with bringing it lower, but to be able to have the team understand that this is this patient's choice at this point.
Donnette Threats:I remember my most difficult hospice patient was a patient who wanted to experience pain for redemption of her family member. I didn't conceptualize it. It wasn't my way of thinking. Mine is get rid of my pain, but for her it was important and to have those types of discussion, capture that so when you're being surveyed, you can read it and see, this is why it was that way. This was her choice, this is what she wanted, and we respected that. However, we also educated. We did do all these other things to be able to clarify that easily in a framework that is not so prescriptive, but it have enough prescriptive to guide you.
Jennifer Kennedy:That is so great because with that consistency we can measure. And, You know undefined can't say This or that without having data from measurement right. So I love that idea of having consistent documentation. It's all right there. Then we can measure the outcome of the application of Age- friendly Care. So kudos to you, Donnette, and your team, for developing this important documentation system. You know, Age-friendly Care, I really feel, is It's going to be the healthcare continuum's future, at least for the next several decades. So when we have, you know, partners like you who are willing to make the investment in capturing all that information, so providers have a little bit of a logistics edge, that's a win-win for everybody, for sure. All right, well, we're at the end of our time here, So I wanted to ask each of you if you had any closing thoughts for all the listeners out there and podcast land today, Donnette?
Donnette Threats:Hmm, closing thoughts. My closing thought would be to continue to grow, because it has never been done doesn't mean it cannot be done. This is just an amazing opportunity to bring two ways of thinking together within a scope of a tool, which is what any EMR is. It's a tool. Use it to the best of your ability to capture the excellent work that you're already doing at the bedside. We have been taught through hospice for years. We need to do patient-family-centered care. This just provides that framework to say this is how you do patient family care.
Donnette Threats:You ask them this question, you make sure you understand this and then your plan needs to reflect what's important to them, what matters to them. It's simple. Yeah, it may be complex at time, but it's worth the journey. It's worth the thought. It's worth you feeling, as a clinician, that, oh my gosh, I'm back to doing what I came into health care to do. I can make a difference. I can see the difference. It's been my perception in the years in hospice that if you're working on your goal, you'll never achieve it, because no one who's dying is going to spend time Achieving your goal. If you figure out what that patient and family goal is, chances are they are going to achieve their goal, and you'll be there to see the smiles. You'll be here to see the laughter, even through the tears, and that's pretty much what we're all about - making sure that, for the time folks have life, they're living the best quality life that they can, and Homecare Homebase is here to support that.
Jennifer Kennedy:Donnette, that was so well stated. Thank you, thank you so much, Teresa. Final thoughts from you.
Teresa Harbour:Yeah, that was a mic drop right there, But I will say that our number one deficiency that we see is always around care planning, coordination of care, care planning, IDG, that completely looped around that. planning. That eliminates our top deficiency when you make it about that patient and having the interventions and goals that truly surrounds what matters to the patient. You know you're going to deliver them that high quality care and, like you said, being able to meet those patients and families goals, which is, you know, while we all started in hospice anyway, is to be able to do that to help that patient achieve their final wish is to die at home with family.
Jennifer Kennedy:Thanks, Teresa, thanks so much, and that was actually a very nice follow-up Donnette.
Teresa Harbour:Yeah, i don't know about that, it's awesome.
Jennifer Kennedy:There's nothing I can say to top that. So what I'll do is just thank everybody for joining the podcast today. I like to learn something new every day, so I really feel like I did accomplish that goal with you ladies, today. So thank you for that. The CHAP team and I thank all of you out there for taking time out of your day to plug into our podcast. From all of us. Stay safe and well, and thanks for all you do.
