Care Worker Training: Evidence from the CMS Health Care Innovation - - PowerPoint PPT Presentation

Innovations in Direct Care Worker Training: Evidence from the CMS Health Care Innovation Awards Portfolio

Presenters: Co-authors: Britta Anderson, Jennifer Satorius, Lynne Snyder, Alana Knudson Health Workforce Research Innovations Session 2017 Health Interest Group Meeting June 24, 2017

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Disclosure

The contents of this publication are solely the responsibility

• f the authors and do not necessarily represent the official

views of the U.S. Department of Health and Human Services or any of its agencies. Research reported in this presentation was supported by the Center for Medicare & Medicaid Innovation under No. HSSM-500-2011-00002I, Order No. HHSM-500-T00010. No author (Britta Anderson, Alana Knudson, Lynne Snyder, Jennifer Satorius) has a relevant commercial relationship to disclose.

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Overview

• Health Care Innovation Award (HCIA) evaluation
• Framework
• Methodology
• HCIA programs training Direct Care Workforce
• Direct Care Workforce Training Models

– California Long-Term Care Education Center (CLTCEC) – University of Arkansas for Medical Sciences (UAMS)

• Models that Include Direct Care Workers

– South Carolina Research Foundation (SCRF) HOMECARE+

• Summary and Thinking Ahead

NORC Evaluation of Health Care Innovation Awards

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Health Care Innovation Awards

• Center for Medicare & Medicaid Innovation (CMMI) testing

payment and service delivery models meeting three-part aim for Medicare, Medicaid & Children’s Health Insurance program (CHIP) beneficiaries

• Better Care, Better Health, Smarter Spending
• Rapid-cycle evaluation to provide feedback to CMMI and

awardees to support continuous quality improvement

• NORC evaluates 23 of the 107 first round Health Care

Innovation Awards (2012-2016)

• Complex/High-Risk Patient Targeting
• Diverse group serving patients with multiple chronic conditions living in

the community (e.g., frail older adults, children with complex health conditions), at high risk for hospitalization, re-hospitalization, emergency department (ED) visits, or nursing home stays.

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Workforce Development

• Staffing
• Training

Implementation Experience

• Scope
• Assistive Technology &

Durable Medical Equipment

• Patient Targeting &

Recruitment

• Communication & Health

IT

• Patient/Caregiver

Engagement

• Dosage
• Fidelity, Adaptability, &

Self-Monitoring Program Effectiveness (Outcomes for Beneficiaries)

• Utilization
• Cost
• Quality of Care

(including Patient Experience)

• Health &

Functioning Outcomes for Program

• Sustainability
• Replicability &

Scalability Intervention Components

• Reach
• Program

Models

• Launch

Timeliness Context (Exogenous)

• Regulatory & Policy

Environment

• Marketplace Dynamics
• Stakeholders &

Partnerships

• Community Resources

& Supports Context (Endogenous)

• Organizational Capacity
• Leadership
• Organizational Culture &

Inter-Professional Teamwork Implications for Workforce

HCIA Evaluation: Conceptual Framework

Implementation Domains Outcome Domains

Do innovations deliver better care, better health, smarter spending? What innovations are effective for which populations, how and why?

California Long Term Care Education Center (CLTCEC)

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Location: California (Contra Costa, Los Angeles, and San Bernardino Counties) Client Population: Disability, Dually Eligible, Limited English Proficiency, Racial/Ethnic Minority, Urban Reach: 6,598 pairs of beneficiaries and IHSS providers Intervention: Trains pairs of Personal Care Attendants (PCAs) and clients who receive services through California’s In-Home Support Services (IHSS) program

• Enhance communication and care coordination across home and clinical settings
• Improve management of chronic disease, to reduce ED visits, hospitalizations, length of stay

in skilled nursing

• Provide better quality, patient-centered care to IHSS consumers
• Integrate PCAs into health care team

Care Team Integration of the Home-Based Workforce

California Long Term Care Education Center (CLTCEC)

Image: California Long-Term Care Education Center

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CLTCEC: Survey Design

• Consumer & Workforce versions (designed by University of California San

Francisco/administered by CLTCEC)

• Goals:
• Consumer survey: Measure impact of care team integration training on IHSS provider’s

integration and involvement in consumer’s care team, as well as the care delivered to consumers

• Provider survey: Assess experiences of IHSS providers with care team integration training,

measuring trainee satisfaction and perceived effectiveness of training in improving home care skills and facilitating integration into consumer’s healthcare team

• Mode: Self-administered via Nook (or paper-and-pencil as needed)
• Timing: Beginning and end of training (pre/post similar design); administered 2014-2015
• Sample:
• IHSS Consumers

– 2,618 consumers completed pre-training survey, and 3,063 completed post-training survey – 1,300 consumer respondents with pre-post matched data included in analysis

• IHSS Workforce

– 6,090 providers completed pre-training survey, and 6,393 completed post-training survey – 4,561 workforce respondents with pre-post matched data included in analysis

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CLTCEC: Workforce Survey Analysis

Pre-training Post-training How often are you now communicating with your consumer’s healthcare team (n=4,213)1 More than before training ___ 59.3% How many times in the past month did you communicate with your consumer’s healthcare team? (n=3,699)1 Mean number of times2 5.3 (n=1,949) 4.1 (n=2,166) Did not communicate with healthcare team this past month 22.2% 18.7% Healthcare Team Integration

1Smaller item sample size associated with both questions due to missing or invalid data excluded from analysis. 2Mean based on number of valid, within-range responses

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CLTCEC: Consumer Survey Analysis

• Healthcare Team Integration

Healthcare Team Integration Pre-training Post-training IHSS providers should be part of healthcare teams (n=1,135)1 Strongly Agree/Agree 94.3% 95.0% Times in the past month main IHSS provider communicated with anyone from healthcare team (n=894)1,2 Mean number of times3 3.4 (n=38) 3.5 (n=466) Don’t know how many times 13.8% 19.2% IHSS provider did not communicate with healthcare team this past month 67.5%* 1.8%*

*Differences between pre/post training surveys significant at p<0.01 1Smaller item sample size due to missing or invalid data excluded from analysis. 2T-test performed on

collapsed responses of “IHSS provider did not communicate with healthcare team” versus “Did Communicate/Don’t know how many times.” 3Mean based on number of valid, within-range responses

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CLTCEC: Consumer Survey Analysis

Self-Reported Health Outcomes

Pre-training Post-training General health (n=1,048)1,2 Excellent/Very Good/Good 22.4%* 42.7%* Fair/Poor 77.6% 56.8% How often did you feel sad or depressed (n=941)1,2 All of the time 13.8%* 10.5%* Some of the time 38.3% 32.7% A little of the time 22.3% 24.4% None of the time 25.6% 32.3% Number of ER visits in the past 4 months (n=942)1: None 67.2% 69.6% Hospitalizations in the past 4 months (n=937)1: None 79.3% 84.3%

*Differences between pre/post training are statistically significant at p<0.01.

1Smaller item sample statistics due to missing or invalid data excluded from analysis. 2T-test performed on collapsed

responses of “Excellent/Very Good/Good” versus “Fair/Poor” and “All of the time” versus “Some/alittle/none of the time.

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CLTCEC: Claims Analysis

• Difference-in-difference (DID) analysis
• Matched group of comparators
• Medicare claims (1/2013 to 3/2016)
• 1,020 Medicare Fee-For-Service (FFS) beneficiaries, comprising 16% of all CLTCEC

enrollees

• Cost
• Significant increase in total cost of care ($1,175 per beneficiary per quarter)

– Significant decrease in total cost of care (-$1,522 per beneficiary per quarter) in second year

• nly
• Significant increase in total cost of care overall ($4,301,627)
• Utilization
• Significant decrease in emergency department visits (-44 per 1,000 beneficiaries per

quarter) in second year only

*Quarterly outcomes are statistically significant at p<0.10. **Overall outcome is statistically significant at p<0.01.

University of Arkansas for Medical Sciences (UAMS)

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Location: Arkansas, California, Hawaii, Texas Sponsored by the Schmieding Center for Senior Health and Education in Northwest Arkansas Reach: 3,447 trainees Client Population: Older adults, Rural Intervention: Provides enhanced training for family caregivers and paid direct care workers to better manage the care

• f elderly adults in the home

Cost-Effective Delivery of Enhanced Home Caregiver Training

University of Arkansas for Medical Sciences (UAMS)

Image: University of Arkansas for Medical Sciences

• Improves caregivers’ mastery of:
• clinical skills
• knowledge of specific health conditions
• provision of care
• ability to encourage client participation in management of their own health
• Provides advanced skills training through Family Care Advocate (FCA) course. Skills include

strategies to:

• improve health literacy
• enhance role of caregivers as part of the health care team

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UAMS: Survey Design

• Workforce survey (designed/administered by NORC)
• Goals: Measure workforce training effectiveness (e.g., trainee satisfaction

with program, skills learned, support provided by employer) and provide important information about client populations served by UAMS trainees and the comparison group.

• Mode: Telephone
• Timing: Post-training, administered August 2014 –June 2015
• Sample: Target 500 UAMS trainees and 500 comparators
• UAMS trainees: 727 family caregivers or direct care workers who completed at

least one UAMS Schmieding Center training course

• Comparators: 249 direct care workers who had not completed any courses at

UAMS Schmieding Center. Comparators were identified or recruited by home care

• r home health agencies
• Response rate: 66%

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UAMS: Workforce Survey Analysis

UAMS Trainees - Employed (n=445) Comparators - Employed (n=204)

Satisfaction with training Very satisfied 90.8% 78.4% Learned techniques for reducing stress 93.6%* 80.3%* Satisfaction with the agency you work for1 n=293 n=195 Very Satisfied 66.6% 68.7% Somewhat Satisfied 24.2% 22.6% Hourly wage1,2 $9.37/hour (n=274)** $8.96/hour (n=190)** Satisfaction with wage Very satisfied 30.1%** 15.2%**

*Difference is statistically significant between UAMS and comparison groups at p<.05. **Difference is statistically

significant between UAMS and comparison groups at p<.01. 1Only asked of respondents who identified as working for a “Home Care or Home Health Agency” or for “Both Agency and Independent Contractor” (n=293 UAMS and n=195 comparison respondents). 2Responses of Don’t Know/Refused have been excluded from the mean.

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UAMS: Workforce Survey Analysis

Family Care Advocate Trainees (currently Employed as Caregivers)

FCA Trainees (n=183) Non-FCA Trainees (n=262) Learned skills to communicate with client’s health care team 97.2% 95.4% Learned documentation skills helpful to health care team 98.4% 97.3% Learned to monitor changes in client’s health 97.8% 98.1% Learned how to talk with clients about their health goals 99.5%* 90.1%* Learned how to provide care the way clients prefer 98.9% 97.7% Learned techniques for reducing stress 95.1% 90.1% Feel prepared to perform job of home caregiver 100% 98.4% Talked with clients about how to set up their homes so they can move around safely 96.7%* 90.1%*

*Difference is statistically significant between FCA trainees and non-FCA trainees at p<.05

South Carolina Research Foundation (SCRF)

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Location: Home care agencies in South Carolina

Client Population: Adult, Rural, Racial/Ethnic Minorities, Disability

Reach: 673 beneficiaries Intervention: Augments existing agency care provided to older adults and adults with disabilities

• Home Care Consultants (HCC) (licensed nurses) provide person-centered care

coordination

• HCCs work with clients, their family caregivers, and HCS to coordinate the

day-to-day care of clients

• 3 care planning sessions per patient
• Home Care Specialists (HCS) support person-centered care planning facilitated by

dedicated HCC

• HCSs trained on management of patients with chronic diseases and acute

conditions who may be at increased risk of hospitalization

• 13 training modules focused on a chronic condition CHCF, dehydration,

pneumonia, incontinence & UTI, heart attack, COPD, hypertension, stroke, diabetes, mental status change, death and dying

Home Care+

South Carolina Research Foundation (SCRF)

Image: South Carolina Research Foundation

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SCRF: Survey Design

• Designed by NORC/administered by home care agencies
• Goals: Measure workforce training impact and HCS’s working

relationship with HCC, and gather information about HCS’s daily work

• Mode: Paper-and-pencil
• Timing: Post-training, administered May-August 2015
• Sample: HCS (Home Care Specialists)
• 187 (of 414) invited HCSs completed a survey (45% Response

Rate)

Workforce

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SCRF: Survey Design

SCRF designed/administered

• Goals: Pre/post survey designed to measure general satisfaction with Home Care+ and

their care-seeking behavior; gather information about who helps with a range of their health needs

• Mode: Self-administered (proxy as needed) paper-and-pencil
• Timing: Enrollment into program and 6-months post-enrollment
• Sample: 454 consumer respondents with pre-post matched data included in analysis

NORC designed/administered

• Goals: Capture consumer assessments of their HCS in terms of effect on access to

care, quality of relationships, and client satisfaction with support received

• Mode: Paper-and-pencil or phone (administered by HCC)
• Timing: Post-enrollment, administered May – August 2015
• Sample: 162 consumers

Consumer surveys

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SCRF: Workforce Survey Analysis

• Almost all HCSs who responded to the survey reported that their

Home Care Consultants (HCCs) were easy to communicate with, supportive, and helped them provide better care to their clients.

• Among HCSs regularly communicating with their HCC, almost 80%

reported speaking with HCC more than once per month.

• Among HCSs who reported ease of communicating with HCC, 99%

felt comfortable talking with their HCC about client health changes.

• Almost all HCSs reported that their HCCs:
• listened to them (99.0%),
• addressed their concerns (100.0%),
• let them know what they were doing well (99.0%), and
• suggested ways they could do better (94.0%).

Home Care Specialists (HCS)

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SCRF: Consumer Survey Analysis

Baseline (n=454) 6 months (n=454) Health1 Excellent/very good/good 33.5%* 53.3%* Fair/poor 66.5%* 46.7%* How well coordinated is your medical care including medications, appointments, and home care needs?1 Excellent/Very Good/Good 88.8%* 97.4%* How satisfied are you with the skill of your aide when providing care?1 Extremely/Very Satisfied 84.1%* 93.2%*

*Difference is statistically significant between baseline and follow-up at p<.05.

1T-test performed on collapsed responses of “excellent/very good/good” versus “fair/poor;” “Excellent/Very

Good/Good” versus “Average/Poor/Very Poor;” or “Extremely/Very” versus “Somewhat/Slightly/Not at All”

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SCRF: Reach and Medicare Claims Analysis

• Difference-in-difference (DID) analysis
• Matched group of comparators
• Medicare claims (1/2013 to 6/2015)
• 172 Medicare Fee-For-Service (FFS) beneficiaries, comprising

26% of all SCRF enrollees

• Cost
• No significant findings on cost
• Utilization
• Significant increase in 30-day readmissions per quarter (112 per

1,000 beneficiaries)

*Utilization outcome is statistically significant at p<0.10

Summary and Thinking Ahead

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Summary of HCIA Direct Care Workforce Findings

• New ideas in training direct care workers
• Core competencies
• Flexibility in mode of training delivery (in-person, web)
• Integration into health care team
• Advanced skill training
• Positive results to date
• High levels of satisfaction
• Skills learned
• Improvements in health care team integration
• Additional analysis of training impacts on:
• Participants’ behavior, wages, and career opportunities
• Consumer’s health and healthcare utilization/cost
• Benefits to organizations employing trainees

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NORC, First Annual Report. 2014. HCIA Complex/High-risk Patient Targeting

• Evaluation. https://innovation.cms.gov/files/reports/hcia-chspt-firstevalrpt.pdf

NORC, Second Annual Report. 2016. HCIA Complex/High-risk Patient Targeting Evaluation. https://downloads.cms.gov/files/cmmi/hcia- complexhighriskpattargeting-secondevalrpt.pdf NORC, Third Annual Report. 2016. HCIA Complex/High-risk Patient Targeting Evaluation. https://downloads.cms.gov/files/cmmi/hcia-chspt- thirdannualrpt.pdf

For more information

Thank You! Thank You!

britta-anderson@norc.org satorius-jennifer@norc.org