Everyone’s talking about “care coordination” these days. The Center for Medicare and Medicaid Innovation has just put $1 billion on the table to test new models of care that can deliver the triple aim: “better care, better health, and lower costs.” Care coordination will be integral to achieving these goals.
That’s because care coordination helps to ensure that a consumer’s needs and preferences for care are understood and shared between providers, consumers and families as a consumer moves from one healthcare setting to another. Good coordination has the potential to improve consumer outcomes, improve consumer satisfaction and reduce waste/duplication, thereby reducing costs.
I’ve been thinking lately about the role direct-care workers could play in new care coordination models. Good care doesn’t stop at the hospital door—we all know that long-term services and supports will need to be incorporated if we are to sustain a healthy elder population outside of expensive institutional settings. With a thoughtful model of “advanced aide” training, home care and certified nursing aides could support better chronic care management and care transitions, thereby ensuring fewer re-hospitalizations for individuals with multiple chronic conditions.
There are several ways that an aide could fulfill this role:
● With better knowledgeof certain chronic conditions and post-hospitalization complications. For example, aides who have extended contact with consumers could be a part of a more pro-active/preventative response to emerging health problems.
● By expanding the traditional direct-care worker roleto include community health worker functions, aides with advanced training can monitor health status, ensure compliance with care plans and help educate and coach consumers and family members to maintain and improve the health and independence of the consumer.
● Through additional trainingon certain diseases and conditions, aide specialists might be deployed to maintain and improve the health of those consumers.
With the right training, this could be a real opportunity to improve the quality of jobs for direct-care workers. An advanced aide role could offer aides a more accessible, industry-recognized—and compensated—step in the typical “home health aide/CNA–LPN–RN” career ladder. The gap between home health aide/CNA to LPN really isn’t a career step—it is a career chasm. Advanced aide positions would provide a doable step.
We are all facing a tumultuous healthcare environment today. We can hunker down and try to save as much as we can of the existing system—or we can think out of the box and look to new models of care as real opportunities to improve quality of care and reduce costs. A new role for direct-care workers is one answer.
For more information on the CMMI Request for Proposals, visit PHI’s Resource Center.