1.1. Home care overview. Part #1
How to start a home care business.
The idea of starting a home care business differs greatly from actually taking action to get an agency open and running. Writing this post comes the presumption the idea of starting a business has grown to where you’d like to actually learn how to start your dream.
Before the action steps to start a home care agency are discussed, let’s cover a topic that many to-be entrepreneurs don’t think about: Evaluation of your strengths and weaknesses by asking some serious questions about yourself. Take a step back and truly consider the following questions, being very honest with yourself and the answers.
First – Ask The Tough Questions About Yourself (before jumping feet first into building the business)
A. Are you a go-getter and self-disciplined?
How well do you manage your time? It’s up to you to make things happen. You’ll need to organize and prioritize your time to create projects, schedule appointments, follow up and delegate tasks. Your phrase each day must become “If it is going to be, it’s up to me!”
B. Are you a people person?
In business, especially home care, people skills are a must. Starting a home care company means establishing and growing relationships with banks, lawyers, employees, doctors, nurses, vendors, accountants, clients, and their families. Can you deal with a hard to please the client? How about unruly employees or pushy vendors?
C. Do you have the time, energy, focus, and money?
To start a home care business (or any business) requires a significant amount of investment! It demands your time, focus, energy, finances and more. You’ll be sacrificing time and focus on family to get it launched, at least in the first 6 to 12 months until you have it set up correctly.
D. Are You Business Minded?
Do you have a general understanding of business? Are you financially inclined enough to regularly review financial reports? You’ll need to understand balance sheets, cash flow statements, Profit & Loss Statements, and various other reports. If numbers aren’t your forte, some of it can be hired out. However, your ability to review, understand and act on financial reports can make or break your business.
E. Are you organized?
The ability to plan and organize will save you tremendous amounts of time, headaches and money as your business grows. Organized systems for scheduling yourself and staff, finances, daily operations, and inventory are essential to smooth operations.
F. Are you motivated?
After you’ve put in 12 to 16 hour days and the excitements of a new business owner wears off, can you maintain the motivation necessary to follow through on your goals and plans? Burnout is a major contributor to businesses failing; self-motivation will be a strong factor in surviving burnout and slow times.
G. Is your family prepared for your commitment?
Does your family understand how they will be affected? Do you understand the time away? Support and understanding from your family will be essential as you launch your business and work to make it profitable. Your business will require much of your time and focus. It may mean time away from events and functions that are otherwise tradition. You may also experience financial hardships for a few months in the beginning and depending on the effort and outside factors – it could mean lean times for a year or more.
H. Do you have any of the personality traits that can help?
Having any of these traits is not pre-requisite, however, they do lend themselves greatly to business owners in the home care profession.
- Basic compassion, understanding, empathy, and desire to serve patients with illnesses.
- Ability to build relationships; a network of individuals, institutions and industry leaders related to care.
- Being a people person who is able to manage a growing staff.
- A good decision-maker.
Once you’ve seriously considered the afore mentioned questions and still feel the home care industry is right for you – then it’s time to take action to start a home care business.
Step 1 – Understand the Home Care Industry
How well do you know and understand the home care industry? The senior care industry or providing care for people? If you’re going to enter this industry, you want to know and understand what you’re getting into. We won’t discuss the demographics in detail as you’ll learn best by doing the research yourself. For now, here are the major areas you should learn about:
- Types of Home Care;
- Types of Home Care recipients (your clientele): seniors/elders, disabled, rehab;
- The benefits of Home Care;
- Services to Provide.
Step 2 – Research, Analyze and Define Your Market
Now that you understand what the industry is about and the options available, it’s time to learn about your own market area, where you plan to do business and its surrounding areas- market analysis.
- Define your geographical location, size, and population as well as coverage area.
- Identify your competition.
- Determine your coverage area.
- Identify state laws and licensing requirements.
Step 3 – Create Your Business Plan
Without a home care business plan, you have no target. Without a target – where do you plan to hit? The business plan should be detailed enough that anyone who does read it can clearly see you’ve thought it through.
The business plan includes your financial details and projections. Many new business owners miss this most important step. Without laying the plan to your financials, your chances of failure are doubled. The reason is simple – by not managing the limited funds you are undoubtedly working with, they will be depleted quicker than you anticipate and your sales may not be where they need to be for the business to be self-sustaining (i/e: profitable).
Step 4 – Set Up Your Business
Here’s where the rubber meets the road. With your well thought out plan in place, it’s time to take action and start putting the pieces together. Many of these pieces can and should come together about the same time so you’ll find yourself very busy.
The summary below outlines the major action steps:
- Choose your business name
- Corporate business name search
- Verify trademarks
- Set up the legal entity
- Obtain a Fictitious Business Name Search
- Obtain business EIN
- Check Domain Names for website
- Create a logo
- Complete State licensure requirements
- Set up your office
- Create marketing paraphernalia
Step 5 – Prepare Operational Systems
Setting your business up with systems is paramount to the foundation you’ll be laying down. Not doing so and you could run yourself crazy. Every task your business requires to operate should have a procedure created for it. Everything from your filing system to your telephone answering script. From time tracking to invoicing, payroll to financial reporting, scheduling to client retention. You’ll also need forms to help make these systems run smoothly.
Step 6 – Hiring Home Care Staff
As you prepare to hire caregivers who will care for your clients, it’s important you have a clear picture of what kind of employees to hire. What are the required qualifications you will have? How will you attract them to your company? Prepare for the applications coming in and how you’ll review them. Having created the processes already, it’s time to screen and interview them, then background check the qualified candidates before offering the jobs.
Once hired, caregivers need to be trained to your company’s operational standards and way of doing things. Then, prepare to manage them.
Step 7 – Signing Clients
One of the most exciting milestones in starting a home care business is signing your first client! Then five and ten. Obtaining the first few clients is simple for some and can present challenges for others.
Remember the character trait of being able to build relationships? Networking, meeting people and establishing relationships within the industry at the same time as carrying out the previous three steps helps enormously to signing your first clients.
Step 8 – Marketing Home Care Services
After the excitement wears away from signing the first few clients, realize that your journey has just begun. To grow the company requires marketing the company’s home care services and not doing so, the company won’t survive.
How to market home care services requires far more than a paragraph or blog posting. If you’ve gotten this far in your home care business development – you’ve probably done it with more guidance than this article. Take your business to the next level and learn How to Market Your Home Care Business.
Home Care Business Plan Template
You will have a clear, concise idea of what the business is about and how the founder and current president, [owner name], intends to start, grow and continue strong and steady growth.
The purpose of a business plan is to create a plan, a blueprint or roadmap on paper to follow. It’s for you to really think through how your business will operate and about areas of the business you haven’t thought about. You’ll be most successful when you put in the effort and really THINK about it. Your goal is to develop a fairly simple plan first to start your Home Care Agency which often is enough for most small businesses getting started using their own capital. If you’re seeking one or more investors, a different, more comprehensive plan will serve you better with much more consideration in which case.
The Executive Summary is a summary of the highlights of your business plan. While it appears first in the layout of your plan, most find it easiest to complete the Executive Summary last. It should be succinct and no more than 2 pages.
The Business Description provides a complete overview about your business idea/concept/ service/ etc. It differs from the Executive Summary in that it goes into detail about the description. Challenge to yourself to truly THINK about what you see your business described as. Your business should be unique, differing from your competition. Describe who, what, why, where and how it’s different. Use the example to help get you started.
Your Home Care
provides [medical / non-medical] care services to [elderly, disabled and people of all ages physical conditions and cognitive abilities] who would like to remain living at home, yet require assistance with certain daily or weekly activities. Working closely with clients and their families we provide personalized assistance in client’s own home, the hospital, long-term assisted living facilities and other places of residence with things like:
- Warm Companionship
- Meal Preparation
- Incidental Transportation
- Light Housekeeping
- Errands & Shopping
- Medication Reminders
- Laundry & Linen Washing
- Recreational Activities
- Personal Hygiene & Dressing Assistance
- Senior Information Resource
- Alzheimer’s care / Dementia care
- Respite Care
Home Health Care Services (Medical)
- Professional Nursing
- Personal care
- Senior care
- Pediatric nursing
- IV therapy
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Alzheimer’s care / Dementia care
To be known as the crème-de-la-crème of home care providers in our market, providing the very best, first-rate care to clients in our geographical market by employing only proven, hard-working, professional, honest, compassionate and ethical home care providers in the market who are dedicated provide outstanding home care services and improving the quality of clients’ lives.
To assist every client with improving their quality of life, encouraging independence and allowing them to be comfortable with excellent care in their own homes by providing first-class, professional care with respect, dignity, compassion, the highest ethical standards and honor
What makes your home care agency services/products better than all the others? This shouldn’t be price – it will be difficult to defend and by differentiating yourself solely by price, it sets your business up as a commodity driven service – often suffering with poor service in lieu of charging a fair price for excellent services.
What does the home care industry look like? Are there trends in your geographic area? What do your target clients buy, eat, education, income, habits, health levels, lifestyles, etc. The more detail you have the better your chances of success. This is an opportunity to find a specific niche that may be present in your own backyard. No example is provided in this area because you should know this. If you don’t – you need to do the homework to know and understand your market and the industry if you plan to enter it.
Who are your competitors? Specifically, by name, location, age of the agency, what they specialize in and how they are different from you. What market share do they have? Are there any other service companies that could be considered competitors? (i/e: really inexpensive care homes, private caregiver market, etc). Even if there are no “direct” competitors, there will ALWAYS be some that are close
How will you get your product into the marketplace? Think of non-conventional (viral Marketing) methods that are cheaper than traditional (TV, radio, print) and have a higher Impact. Examples:
Networking –meeting people and creating the relationships with the many faces who refer clients to various home care service providers. By attending the opportunities for networking, meeting business leaders and more.
Website. Develop an informative website and will include the website address in all online and offline marketing collateral.
Press Releases. Work with online press release distribution firms to generate awareness of our services by issuing press releases to leading search engines and online news sites.
Social Media Marketing. Promote your agency on Facebook, Twitter, LinkedIn and other social media channels that may be frequented by your target market. All social sites will be used to generate a buzz about your services and build your agency’s image. The goal is solely to build connections with the health care industry and consumers and convince them to avail your services.
E-mail Marketing. Implement an e-mail marketing campaign to target local health care facilities and professionals that could provide client referrals to agency.
E-mail Program. Regularly distribute a newsletter to highlight new services, employees, agency certifications and home care industry news. Include links to lure subscribers to visit your website for further information.
- Cold Calls. Develop a list of local health care facilities, senior organizations and social centers to cold call in an effort to gain client referrals.
- Brochures/Flyers. Develop informational (postcard) brochures and flyers and distribute via a targeted direct mail campaign.
- Press Releases. Share press releases highlighting news about our agency to print news outlets in our target area.
- Business Cards. Distribute business cards in high-profile gatherings and share them indiscriminately to spread word of mouth regarding your services.
- Exhibitions. Participate in health care industry trade shows and events hosted by senior organizations and other relevant industry events, workshops and seminars to generate buzz about your agency.
- Organization Affiliation – Joining local and regional organizations like Health Care Industry Orgs, and Insurance company orgs.
- Public Speaking – By speaking to organizations, senior centers, doctor, nurse and discharge planner meetings, etc. we’ll become seen as experts in our given niche.
Business & Health Fairs – Attending and showing the presence at these shows brings more
Barriers to Entry
What will stop you from entering your market place? Regulations, competition, cost of entry, monopoly, syndication? Also, how will your setup your own barriers to entry for other potential entrants into the marketplace?
State and county laws can thwart certain services from being provided by increasing the requirements and certification levels. Are there any present in your area? Maybe it’s obtaining the State Survey sign off or Medicare certification. List the obstacles that could keep you from getting started and growing.
How will you get your services/product to your market? For example – if you cover 3 counties – how will you manage logistics? Who will provide the care? Who will do the follow up visits and ensure care quality? Will you team with another company that provides a complimentary business where you can team with one another?
Often this can be the most important part of your business plan. Who else believes in the idea of you entering the home care industry and the experience of your team in the various areas? (Technical, business, marketing, operations, HR, etc.)
You will initially hire four staff members to manage the agency’s operations. Each hired staff member will meet the state of Colorado educational and training requirements. Additional recruiting will occur as the agency enters the expansion phase.
Organizational Hierarchy (example):
- CEO/ Administrative Director
- Administrative Assistant
- Home Care Aide
The Administrative Director will be responsible for planning, implementing, organizing, and developing in-home care services. This work includes, but is not limited to: operations administration, community/client education and staff supervision. This individual also will assume all social work services during the agency’s initial phase.
The Administrative Assistant will perform routine clerical and organizational tasks. This individual will organize files, draft messages, schedule in-home care appointments and support other staff.
Home Care Aides will administer in-home client services. These individuals will assist with activities such as bathing and dressing, and will provide services such as light housekeeping, errand services, personal care and companionship.
Insert all the financial projections and forecasts here. Cash flow, income statements, balance sheet, as well as start-up income required. This is arguably the most important part of your business plan, spend plenty of time on this and be able to justify any assumptions.
Strengths Weaknesses Opportunities Threats
Consider the conditions in which your service business will operate. What are your Strengths and Weaknesses? These are internal (team, company, service). Opportunities and threats are external (local, regional and national market place, trends, etc.)
- Comprehensive Home Care and Geriatric Services. Custom home care and geriatric services aimed at enabling staff to deliver reliable, responsive care.
- Experienced, Well-Trained Staff. Staff members will undergo initial and continuing education and training programs required by the home care industry.
- Long Operational Hours. Provide service during normal business hours and also will be available for on-call emergencies 24 hours, seven days a week.
- Lack of Brand Identity and Image. As a start-up business, currently lack a brand identity and image. Will need adequate time to create awareness of your agency.
- Low Staffing Numbers. Professionals hired to manage the agency’s initial operations will be experienced, yet you may not have enough staff to effectively cover the needs of the market. This could cause slow growth of your operation, which management could not afford.
- Small Marketing Budget. A sizable marketing budget is required to get the most out of the agency’s initial launch. Anticipate needing a larger budget to make a substantial impact on the market.
- Growing Market. The home care market is rapidly increasing which presents extensive opportunities for new agencies entering the sector.
- Aging Population. As the U.S. population continues to age, the demand for personal home care and companionship is expected to significantly increase.
- Affordability and Comfort. Home care services are less expensive than nursing homes and assisted living facilities. Studies show that most people would prefer to receive care in their own homes versus a facility or hospital.
- Expandable Business Model. Home care agencies have the ability to expand into other markets as consumer needs grow.
- v Local Competition. Several local competitors have national, well-recognized and trusted brands.
- v Professional Staff. Recruiting, hiring and retaining quality, professional staff pose substantial risks. You will conduct extensive candidate research and background checks to eliminate some of the risks associated with employee recruitment and retention. Because studies predict patients will outnumber caregivers in the near future, you will need to position the agency as an attractive place to work with competitive and fair pay and benefits.
- v Business Cash Flow and Funding. While the owner is using personal cash flow to cover start-up expenses, continuing to maintain adequate cash flow and solicit funding from outside sources presents a challenge you must overcome to succeed.
- v Regulatory Changes. Federal health care laws like the Affordable Health Care Act and changes to Medicare and Medicaid payments can greatly affect your agency. In addition, state home care aide certification laws also could impact your business.
Goals and Objectives
What are your overall business goals? Your financials should include a lot of the income and expense goals. These goals/objectives are about identifying what you plan to accomplish with your business. It could be as simple as create a new career of owning a business or more in depth like using 10% of net profits going to a certain cause you believe in. The possibility of these things
Critical Success Factors
What needs to be achieved that will enhance chances of your agency’s success? Identify what the possibility of these things happening are.
How will you (or any investors) exit out of this project (if you want to) and make excellent return or to move onto your next “big idea”?
What future plans do you have for your services (and products, if any)? As your company grows, what other plans do you have for your services? Do you want to grow into a regional or state-wide provider? Maybe you want to expand into medical and non-medical. The sky is the limit to what you’d like to do.
Add any additional information here that may not fit into the sections above (quotes, Recommendations, statistics, etc.). Your completed financials & projections should be included in the Financial Projections, however, you could place them in this section.
What is “A home health care agency”?
A home health care agency is a business that provides certified nursing and home health aides to private customers. These professionals typically provide light medical care, such as administering medicine and taking vital signs, and performing light housework, such as cooking, housekeeping and shopping, for the elderly, invalid or others who are not able perform said functions on their own. In 2008, U.S. News & World Report indicated that home health care agencies were one of the best small businesses to start, due to anticipated industry growth. Entrepreneurs entering this field must be conscious of potential problems they may encounter with launching this new business.
Although a formal education is not required to open a home health care agency, an operating license is required in most jurisdictions. Licensing requirements vary from place to place, but, depending upon the type of license that must be obtained, this may be hurdle for some entrepreneur. Many jurisdictions require that a detailed package be included with a licensing application. Entrepreneurs may have to submit a formal business plan, an in-depth description of planned operational policies, as well as the resumes and documentation prospective employees’ professional licensing. In addition, many locales require that applicants successfully pass a criminal background screening.
A home health care agency is only as good as the quality of its staff. An agency can ensure it establishes and maintains a stellar reputation by hiring only the best most qualified caregivers. Identifying top-tier candidates, however, can be a challenge. That said, that are a variety of options an entrepreneur may use to overcome this obstacle. A cost effective method for recruiting talent is by working with a local community college or proprietary school that offers training to prospective certified nursing aides. These institutions are obligated to secure employment for as many matriculating students as possible, so will most likely welcome a partnership. Alternatively, home health care agencies with larger budgets and not much time to fill job openings can engage the services of local staffing firms that specialize in the placement of entry-level medical professionals.
New home health care agencies must tackle the problem of finding clients to serve. Although this may not be much of a hurdle for entrepreneurs with industry experience, it can definitely be a challenge to those without a professional network. In addition to placing traditional advertisements, an agency can also have business referred from other agencies in the local health care community. Long-term care facilities, hospitals, rehabilitation centers and social workers all partner with home health care agencies to provide care for their patients and clients.
10th Reasons HomeCare Businesses Fail
There can be many reasons why a business fails, yet learning to avoid those pitfalls is the mark of a successful entrepreneur. Here is a list of the most common reasons why homecare businesses fail.
Reason 1: It’s All About The Money
It’s all about how money flows through your homecare business. When you are developing a business plan, be sure to focus firmly on the financial. Certainly, marketing and human resources play large roles in the success of a business, but nothing helps a business fail faster than the lack of capital. Look closely at the different investments you need to make to get this business off the ground. Consider software, phones, rent, mileage, reimbursement, and payroll (and don’t forget to pay yourself, too.) Often business owners underestimate how much money is needed and are forced to close before they have a fair chance to succeed.
Reason 2: Be A Great Caregiver
Because owning a business requires a different skill set than being a caregiver, there’s no guarantee that if you are an outstanding caregiver you will be a successful business owner. Business training comes from many places, and you should consider every job you’ve had as training for the challenges of owning your own business. Learn to recognize what you do not do well, and seek assistance from professionals and employees or you may be headed for disaster. Specifically, in homecare, you need excellent skills in hiring, managing, accounting, analysis, and marketing.
Reason 3: Go It Alone
Are you doing all of the work in your business yourself? If the answer is yes, then it’s time to reevaluate. Many owners of homecare agencies get focused on the day-to-day operations of the business and neglect the bigger, business-savvy vision of making the homecare organization grow. Perhaps it is time to hire a scheduler, caregiver coordinator, or office manager so you can focus your energy on business strategy and growth. Provided you hire an outstanding team, your business is bound to succeed.
Reason 4: Ignore The Possibilities
How do you respond when a caregiver makes a suggestion to improve the business? How many conferences or industry-based events do you attend? It’s a good idea to attend at least one conferences a year so you can talk with other homecare business owners and share ideas. You can and will learn from others who have gone before you in the homecare business. By the same token—and because you never know where the next great idea may come from—you should keep an open eye when listening to suggesting from caregivers and office staff, too.
Reason 5: Ignore Everything
If Mr. Smith reports an issue with a caregiver, how quickly do you respond to the situation? Do you respond differently to personnel issues and financial issues? Having a pro-active and balanced response to the variety of issues that arise during the course of the business day can greatly enhance your ability to grow your business.
Reason 6: I’m Better Than Everyone
One sure-fire way for your homecare business to fail is to underestimate or ignore the competition in your area. You should know what they are charging, how their businesses are run, and how to distinguish your business from theirs. You do not need to be the lowest priced provider as customers rarely make a decision on price alone, but you do need a compelling reason for potential clients to select your agency. Features like the staff skill level and training, technology used to verify visits, or some other clear benefit helps you avoid become another “me too” business.
Reason 7: Get Rich Quick!
There are many reasons to start a homecare business, and getting rich should not be one of them. Before you begin your business, check in with yourself. Why are you starting this business? Do you think that if you had your own business you will have more time to spend with your family? Or that perhaps you won’t have to answer to anyone else? If so, you’d better think again. Owning a business is demanding in many ways, and though you may get rich eventually, success takes a lot of persistence and hard work.
Reason 8: Marketing Schmarketing
Marketing makes or breaks your business and includes not only advertising to potential clients, but also relationships with potential referral sources. To determine what works best in your area, experiment with a variety of marketing techniques. Don’t neglect maintaining relationships with people and organizations that can refer clients to you. Their recommendations are critical for strong business growth. If you get caught up in the day-to-day running of your business and neglect the marketing, the business will flounder.
Reason 9: No Computers Here
All else being equal, an agency that can utilize technology to its fullest will have a distinct advantage over the competition. Homecare software programs are designed to support and streamline the variety of activities that an agency encounters during a typical business day. In addition to a software program, the use of telephony puts sophisticated time-keeping in place for more accurate billing and payroll. Ultimately, homecare software has the ability to relieve the business owner of day-to-day details, and therefore exponentially increase the time spent on strategic thinking.
Reason 10: Fear Change
Failure to adapt your business as the industry changes gives your competition an advantage and will, no doubt, doom your business. You need to keep current on the changing market conditions and trends. This is relatively easy to do by subscribing to newsletters targeted specifically, for private duty homecare, and also by attending conferences where you can talk with industry experts and other business owners. Once you sense a change in the industry, take pro-active steps to adapt.
Top 10th Complaints from Home Care Clients.
1. Confusion in Communication Due to Multiple Caregivers for One Person.
Clients like having the stability of one caregiver and one point of contact. Having a “point man” ensures responsibility is taken and assures clients that nothing will be lost in communication.
2. Caregivers Lack of Punctuality
Home care clients commonly report that caregivers come late or leave early. Some clients are on a strict schedule, and having a caregiver show up late means they could be left unattended. It can be a huge inconvenience for family members who have to stay longer while missing out on those extra 10-20 minutes they’re paying for.
3. Quality of Care is Inconsistent
Some caregivers are better at their job than others, but it can be really frustrating for a client when one caregiver is exceptional, then the next performs only basic tasks. Read our posts on recruiting, retaining and training quality caregivers to ensure your level of care is always reliable.
4. Caregivers Texting/Calling/Surfing the Web
Clients get really irritated when caregivers are on the clock and wasting time on their phones, neglecting the client. Enforce strict rules about cell phone usage, set a standard penalty for those who break the rules, and hold your caregivers accountable.
5. Lack of Caregiver Training
Clients are sometimes upset when caregivers can’t perform basic cooking and cleaning requests. One woman said when she asked her caregiver for a grilled cheese sandwich, the young woman stuck cheese on a piece of bread then dropped it in the toaster, creating a huge mess. Some caregivers may benefit from basic cooking instructions or recipes.
6. Cultural Differences/Language Barriers
Many cultures have different standards for cooking and hygiene. If you hire someone from another country, teach them about our customs and basic words in English before they start working. Language barriers and cleanliness differences can be very troubling and frustrating for your clients.
7. No Discounted Rates for 12+ Hour Shifts
Clients who have a greater need for help will pay much more than those with only basic help needed. If your budget allows, try to take off a dollar or two for those long visits. This could be more difficult with the recent changes to caregiver exemptions, but clients will appreciate whatever effort you can make.
8. Pay Schedule is Inconvenient
Some companies send out a weekly bill, but some clients prefer monthly billing since it’s easier to keeping track of payments. Keep clients in mind when planning your billing schedule.
9. Being charged time and a half
Clients complain of being charged time and a half on holidays, which equals to about $30/hour. They feel that’s too steep and care shouldn’t cost that much. If you’re able to make adjustments, do so. At the very least, provide information for clients, so they understand why this policy is in place.
10. Not Being Told When Caregivers Call in Sick
It’s not uncommon for caregivers to call in sick to the office, but the office doesn’t call the clients or send a replacement. This is a communication problem that could cause astronomical problems for your clients and your home care business. While all businesses struggle in one way or another, it’s important to take a detailed and honest inventory of your performance. Only by doing this can you begin the road to improvement and create a growing, healthy home care business. If you’re making one or more of these mistakes, take the necessary steps to solve the problem and prevent the negative impact these issues could have on your client pool and reputation.
Home Healthcare Best Practices Guide for Risk Management.
Home healthcare is one of the fastest growing segments in the healthcare industry. People are living longer, they desire to stay in their homes as long as possible, and the medical system encourages them to do so. According to an excerpt from First Research’s profile on home health care:
INHERENT RISKS OF HOME HEALTHCARE
- Home healthcare places an unsupervised individual in the home of a person who may have significant physical and/or cognitive problems. What would be regarded as a minor injury in a healthy individual can be catastrophic to some patients?
- The Home healthcare worker provides personal and/or professional services in an environment they do not control and has access to personal information and valuables.
- Home healthcare workers are exposed to safety related risks similar to those encountered by nursing assistants in a nursing home or other direct care workers in a hospital environment because they perform some common job tasks. However, studies of the home health service industry have documented inherent occupational hazards to home health workers due to the nature of the highly variable non-institutional settings and “uncontrolled” work environments.
- Home care aides for example, typically provide a variety of services which include housekeeping, and may include personal care (bathing, dressing) and assistance with moving and transferring (patient handling.) All of these tasks are characterized by risk factors for musculoskeletal symptoms, including forceful exertions and awkward postures. Research indicates that patient handling is a significant risk factor for back pain and other musculoskeletal symptoms in home settings.
For several years, the overexertion injury rate for Home Health Care workers has been more than double the national rate for all industries, ranking among the 10 highest (Bureau of Labor Statistics [BLS], 2006.)
Additional inherent risks exist due to the nature of the work done. Any work with patients, particularly in a non-hospital environment presents exposure to claims of negligence, abuse or theft. Losses under these circumstances can be significant, particularly when the patient suffers a significant injury that exacerbates existing health problems. Loss costs associated with injuries occurring to persons with compromised health, such as a paraplegic falling from a wheelchair, can be huge. There are also additional risks when home care workers drive personal vehicles inadequate insurance, poor driving records, inadequate vehicle maintenance and drive patients to appointments.
Non-medical home care duties associated with personal care/non-professional services can encompass everything from light housekeeping to transportation, running errands, preparing meals and assisting with the activities of daily living. Any of these activities can produce losses. Of particular concern are activities of daily living, which include bathing, getting dressed, personal grooming and using the toilet. Assisting with these activities often requires providing physical assistance up to and including transferring the patient to and from a bed, chair, toilet or vehicle.
Even medical professionals (professional care services) working with patients in their homes are at risk for injury.
Patient handling while providing physical therapy, checking for wounds or responding to events that occur during a visit, such as a patient needing to use the toilet. The reality is that patient handling and periodic transfers are a part of the job.
- Wound care exposes workers to blood borne pathogens, including MRSA , AIDS and other contagions
- Needle sticks are fairly common and can be an additional source of exposure
Both professional and non-professional employees can also be exposed to dangers associated with what is going on in and around the patient homes. These are environments that are not under the control of the HHC agency. They may include exposures to:
- Trips and falls as a result of physical conditions at the property and weather. The possibility of falls also increases if patient transfers or handling are required
- Contamination and exposure to any number of airborne contaminants
- Family members and others. In some areas of the country, this can be the signal greatest threat to the safety of the home care worker
Preventive options, client and home assessment, financial health of your agency.
1. Preventive options, client and home assessment, financial health of your agency.
When a risk creates loss or potential for loss, management needs to consider options available to prevent the loss. If the loss cannot be absolutely prevented, methods need to be employed to keep the impact of the loss, or loss type, in check. Regardless of the type of problem being addressed or the industry involved, risk management theory outlines the same approach to developing controls. You can transfer the risk away, engineer the problems out, or implement practices and policies to reduce the possibility for loss.
v Transfer or avoid the hazard – The most effective way to avoid a risk is not to engage in practices that create a potential source of risk. In many cases, however, being willing to accept a particular risk is the reason companies are in business. Something a company could do but chooses not to. Examples of avoiding a hazard in home healthcare are, a company’s refusal to transfer bariatric clients, or to provide services to customers owning dangerous dogs.
v Develop engineering controls – For the risks we accept, when problems occur or there is a potential for a loss, the most effective control is to engineer or design the problem out. In the manufacturing world, this might include installing a guard on a machine, or changing the way a machine works to avoid amputations. In the home healthcare arena, this could include eliminating the need to physically lift a client. Regarding client transfers, an engineering control would be the use of client transfer equipment which eliminates the need to lift or reduces the physical stress on the healthcare worker.
v Implement Administrative control practices – Engineering solutions are not always possible. They can be prohibitively expensive or impractical. Where we cannot remove a hazard by avoiding it or engineering the risk out, we have to take other measures. While the least effective, in the home healthcare world, most of the controls to prevent loss are administrative controls. Administrative controls for client transfers involve things like hiring, training and the use of client transfer protocols.
v Accept the risk – A company can always decide to accept a risk and not to apply any controls. While this might seem like a poor way to manage risk, the reality is that most companies do this on a daily basis, usually for minor or insignificant risks. Helping someone to take a seat or holding a chair are activities that most organizations would not refuse to do or have written procedures or training on how to handle. While there is a potential risk, it is judged as too small to try and actively manage.
CLIENT AND HOME ASSESSMENTS
Client and home assessments are critical, not only to prevent injuries to the healthcare worker, but also to avoid situations that place a home healthcare organization at a higher risk for potentially fraudulent liability claims.
Thorough evaluations of client current status, future needs, and what is required to promote safety for both client and caregiver is key.
- The assessment of the client identifies physical and psychological characteristics that must be considered in the plan of care. When done correctly, these assessments provide a detailed plan that should incorporate specific client transfer equipment (chair lifts, Hoyer lifts etc.) Ergonomic tools (pivot discs, slip sheets etc.) and instructions to the home care provider on how to deal with psychological needs (“client suffers from dementia…”.)
- Examination of the home environment can uncover situations that present a hazard to both the client and the caregiver. These needs must be incorporated into the clients care plan, and updated on an ongoing basis as needs change. Use of and regular documentation of formal care plans plays a key role in preventing injuries to employees and expensive lawsuits related to client care.
Some accrediting organizations, such as the Joint Commission, specify what these assessments need to include. Companies must also be willing to walk away when these needs cannot be addressed due to financing or other reasons.
Client physical characteristics requiring adaptive equipment.
The initial assessment needs to include an evaluation of specific duties and activities required of the home healthcare worker, and the physical and mental characteristics and limitations of the client. Whenever possible, client transfers should not be done without mechanical assistance. This should be mandatory for bariatric clients and those with significant cognitive or physical limitation that prohibit or limit their ability to assist with the transfer. Where equipment is needed there may be challenges related to expense and funding for the equipment. As difficult as it may be, if the caregiver is at risk for injury, chances are the client is as well. Back strains and serious falls can result in permanent disability and in hundreds of thousands of dollars in medical expenses. If equipment is needed and cannot be obtained, the home health agency needs to decline the assignment. Where there is a need for ergonomic equipment, procedures and vendors need to be identified that can aid in proper selection, requirements for client education, maintenance and inspection. Homecare staff needs to be adequately trained in its use, and this may be best facilitated by a physical therapist.
Over time, the client’s condition may change. It is important to monitor these changes and to take appropriate action. Action certainly includes notations to the file and may require notification of the physician and changes to equipment or client care instructions.
HAZARDS AROUND THE HOME.
Home healthcare employees all too often encounter hazards in the home that can present a danger to themselves and potentially the clients as well. Client homes represent environments not under the control of the home care agency. Housekeeping neglect, smoking, vermin, spoiled food and other conditions increase risks to both the caregiver and the client. When detected during the initial assessment, the organization needs to require that hazardous conditions be corrected before initiating care, or find ways to protect the person or persons who will be working in the home.
Slip, trip and fall hazards– These represent a significant potential for injury to the worker and the client. Statistically, falls are the number one source of injuries to clients in the home care environment and second only to strains and sprains as injury sources for employees.
The potential for a fall injury increases when you are assisting a client with a move, or while carrying something. In home care, this might involve helping a client to stand, carrying groceries, handling trash or moving furniture.
Begin with the exterior of the home.
- Where will your employee be parking? If they will be providing services at night, is lighting adequate?
- What is the route like from the car into the home? Are walkways free of debris, holes and large cracks? Are stairways provided with handrails and well maintained?
In inclement weather, the contract should require that the walkway and any exterior stairs be kept free of snow and ice. Some companies also keep small quantities of sand in their vehicles for use by homecare providers to improve traction. Another option is to require wearing of shoes with slip resistive soles or to provide removable traction aids for shoes.
Inside the home
Falls most often occur in the home when we trip over objects, when there is inadequate friction between our shoes and the walkway, or when a surface we are standing on is unstable. Look for:
- Cords, household goods or other items in main walkways or in areas where client transfers will occur;
- Spills and slippery surfaces.
- The client’s footwear can be a problem on smooth surfaces.
If there is a need to reach an object at a higher level, use only step stools. Never use chairs or other objects not designed for the purpose.
May not become apparent until after service starts or when medical equipment or electric beds are installed.
- Extension cords, which are designed for temporary use, can catch fire if overloaded. The possibility of overload and fire is more extensive with light weight, ungrounded cords. Whenever possible, equipment should be plugged directly into the outlet.
- In older homes, wall sockets may be ungrounded or circuits unable to handle additional load. This will usually be identified as a problem when equipment is delivered and installed. If during the initial walkthrough and home assessment, things like grounding plugs being cut off, wall plates without grounding sockets or gang plugs (one outlet with multiple plugs) are noticed, the home healthcare provider should require that the system be checked and wiring updated as necessary to safely handle the equipment. While primary responsibility would ordinarily rest with the home medical equipment company, the home healthcare provider could be found liable as well. Where the home healthcare provider provides equipment, they may be fully liable for any fires that may result.
- On future service visits, look for modifications made by the homeowner, client or other caregiver. Telltale signs are when equipment has been moved from the original location. Look for added extension cords.
- Watch for situations where electrical cords extend into walkways and around the bed. While extension cords should ordinarily not be used, if they are, they need to be out of the way or secured to the floor.
Mold, insect or rodent infestation or other unhealthy conditions–
These conditions can present serious health problems to the home healthcare worker, and, have resulted in significant claims. Be aware of and follow any legal obligations for reporting these situations, and do not accept contracts where these conditions present a hazard to employees.
Animals– Pets can be important to the health and general well-being of clients, but can also represent potential problems. The obvious problem is a vicious or overly protective animal. These animals need to be secured or removed during service calls. Small, friendly pets have also been associated trips and falls, particularly during client transfers.
Making sense of your financial.
What’s the first thing you look at when you get your homecare agency’s Profit and Loss statement (P&L) each month? If you’re like most people, it’s the bottom line. You want to know how much money your agency made or lost. Maybe you even glance at revenue or salary expenses. But if the results aren’t good, do you know how to improve them?
Imagine if you visited a patient whose primary complaint was that he “just didn’t feel good.” How would you know how to treat him? You would probably ask him questions and perform an examination. In other words, you would diagnose him so that you could develop a plan of care.
Think of the P&L as a tool for diagnosing the financial health of your agency. You might know that your agency “just doesn’t feel good” based on its bottom line, but you need to know what questions to ask and what examinations to perform to manage its financial outcomes.
Let’s take a look at the major categories on the P&L, also known as the income statement.
- Start at the Beginning – The first item on the P&L is revenue. Revenue is the income the agency earns by providing services to patients. Revenue can be influenced by a number of factors, the most obvious being patient volumes like admissions or census. Generally speaking, a higher census results in higher revenue. But there are a number of other important factors impacting revenue that your agency should be measuring, reporting, and managing on a regular basis.
- Home Health Revenue – Many home health payers, particularly Medicaid and Commercial Insurance, reimburse home health agencies in a straightforward manner. Payments are based on the number of visits or the hours of care provided to each patient. If clinically appropriate, additional visits and hours can result in additional revenue.
Things get more complicated when we start talking about Medicare reimbursement. Medicare pays agencies under the Prospective Payment System (PPS). PPS reimbursement is a predetermined amount that is based on each patient’s condition and service use during a 60-day episode of care. A number of Commercial Insurers have adopted the PPS reimbursement methodology over the last several years.
There are three wonderful things about PPS payers. One, reimbursement from these payers typically makes up the majority of an agency’s home health revenue. Two, PPS payers are more profitable than other home health payers. And three, each agency actually has the ability to influence its PPS reimbursement on a patient-by-patient basis. How?
Agencies perform an evaluation of each PPS patient known as the Outcome and Assessment Information Set (OASIS). The OASIS reflects the client ‘s condition and service needs, which in turn determines the agency’s reimbursement for providing care for that client t. In other words, the agency’s reimbursement depends on how acute the client is, and how well the agency reflects that acuity in its OASIS documentation. Remember, Medicare and other PPS payers want to reimburse you more for caring for sicker client s.
If your agency’s PPS revenue is low, there’s a good chance your caregivers and staff aren’t properly educated on how to maximize appropriate PPS reimbursement. Poor revenue results may also be caused by a failure to closely monitor LUPA, PEP, and Therapy Adjustments, which can be devastating to PPS reimbursement. Both caregivers and management need to understand what causes PPS adjustments and how to minimize their frequency. The cost of an OASIS training and education program can pay for itself many times over through revenue improvements and long-term financial sustainability.
- Where Does the Money Go? – The remainder of the P&L deals with the agency’s expenses. Expenses are the costs required to operate the agency.
It’s extremely important that your agency’s P&L separates direct expenses from administrative expenses. Let’s looks at what that means and why it’s so critical.
- Direct (Caregiver) Expenses – Direct expenses are the costs directly associated with providing hands-on care for clients. They’re sometimes referred to as caregiver expenses since it’s the caregivers who provide client care. Direct expenses include caregiver salaries, caregiver benefits, contracted caregivers, caregiver mileage, and medical supplies. Hospice direct expenses go a step further to include the costs of pharmaceuticals, DME, imaging, labs, diagnostics, and all other ancillary services involved in providing client t care.
As a rule of thumb, total direct expenses for a home care-based agency should be between 60% and 70% of revenue. The number varies from agency to agency, but lower percentages are always better. So for example, let’s say your agency had $100,000 in revenue and $75,000 in direct expenses in January. That means direct expenses were 75% of revenue ($75,000 4 $100,000) for the month.
Based on our criteria, direct expenses as a percent of revenue are too high in the example above. Your next step would be figuring out why. Excess caregiver utilization and low caregiver productivity are two common causes of excessive direct expenses. A professional review of your agency’s utilization and productivity might be beneficial if your direct expenses are too high.
Does your current P&L display separate salary amounts for caregivers and office staff? Or are all agency salaries reported as a single dollar amount? What about benefits? If these expenses aren’t itemized, you obviously can’t perform the recommended calculation. Work with your accounting department to improve your P&L so that it lends itself to more straightforward analysis. Only then can you evaluate the appropriateness of your agency’s expenses.
- Administrative Expenses – Administrative expenses are the agency expenses not related to client care. The list of administrative expenses is long but typically includes management and clerical salaries; management and clerical benefits; building lease and maintenance; utilities; office supplies and equipment; telephones, cell phones, and pagers; insurance; conferences and training; licenses and certifications; advertising, recruitment, and community relations; and everything else!
Administrative expenses may also include overhead allocations from an affiliated hospital or corporate office. Overhead allocations are simply a way of assigning costs shared by the whole organization to each department of the organization. Common examples of shared costs include human resources, information technology, payroll, accounting, and marketing.
As a rule of thumb, total administrative expenses for an agency should be about 30% of revenue. Again, the number varies from agency to agency, but lower percentages are always better. So for example, let’s say your agency had $100,000 in revenue and $35,000 in administrative expenses in January. That means administrative expenses were 35% of revenue ($35,000 4 $100,000) for the month.
Based on our criteria, administrative expenses as a percent of revenue are too high in the example above. Like before, your next step would be figuring out why. Excessive administrative expenses can be caused by a number of factors including inefficient office processes, more office FTEs than the agency’s client census calls for, or excessive line-item expenses. A professional assessment of these areas might be beneficial if your agency’s administrative expenses are too high.
The Bottom Line
Revenue minus total expenses is called net income. If revenue is more than total expenses, the result is a positive number called a profit. If revenue is less than total expenses, the result is a negative number called a loss.
Many healthcare systems view homecare as part of the organization’s larger mission and don’t expect the agency to be profitable. But you should expect better. Even if you’re a non-profit agency, profits can be reinvested so that the agency can continue to provide the most efficient and effective care to your client s. If your agency isn’t profitable, now you know how to use the P&L as a starting point to diagnose its financial health.
For expert homecare advice, consult the experts
2. Personnel Management
HIRING AND RETAINING EMPLOYEES
Traditional employee screening as practiced in the industry by most firms is not effective in finding persons least likely to be injured on the job. Most home care providers are low wage, older and high turnover positions. HHC companies are reluctant to conduct extensive evaluations, including physical capability assessments, when skill requirements are low and turnover is likely. Professional employees are typically hired for professional and relationship skills, not for patient handling ability. Even where the employer spends the money to screen employees, screening, at least of physical capabilities, only addresses prospective/new employees. Unless a company conducts annual fitness for duty testing, they need to employ other methods to control losses.
Screening of potential employees is necessary (criminal background checks are mandated) and physical examinations may be beneficial, but the jury is out regarding the most effective – physician provided or evaluations conducted by testing facilities using isometric examinations. Some research indicates psychological profiles to examine such things as honesty, work ethic and motivation may be just as or even more effective in preventing injuries than physical examinations.
Who a company hires has a significant bearing on the possibility of future claims of employee injuries, motor vehicle collisions and potential liability claims related to patient care. In home healthcare, as with any profession, the employee selection process starts with the basic process of identifying the requirements for the job and matching an employee to the job requirements. Beyond this basic requirement, employee selection practices can also be used as a risk mitigation opportunity. Where can a company experience a loss, and what can be done to improve the possibility that an employee won’t put the company at risk and/or injure themselves or others?
- Job description– Begin with an accurate description of job requirements, including “essential functions.” Essential functions are those aspects of the job that must be done for the job to be accomplished at a minimum. Employment practices suits are often related to aspects of the job being defined as essential that were in fact not. Job descriptions need to reflect realistic performance requirements. “Must be able to transfer clients to and from beds, chairs, toilets, baths etc.” is an unrealistic expectation. Caveats need to be added that consider client assessments, transfer devices and client characteristics (physical, mental etc.). With regard to client transfers, the ideal is to eliminate the need to manually move clients without mechanical assistance. Before writing the job description, start by making the job as safe as possible to do.
- Job application – Prospective employees need to be required to complete, sign and date a formal written job application. In addition to standard application questions, signing the application should serve as a notice to the prospect that what they have said is true and accurate, and they understand the company has permission to verify the information through checks of references, criminal background and motor vehicle records. If the company provides post offer, pre-employment physical examinations or assessments, drug tests or other examinations, such as a written personality or behavioral test, the signature should also authorize the company to conduct these evaluations.
- Interview – A key objective of the interview process is to accurately match the prospective employee with characteristics of a successful employee. In home care, honesty, judgment, decision making ability and commitment to the profession are critical. Situational questions are important parts of the behavioral interview. How would they respond to things like customer complaints and personality conflicts? Can they provide examples of situations where they have encountered situations like this? How did they respond?
- Criminal background check – Since the caregiver may have access to personal valuables and finances, obtaining a criminal background check is a recommended practice. Doing so may also be a legal requirement in the state where the organization operates. Prospective employees should provide a written acknowledgement the company will conduct such a check as a condition of employment and subsequent to employment commencement. Before making a decision to refuse an employment offer, or for terminating employment, consult with legal counsel if it is discovered the employee or applicant has been convicted of a crime.
- Reference checks and skills – Check the references and verify education and technical qualifications. While some employers may be reluctant to provide details about previous employment, most will not hesitate to respond honestly to the question “would you hire them again?” Ask specific questions about what the person did from business references, and try to get a sense of who the person is (integrity, honesty, passion for the work etc.) from personal references.
- Post offer, pre-employment screening – Employers are allowed to screen employees regarding their ability to perform “essential functions” of the job. When applied consistently to specific classifications of employees, these tools can be applied to help the employer match the employee with the job. They are referred to as “post-offer, pre-employment” because they are conducted after a conditional offer of employment has been made.
These types of screens, consisting of physical examinations or functional capacity tests, can be conducted in a variety of settings and by different sectors of the healthcare industry. For the employer, the question is not who performs the testing and the cost, but the effectiveness and track record of the company doing the tests. In home healthcare, this is one of the few ways of preventing a company from “hiring a claim,” or a person with pre-existing physical limitations or limited capacity to conduct essential functions, which may include client transfers.
Not all home healthcare agencies require physical examinations. Some have been successful in controlling loss experience through effective background checks, reference and skill verification and effective patient assessment and care management planning.
Drug testing– Another type of post-offer, pre-employment screen is drug testing. Prior to testing for drugs, it is important to establish a company policy regarding impairments on the job. Consider if you will only be testing applicants or current employees as well, and under what conditions (random, for cause etc.)
Driving skills – When employees drive company vehicles, or drive on behalf of the company, it is important to understand if they drive, what they do will reflect on the company. Should an employee cause a serious collision, the plaintiff may seek to access the financial resources of the company. If the driver has a history of poor driving and the employer should have known and should have done something to prevent the loss, they may be found financially responsible.
Evaluating driving skills can be as simple as riding along with the employee or as complex as requiring mandatory defensive driving training.
- Employee handbook – Explains who the company is, what they do and what is important to the organization. Because the handbook can spell out details of benefit plans, rules and regulations and disciplinary procedures, it should be reviewed by legal counsel before implementation. All employees should sign off to verify that they have reviewed and understand the material. Sign-off should include a confidentiality agreement to protect personal information about patients. GIFT GIVING, NOT ASSISTING CLIENTS ON THEIR PERSONAL TIME, FOLLOWING CARE PLANS, NOT DIRECTLY HANDLING CASH OR CREDIT CARDS.
- Orientation – the orientation process helps the new employee understand what the organization is about. What are the values and principles the company works off of? What is the mission statement and scope of what the company does? What are the expectations of the new employee? What can the employee expect of the company?
- Probation – Probation provides the organization with an opportunity to see how well the new employee actually fits with the culture of the company. It can also provide a chance for learning, correction of mistakes and an opportunity for growth. A key consideration is that even with successfully passing the probation period, employees need to be held to a standard where serious misconduct will not be tolerated.
One of the most significant challenges faced by many home healthcare organizations is high employee turnover. Organizations achieving the highest levels of success in the industry often credit the quality and loyalty of their employees for their success. Companies experiencing problems with profitability, liability and workers compensation claims are also frequently plagued by high levels of turnover. When turnover is high, everything costs more. Companies experiencing high turnover may not be able to justify extensive and through background checks or screening practices. Probationary periods are out of the question, the employees are needed yesterday.
While not every aspect impacting turnover is under the control of every home healthcare agency, there are some consistent characteristics of companies that have a good deal of success in keeping good, productive employees.
Basic motivation – People who do well in healthcare have a genuine love for the work they do. They get high levels of personal satisfaction from helping others in need, and from the relationships they form.
Recognizing and appreciating employees – One of the greatest motivators is feeling that your work is valued; that you contribute. People that get into healthcare want to do something that makes a difference. They want to help and most genuinely care. Gratitude from the client or the family goes a long way to motivating someone to stay in the profession. Failing to be recognized by the employer and that they value your contributions opens the door for finding greener pastures to practice the profession in.
Job and Career opportunities – Despite a love of work, everyone has bills to pay and personal responsibilities to take care of. Retention does depend on compensation. Organizations that don’t offer competitive wages and benefits are not selecting from the pool of the best available employees. Retention is also a factor when the best employees look down the line for promotion opportunities.
MANAGEMENT CONTROL PRACTICES – KEEPING THINGS UNDER CONTROL TRAINING
Training is an essential tool in ensuring that employees understand their jobs and perform them in a safe and efficient manner. Training may also be required by law for some occupations. Unfortunately, in the realm of finding ways to control losses, training is often regarded as the “silver bullet.” Training is relatively cheap to purchase, develop and provide in comparison to other, more effective measures that eliminate or reduce the hazard because these types of controls may be more difficult to apply.
In workers’ compensation, general lift training (lift with the legs and not with the back) is ineffective. The science of biomechanics demonstrates that you cannot teach a 125-pound home care provider to safely lift a 300-pound client from a bed to a wheelchair without mechanical assistance. In fact, research conducted by the Veterans Administration and others to develop patient handling algorithms and teaching scenario specific transfer techniques, such as bed to wheelchair transfers, resulted in, at best, only a slight reduction in the risk of injury. Findings from the research led to the development of “zero lift” policies being implemented in hospitals and nursing homes across the country. Unfortunately, these policies are more difficult to implement in the home healthcare environment.
If all client transfer tasks cannot be engineered out, training needs to focus on task specific techniques based on best practice methods.
WRITTEN PROCEDURES AND DOCUMENTATION
Company policies and practices designed to achieve client satisfaction, and prevent losses, are worthless if not verified. Document everything. In the event a situation end up in front of a judge, “if it wasn’t documented it didn’t happen” is all too often the deciding factor in assigning liability. Procedures and related documentation should address:
- Physician orders
- Care plans
- Verification that care plans were discussed with the client, family and caregiver
- Any physical hazards
- Observations made at visits regarding changes in the client’s physical condition or psychological state. Document notifications to the physician and/or family
- Anything that interrupts or prevents the ability to provide services contracted for. This could include hazards around the home, threats from family members, dangerous animals, or patient refusal to accept services.
- Any situation where there was an injury or suspected injury to the client, your employee or anyone else
The organization should have specific practices in place to routinely evaluate both customer satisfaction and employee potential for client abuse and injury to themselves or others. In addition to scheduled performance evaluations against established criteria, another approach is to periodically contact the client and their family members. What you discuss should be recorded.
Care plans, client transfers, infection control, violence in home health care setting, liability risks.
3. Care Plans, Client Transfers, Infection Control, Violence In Home Health Care Setting, Liability Risks.
Care plans are the roadmap to delivering effective, caring and safe services to clients. Pre-planning, doing appropriate assessments, developing the plan and documenting the flow of the plan translate not into not just business sense, but potentially saving the organization from major financial loss.
While the format and specifics may vary based on the type of client or customer served, accreditation and regulatory requirement, care plans generally need to address:
- Physician orders and treatment plans
- Past medical history
- Medical provider contact information
- Frequency of visits
- Correspondence between the physician and the family
- Drug handling procedures
- Properly completed informed-consent forms
Home care workers often work alone in environments they do not control. Client transfer tasks may be complicated by confines spaces and inaccessible or difficult to negotiate areas of the home. Workers are likely to encounter situations where there are no mechanical transfer devices and clients may prefer to use their own beds rather than powered and/or adjustable hospital beds. Physical handling required to assist in daily activities of living may be frequent, requiring a wide variety of postures. Client sizes are increasing and a higher percentage of the population is electing to or being forced to stay in the home. Clients may be instable, combative, agitated or confused.
The overwhelming majority of home care workers are female, and the population of workers in this field is aging. Workers may also be unaware of opportunities to access and the availability of mechanical transfer devices. In some areas and companies, many workers, and even employers, in the profession follow the philosophy of “we transfer patients this way because that’s the way it’s always been done.”.
In addition to client transfers, the home care worker may assist with other activities of daily living, such as cooking, cleaning, shopping and laundry. These activities can contribute to cumulative physical stress and in some cases, may be more hazardous than patient handling.
PREVENTION AND CONTROL
If an organization is willing to accept the risk of transferring clients, there need to be parameters established as to who will be transferred and under what circumstances. Are there clients with specific physical or cognitive limitations or disabilities that the organization does not wish to transfer? What does “transfer mean?” Specific transfer specifications should be carefully outlined in the client care plan. Are transfers considered things such as to/from beds, wheelchairs, bathtubs, automobiles?
Engineering involves the use of equipment to reduce the risk of injury to the client or the employee from primarily lifting and handling or trips and falls. Some of the more common engineering controls in the field of home healthcare include:
- Mechanical Lifts – Mechanical lifts take many forms dependent on the client and circumstances of the transfer. These include full body lifts, lifts to assist in transferring the client who has some mobility and ambulation lifts help to support the client while walking.
- Trapeze bars – A trapeze bar allows the client to grasp and position themselves in bed or to help when they are being transferred.
- Gait belts – are the most frequently used client transfer tool in the industry. In its most basic form, the belt is a towel wrapped around the client’s waist. More commonly, these are made of canvas. Transfer belts are wider and have handles on each side for better control.
- Slip sheets or transfer sheets – can be thin, plastic boards or heavy cotton linens placed under the patient to slide them horizontally or to help in positioning in beds or chair.
- Pivot discs – many injuries suffered by nursing, CNAs and other healthcare personnel are injuries to the knees while transferring patients from beds to/from wheelchairs and wheelchairs to/from toilets. When shoes and floor surfaces combine to limit the ability to pivot, significant stress can be placed on the knees. The pivot disk, placed at the point of transfer, permits easy pivoting and reduces stress on the back.
Of all the engineering controls listed, none except the full body mechanical lift eliminates physical stress. Other than the full body lift, any client transfer task places the homecare worker at risk from either a traumatic injury, or injury as a result of cumulative injury over time.
SLIPS TRIPS AND FALLS
Slips, trips and falls are the second leading cause of injury to home care workers. They happen when walking to the patient’s home, when negotiating through the home and most frequently while providing assistance to the patient.
Prevention and Control:
Because the home care worker does not control the environment they work in, it is often difficult to “engineer out” the potential sources of injury. As with client transfers, there are measures that can significantly reduce the potential for injury.
Home assessments can be helpful in identifying slip, trip and fall hazards for the prospective new customer. Identification of hazards and requirements to make corrections before accepting the client as a client are not necessarily the easiest solution, but are the best answer. These assessments are necessary at least informally at every visit.
Proper slip resistive footwear goes a long way in preventing slips and falls on wet and snowy surfaces. In heavy show or where ice is present, consider ice cleats for shoes and keeping small amounts of sand in the car. Keep floors clean and dry.
Look specifically for:
- Large cracks or holes in the walkway;
During winter months, are the walkways cleared? This needs to be a requirement in the contract and there needs to be a plan for dealing with the situation if it is not (refuse to do the work, carry equipment and materials to deal with the situation or arrange for another party to clear the way);
- Steps and stairs need to be sound and sturdy. Watch especially for railings. Are they firmly anchored and secure?
Ponding water can create serious accumulations of ice. Do workers need to walk in areas where this occurs?
If services will be provided during hours of darkness, is lighting adequate from where they park to the doorway?
According to the World Health Organization, approximately 6% of healthcare workers experience a potential exposure to infectious disease annually. These include almost 400,000 sharps injuries annually to hospital based personnel alone in the U.S. (CDC) Any use of needles, scalpels, scissors or handling bodily fluids exposes workers to over 20 types of pathogens, including hepatitis B&C and HIV. While some contagions present a higher risk than others for transmission (up to 10% for HCV from a single needle stick,) any exposure carries a risk. For some injectables, the medicine itself can be hazardous to the healthcare worker if they inadvertently inject themselves. In home care, even where injections are not given by the worker or other activities exposing the worker to bodily fluids, there may still be exposure from patient administered drugs and when disposing of trash, handling laundry, soiled patient care equipment and other sources.
- Safety equipped injection devices, training and education, alternative ways of administering medication
- Educate employees about the dangers of potential punctures and blood borne pathogens, how to prevent them, reporting when they occur and describing what happens after an exposure
- Vaccinate employees against threats they are exposed to, such as hepatitis B (HBV)
- Establish and use sharps safe handling and disposal protocols, following CDC “One and Only Campaign”
- Early detection of medical conditions that are hazardous and contagious during the client assessment;
- Follow universal precautions for every client. As outlined by the CDC, treat all blood, bodily fluids, secretions, excretions (except sweat,) non-intact skin and mucous membranes as if they contain infectious agents;
- Use appropriate personal protective equipment such as gloves and masks, gowns, eye protection depending on the exposure, and rigidly follow hand hygiene practices;
- Vaccinate employees against influenza;
- Soiled client care equipment – wear gloves if visibly contaminated and follow proper hand hygiene practices;
- Laundry – handle to prevent the transfer of any microorganisms to others and the environment;
- Client resuscitation – use a ventilation device to prevent contact with oral secretions;
- Coughing and sneezing – instruct employees to cover their mouth, dispose of tissues in a no-touch container, wash hands, maintain a 3’ or greater separation, wear a mask if tolerated.
Home healthcare workers face the potential for violence ranging from verbal and psychological intimidation to physical violence and assault. In addition to facing many of the same risks encountered in any healthcare setting, workers may find themselves alone, often at night, in high risk or high crime areas and in the presence of animals, guns and family members. Family members with a history of violence, under the influence of drugs or alcohol or diagnosed with a mental illness increase the danger to the home care worker. Unlike the hospital, the home care agency does not control the environment.
Client care can also be affected where the fear of violence causes the home care worker to limit visit duration or to cancel appointments.
Prevention and Control:
- Training and education about the risk of violence, identification and response to agitation, disruptive and aggressive behavior and conflict de-escalation techniques;
- Patient, family member and home assessment;
- Clear policies and procedures for handling threats;
- Personal alarms, cell phones, escorts;
Home healthcare workers, and their employers, are uniquely exposed to potentially significant liability risks associated with working unsupervised in a client’s home. While in that environment, anything that happens to the patient or their property can potentially be viewed as under the care, custody and control of the HHC agency. Incidents can translate into claims of sufficient magnitude to put the organization at financial risk.
The most frequent type of situation resulting in claims involves client falls. Those that usually occur that result in claims are most often associated with client transfers, and can occur when providing professional medical services or when attending to activities of daily living.
- To and from beds;
- Transfer to/from toilet or bath tub;
- Assisting the client with walking;
- Falls from wheelchairs;
- Falls when getting in and out of automobiles.
Beyond physical and mental impairments or other client characteristics, HHC workers often have to contend with tight confines, trip and fall hazards, poor lighting, animals, family members, poor or deferred maintenance and other conditions that increase physical risk.
One of every three older adults falls one or more times each year. Fall-related injuries are the leading cause of injury, death and disabilities in adults over 65, the most serious injury being hip fracture. Half of older adults hospitalized for hip fracture never regain their former level of function, and nationwide only 50% of older adults hospitalized for hip fracture are able to return home or live independently after the injury.
The American Geriatric Society’s Guidelines for Prevention in Older Adults advises “providers across diverse settings need to screen individuals for risk using generic criteria at multiple points of access,” “adding “all people identified at risk should be offered a multi-factorial assessment and tailored interventions..
Home health care workers are often faced with disturbing ethical issues; among them, illegal activities going on in the home. HCW may be confronted with illegal drug dealing or consumption. Home Care staff are conflicted as to whether to report this to the police for fear of retaliation or, if unable to return to the home and the client, the client ‘s health may be endangered or compromised.
Gender and Race Issues
Sexual harassment has been reported by both sexes while on the job. Young female nurse’s report being particularly vulnerable be it by male patients or family members. Men also reported being harassed by clients.
Racial issues, where staff of a particular race went into neighborhoods or a home of a different race, increased staff fears and perceptions of risk.
Professional care services
Some of the most expensive claims relate to situations where Home care services are not provided as provided in physician instructions and care plans. These types of claims are typically associated with:
- Failing to notice a new infection;
- Failing to perform contracted services;
- Not identifying fundamental changes in the client’s condition.
Theft and damage to client property
Theft and damage to client property, including access to personal health and other confidential information can be a serious problem.
- Criminal background checks on all employees needs to be mandatory. Be sure to understand the laws of your state and how they apply. In general, you should be able to deny employment to any prospective employee with a felony conviction or a felony or misdemeanor related to physical abuse or assault, theft or fraud.
- Develop specific policies on what employees are or are not allowed to do regarding client finances, purchases or anything related to personal records. Employees should not be allowed to use a caregiver or client credit card under any circumstances, and any other access or use of funds to purchase personal items for the client should be specified in the contract with the client or their caregiver.
- Another area to watch for is theft of telephone services. Consider blocking international calls.
- Damage to furniture and potentially the HHC worker and client, can occur when handling cleaning chemicals. Avoid bleached based solvents. Candles cause fires. Avoid fires of any kind if at all possible. Turn down the water heater to medium heat.
Liability practices and control, driving policy, accident and incident investigation and analysis.
4. Liability Practices And Control, Driving Policy, Accident And Incident Investigation And Analysis.
In a difficult competitive environment, organizations are often under pressure to differentiate themselves from others. Unfortunately, differentiation by overstating capabilities or quality of services can result in significantly higher levels of liability. Watch for overstating promises and guarantees that generate unrealistic client expectations, have legal counsel review all marketing material.
Checklist of liability practices and controls
With regard to liability, regardless of the size of the organization, there are recommended best practices that need to be put in place and followed:
- Quality assurance requirements and measurements conforming to state licensing requirements, certifications and accepted professional standards and practices;
- Policy and procedure manual for daily operations, and for handling complaints and incidents;
- Management of confidential employee and client information;
- Infection control policy, including TB screening;
- Written job descriptions that clearly define duties;
- Criminal background and sex offender registry checks;
- Validation of personal auto insurance and checks on driving records if employees operate their own vehicles;
- Employee selection that includes a competency assessment, and verification of references and credentials;
- Procedures for documenting and handling complaints from client s and client family members;
- Requirement for and use of written service and care plans for each client;
- Continuing education covering client rights, compliance, infection control and ethics.
In any situation where someone drives on behalf of a company there is an exposure for that company. Regardless of whose car they are driving, when and in some cases, for what purpose. Over the past several years, companies are facing charges of vicarious liability or “negligent entrustment” when the employed driver causes a collision and the employer did nothing to verify that the employee was qualified to drive.
Some Home Healthcare agencies do not compensate home care workers during transit between client appointments. Even where the vehicle belongs to the employee and they are driving without compensation, the employer may still be liable for their actions. In addition to potential suits for vicarious liability, there may also be an exposure to workers compensation claims should the employee be involved in a collision. Specific rules regarding what does or does not qualify as being in the course and scope of employment vary by individual state, but the majority will allow coverage if traveling directly from one appointment to the next.
If a company requires any driving for business purposes, it needs to have a written driving policy. This is particularly important when the employee transports patients to appointments, shopping or other functions, and even where they run errands on behalf of a client or the company. The policy may not need to be extensive, but needs to clearly cover company expectations.
- Anyone driving a vehicle on company business must obtain authorization to do so.
- When an employee drives a vehicle on company business, the company has a right to check motor vehicle records. By signing the acknowledgement the employee authorized the employer to check.
- MVRs will be checked at least annually. This is a low cost investment that can pay huge dividends in preventing the employment of someone with a history of dangerous or reckless driving.
- State unacceptable driving records or when a review of privileges will be conducted (revoked or restricted, three tickets in three years, DUI/OWI convictions etc.)
- Insurance that the employee carries on their own vehicle will act as primary coverage for any collision. Require proof of insurance coverage if the employee will be driving his or her own vehicle. Check this every 6 months. Require that it at least meets minimal state requirements for coverage.
- Make sure your company carries Non-Owned auto coverage. This coverage applies over personal coverage and this additional coverage is often needed when the at-fault driver is on company business when the collision occurred. If they will be driving clients, consider requiring higher limits, or require they drive the client’s auto and ensure it has proper coverage.
- Consider inspecting the employee’s automobile to ensure it is safe. Again, the importance of doing so increases significantly when transporting patients.
Accident And Incident Investigation And Analysis
As the saying goes “fool me once, shame on you, fool me twice, shame on me.” While we do everything reasonable to prevent incidents and injuries, they can happen, and we have to be prepared to minimize the extent of the loss. If we do not learn from the occurrence, or patterns of loss, and use lessons learned to prevent future problems, there is a likelihood that we will repeat the loss, and subsequent events often end up being worse than the initial event. In the case of liability claims, a pattern of failing to identify and correct ongoing problems can play a key role in the extent of a court award or judgment.
Incident reporting – Regardless of the type of event – client injury, employee injury or vehicle collision, the accident or incident investigation and analysis needs to incorporate the following:
1. Demographics + Analysis = Corrective Action
- Demographics. Who was involved and were there witnesses – obtain names and contact information What happened – Clear, concise and non-judgmental. Just the facts. When did it occur? Where did it occur – be specific
- Analysis. Analysis is the “why” of the equation. This is also the most difficult part and why many accident or incident analysis efforts are ineffective, and sometimes ignored.The most frequent weaknesses of analysis efforts are.
2. A focus on finding blame. In many organizations, analysis begins with the premise that someone did something stupid and they need to be punished or receive remedial training. The focus needs to be on accepting that there was an underlying management control deficiency responsible. The deficiency may very well be that the company hired the wrong person or that the employee was inadequately trained, or there was an undetected hazard, but ultimately, everything the company or its employees are exposed to is under the control of the company.
3. Not to extend the effort. Accident or incident reports with conclusions such as “unavoidable” “employee was stupid” “should have been more careful” “should have known better” are lazy and unproductive. These types of conclusions don’t lead to corrective action, but may result in finger pointing. Getting to the heart of what truly caused the loss to occur can be a difficult process, but truly eliminating a source of injury and/or dollar loss is worth the investment. An often-unrecognized benefit of conducting detailed analysis is that while solving one problem, it is often possible to uncover a fundamental management control deficiency that may be responsible for the occurrence of other accidents or the existence of potential sources of injury or property damage.
4. Why do companies fail to do thorough analysis? Often, when it is time to complete the paperwork, the initial damage is done and people want to move on to other priorities. Responsibility for the analysis may be dropped on someone without authority for completion. If there is a history of that person’s recommendations being ignored, it is a guarantee of an ineffective investigation.
5. How do you approach the analysis? Companies should have protocols as to which incidents and accidents are investigated and the extent of the investigation. In the healthcare arena, companies often establish incident review boards, peer groups or committees that may be accountable for investigating any serious incident which has occurred, putting the organization at risk for substantial financial loss. This may include any client incident involving an injury, employee injuries requiring time away from work or collisions where injury and/or property damage occurred. In other organizations, all incidents may first be reviewed by an individual, such as a risk manager, human resources professional or the owner. Regardless of who investigates the incident, the basic process should consider the following.
6. People – Without looking to place blame, consider factors related to the person or persons involved;
For a client – were there characteristics about the client or something they did that contributed to the incident? Did we already know about this? If not, should we have known about this? Did we take proper steps to control against the problem? Does this need to be included in the patient’s care plan?
For an injured employee – were they qualified to do the work? Should they have been doing the job based on the ability to functionally perform the task safely? Did they understand what they needed to do? Was this particular task something not normally performed?
For an “at fault” collision – Could they have taken action to avoid the collision? Were they legally qualified to drive? Did they understand company policies? Have they acknowledged the company driver policy?
7. Equipment – Equipment refers to the things that were involved in the incident, such as transfer equipment, beds and vehicles;
Was the equipment used appropriate for the task? For a client transfer device, was it designed for the client?
Was it used for the purpose intended and was it used correctly?
Did it work as designed? Was the equipment in good working condition?
8. Materials – Materials are elements introduced into the environment. “Materials” in the world of home healthcare include clients and everything to do with them. Was there something about the client that increased the risk or contributed to the incident? Did they do something unexpected? Should we have known about it? Was there a change in condition that we did not identify?
Where there chemicals, drugs or other substances involved? Did we understand the hazards and provide sufficient protective measures and training?
Did materials or people traveling in a vehicle involved in a collision contribute to the crash?
9. Environment – Basically, the world we live and work in did weather have a role to play? Could we have protected against or prevented the loss by taking appropriate measures?
Were there conditions in or around the home that caused or contributed to the incident? Were people or animals involved?
10. Corrective Action. After identifying the causal factors, take a look at how they influenced the incident and determine what changes could be taken or implemented to prevent a similar situation from occurring in the future. As noted in “General Principals of Risk Management” above, solutions need to be prioritized as:
- Transfer or eliminate the risk;
- Engineer the problem out – add or replace transfer equipment, add a handrail;
- Take administrative action – training, new procedures
11. Follow-up. Clear responsibility needs to be assigned for making corrections, by a specified date, and reporting when completed.
Patient Care Ergonomics Resource Guide: Safe Patient Handling & Movement Department of Veterans Affairs. One of several references to studies and research conducted over the years into patient handling. Provides guidance on patient transfer equipment, handling algorithms. Available at http://www.va.gov/
CDC/NIOSH – Safe Patient Handling. Includes NIOSH Hazard Review: Occupational Hazards in Home Healthcare http://www.cdc.gov/niosh/topics/safepatient/
American Nurses Association (ANA) Needle Safety http://www.needlestick.org
National Institute of Occupational Safety and Health (NIOSH) Stop Sticks campaign and sharps injury prevention protocols. www.cdc.gov
National Institute of Occupational Safety and Health (NIOSH) State of the Sector – Chemicals and Other Hazardous Exposures www.cdc.gov
CDC – Healthcare-Associated Infections (HAIs) http://www.cdc.gov/hai/
OSHA Standards Related to Healthcare http://www.Osha.gov/SLTC/healthcarefacilities/standards.html
CDC – Home Healthcare Workers, How to Prevent Violence on the Job http://www.cec.go/niosh/docs2012-118/
The International Council of Nurses – Abuse and Violence Against Nursing Personnel – http://www.icn.ch/images/storeis/documents/publications/position_statements/CO1_Abuse_Violence_Nsg_Personnel.pdf
Society for Human Resource Management (SHRM) Annual Membership http://www.shrm.org
World At Work Compensation education, resources, benefits and work-life training www.worldatwork.org
American Geriatriacs Society Falls prevention in older adults http://americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/
CMS Outcome and Assessment Information Set (OASIS) http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/OASIS/index.html