Promoting A Culture of Awareness and Safety for Hospice Aides

1. Promoting A Culture of Awareness and Safety for Hospice Aides Christine Clement, MSW, LICSW, Manager EvergreenHealth Hospice Care October 2019

2. About the Presenter • Graduated in 1990 with a Master of Social Work degree specializing in geriatrics and health care. • Employed with EvergreenHealth since 1990: • COPES case manager (3 years) • Hospice social work case manager (14 years) • Hospice manager (12 years)

3. Session Description This session focuses on specific challenges faced by Hospice Aides (aka, CNAs) and ideas for supporting this key member of the hospice team. This includes recognizing safety risks which is the first step to preventing injuries. Promoting clinician safety helps keep our patients safer, too.

4. Learning Objectives At the end of this presentation, participants will be able to: • Recognize challenges faced by Hospice Aides. • Understand and promote strategies for Hospice Aide and patient safety including the “Power of Two” and use of hospice-provided durable medical equipment (DME). • Empower Hospice Aides, Hospice nurses (and all clinicians) to pave the way for Hospice Aide success. 

5. Overview of the Hospice Aide Role

6. Hospice Aide vs. CNA vs. HHA vs. Bath Aide Centers for Medicare and Medicaid (CMS) uses “Hospice Aide” as the title for Certified Nursing Assistants (CNAs). This title speaks to the expertise required of the role—hospice care is specialized care. Hospice Aides are so much more than “bath aides.” (Bath aide) Home Health Aides (HHAs) work in Home Health.

7. Overview of the Hospice Aide Role (2) A Hospice Aide is trained to provide personal care to patients in the patient’s home environment. Visits are generally one to three times a week (or more) depending on the patient’s needs as assessed by the Hospice RN. The Hospice Aide performs a variety of tasks (list to follow) as determined by the Hospice RN including educating those responsible for the patient’s custodial care to help them feel confident in providing day to day care to the dying patient.

8. Care Provided by Hospice Aides The care provided by a Hospice Aide is based on individual patient need as assessed by the Hospice RN. Typical tasks include: Shower, tub bath, or bed bath Washing hair Combing hair Shaving Dressing Oral care or denture care Help with toileting or incontinent care  Care and cleaning of foley catheters

9. Care Provided by Hospice Aides (2) Nail care Lotion rubs Turning and repositioning bedbound patients Transferring from bed to chair or chair to bed Assistance with ambulating (walking) Range of motion exercises Changing bed sheets Light housekeeping Preparing simple meals Feeding assistance

11. “Houston, We Have a Problem” As a new manager, I began receiving occasional phone calls from AFH owners requesting a different Hospice Aide (the same Hospice Aide involved with each request—I’ll call her Stacy). In meeting with Stacy about this pattern, she said the reason she is getting “fired” is because she asks for help with patient care to prevent injuries and promote patient comfort. Often paid caregivers do not think helping should be necessary (“That’s your job”). If help was not forthcoming, Stacy would not provide care, respectfully departing and then informing the RN case manager.

12. “We Have a Problem” (Continued) Over time I continued to learn about the magnitude of this issue by listening to our Hospice Aides about their experiences—and observing, as well as seeing injuries that were occurring (for example, a torn ligament and several back injuries). Stacy had professional, common sense ideas for preventing injuries—not new ideas to Hospice Aides and RNs, yet not practiced as they should be—for a variety of reasons. As a manager, I have been able to help highlight these issues and reinforce the importance of basic safety practices.

13. Challenges Experienced by Hospice Aides • Expectations by others for care to be provided alone. • You’re not going to give my (280 lb. bedbound) husband a shower? • It’s just a bed bath—how hard could it be? • You’re from Hospice—that’s your job. • Misunderstandings about the role. • You’re not going to clean the whole house? • People “looking down” on Hospice Aides, as demonstrated by: • Verbal bullying (intended to intimidate or harass) • Racial and/or ethnic slurs • Refusing to partner in the care of the patient • Feeling disempowered. • If I speak my opinion about what I think is right, she’ll tell my manager and I’ll get in trouble. My manager will think I can’t do my job.

15. Expectations to Provide Care Alone Heavy care provided alone is a recipe for injuries. And the following are not solutions: Changing the care plan from a shower to a bed bath. In fact, bed baths can be more strenuous than a shower and often more uncomfortable for the patient when provided alone. Assign a male Hospice Aide. In fact, male Hospice Aides are equally susceptible to injury.

16. Hospice Patients are Typically Weak Hospice patients become weaker over time as a consequence of their illness(es). Eventually (if not immediately upon admission) our patients require assistance with personal care due to fatigue and/or weakness. Yet we generally expect our Hospice Aides to provide care with no assistance.

18. Learning From The Experts Even when using proper body mechanics, injuries can be common for Hospice Aides. Consider the strain of someone trying to provide personal care to patients who are unable—or minimally able—to assist? Whether a shower or bed-bath, the Hospice Aide is pulling, pushing, holding, rolling (etc.) the patient and trying to clean them at the same time.

19. Maximizing Patient ComfortMinimizing Risk of Injury Every patient has a plan of care specific to his/her needs written by an RN. For patients who are minimally able—or completely unable—to assist with their personal care, insist upon the “Power of Two” for meeting the patient’s personal care needs. The “Power of Two” can maximize the patient’s comfort while receiving personal care and minimize the risk of injury for both patient and CNA.

20. What is “The Power of Two?” The “Power of Two” is two people working together to provide patient care. Generally the Hospice Aide will take the lead—directing the person helping and also guiding the patient. GOALS of the “Power of Two” • Involve an additional person in the patient’s care. • Promote CNA safety. • Promote patient safety. • Promote patient comfort. • Demonstrate & teach appropriate care to the person helping.

21. Promote “The Power of Two” Include the expectation within your hospice literature that caregivers and/or family members are part of the Hospice Aide’s POC for patient and caregiver safety. Ensure good understanding (provide education) within your program about the importance of “The Power of Two.”

22. Engage Family Members and Caregivers Often family members want to help. Provide a consistent message: Patient personal care usually takes more than one person.

24. Durable Medical Equipment (DME) In addition to the “Power of Two,” the Hospice Aide plan of care will vary depending on what DME is available to provide care safely. For example, a hospital bed in necessary to minimize back strain caused by leaning over the patient. Another example: A 3-in-1 commode or shower chair used in the shower to provide a place for the patient to sit (because even if the patient wants to stand, weakness occurs during showers and falls are common).

25. DME (continued) If the patient, caregiver, or legal representative will not allow delivery of appropriate DME, consider discontinuing Hospice Aide services rather than risk injury. Changing from a female to a male Hospice Aide—someone stronger—is not a solution; a male can just as easily become injured.

26. RN: Assessment & Collaboration RNs: Collaborate with the patient and/or patient’s caregiver regarding the patient’s personal care needs; assess their abilities to assist with care. RNs: Educate patient and/or caregiver about the scope of the Hospice Aide’s role and the caregiver’s responsibility to help with the patient’s personal care. RNs: Collaborate with the Hospice Aide to ensure the Hospice Aide POC maximizes the patient’s safety, Hospice Aide’s safety and patient’s comfort. RNs: Communicate the CNA POC to Hospice team members, caregivers and family members so everyone is on the same page.

27. Hospice Aide Empowerment Hospice Aides are responsible to contact the RN case manager if: • The Hospice Aide POC seems unsafe for self and/or patient. For example: • There is no one to help with the care that requires two people. • Certain elements of care seem too risky (perhaps the patient is agitated and/or has changed in other ways). • You are being treated disrespectfully. • You have suggestions for the Hospice Aide POC. • When in doubt, speak up.

28. Policy Amendments • Amend policies regarding “discrimination and harassment-free work environment” to include “customer” in the scope. • This gives the organization a baseline for holding patients, their caregivers and family members accountable to be respectful. • When following appropriate regulatory steps, it may also provide a basis for discharging patients when discrimination, verbal abuse and/or harassment continues in spite of interventions.

29. No Discrimination or Harassment Bottom line, clinicians should not have to experience discrimination in the workplace. In home hospice care, the “workplace” includes the patient and who the patient lives with.  

30. Rights & Responsibilities of the Organization We are responsible to provide the best patient care possible and equally responsible to keep our clinicians as safe as possible. • Organizational boundaries • Zero tolerance when staff are treated disrespectfully. • Setting limits when Hospice Aides do not receive assistance with care. • Setting limits when patient, legal rep or caregiver refuses proper DME.

31. Hospice Care Takes a Village Change starts with awareness of the problem and working together toward collaborative solutions because… We’re all in this together and it takes each of us, doing our part, to provide exceptional hospice care.