August 1, 2023 • 25 mins
What if patient care stepped away from mere box-checking and became truly patient-focused? This episode is an eye-opener as we welcome Donnette Threats from Homecare Homebase, whose 30 years of hospice experience bring a profound understanding of software's role in building comprehensive care plans. With Donnette, we shift the focus back to what truly matters - the patient and their family, and how clinicians can utilize software to ask the right questions, thereby making care more personalized.
We discuss person-centric care, dual verification, guidebooks, and the role of EMRs in capturing the four Ms. Tune in to find out how investing in age-friendly care can be a game-changer in delivering quality healthcare.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Jennifer Kennedy (00:08):
Greetings and salutations.
I'm Jennifer Kennedy, the leadfor Quality at CHAP, and welcome
to this month's CHAPCast.
Today I'm talking with a doubleduo here and it's my pleasure
to introduce Donnette Threatsfrom Homec are Homeb ase and our
very own, Teresa Harbour, totalk about patient-centered care
(00:29):
plans and age-friendly care athome.
Before we jump into all thegood age-friendly stuff, I
wanted to welcome Donnette andactually ask you, Donnette, if
you could talk a little bitabout your organization and your
role there.
Donnette Threats (00:44):
Hi, i'm Donette Threats.
I'm with Home Care Home Baseand Home Care Home Base has been
a leader in EMR that'savailable to anyone in the
hospice space for many, manyyears now.
I recently joined the team backin November and my primary
focus is Director of ProductManagement with a focus on
hospice.
I have about 30 years inhospice experience so I come
(01:09):
with a lot of fun experiencefrom that background and just
really get involved with thisamazing group of folks where
folks focus primarily onbuilding a product that supports
hospice and hospice care.
Jennifer Kennedy (01:22):
Let's do that.
I'm glad a fellow hospiceperson with that many years is
on the call to talk about atleast which you're helping that
sect of the home care continuumdo.
Teresa, haven't had you on aCHAPCAST before, have we?
Well, welcome to CHAPCAST.
Teresa Harbour (01:42):
So glad to be here.
Jennifer Kennedy (01:43):
Yeah, so for our listeners, could you tell a
little bit about what you dohere at CHAP?
Teresa Harbour (01:48):
All right.
Well, I am a registered nurse.
I'll give you a little bit ofhistory.
I started in hospice in 1990 atour local community hospice
here where I live in NorthCarolina, and just completely
fell in love with care in thehome and knew that's where I
wanted to stay.
And so I've been either in homehealth or hospice ever since.
(02:09):
so 33 years now.
.
q uite sometime.
I've been at CHAP for almostfour years; Be four years in
September.
I'm the Chief Operating Officerhere at CHAP and get to work
with you, Jennifer, and othergreat people every day.
Jennifer Kennedy (02:26):
Thanks, theresa.
It sounds like all three of usshare that passion for
community-based, home-based care.
So this is going to be anexciting discussion today, and
let's get to it.
We want to , but we want toframe it in the terms of the
(02:46):
patient-centered plan of care,which is really so important,
not only to hospice, but to homecare, but to any
community-based service that isprovided at home.
But we wanted to talk to thisspecific topic as it relates to
Age-friendly Care .
So I'm hoping some of you outthere have looked at our
(03:10):
Age-friendly Care materials,that you know a little bit about
it.
What I'd like to do is give youthe one minute or less
description about , because Ireally want to give time to
Donette and Teresa to talk aboutthe innovation of care planning
and applying this particularmodel to older patients in the
(03:35):
home.
Age-friendly Vare isspecifically for 65, age 65
years and older.
We know that that population isexploding into the health care
continuum and will continue tobe the highest-served population
, probably for the next coupleof decades.
(03:55):
So they need a differentapproach.
They need to be in charge oftheir care, they need to be
partners in their care and theyneed to have care that's
specifically tailored to thembeing an older adult.
So having a goodpatient-centered care plan is
really important.
(04:16):
It's individualized, but thenwhen we apply that perspective
to someone who's in that olderadult category, where I feel
like we're pushingpatient-centered care to the
next level, if you will, interms of individualizing it,
partnering with that patient andtheir caregiver about what they
(04:38):
really want to happen, whatmatters to them in their space
that they occupy today and everyday moving forward.
So, with that said, that'sprobably more than one minute of
description about Age-friendlyCare.
Age-friendly Care at home issomething that CHAP has taken
(05:01):
under our wing as a reallyinteresting project and we're so
passionate about pushing it outthe door.
We developed Age-friendly Carestandards and we developed an
Age-friendly Care Certificationprogram for those who want to
put your toe in the water and beable to provide your older
adults with a really wonderfulcare model as they age out.
(05:27):
So, with all of that said, I'mgoing to swing over to Donnette
here, and there are someinteresting things that
home-care home-base is doingwith patient-centered care
planning and age-friendly.
Is that fair to say?
Donnette Threats (05:46):
Yes, very, very fair to say.
I think it's great when youthink about the concept of
providing patient-centered careand then you apply the 4M's that
are a part of Age-friendly Care, and you think about it and you
go in the patient's home andyou're like okay, so what do I
do with this?
One of the great things that asoftware can do is help to guide
(06:09):
that discussion, prompt theuser to ask certain questions,
to ask what's important to you,what matters right now, what
really matters for your life.
And as you're completing thatassessment and developing that
most important plan of care, notonly to make it specific,
because sometimes the regs saymake it specific and you're like
, okay, so how do I do that?
(06:30):
now, do I say she likes cats?
Well, if the cat matters, thenyeah, it's important.
So it's that ability to helpthat clinician think through.
How do I create that plan ofcare that focuses on this
patient, this family, and alsofocus on what matters to them,
(06:50):
and create that in a way thatthe rest of the team can come
around and support the carethat's needed at that point in
that patient's life.
So Home Care, home Base hasbuilt that plan of care to
provide that tool to help withthat process.
Jennifer Kennedy (07:05):
Donnette, I gotta tell you I'm so excited
that Home Care Home Base didthis.
I've been out on the road for acouple of months talking about
Age-friendly Care at home withboth Home Care and Hospice
providers and they're slow towarm up to the approach.
You know.
Once I think that I've got themand that they understand it,
(07:26):
the next big thing they say iswell, guess what?
Our EMR doesn't support it, soit's gonna We feel that it would
be a heavier lift in terms oflogistics to apply this
framework w
Donnette Threats (07:40):
And they're right, because sometimes, if you
have something that is sostructured that you can't say
what the patient want is da, da,da, da da.
What really matters is for meto stay at home, surrounded by
my family, and I need you totake care of my medication in a
way that allows me to do that.
I want you to watch how I'mthinking, to make sure I am
(08:01):
alert for when my grandbaby comethrough the door or that
granddaughter you know thatgranddaughter that you know
needs my attention to be able totalk to that person and do
what's important to me right now.
You need the flexibility in theway that the software is
structured to allow you to dothat, And the patient- centered
care plan allows that clinicianto create that plan in a way
(08:24):
that is meaningful not only tothat patient but also to the
care providers.
Jennifer Kennedy (08:29):
You know, I also think, as I'm listening to
you talk, I'm thinking, you know, one of the things I think that
H Friendly Care does is sort ofpush providers out of the
things that they've always doneand they've, you know, they
always do this, we do this, wedo this meaning.
And here's a good example.
And I was talking to a group, Iforget which state, but and it
(08:53):
was a hospice group and theysaid oh, we already know what
matters to the patient.
Well, they might know whatmatters in a very little space.
They're not looking at thebroader, the bigger, what
matters to that patient.
(09:23):
Most definitely, becauseoftentimes it's given to in your
check-in And you know I washaving a conversation with
someone else and they're sayingyou know, it's like critical
thinking is gone.
I don't know, I don't get theopportunity to sit down and
think about OK, I've assessedall of this.
What is the problem?
Well, you don't have to thinkabout it.
Ask the patient and family Whatis important to you right now?
(09:45):
What matters?
What do you really want to workon?
You've been having pain.
Is it important to you thatthat pain get decreased down to
zero and that caregiver may say,or that patient may say, not if
it means I'm not going to beable to interact, so get me to
the point where I can stillinteract, i can still do what's
important to me.
That is what care at this pointin life is really about to
(10:09):
allow that individual to directtheir care not just to you know,
actively show up, but toactively direct it.
And I think that's what'sreally unique about age-friendly
care And when you take it andthat old patient-centered care
that's been around for eons now,that helps us to build that
relationship, to be able to geta framework that's
(10:32):
evidence-based that you can thenincorporate into software and
also help with the quality ofcare that is provided and make
that family feel as if they'reliving their life to the fullest
for as long as they have got.
Oh my gosh, well stated.
You know the critical thinking.
That's a whole other podcast,isn't it?
Yes, Just turn it out there,All right.
(10:54):
Well, we have another sort ofexciting development here with
dual verification, Home careHome base.
And, Teresa, I want to inviteyou into this conversation
because you know you've had alot to do with the verification
process at CHAP.
Teresa Harbour (11:11):
Absolutely So.
First of all, you know,congratulations on being our
first EMR to achieveAge-friendly Care at home CHAP
verification.
I know that there was a lot ofwork went into that, you know,
and it's definitely going to payoff in regards to the delivery
of high quality,patient-centered care.
So I just want to provide justa little bit of feedback on what
(11:33):
we've been hearing from some ofour home care home-based
customers in regards to goingthrough our pilot site visits
and becoming Age-friendly Careat home certified.
You know, in talking about theperson-centered care plans, you
know the feedback that I haveheard from clinicians is that it
truly makes itinterdisciplinary and it saves
(11:55):
so much time.
So you know.
So here you are, you know,working with clinicians that
don't have a lot of time andthey're saying that it saves
time.
So I just wanted to share thatwith you.
That's one of the things thatI've heard about the
patient-centered care plans.
But, yeah, the dualverification and the workbooks,
the guidebooks that you knowKatherine had developed
(12:18):
completely outstanding how shetook the four EMS and laid that
out and explained through theguidebooks with screenshots and
you know where to go and to homecare home base to document this
, where it's not adding extrawork to clinicians.
You know this is all part ofthe workflow.
So I mean great, great job withthe guidebooks and I believe
(12:41):
they're on your customerexperience portal for your
customers to be able to access.
So okay, great, great, yeah.
But the dual verification, youknow, not only verifying your
home health and hospiceplatforms to ensure that they
meet our CHAP standards, thenthat additional component,
having them verified to makesure it meets our age-related
(13:02):
care at home standards.
So kudos to Hump Care Home Basefor that.
So when you're looking at beingable to capture those four EMS,
you know part of the pilot sitebusiness that we've
accomplished is that.
You know we don't want extrawork added to clinicians and I
mentioned before you know, thepatient-server care plans.
(13:23):
You know saves time does notadd additional work, but just
the whole approach itself doesnot add work to clinicians.
And you know being able tocapture that in the EMR is
critical and key being able toidentify, just like what you
said.
You know what matters to thatpatient and how it's impacting
or how medications can impactwhat matters mobility, mentation
(13:46):
and having that captured inyour EMR.
That's getting pushed in to theplan of care so that every
clinician going into the homeknows this is what matters.
I mean, that's really going tomove the needle on patient
outcomes.
Jennifer Kennedy (14:03):
You know I can't agree more and I know you
get very passionate, theresa,when you talk about Age-friendly
Care in the home.
You know you were out there onour pilot.
You saw some of the reactionsof the clinicians.
You know what are they saying.
I mean, do they feel like it'sreally helping them, that this
approach is helping them workbetter with their patients?
Teresa Harbour (14:26):
Absolutely.
And having worked in many homehealth and hospices, I can tell
you as a case manager, anytimeadministration brought anything
to us clinicians, you know I'dbe like here goes the
eye-rolling in, and this isgoing to add so much work and
it's not going to have apositive impact on patients.
But with this pilot and thefeedback that we've got from
(14:49):
clinicians and we heard all ofthis with our work with the John
A.
Hartford Foundation and IHIthat in the American Hospital
Association that you knowclinicians like it and we heard
that that we actually got toexperience that and see that and
feel that and hear that fromthe clinicians in the pilot site
visits that the statement waswe love this because we get to
(15:14):
be clinicians And they're seeingthe positive outcome obvious.
You know we make home visitsduring our site visits and
during the home visits patientsknew their goals.
So here you've got cliniciansloving something and patients
(15:34):
know their goals.
That's a huge win.
And what more could you ask for?
with that?
I mean truly looking at youknow value-based care models.
you know having that, improvedpatient outcomes, improved
patient satisfaction this justgoes hand-in-hand with that.
Jennifer Kennedy (15:51):
Yeah, I believe that too, and I really
think it pushes clinicians.
Like I said, I think someclinicians get a little bit
stagnated when they're in aparticular area for a long time,
but I feel like this issomething that would sort of
push them, push their skill setfarther than maybe they have
been exercising it previously.
(16:13):
So I know that, as I said, I'vebeen out and about, and not all
clinicians are like on board,but they're like marinating.
You could see they'remarinating about it, you know.
But I do believe it may takejust a little bit of time for
some to sort of embrace this asa not only is it better quality
(16:36):
practice and care, but it'sgonna, you know, as you said,
move our needle forward in thewhole quality space.
Teresa Harbour (16:44):
Absolutely, absolutely Well, and I think
that you know just getting pastI mean once again hearing the.
You know the conversations thatyou know this is not a project.
I mean it's a framework.
You know it's what clinicianshave to get to the point They're
going through the training.
You know that does add a littlework to you know to the
clinicians and to the team.
(17:05):
Just learning aboutAge-friendly Care.
You know how to have thoseconversations about.
You know what matters to thepatient, how to identify some of
those high-risk meds that youknow older adults should not be
taken, and how you know toconstantly keep them on the top
of your mind.
You know mentation and lookingat of course, you know during
(17:26):
our initial assessments wecapture and screen for you know
depression, dementia, you knowthose type of things.
But then you know keeping thattype of mind during every home
visit that you make as well.
And same thing with mobility.
We often do screenings onadmission for mobility.
You know home safetyassessments follow risk, those
type of things.
(17:46):
But once again, just keepingthat on top of mind with every
visit, that this is truly aframework.
So once they understand thatthis is truly not adding any
work, it's changing kind oftheir mindset and just
implementing the frameworkduring the workflow and being
then once again able to capturethat in home care home base and
(18:08):
make an update to that plan ofcare.
When you're talking about, youknow, patient-centered care,
this completely equalsage-friendly care at home.
Jennifer Kennedy (18:20):
Absolutely, and, and, Donnette, the software
approach that you've developedis really going to help to
greater individualize thatpatient's plan of care to a
better degree, which CMS alwayshas a problem with the care
isn't, doesn't lookindividualized right.
So do you feel like that your,your care plan that you
(18:40):
developed here, really helps toaccomplish that?
Donnette Threats (18:44):
It really does .
It provides a lot of tools tohelp that clinician think
through those pieces.
It allows the clinician evensomething as simple or complex,
i should say, as medication.
It gives that medicationinformation to say, hey, you
know, these are the side effects, these are interactions You can
discuss with the physician Andthen, as you're developing that
(19:06):
plan of care, if the patientgoal is to continue to be as
mobile as possible, everydecision you're making and your
documenting as interventionsthat the teams are going to
provide can be aligned towhatever that goal is, because
you're able to clearly statewhat that goal is.
It's not a matter of being in abox where you have to stay in
(19:28):
this box.
You're able to go in and saythis patient would like their
pain, though we don't like it,they would like their pain to
stay at a four, just so thatthey can be alert for and you
may continue to educate on waysyou can achieve it with bringing
it lower, but to be able tohave the team understand that
(19:50):
this is this patient's choice atthis point.
I remember my most difficulthospice patient was a patient
who wanted to experience painfor redemption of her family
member.
I didn't conceptualize it.
It wasn't my way of thinking.
Mine is get rid of my pain, butfor her it was important and to
(20:11):
have those types of discussion,capture that so when you're
being surveyed, you can read itand see, this is why it was that
way.
This was her choice, this iswhat she wanted, and we
respected that.
However, we also educated.
We did do all these otherthings to be able to clarify
that easily in a framework thatis not so prescriptive, but it
(20:35):
have enough prescriptive toguide you.
That is so great because withthat consistency we can measure.
And, You know undefined can'tsay This or that without having
data from measurement right.
So I love that idea of havingconsistent documentation.
(20:59):
It's all right there.
Then we can measure the outcomeof the application of Age-
friendly Care.
So kudos to you, Donnette, andyour team, for developing this
important documentation system.
You know, Age-friendly Care, Ireally feel, is It's going to be
the healthcare continuum'sfuture, at least for the next
(21:24):
several decades.
So when we have, you know,partners like you who are
willing to make the investmentin capturing all that
information, so providers have alittle bit of a logistics edge,
that's a win-win for everybody,for sure.
All right, well, we're at theend of our time here, So I
(21:48):
wanted to ask each of you if youhad any closing thoughts for
all the listeners out there andpodcast land today, Donnette?
Hmm, closing thoughts.
My closing thought would be tocontinue to grow, because it has
never been done doesn't mean itcannot be done.
This is just an amazingopportunity to bring two ways of
(22:09):
thinking together within ascope of a tool, which is what
any EMR is.
It's a tool.
Use it to the best of yourability to capture the excellent
work that you're already doingat the bedside.
We have been taught throughhospice for years.
We need to dopatient-family-centered care.
This just provides thatframework to say this is how you
(22:30):
do patient family care.
You ask them this question, youmake sure you understand this
and then your plan needs toreflect what's important to them
, what matters to them.
It's simple.
Yeah, it may be complex at time, but it's worth the journey.
It's worth the thought.
It's worth you feeling, as aclinician, that, oh my gosh, I'm
(22:52):
back to doing what I came intohealth care to do.
I can make a difference.
I can see the difference.
It's been my perception in theyears in hospice that if you're
working on your goal, you'llnever achieve it, because no one
who's dying is going to spendtime Achieving your goal.
If you figure out what thatpatient and family goal is,
chances are they are going toachieve their goal, and you'll
(23:15):
be there to see the smiles.
You'll be here to see thelaughter, even through the tears
, and that's pretty much whatwe're all about - making sure
that, for the time folks havelife, they're living the best
quality life that they can, andHomecare Homebase is here to
support that.
Jennifer Kennedy (23:31):
Donnette, that was so well stated.
Thank you, thank you so much,Teresa.
Final thoughts from you.
Yeah, that was a mic drop rightthere, But I will say that our
number one deficiency that wesee is always around care
(23:53):
planning, coordination of care,care planning, IDG, that
completely looped around that.
planning.
That eliminates our topdeficiency when you make it
about that patient and havingthe interventions and goals that
(24:15):
truly surrounds what matters tothe patient.
You know you're going todeliver them that high quality
care and, like you said, beingable to meet those patients and
families goals, which is, youknow, while we all started in
hospice anyway, is to be able todo that to help that patient
achieve their final wish is todie at home with family.
(24:36):
Thanks, Teresa , thanks so much, and that was
actually a very nice follow-upDonnette.
Teresa Harbour (24:43):
Yeah, i don't know about that, it's awesome.
Jennifer Kennedy (24:46):
There's nothing I can say to top that.
So what I'll do is just thankeverybody for joining the
podcast today.
I like to learn something newevery day, so I really feel like
I did accomplish that goal withyou ladies, today.
So thank you for that.
The CHAP team and I thank allof you out there for taking time
out of your day to plug intoour podcast.
(25:07):
From all of us.
Stay safe and well, and thanksfor all you do.
Greetings and salutations.
I'm Jennifer Kennedy, the leadfor Quality at CHAP, and welcome
to this month's CHAPCast.
Today I'm talking with a doubleduo here and it's my pleasure
to introduce Donnette Threatsfrom Homec are Homeb ase and our
very own, Teresa Harbour, totalk about patient-centered care
(00:29):
plans and age-friendly care athome.
Before we jump into all thegood age-friendly stuff, I
wanted to welcome Donnette andactually ask you, Donnette, if
you could talk a little bitabout your organization and your
role there.
Donnette Threats (00:44):
Hi, i'm Donette Threats.
I'm with Home Care Home Baseand Home Care Home Base has been
a leader in EMR that'savailable to anyone in the
hospice space for many, manyyears now.
I recently joined the team backin November and my primary
focus is Director of ProductManagement with a focus on
hospice.
I have about 30 years inhospice experience so I come
(01:09):
with a lot of fun experiencefrom that background and just
really get involved with thisamazing group of folks where
folks focus primarily onbuilding a product that supports
hospice and hospice care.
Jennifer Kennedy (01:22):
Let's do that.
I'm glad a fellow hospiceperson with that many years is
on the call to talk about atleast which you're helping that
sect of the home care continuumdo.
Teresa, haven't had you on aCHAPCAST before, have we?
Well, welcome to CHAPCAST.
Teresa Harbour (01:42):
So glad to be here.
Jennifer Kennedy (01:43):
Yeah, so for our listeners, could you tell a
little bit about what you dohere at CHAP?
Teresa Harbour (01:48):
All right.
Well, I am a registered nurse.
I'll give you a little bit ofhistory.
I started in hospice in 1990 atour local community hospice
here where I live in NorthCarolina, and just completely
fell in love with care in thehome and knew that's where I
wanted to stay.
And so I've been either in homehealth or hospice ever since.
(02:09):
so 33 years now.
.
q uite sometime.
I've been at CHAP for almostfour years; Be four years in
September.
I'm the Chief Operating Officerhere at CHAP and get to work
with you, Jennifer, and othergreat people every day.
Jennifer Kennedy (02:26):
Thanks, theresa.
It sounds like all three of usshare that passion for
community-based, home-based care.
So this is going to be anexciting discussion today, and
let's get to it.
We want to , but we want toframe it in the terms of the
(02:46):
patient-centered plan of care,which is really so important,
not only to hospice, but to homecare, but to any
community-based service that isprovided at home.
But we wanted to talk to thisspecific topic as it relates to
Age-friendly Care .
So I'm hoping some of you outthere have looked at our
(03:10):
Age-friendly Care materials,that you know a little bit about
it.
What I'd like to do is give youthe one minute or less
description about , because Ireally want to give time to
Donette and Teresa to talk aboutthe innovation of care planning
and applying this particularmodel to older patients in the
(03:35):
home.
Age-friendly Vare isspecifically for 65, age 65
years and older.
We know that that population isexploding into the health care
continuum and will continue tobe the highest-served population
, probably for the next coupleof decades.
(03:55):
So they need a differentapproach.
They need to be in charge oftheir care, they need to be
partners in their care and theyneed to have care that's
specifically tailored to thembeing an older adult.
So having a goodpatient-centered care plan is
really important.
(04:16):
It's individualized, but thenwhen we apply that perspective
to someone who's in that olderadult category, where I feel
like we're pushingpatient-centered care to the
next level, if you will, interms of individualizing it,
partnering with that patient andtheir caregiver about what they
(04:38):
really want to happen, whatmatters to them in their space
that they occupy today and everyday moving forward.
So, with that said, that'sprobably more than one minute of
description about Age-friendlyCare.
Age-friendly Care at home issomething that CHAP has taken
(05:01):
under our wing as a reallyinteresting project and we're so
passionate about pushing it outthe door.
We developed Age-friendly Carestandards and we developed an
Age-friendly Care Certificationprogram for those who want to
put your toe in the water and beable to provide your older
adults with a really wonderfulcare model as they age out.
(05:27):
So, with all of that said, I'mgoing to swing over to Donnette
here, and there are someinteresting things that
home-care home-base is doingwith patient-centered care
planning and age-friendly.
Is that fair to say?
Donnette Threats (05:46):
Yes, very, very fair to say.
I think it's great when youthink about the concept of
providing patient-centered careand then you apply the 4M's that
are a part of Age-friendly Care, and you think about it and you
go in the patient's home andyou're like okay, so what do I
do with this?
One of the great things that asoftware can do is help to guide
(06:09):
that discussion, prompt theuser to ask certain questions,
to ask what's important to you,what matters right now, what
really matters for your life.
And as you're completing thatassessment and developing that
most important plan of care, notonly to make it specific,
because sometimes the regs saymake it specific and you're like
, okay, so how do I do that?
(06:30):
now, do I say she likes cats?
Well, if the cat matters, thenyeah, it's important.
So it's that ability to helpthat clinician think through.
How do I create that plan ofcare that focuses on this
patient, this family, and alsofocus on what matters to them,
(06:50):
and create that in a way thatthe rest of the team can come
around and support the carethat's needed at that point in
that patient's life.
So Home Care, home Base hasbuilt that plan of care to
provide that tool to help withthat process.
Jennifer Kennedy (07:05):
Donnette, I gotta tell you I'm so excited
that Home Care Home Base didthis.
I've been out on the road for acouple of months talking about
Age-friendly Care at home withboth Home Care and Hospice
providers and they're slow towarm up to the approach.
You know.
Once I think that I've got themand that they understand it,
(07:26):
the next big thing they say iswell, guess what?
Our EMR doesn't support it, soit's gonna We feel that it would
be a heavier lift in terms oflogistics to apply this
framework w
Donnette Threats (07:40):
And they're right, because sometimes, if you
have something that is sostructured that you can't say
what the patient want is da, da,da, da da.
What really matters is for meto stay at home, surrounded by
my family, and I need you totake care of my medication in a
way that allows me to do that.
I want you to watch how I'mthinking, to make sure I am
(08:01):
alert for when my grandbaby comethrough the door or that
granddaughter you know thatgranddaughter that you know
needs my attention to be able totalk to that person and do
what's important to me right now.
You need the flexibility in theway that the software is
structured to allow you to dothat, And the patient- centered
care plan allows that clinicianto create that plan in a way
(08:24):
that is meaningful not only tothat patient but also to the
care providers.
Jennifer Kennedy (08:29):
You know, I also think, as I'm listening to
you talk, I'm thinking, you know, one of the things I think that
H Friendly Care does is sort ofpush providers out of the
things that they've always doneand they've, you know, they
always do this, we do this, wedo this meaning.
And here's a good example.
And I was talking to a group, Iforget which state, but and it
(08:53):
was a hospice group and theysaid oh, we already know what
matters to the patient.
Well, they might know whatmatters in a very little space.
They're not looking at thebroader, the bigger, what
matters to that patient.
(09:23):
Most definitely, becauseoftentimes it's given to in your
check-in And you know I washaving a conversation with
someone else and they're sayingyou know, it's like critical
thinking is gone.
I don't know, I don't get theopportunity to sit down and
think about OK, I've assessedall of this.
What is the problem?
Well, you don't have to thinkabout it.
Ask the patient and family Whatis important to you right now?
(09:45):
What matters?
What do you really want to workon?
You've been having pain.
Is it important to you thatthat pain get decreased down to
zero and that caregiver may say,or that patient may say, not if
it means I'm not going to beable to interact, so get me to
the point where I can stillinteract, i can still do what's
important to me.
That is what care at this pointin life is really about to
(10:09):
allow that individual to directtheir care not just to you know,
actively show up, but toactively direct it.
And I think that's what'sreally unique about age-friendly
care And when you take it andthat old patient-centered care
that's been around for eons now,that helps us to build that
relationship, to be able to geta framework that's
(10:32):
evidence-based that you can thenincorporate into software and
also help with the quality ofcare that is provided and make
that family feel as if they'reliving their life to the fullest
for as long as they have got.
Oh my gosh, well stated.
You know the critical thinking.
That's a whole other podcast,isn't it?
Yes, Just turn it out there,All right.
(10:54):
Well, we have another sort ofexciting development here with
dual verification, Home careHome base.
And, Teresa, I want to inviteyou into this conversation
because you know you've had alot to do with the verification
process at CHAP.
Teresa Harbour (11:11):
Absolutely So.
First of all, you know,congratulations on being our
first EMR to achieveAge-friendly Care at home CHAP
verification.
I know that there was a lot ofwork went into that, you know,
and it's definitely going to payoff in regards to the delivery
of high quality,patient-centered care.
So I just want to provide justa little bit of feedback on what
(11:33):
we've been hearing from some ofour home care home-based
customers in regards to goingthrough our pilot site visits
and becoming Age-friendly Careat home certified.
You know, in talking about theperson-centered care plans, you
know the feedback that I haveheard from clinicians is that it
truly makes itinterdisciplinary and it saves
(11:55):
so much time.
So you know.
So here you are, you know,working with clinicians that
don't have a lot of time andthey're saying that it saves
time.
So I just wanted to share thatwith you.
That's one of the things thatI've heard about the
patient-centered care plans.
But, yeah, the dualverification and the workbooks,
the guidebooks that you knowKatherine had developed
(12:18):
completely outstanding how shetook the four EMS and laid that
out and explained through theguidebooks with screenshots and
you know where to go and to homecare home base to document this
, where it's not adding extrawork to clinicians.
You know this is all part ofthe workflow.
So I mean great, great job withthe guidebooks and I believe
(12:41):
they're on your customerexperience portal for your
customers to be able to access.
So okay, great, great, yeah.
But the dual verification, youknow, not only verifying your
home health and hospiceplatforms to ensure that they
meet our CHAP standards, thenthat additional component,
having them verified to makesure it meets our age-related
(13:02):
care at home standards.
So kudos to Hump Care Home Basefor that.
So when you're looking at beingable to capture those four EMS,
you know part of the pilot sitebusiness that we've
accomplished is that.
You know we don't want extrawork added to clinicians and I
mentioned before you know, thepatient-server care plans.
(13:23):
You know saves time does notadd additional work, but just
the whole approach itself doesnot add work to clinicians.
And you know being able tocapture that in the EMR is
critical and key being able toidentify, just like what you
said.
You know what matters to thatpatient and how it's impacting
or how medications can impactwhat matters mobility, mentation
(13:46):
and having that captured inyour EMR.
That's getting pushed in to theplan of care so that every
clinician going into the homeknows this is what matters.
I mean, that's really going tomove the needle on patient
outcomes.
Jennifer Kennedy (14:03):
You know I can't agree more and I know you
get very passionate, theresa,when you talk about Age-friendly
Care in the home.
You know you were out there onour pilot.
You saw some of the reactionsof the clinicians.
You know what are they saying.
I mean, do they feel like it'sreally helping them, that this
approach is helping them workbetter with their patients?
Teresa Harbour (14:26):
Absolutely.
And having worked in many homehealth and hospices, I can tell
you as a case manager, anytimeadministration brought anything
to us clinicians, you know I'dbe like here goes the
eye-rolling in, and this isgoing to add so much work and
it's not going to have apositive impact on patients.
But with this pilot and thefeedback that we've got from
(14:49):
clinicians and we heard all ofthis with our work with the John
A.
Hartford Foundation and IHIthat in the American Hospital
Association that you knowclinicians like it and we heard
that that we actually got toexperience that and see that and
feel that and hear that fromthe clinicians in the pilot site
visits that the statement waswe love this because we get to
(15:14):
be clinicians And they're seeingthe positive outcome obvious.
You know we make home visitsduring our site visits and
during the home visits patientsknew their goals.
So here you've got cliniciansloving something and patients
(15:34):
know their goals.
That's a huge win.
And what more could you ask for?
with that?
I mean truly looking at youknow value-based care models.
you know having that, improvedpatient outcomes, improved
patient satisfaction this justgoes hand-in-hand with that.
Jennifer Kennedy (15:51):
Yeah, I believe that too, and I really
think it pushes clinicians.
Like I said, I think someclinicians get a little bit
stagnated when they're in aparticular area for a long time,
but I feel like this issomething that would sort of
push them, push their skill setfarther than maybe they have
been exercising it previously.
(16:13):
So I know that, as I said, I'vebeen out and about, and not all
clinicians are like on board,but they're like marinating.
You could see they'remarinating about it, you know.
But I do believe it may takejust a little bit of time for
some to sort of embrace this asa not only is it better quality
(16:36):
practice and care, but it'sgonna, you know, as you said,
move our needle forward in thewhole quality space.
Teresa Harbour (16:44):
Absolutely, absolutely Well, and I think
that you know just getting pastI mean once again hearing the.
You know the conversations thatyou know this is not a project.
I mean it's a framework.
You know it's what clinicianshave to get to the point They're
going through the training.
You know that does add a littlework to you know to the
clinicians and to the team.
(17:05):
Just learning aboutAge-friendly Care.
You know how to have thoseconversations about.
You know what matters to thepatient, how to identify some of
those high-risk meds that youknow older adults should not be
taken, and how you know toconstantly keep them on the top
of your mind.
You know mentation and lookingat of course, you know during
(17:26):
our initial assessments wecapture and screen for you know
depression, dementia, you knowthose type of things.
But then you know keeping thattype of mind during every home
visit that you make as well.
And same thing with mobility.
We often do screenings onadmission for mobility.
You know home safetyassessments follow risk, those
type of things.
(17:46):
But once again, just keepingthat on top of mind with every
visit, that this is truly aframework.
So once they understand thatthis is truly not adding any
work, it's changing kind oftheir mindset and just
implementing the frameworkduring the workflow and being
then once again able to capturethat in home care home base and
(18:08):
make an update to that plan ofcare.
When you're talking about, youknow, patient-centered care,
this completely equalsage-friendly care at home.
Jennifer Kennedy (18:20):
Absolutely, and, and, Donnette, the software
approach that you've developedis really going to help to
greater individualize thatpatient's plan of care to a
better degree, which CMS alwayshas a problem with the care
isn't, doesn't lookindividualized right.
So do you feel like that your,your care plan that you
(18:40):
developed here, really helps toaccomplish that?
Donnette Threats (18:44):
It really does .
It provides a lot of tools tohelp that clinician think
through those pieces.
It allows the clinician evensomething as simple or complex,
i should say, as medication.
It gives that medicationinformation to say, hey, you
know, these are the side effects, these are interactions You can
discuss with the physician Andthen, as you're developing that
(19:06):
plan of care, if the patientgoal is to continue to be as
mobile as possible, everydecision you're making and your
documenting as interventionsthat the teams are going to
provide can be aligned towhatever that goal is, because
you're able to clearly statewhat that goal is.
It's not a matter of being in abox where you have to stay in
(19:28):
this box.
You're able to go in and saythis patient would like their
pain, though we don't like it,they would like their pain to
stay at a four, just so thatthey can be alert for and you
may continue to educate on waysyou can achieve it with bringing
it lower, but to be able tohave the team understand that
(19:50):
this is this patient's choice atthis point.
I remember my most difficulthospice patient was a patient
who wanted to experience painfor redemption of her family
member.
I didn't conceptualize it.
It wasn't my way of thinking.
Mine is get rid of my pain, butfor her it was important and to
(20:11):
have those types of discussion,capture that so when you're
being surveyed, you can read itand see, this is why it was that
way.
This was her choice, this iswhat she wanted, and we
respected that.
However, we also educated.
We did do all these otherthings to be able to clarify
that easily in a framework thatis not so prescriptive, but it
(20:35):
have enough prescriptive toguide you.
That is so great because withthat consistency we can measure.
And, You know undefined can'tsay This or that without having
data from measurement right.
So I love that idea of havingconsistent documentation.
(20:59):
It's all right there.
Then we can measure the outcomeof the application of Age-
friendly Care.
So kudos to you, Donnette, andyour team, for developing this
important documentation system.
You know, Age-friendly Care, Ireally feel, is It's going to be
the healthcare continuum'sfuture, at least for the next
(21:24):
several decades.
So when we have, you know,partners like you who are
willing to make the investmentin capturing all that
information, so providers have alittle bit of a logistics edge,
that's a win-win for everybody,for sure.
All right, well, we're at theend of our time here, So I
(21:48):
wanted to ask each of you if youhad any closing thoughts for
all the listeners out there andpodcast land today, Donnette?
Hmm, closing thoughts.
My closing thought would be tocontinue to grow, because it has
never been done doesn't mean itcannot be done.
This is just an amazingopportunity to bring two ways of
(22:09):
thinking together within ascope of a tool, which is what
any EMR is.
It's a tool.
Use it to the best of yourability to capture the excellent
work that you're already doingat the bedside.
We have been taught throughhospice for years.
We need to dopatient-family-centered care.
This just provides thatframework to say this is how you
(22:30):
do patient family care.
You ask them this question, youmake sure you understand this
and then your plan needs toreflect what's important to them
, what matters to them.
It's simple.
Yeah, it may be complex at time, but it's worth the journey.
It's worth the thought.
It's worth you feeling, as aclinician, that, oh my gosh, I'm
(22:52):
back to doing what I came intohealth care to do.
I can make a difference.
I can see the difference.
It's been my perception in theyears in hospice that if you're
working on your goal, you'llnever achieve it, because no one
who's dying is going to spendtime Achieving your goal.
If you figure out what thatpatient and family goal is,
chances are they are going toachieve their goal, and you'll
(23:15):
be there to see the smiles.
You'll be here to see thelaughter, even through the tears
, and that's pretty much whatwe're all about - making sure
that, for the time folks havelife, they're living the best
quality life that they can, andHomecare Homebase is here to
support that.
Jennifer Kennedy (23:31):
Donnette, that was so well stated.
Thank you, thank you so much,Teresa.
Final thoughts from you.
Yeah, that was a mic drop rightthere, But I will say that our
number one deficiency that wesee is always around care
(23:53):
planning, coordination of care,care planning, IDG, that
completely looped around that.
planning.
That eliminates our topdeficiency when you make it
about that patient and havingthe interventions and goals that
(24:15):
truly surrounds what matters tothe patient.
You know you're going todeliver them that high quality
care and, like you said, beingable to meet those patients and
families goals, which is, youknow, while we all started in
hospice anyway, is to be able todo that to help that patient
achieve their final wish is todie at home with family.
(24:36):
Thanks, Teresa , thanks so much, and that was
actually a very nice follow-upDonnette.
Teresa Harbour (24:43):
Yeah, i don't know about that, it's awesome.
Jennifer Kennedy (24:46):
There's nothing I can say to top that.
So what I'll do is just thankeverybody for joining the
podcast today.
I like to learn something newevery day, so I really feel like
I did accomplish that goal withyou ladies, today.
So thank you for that.
The CHAP team and I thank allof you out there for taking time
out of your day to plug intoour podcast.
(25:07):
From all of us.
Stay safe and well, and thanksfor all you do.
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