Chenjuan Ma, PhD, MSN

The landscape in which home health agencies operate is changing dramatically, including the launch of various quality initiatives and programs, such as the home health value-based purchasing (HHVBP) model, patient-driven grouping models (PDGM), and the recently signed executive order by President Biden. Effective communication among home care providers, including skilled home health providers (e.g., nurses, therapists) and home health aides, as well as family caregivers, has become critical in quality home healthcare.

Meanwhile, evidence from our research and that of others have repeatedly documented the lack of communication among skilled providers, home health aides and caregivers. Given the rapid growth in the number of Americans seeking and receiving home health care, there is an imperative for new commitment and creative solutions to improve the communication among home care providers.

A good first step is to increase the understanding of the roles, responsibilities and unique contributions of each team member in home healthcare. Various research from home health care and other care settings have pointed out that one common barrier in communication is the lack of understanding of each other’s roles by team member, which further leads to mistrust among care team members.

Providing trainings on appropriate and timely communication of patient information and health conditions, particularly for home health aides and family caregivers, can be another approach of promoting collaboration and communication among home care providers. Home health aides and/or family caregivers are usually the first ones to observe any changes in patient health status or behaviors; however, they often do not know when, what and how to communicate with skilled providers.

In addition, the inclusion of home health aides and/or family caregivers in the development of care plans can also be effective in improving communication. Currently, patient care plans are developed and (may or may not be) updated by nurses based on their assessment of patients during their intermittent visits to patient homes. Input from home health aides and family caregivers is usually not sought, even though they provide assistance and support to patients on a daily or near daily basis.

Providing venues for effective communication is necessary, too. Using technology to create a secure patient information exchange platform, such as an e-message system for timely communication and changes of patient information and health conditions, can be a great solution for improving communication and translation of patient information in the care team. This can also inform timely adjustment of patient care plans.

Last but not least, under the current home health care payment model, communication among care team members — which falls under care coordination — is not separately billable. It is also not a care component required to be assessed and reported for home health agency performance benchmarking and national comparison. Therefore, compared to other patient care activities, care coordination and communication are often not the priority in patient care. Communication among care team members should become a required component of home health care with financial incentives.

With the increasing pivotal role that home health care plays in serving millions of Americans “aging in place,” providing quality care is a key. Without timely and effective communication among home care providers that includes skilled providers, home health aides, and caregivers, there is no quality home health care.

Chenjuan Ma, PhD, MSN, is an assistant professor and health services researcher at NYU Rory Meyers College of Nursing and an affiliate faculty of the Hartford Institute of Geriatric Nursing (HIGN). Her program of research focuses on understanding how to improving the health outcomes and safety of older adults via optimizing care quality and promoting care equity with a particular focus on home health care and vulnerable populations.