5 Approaches to Improving Home Care Safety

Several steps are required to accelerate home care safety, including a commitment to self-determination and fostering a safety culture.

Initiatives to improve home care safety are far behind safety efforts in the hospital setting, according to a presentation at this week's IHI National Forum.

There are several sources of potential patient harm in the home, including adverse medication events, fall hazards, injuries related to medical equipment such as oxygen fires, infections, and medical conditions linked to poor nutrition. For health systems and hospitals, home hazards can lead to costly readmissions, and accountable care organizations face higher costs of care.

"Safety culture is a concept in hospitals," said Alice Bonner, PhD, RN, secretary of the Massachusetts Executive Office of Elder Affairs, and a presenter at the IHI National Forum session "Advancing Safe Care in the Home Setting."

"It's a culture where people can learn when errors happen in order to prevent serious harm and people can look at data to continuously learn from each other. We have learned this in hospitals pretty well; but in home care, this is a new concept," she said.

Bonner presented five principles and related recommendations to improve home care safety that are featured in a recent IHI report.

1. Self-determination and person-centered care
 

Many people such as the disabled do not view themselves as patients in their home. Honoring self-determination in the home balances autonomy with risk mitigation. A person-centered approach is broader than patient-centered care, accounting for family members, all caregivers, and the support that care recipients need to be active participants in their care.

• For care workers, a benevolent communication style is crucial to advancing safety in the home, Bonner said. "It means asking questions and sitting down with someone and trying to breakdown an us versus them dichotomy. You need to say, 'I'm here to help you reach your goals. I need to get to know you. I need to understand you. I need to know what is most important to you.' "
   
• Meaningful and relevant educational tools should be provided to home care recipients such as one-page information sheets about safety risks.
   
• Tools and strategies to provide person-centered care should be employed, including a standardized assessment of the care recipient's needs that is based on the recipient's values and accessible to all caregivers.

2. Safety culture
 

Safety in the home requires an overarching commitment to safety from all organizations and individuals involved in the effort. "There are not just physical but also emotional and psychological aspects of safe care in the home for the care recipient, the home care workers, and family members. It's not just the caregiver burden," Bonner said.

• Home care organizations and workers should create a safety culture vision such as discussing safety risks during every encounter with the care recipient and family members.
   
• The emotional and physical safety of family caregivers and home care workers should be a top concern.

3. Learning and improvement
 

Developing a learning system is essential to improving home care safety. A learning system features leadership, transparency, reliability, measurement, improvement, and continuous learning. For example, widely sharing safety data and best practices across multiple healthcare organizations can significantly improve care recipient safety.

• To support a learning system, build a measurement and reporting infrastructure such as population-based studies to determine the prevalence and types of harm. At least initially, measurement sets that gauge harm can be simple and easy to adopt.
   
• Sharing data on home care safety requires creating a culture and expectation of transparency such as encouraging voluntary reporting of medical errors in the home.
   
• Safety and improvement skills should be taught to all care workers and caregivers including simulation courses.
   
• Intensive improvement collaboratives on risks such as adverse medication events should be created for early adopter organizations, with lessons learned widely distributed to partners.

4. Care coordination
 

Home care workers cannot function effectively in a vacuum, and they should have a coordinated team that includes supervision, management, and accountability. Team-based care is crucial to avoid medical errors, particularly during transitions of care.

• The care recipient should have a care plan that is accessible to all healthcare providers, home care workers, and family caregivers.
   
• Foster team-based care such as striving for consistent home care worker staffing that builds a strong relationship with the care recipient.
   
• Promote the use of community-based services and underutilized resources such as behavioral health and firefighters.
   
• Electronic medical records and other technology assets can boost care coordination.

5. Policies and payment models
 

Home care providers face a challenge from policies and payment models that fragment care in the home setting such as Medicaid waivers that only cover certain services.

• Home care providers should encourage the Centers for Medicare & Medicaid Services and commercial payers to test new payment models such as financing through community-based organizations.
   
• Lobbying for reforms should also focus on reduction of regulatory burden.