Knowing the Environment

Erin Buell

Concordia University

Issues in Human Service Administration

HS550

Angela Kollbaum

September 13, 2013

BUELL.KNOWING THE ENVIRONMENT1

Knowing the Environment

Like any new organization, Grace’s House will need to look at and address many factors of the environment in which it will be implemented. Grace’s House will be a resource for patients and families who are dealing with Alzheimer’s disease and dementia (A/D), and will provide information, support, health management resources and day care.

The text,Management of Human Service Programs(Lewis, Packard, & Lewis, 2012)provides important information on these environmental factors.In particular, Lewis, et al. give the analysis of social, political, economic and technological trends that need attention in a successful human service organization (p. 24-32).

The social trends that I think will have an effect on Grace’s House will largely be in relation to the statistical numbers of our growing elderly population. As baby boomers are aging, they are not only looking for ways to continue to contribute to society(Lewis, Packard, & Lewis, 2012; p.29), but many are also in the throes of managing care for elderly parents. This demographic holds serious implications in our health care systems, issues of quality of life, financial management, and family structures.

I would like to consider a more modern social trend for Grace’s House than what has been considered the norm for many years. When my mother was in a dementia care facility, the common spaces were filled with piped-in Lawrence Welk - era music, and the televisions played old black and white shows and movies. While my mother certainly had this type of entertainment in her past, she also loved to watch CNN and listen to Van Morrison. Even at 80 years old, my mother was more modern than the social element of her environment was providing. There is also a way that people tend to talk to elderly that mimics the way we talk to babies. I would think that this is fairly condescending to most elderly people. I would like to create a social environment at Grace’s house that is respectful, modern, personal, and caring without condescension. While many people with dementia do revert back to themes from their childhood, not all of these patients will be elderly; unfortunately, some diseases that have symptoms of dementia strike people before the elderly years. The social environment should be relative to all ages.

The economic environments will include setting up a non-profit structure, understanding if and how insurance, Medicare and Medicaid might be involved, and creating funding sources. With this, I would need a solid understanding, as well as supportive staff, for accounting and budgetpurposes. All operating expenses would need to be understood and delineated in order to move forward at every step. Grant researching and writing will be essential supports for the economics of this organization as well.

The technological angle for Grace’s House will include a good organizational structure mapped out, such as the conceptual framework for management that Lewis, et al display in their text (Lewis, Packard, & Lewis, 2012; p.9). We would also need a strong media format that would produce a compelling website and marketing tool. My research into Swiftsure Ranch Therapeutic Equestrian Center (swiftsureranch.org) and their well-executed website, convinced me of the importance of a compelling appeal to the community and to the supporters. This also reaches into the economic factors.Appropriate computer programs and software will need to be determined, purchased and installed.

Political factors will be affected by Obamacare and the upcoming health insurance exchange programs. With the country quite divided in the political spectrum, there is a high likelihood that anything in the health industry will face changes in the next several years as the health care reform evolves. When the Obama administration ends and a new president comes to office, even more changes can be expected. Regulations and implications in regard to Medicare, Medicaid, health insurance, as well as tax laws and government mandates for non-profits are constantly changing and Grace’s House will need to stay updated.

In order to track the needs of the community around the issues of dementia and Alzheimer’s, I will need to gather statistics from health care and government agencies,study the potential growth of this demographic and the health care implications, research all existing care options for these patients within our community, and interview caregivers, physicians, patients and families who deal with A/D and formulate a needs assessment with these findings. Furthermore, I will create a resource map of all the programs and services of which our community members have current access. This will involve my deeper exploration of specific programs and services that organizations such as hospice, Swiftsure and the Senior Center currently facilitate. I would also look into a broader region to see what other parts of Idaho have in place.

In my interviews with the hospice and home health organizations, I realized that there is not much being provided for our Hispanic and Asian population. While there currently may not be a big need for the specialized care of Grace’s House for this population, I would like to set into the structure a plan to build on this, and create interpretive services and resources. In my interview with Bonnie Marsh from St. Luke’s Home Care, it was speculated that perhaps these ethnic groups have a nuclear family structure that helps with the issues of illness and aging. There might be a model of care that could be adapted from families who care for their elderly at home.

My interview with Bonnie has me a little nervous about a small non-profit. Her experiences have led her to believe that a large non-profit, such as St. Luke’s Health System, which supports her department, has a lot of internal and external supports that she did not have in her jobs in smaller organizations. This will be something I need to look at in terms of the environment that Grace’s House is established. My interview with Bonnie is included after the references.

Reference

Lewis, J. A., Packard, T. R., & Lewis, M. D. (2012). Management of Human Service Programs (5 ed.). Belmont, CA: Brooks/Cole.

HS 550

Interview

September 12, 2013

St. Luke’s Home Care

Bonnie Marsh, Clinical Supervisor

1450 Aviation Drive

Hailey, ID 83333

(208)727-8765

  • How long have you been with St. Luke’s Home Care?

Bonnie Marsh (BM): This Home Care department started last Fall (2012), and I was hired as the clinical supervisor.

  • Where were you employed prior to this?

BM: I worked as the branch manager of Idaho Home Health and Hospice [IHHH] in the Hailey office for 14 years. In 2011, IHHH closed the Hailey branch and we all commuted to the Gooding office. One of my nurses, Cathy, who also was working for St. Luke’s, and I started a dialogue with St. Luke’s Wood River to get the hospital to start doing home health. It took about a year, but it happened. Prior to IHHH, I worked for another home health system that was here called Community Home Health. They were bought up by a big corporation and there was a lot of money that was not well spent. They went under a few years later.

  • So you have had the experience of working with two smaller home care organization, one that went corporate and then folded, and now you work for a large non-profit health system. Tell me about some of the pros and cons of these.

BM: I loved working for Community Health when it was small, but it was very difficult to manage all the mandates of CMS [Centers for Medicare and Medicaid Services]. When we were bought up, all of the billing, licensure and regulatory issues were outsourced, which made it easier in some ways, but it was stressful because it was not well managed. IHHH was good too. Our main branch was in Gooding, which is only 60 miles, but a brutal drive in the winter. When they closed the Hailey office, I could see that all of the staff was going to leave. I was so grateful that St. Luke’s was open to starting this department. Almost all of the IHHH staff from the Hailey office works at St. Luke’s now.

  • How does St. Luke’s compare to your other home health experiences?

BM: It is great. St. Luke’s is really trying for this coordination of care approach for the community and throughout the system [of all St. Luke’s venues]. At the time that Cathy and I were communicating with St. Luke’s about this, there was a big campaign in the organization called “One.” One system for health care; One commitment to patients, family and community. The timing was really good, and it fit what I am passionate about in that we need to fill health care gaps. Without home care, there was a huge gap in health care in this town.

  • Are there political elements to your work or within the department?

BM: Hmmm, I suppose there always are. I think that accountable care is somewhat political, but it is an important part of the work. We do have to give patients a choice of care. The patient needs to fit into specific criteria and have a physician referral to get home care. When the criteria are there and the service is prescribed, it would be easy to just tell the patient about our Home Care, as we are the only one in the area. But patients are informed of Safe Haven, which is inpatient and respite care, and of IHHH in Gooding.

  • How are the criteria determined?

BM: The patient has to have a clinical or skilled need. Then there needs to be a physician’s order. A lot of people here use the nurse practitioners; they still have to have an MD sign off. A three day hospital admission can qualify someone, and the discharge planner or the hospital social worker can write up the papers and have a doctor sign them.

  • Tell me about the economics of home care?

BM: People think that Medicaid or Medicare pays for home health services, or that insurance does. Of course that is a big part of it, but we treat a lot of young adults and kids and people who are uninsured or don’t have these government services. St. Luke’s is a non-profit, so we can’t refuse to treat someone who needs the care. There is a huge charitable write off that this department processes. I get nervous about that; it just seems like the system wouldn’t be able to support so many non-payers. But we keep working with the [St. Luke’s] financial care people in Boise, and on and on it goes. It does feel good to be able to help people even when we know that there is no way they can pay. We have the Foundation [philanthropic department] that is amazing and really strong. I am sure that helps.

Medicare is really tricky. There is a lot of documenting, a lot of loopholes and gaps that people fall into. I don’t know if it is helpful or not for people to have the Medicare supplemental insurances. These programs are so picky, that sometimes a patient actually ends up paying more in the end through their premiums and the policies aren’t helping with the service that the patient needs. We have a lot of paperwork, and it gets more involved all the time.

  • What are some of the tools that are used to help your department work efficiently and address patient needs?

BM: We recently did a huge community needs assessment. It is part of the St. Luke’s efforts for coordination of care in the community. We are trying to find where the gaps are. I went with some other department heads to Washington DC for a coordination of care seminar.

The ER, hospice, and the physicians are really important tools to direct patients our way. It is amazing, however, that after a year of our department being here, some of the physicians don’t know what we do. They might have a patient that needs help with ADL [activities of daily living] and suggest home care. We aren’t supposed to do dishes or tidy up. We help with bathing if it is part of care due to a total hip or something, but we don’t really do personal hygiene things. However, sometimes we just have to make our jobs do-able and that might mean tidying up the house a bit so that we can more easily move the patient.

We document all of our visits into EPIC [electronic charting], which gets better all the time. We can communicate back and forth with the doctors and see where the patient is with medications and exams and all that easier now.

We also get evaluated by the Joint Commission every year. This isn’t mandatory for a hospital system, but it gives us a “deemed status.” They are really picky, and we always stress out when they come, but it does make us accountable and careful in our work as far as ethics, safety, documenting and all that.

I manage all of the charts with as close to real-time overseeing as I can. Plus I do random chart reviews. Sometimes I feel like Big Brother, but I think it is important to keep everyone on their toes. I also make sure all the clinical staff are compliant by doing their annual skills fair.

  • What cultural implications come up in Home Care?

BM: Hmm. That’s interesting. We really don’t have many patients that we see that don’t speak English, if that’s what you mean. When we do, usually the family members translate and interpret for us. We have had a few Vietnamese patients, but not many. There are these family groupings and they seem to take really good care of each other.

  • Do you think that some of the Asian or Hispanic population just don’t seek medical care as much as the Caucasian/ American population?

BM: That could be. I just don’t know if the gaps exist to the same degree when people are living in a nuclear family environment.

  • Some people complain because St. Luke’s is getting bigger and they cover more medical needs under one umbrella compared to a lot of different private structures; that maybe there is a monopoly of sorts going on with the St. Luke’s system. What do you think?

BM: I think the larger system is better. I see more people getting access to help now then when I worked for Community Home Health or IHHH. The financial structure is stronger, the communication between a patient’s different care providers is better and the gaps are fewer.