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As more home health nurses and aides find themselves visiting assisted-living centers, they need to understand how these unique facilities work so they can best coordinate care for their patients.
More than 1 million Americans live in an estimated 30,000 such facilities, according to the Assisted Living Federation of America. The centers can range from freestanding apartment buildings to special independent-living wings at conventional nursing homes.
While requirements for assisted-living centers vary widely from state to state, they generally feature apartment-style units, often with carpeting and residential lighting, says Chris Hollister, MBA, of Southern Assisted Living in Chapel Hill, NC. They are usually seen as an option for people who need assistance with anywhere from one to five activities of daily living.
People generally understand that care in a nursing home is more detailed than in an assisted- living facility, he says. "But there is a real philosophical difference in how care is given, that this is a residential alternative — we’re not institutionalizing people — that we’re not a place to go die but a place to go live."
Home health plays a vital role in allowing people to maintain that level of independence, says Carole Eldridge, RN, vice president of tenant and health-related services for Assisted Living Concepts, a Portland, OR-based firm.
Eldridge has seen the relationship from both sides: She was chief executive officer for a home health agency that had workers in assisted-living centers. She says communication among home health and assisted-living staff is key to coordinating care successfully for tenants.
"The home health agency needs to understand they’ve taken on not just the tenant and their family, but they’ve taken on another element that requires communication," she says. "You can’t leave out any of them or you’re going to have trouble. The successful relationships I’ve heard about have been when people were just talking to each other about what was going on in a professional manner."
Problems can arise when one agency doesn’t communicate fully, Eldridge says. For example, when she worked in home health, assisted-living staff would complain that other agencies didn’t share information about tenants they were treating. "A change in a tenant’s medication would occur, and the home health agency took the order and did not communicate it to the facility," she says. "The facility is required under most assisted-living regulations in most states to maintain a current active medication list, whether they assist with their meds or not."
Similar problems would occur in the reverse, with the facility’s staff refusing to give out information or not allowing home health staff to make notes in tenants’ files. Both sides were concerned about violating their clients’ confidentiality.
"But patients in home health agencies and tenants in assisted-living facilities always sign something saying they release that when there’s coordination of care involved," Eldridge says. "That’s something that both home health agencies and assisted-living facilities need to be aware of, that confidentiality isn’t an issue when you’re coordinating care for someone."
Facilities generally set up procedures they ask all home health agencies to follow, including signing in and noting changes in treatment in tenants’ charts. When a nurse or aide goes to a facility for the first time, he or she should check to see what arrangements the home health agency has made with the center and then work within that system.
Eldridge advises trying to build an ongoing relationship with assisted-living staff — learn how things work and who to turn to if there are problems. That makes it easier to find the right help when a tenant needs it.
"A home health nurse might go into the facility and see that something needed to be done differently in the personal care," she offers as an example. "She would grab the closest attendant, say, This is how I want you to do this,’ and then would document that she had trained the facility staff. But all she had trained was an attendant who had failed to tell anyone else.
"We always tried to make sure as the home health agency, if we had to do some training or needed to communicate a change in the patient’s plan of care, that we communicated it to the administrator or the nurse in the facility and that they knew they needed to communicate it to all their staff."
Although communication is essential, Hollister says, facilities recognize that the tenant is in charge of his or her own care. "I think [home health workers] should think of it very much as if they’re with someone in their private home. They hopefully will feel welcomed by the assisted-living owner or manager, but they’re dealing primarily with the resident, not the owner or manager."
Skilled nursing services — and who provides them — can be a tricky issue, with regulations varying widely across the nation. In some states, assisted-living staff have authority to do some occasional procedures. In others, regulations are much tighter. The assisted-living communities Southern Assisted Living operates in the Carolinas generally are staffed by certified nursing aides, Hollister says.
"The director of care is typically an LPN, so we can provide care, but the bulk of our home health is physical therapy for people recuperating from a fall or an accident," he says.
Eldridge, who is based in Arlington, TX, says she sees a range of restrictions on assisted-living staff. Home health workers need to understand those restrictions in their own states, so they’ll know when they’re needed. In Indiana, for instance, nurses in assisted-living facilities can help coordinate care and train staff, but they are prohibited by law from giving direct, hands-on care, she says.
"So they’ll call a home health agency and say, We have this tenant who needs this skilled nursing service.’ But they’ll have a lot of home health agencies refuse to come, saying, Well, you have a home health nurse in the building. That means you can provide that service; that means Medi care won’t pay for us to do it.’ They need to understand the rules in their state. Home health agencies need to be real cognizant of what can and can’t be done in assisted-living facilities."
The Assisted Living Federation of America and its state affiliates across the country can be a good source of information about state requirements, Hollister says.
Eldridge says access to home health care is vital for assisted-living tenants, particularly seniors, who want to stay as independent as they can for as long as they can. "It’s absolutely essential. I believe in the combination of the two with all my heart. It’s just very, very important if we’re going to help people stay independent, and age in place. I’m a big home health believer."
• Chris Hollister, MBA, Southern Assisted Living Inc., 10003 Main St., Chapel Hill, NC, 27516. Phone: (919) 932-1015.
• Carole Eldridge, RN, Vice President of Tenant and Health-Related Services for Assisted Living Concepts, 3008 Rush Court, Arlington, TX 76017. Phone: (800) 330-5574. E-mail: firstname.lastname@example.org
• Assisted Living Federation of America, 10300 Easton Place, Suite 400, Fairfax, VA 22030. Phone: (703) 691-8100. Fax: (703) 691-8106.