The Clinical Lessons That Can Transform Care at Home

The Clinical Lessons That Can Transform Care at Home

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Hello and welcome to CareSmartz360 On Air. I’m Dennis Gill, Senior Sales Consultant at CareSmartz360. Today we are joined by Ann Soliman, founder of Care Crew Home Care, a nurse practitioner and healthcare leader. With more than 13 years of experience supporting patients and families at home, Ann brings a unique perspective on care quality, transitions and the challenges families face outside traditional healthcare settings. In this episode, we’ll explore what home care teams can do to identify risks earlier

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support better outcomes and prepare for the growing complexity of care at home. Welcome to the podcast, Ann. >> Yes, thank you so much for having me. No, we are really glad that you were able to take out the time for our our listeners today and we hope this to be a very fruitful session for all the listeners who are listening from all over the world. Thank you for that. >> You’re so welcome. >> Okay, so without wasting any time, let’s just start with the first question for

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you. >> So, you work with patients in clinical settings and now in home care. So, what are some of the problems that become visible only after a patient returns home? Yeah, I think the biggest thing is just transparency. So in a hospital or a clinic or any other traditional health care setting, you see a very small snapshot and like you probably hear with uh people’s complaints of the current health care system, you know, oh, I got five minutes with my doctor. I waited for an hour and in and out and um and

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even in the hospital they’re seeing how your your care is going in a very different environment in a controlled setting in a hospital room. When you get home, you know, all of the gloves are off. So at home, you can see are they actually being compliant with their medication? Are they in a safe environment? Do they have a physical environment around them that’s causing them to have frequent falls or or such things? Um, a lot of those things don’t just show up in a snapshot in a visit.

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Uh, and they can’t mask it either at home. You know, in a visit, a lot of times our older generation, they’re proud and rightly so. Um, and so when they go to a doctor’s appointment, a lot of my adult children for my clients get frustrated that, you know, well, mom just outright lied. She said she’s perfectly fine and she’s not struggling with any of these things and her doctor believed her. And then we get home and you know she’s struggling and requires you know two different family members to

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come by and and maintain her safely at home. >> And so in those settings those things just don’t come to light. So in in the home setting all of that comes comes to light and and you can identify really where those those risk factors are and you can see that family dynamic. You know maybe there’s a lot of other u caregiver strain. maybe the spouse is really struggling and that wasn’t apparent in the in the appointment that they’re doing a lot more for that person than we realized. Um

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>> and and a lot of times too after an acute discharge um that transition home that that discharge instructions while they might sound clear in the hospital setting once they get home it’s like amnesia hits and they have no idea what what the hospital nurse told them. I don’t know what any of these meds are. I wasn’t on these before. Um, and so when you go visit with them at home, all of a sudden all these things, you know, again come to light. So, uh, yeah, I think those are the the biggest things that

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that we see in the home setting are, you know, you’re seeing a more holistic view of the person. You see a lot narrower perspective in a clinic visit or in a hospital, say, than you do at home. >> Oh, great. And what are the early signs that an older adult may longer be managing safely at home even when the families believe everything is fine? Just continuing with the previous question. >> Yeah. Again, it’s I think it’s a lot more subtle than families realize. A lot

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of adult children, you know, they also they sort of have like a bias because they’ve they’ve seen this person their whole life. And so it’s kind of uh if they’re seeing them frequently, sometimes those really subtle changes, they don’t they don’t necessarily identify them as easily. So when we come in and meet with them, >> we’re looking at some of those really small subtle things that maybe families don’t pick up on. For example, um there’s a lot of expired food in the

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fridge or the pantries. Um you know, maybe there’s there was yogurt in there from two years ago and nobody’s, you know, thrown it away. Um there’s mail piled up everywhere, letters, bills, things are just kind of stacked up and haven’t been looked at. Um sometimes even repeating the same questions in a conver usually families can see that, but sometimes not. You know, sometimes they just think they’re just getting a little forgetful or something. Um other things are bruises. A lot of times

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people will have these near fall episodes, but not a major fall, and they kind of cover that up a little bit, just say, “Oh, I just tripped. I stumbled. I I’m fine.” But meanwhile, they’re actually having falls that the family’s not really aware of because they can compensate, and they can get up. They’re not having to call EMS to get them up off the floor. So, um, you know, it’s indicating maybe there’s a mobility challenge that we’re not aware of or a balance issue, something like that. Um,

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and then subtly too with the withdrawal. Some people, um, you know, are not participating in the same hobbies and the same activities that they used to do. Uh, maybe mom always used to go to bingo at the senior center every Wednesday and brunch with her church friends, and she’s sort of it’s becoming more spaced out, rarer for her to go and attend those things. Um, and those all could be indications that there’s some kind of decline or change going on. And uh families sometimes just don’t

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pick up on those really subtle things or even maybe like weight loss is another one too. Um you know a lot of times they’re not stepping on a scale and so you don’t have a concrete number but you realize that now they’re having to buy the medium pair of pants instead of the large pair of pants because they’re too big and it’s could be an indicator that there’s a medical issue going on. They’re not eating. They can’t prepare meals for themselves. You know those kinds of things. So again, I

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think really um they’re very subtle and can really easily be overlooked or excused by you, oh they’re just getting older or they just forgot about that or um such things, but they really could be early red flags that you need to be tuned into. >> Correct. Absolutely correct. And hospital to home transitions can be where things start to unravel. What should home care teams be paying closer attention to during those first few days or first few weeks we can say? >> Yeah, the first 72 hours statistically

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are going to be the highest risk for rehospization. So, >> making sure that they have care set up the day of discharge, next day uh is going to be super important. Sometimes we’ve had folks discharging home knowing that there was going to be a risk for um you know not really knowing how they’re going to manage uh and then they want to wait until Monday. You know they’re discharging on Thursday, Friday, well we’ll just start on Monday. Well by then there could have been a whole lot that

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goes on between that period of time. So making sure that you advocate of course you can’t force them to but trying to encourage and give that professional recommendation of well I understand that but I think because you know we’re having this discharge let’s at least have one visit before so we can make sure you get home safely and get settled. Um that’s one. Also again, medication we kind of touched earlier. Most of the time there’s a lot of confusion with their discharge

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instructions and what medications they’re supposed to take. So, making sure that if the client really can’t do it themselves, that we’re engaging with a family member or their primary care physician or um another trusted professional to ensure that the list that the hospital has is accurate, that they are they understand the instructions and will take those things appropriately. Um, because that could be life altering. for example, maybe they were started on um an antibiotic for a

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UTI. If they don’t realize that they that’s necessary to start, they don’t pick it up and they don’t understand now that could become a septic situation because now, they’re not getting proper treatment for that infection. >> Um things like that. >> And also, follow-up appointments. You know, many times those appointments aren’t scheduled for them. They have it on the instructions to call and schedule a follow-up. um that sometimes can easily get forgotten or put to the

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wayside. So, you know, when we get them home, get them on the phone, help them call if we need to and get that scheduled and let them know, hey, this is a post-discharge visit. We need the first available. Can we get on the cancellation list, you know, trying to get them in as soon as possible to follow up with their provider about everything that happened during the hospital stay is super important. and making sure if they can’t get there safely that we are engaged with them to get them to that appointment safely so

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that they can do that important follow-up visit to make sure that whatever happened in the hospital has stabilized and it’s continuing to stay stable. Um and then just again overall tracking, you know, are they still functionally the same? Like we always do a reassessment. So whenever someone um gets discharged, we reassess our entire care plan, their functional assessment. So making sure you really do a top to bottom, you know, maybe before the hospital, they just required a

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walker for safety, but now that we’re seeing them at home, they’re much too unstable even with the walker. and we need to look at, you know, bringing in a wheelchair for safety or yeah, other equipment. And so really just making sure that you’ve got a new assessment and that we’re seeing what their new baseline is now that they’re home from an acute stay and adjusting our care plan appropriately to make sure that our interventions that we’re recommending and doing during our care match up with

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their new abilities. So those would be the main things I would recommend. >> Those are the main things. And just continuing with this thing, like families often struggle to know when someone needs more support. So what conversations should caregivers and care teams be having earlier? >> Yeah, that’s a hard one. I will say that it’s always a battle. Usually, I would say most of the time we get engaged by adult children, not clients themselves. Um >> they whether they acknowledge they need

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That help or not, uh it’s a hard thing. You know, people don’t want to stop and admit that they need help with something. That’s humbling. And so, they’ll try to manage, they’ll mask; do what they need to do to, you know, manage on a day-to-day basis. Um, and so a lot of times it’s the adult children that again, they’ve started to identify some of those things and they want to engage for help and there’s there’s sometimes resistance,

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you know, no, I don’t want to. I don’t need anyone. I want my privacy. I don’t want to pay for that. Um, so the conversations that I try to have, especially earlier on in those journeys, is that our goal is really the same. It’s not to take away their independence, but trying to show them with stats and information and education that engaging earlier when you only need a small amount of help will likely prevent that and slowdown that decline and support you so that you can stay

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independent longer. Um, I just did a talk on this at an independent living recently and the way I explained it was it the question is not can you do these tasks anymore because maybe you can shower yourself independently, but what does that cost you on the backside? Does that now mean that your entire day is done because you’re so exhausted from what it took out of you to do that task that now you can’t go down to your activities that you enjoy. you can’t get down to the dining room for dinner

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because you have to take a nap because you are just exhausted. >> So, it’s choosing what you want to use your energy for. Do you want to use your energy for the fun things to go out to a store and go shopping or do you want to have to spend that to get dressed in the morning and to make yourself breakfast? It’s choosing, you know, what task you value and find important. So sometimes that softens the conversation and just explaining that, you know, us coming in for periods of time and helping you with those, it

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allows you to do the things you want to do for a longer period of time and stay independent. >> That usually will kind of perk their ears up a little bit more versus no, you need help. Someone has to sit here with you all day and help you. You know that doesn’t usually go very well. >> Yeah. Just the way of presenting. Now you’re presenting the same thing, but even the outcome is the same. Just the way of presenting Mhm. >> And as homecare clients have more complex needs, you must be aware of that. So

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What should effective caregiver training look like according to you? >> That’s a loaded question. So I think that, like any profession, effective caregiver training should never stop. So, we all have the basics, you know, most states that have leisure requirements. You know, we have minimum requirements as far as training um that we’re mandated to do. To me, that is what it says, the minimum. That should never be a standard of, well, this is what I do because that’s what the state

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tells me to do. >> Um, my recommendation is obviously follow those standards, keep it comprehensive, but find, >> you know, whether it’s with your your quap, like for us, we find a lot of gap spaces by doing our QA and our quabi process and seeing, okay, what things do our staff seem to struggle with that we should be investing in an additional training for? So for example, when we were a newer company, we started getting a lot of hospice patients. And sometimes caregivers don’t understand or know what

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the normal transition process looks physiologically for someone. And if they start to look a little freaked out because they’re seeing something that they don’t know is an actual normal part of the dying process, that can make a family uncomfortable cuz they are like, “Well, should I worry?” Because they kind of look weary. Is this normal or not normal? >> So we saw that um with an increasing um amount of hospice patients, we invested in additional hospice certifications. So

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we have a comprehensive certification that all of our staff complete by 90 days of employment with us in hospice and end of life care specifically and it’s a series of different courses. So again, looking at your particular business who you serve the most, you know, do you do a lot of dementia? So, we found that dementia it’s such a widespread diagnosis that you know most of our patients I would say almost a super majority probably 75% have some type of dementia or delirium at some point

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>> uh during their time with us. So, you know, we also have them undergo a dementia and Alzheimer’s certification and we do dementia live in house with all of our caregivers so that they also can get a perspective on what their patients and clients are dealing with day to-day, >> right? >> Um, so again, I think it’s something that can never stop. It’s not just the bare minimum that the state is requiring you but look internally. Who do you serve? What things are you seeing with

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your care that maybe could be done better or, you know, caregivers that seem to be struggling with certain things? Because it also really is a great tool to retain caregivers if they feel that they now have been really prepared to go out and handle those clients because you’ve invested the time, money, and energy to train them on these things. they will want to stay with you because they really see that a you care enough to train them and b that they don’t go out to a home and feel lost and alone and have no idea how to

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Manage what’s going on. Um so we use it as you know a quality care metric and a retention metric. So um again that might look a little different for every agency, but I think um >> just knowing that it’s not something you ever just stop doing. Um, you know, it’s a continuous process that is super important. >> Yep. >> And the most important thing everybody’s talking about. So, where do you see the most meaningful opportunities for AI in home care? >> AI. Yes. The big buzz word

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>> everywhere. Everywhere. And what should agencies be, and what should agencies be careful not to replace with technology? Um, I’ve talked a lot in the community about not relying on AI to replace the human connection and the clinical judgment. Um, I think AI is amazing. We’ve been early adopters of a lot of different AI technology in our agency because again we know that there will be >> issues as time goes on with workforce and um you know people get burnt out in this industry it can happen. And so any

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way that we can take more redundant administrative type tasks off their plate and streamline their workday for them to free them up for the human aspects of their job, >> I’m 100% on board. So, we utilize it from using smart automation so that all their phone calls automatically get documented for them. You know, that was a huge timesaver, and they were very grateful for that. Um, you know, obviously a lot of the software have built-in AI aspects to them. You know, those are great. Um, but I think relying

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On AI, to try to be very um client facing or utilizing it to try to replace the judgment of a seasoned health care professional are not going to end well. So those are the thing I think AI has a great place and it’s going to continue to grow and continue to serve us. But you know my opinion, and I think other people share it as well is that it’s really to take the other mundane things off our plate so that the people that have that experience can do what we do and have more time to do it.

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>> Correct. Rightly said. And finally, the last thing, what do you think uh the homecare industry needs to get better over the next 5 years if the goal is better outcomes for people aging at home? >> Well, this might be a bit of an unpopular opinion, so I might get some hate for this. One of my biggest pet peeves in the industry, it might be a little more specific to Texas. I know every state’s a little bit different, but um I think we’ve learned in as an industry to the the the terms,

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You know, unskilled, non-medical as an excuse for not holding ourselves to a higher standard of data tracking and clinical engagement. So, I I’ll kind of expand on that. So, I feel like one of my biggest pet peeves is that I understand we don’t do skilled tasks most of the time in this industry, but if someone can’t do basic day-to-day tasks, they can’t shower, bathe themselves, they can’t take their medications, they’ve gotten out of the hospital, they have all these things

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going on that we’ve talked about throughout this conversation. If you are sending people out there to assess their condition and these people are, you know, teachers and, you know, IT professionals that bought a franchise and they’re doing an assessment, >> they don’t know what they don’t know. It’s nothing against them, but I think that leaning in, well, we don’t need any healthcare experience. You can own an agency, and you can do all of this, that, and the other thing, and

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You don’t have to know a darn thing about anything. I feel that’s a disservice to the patients because we spend the most amount of time with these individuals than almost any vendor or any other professional will. >> You know, especially if you’re spending four to 24 hours a day sometimes in their home. So, we have eyes and a unique ability to capture all of those early red flags, identify the early declines, engage with the community resources that they need, all of these things. And if you don’t have some type

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of clinical eyes on what’s happening in the home, I just think it’s a disservice. So, I think we need to lean into the fact of yes, we might not be a skilled medical type of service, but we are medically adjacent and we should be held to the same standard. So you know, we should know what our rehospization rates are. We should know what our fall prevention program looks like. We should know what’s going on with our patients. It shouldn’t be where you place a caregiver in there, see you next

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year to reassess them. You know, you should be knowing what’s happening with these people if you’re going to truly do a service for them. Um, and so I think that’s also why we’ve not always gotten a seat at the table with our colleagues. Our professional colleagues look at us a certain way sometimes because that’s how we behave. We’re going to be treated how we bring if you come to the table like I meet with all my community partners. I know how I train, how what I train on, what my

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Readmission rates are what all all of our copy data. I know all of these things. I can spout off at at the tip of the tongue if they have a question about it. >> We should know these things because then we can come to the table and give valuable input and be a voice. You know, we should be advocating for our patients, for our industry. And to do so, you need to act accordingly. Be a professional. You know, hold yourself to a professional medical standard. um because that’s the industry we work

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in. That’s the type of work that we do. And um so yeah, I think over the next five years, I would love to see home care just lean into the fact that we are a supportive service, but we are in the the medical sphere and we treat ourselves accordingly. We stay on top of all of these points, and we bring valuable input, valuable perspective to the care continuum, and we are a vital part of that care continuum to get us really a consistent seat at the table with everyone else that we interact with. So that’s my goal and that’s what

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I try to advocate for and lead by example in our little neck of the woods. Correct. Absolutely correct. Because the thing is why I would concur on that thing is like my father, he’s a doctor. My sister is RN. So I completely understand this field. I’m not into this field but I’m into the sales or but I’m just related to this field for the past now I have loved it for seven years now. So I can completely understand your point of view on that. >> Yeah. >> All right. So thank you. Thank you and

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today it was lovely talking to you and >> it was very nice. >> Oh, thank you. Thank you and we will love to have more sessions with you in the coming future with more interesting topics and uh rest it was nice meeting you and thank you to all my listeners today and I’ll be in touch with you shortly. So this is Dennis Gill signing off for today.