Assisting Patients to Age in Place

Abstract

This article describes how one large not-for-profit home health care agency sought to stimulate a practice change among their nurses to better service the frail, complex patient population in a Long-Term Home Health Care Program (LTHHCP). This LTHHCP designed an innovative initiative that encouraged a combination of coaching techniques, assessment tools, and a range of patient-centered evidence-based practices to provide clinicians with necessary skills and competencies to provide the highest standards of care for their patients. The innovative model, called patient-centered care model (PCCM) was piloted in one service area, and a formal evaluation was integrated into the initiative to allow measurement of desired outcomes. This article describes the long- and short-term goals of PCCM, examine the components of the PCCM model, and discuss how the progress of the initiative is being evaluated and assessed.