Communication and Collaboration Needs in Home Based Care

As an independent RN Patient Advocate I collaborate with home health, home care, skilled care, families, and all the healthcare providers in between. I see a lack of respect everywhere I turn, and caregivers (hospital and home) that feel squeezed between administrative mandates and patient expectations. I consider learning and practicing HOW TO communicate and collaborate across the great divide of health care agencies and professionals to be an important first step. This applies to leaders, administrators, caregivers, office staff….everyone must be engaged in learning new tools so that the patients we care for ultimately benefit.

The home care provider sector is one of the fastest growing in healthcare and even when measured against other industries. This is particularly true in the US and around much of the rest of the western world. This is mainly because most governments have now recognized that home care can save considerable money every year by treating patients or dealing with high care need people (such as seniors) in their own homes instead of in hospitals and other institutional providers. Over the last five years, these factors have contributed to an annualized revenue growth rate in the sector of almost 5% per annum and a home care and home health sector with combined estimated revenues of around $90 Billion.

Before we go on to look at what the future potentially holds for this sector within the large healthcare industry, let’s distinguish what we mean by “home care” versus “home health”. Home health generally refers to agencies that provide a skilled service in a person’s home (in the US typically under a Government run Medicare payer source). Skilled services include those provided by a registered nurse, physical therapy, and occupational therapy. Home care, on the other hand, generally refers to mainly private pay services in a person’s home (mainly because there is little or no government or insurance coverage for it). Most home care agencies provide basic personal care and homemaker services. Personal care typically relates to bathing, personal hygiene, dressing, transportation, light housekeeping, and meal preparation.

Despite strong growth, particularly in the last decade or so, sector profitability (on both sides) has been under pressure. The largest payers for home health services are government programs. But these budgets have shrunk greatly, and decreased funding has thus resulted in reimbursement cuts for the industry and has suppressed operating profit. However, the numbers of adults aged 65 and older, as well as the fact that people are living longer means that home care and home health will continue to grow in both size and reach over the next 20 years. The question is therefore how will this growth occur and what major challenges will need to be overcome? In this article we want to describe six areas that need to be carefully considered.

Client Satisfaction

In both home care and home health clients are not only highly varied in their needs (ranging from the young seniors to the “old-old” and with “light support” needs to a number of specialized and chronic “heavy support” needs) but they can readily switch from one agency provider to another. In addition, seniors are not the only ones to make the judgment call about whether or not they are satisfied with the service but their children (who often pay for home care) are also likely to take a view as well. The implications of these expectations, is that every home base care provider needs to take client satisfaction extremely seriously and seek to tailor their services as much as possible. This might be to offer specialized services, in areas like Alzheimer’s or COPD for example, or to better match a carer with a customer and his or her personal, social or health needs.

Access to greater numbers of high quality people to provide care

Since 2014, the so-called “baby-boomer” population has been retiring at the rate of 8-10,000 people every day. This is a situation that will continue for almost the next 20 years. Combined with the cost savings to be had from treating people at home and making sure patients are not re-admitted to healthcare intuitions, this has meant that there are many more home care agencies chasing more home care staff. This presents both a quantitative problem (there are not enough people to currently meet the demand) and a qualitative problem (the quality of people has declined on average). Both of these challenges can only by addressed by recruiting more people to come into the sector and training both existing and new recruits to operate at a high standard of care.

Developing and retaining home care and home health staff

Historically, home based care staff came into the sector with little or no direct qualifications or much in the way of experience. But in this fast-changing area, which is both growing in number and in terms of having more demanding clients, this is not sustainable. Home care and home health workers therefore need more and better training and even more importantly need to be nurtured to stay in the sector. This need for better retention strategies has many facets to it. Apart from regular and ongoing development it entails designing the work to be more interesting, giving the individuals chances to progress to more interesting/higher level work over time, learn about and use a wider range of technology and designing more creative reward and recognition approaches, just to name a few.

Navigating the law

Most western countries are starting to regulate the home care sector to a much greater extent. In the US, for example, the law has gone much further to create more rigorous licensing standards (although these vary by state)and to dictate employment conditions. The two most pressing of these employment condition changes relate to treating all staff that work almost exclusively for a given agency as a full-time employees (and not as contractors) and for all care employees and contractors to be given overtime pay when they go beyond minimum hour standards. Both of these stipulations add to agency costs and either squeeze relatively low margins in the sector or make the costs of care higher to the customer (whether they are paying cash or seeking reimbursement).

Getting paid

The home-based care market has two sides to it-cash revenues (around 10% of the population or 15% of the value) and reimbursable revenues, where insurance or government schemes operate). Home care is heavily cash pay based and home health is heavily reimbursement based. In both cases however, home based care organizations are under pressure to get paid for their services. At average rates of $20-$25 per home care non-overtime hour, service is only affordable to individuals and families that are typically earning above median wages (especially if a senior needs considerable care or has a chronic condition). Home health is more expensive (typically $30-$65 per non-overtime hour) but is often fully or heavily reimbursable. However, a provider still takes the risk of rendering the service and receiving the expected reimbursement, both in terms of time it takes and quantum (and it may fall considerably short of expectations thereby reducing profit margins).

Making the best use of technology

Healthcare in general has been slow to adopt technology compared to other industries and this is perhaps even more the case in home-based care. However, gradually this is changing with technologies such as the deployment of a variety of medical devices to monitor vitals, for example, sensors in the home, smart phone and tablet based applications and telemedicine all being increasingly used. Perhaps more interestingly, there are now several care platforms, which operate, that use web-based technology to better match carers and clients and to schedule service using a range of technology. This has helped to lower costs to clients in some cases although a determination of whether the quality of care has been improved has yet to be determined.


Home based care as a sector is growing rapidly due heavily to the “boomer” population retiring and living longer. This is also because it’s estimated to be anywhere from 30% to 60% cheaper to render the care that is needed in a home setting than in an institutional environment of any kind (such as hospital, skilled nursing home, assisted living facility, or hospice, for example). However, the industry faces many management-side challenges that need to be quickly addressed if it is to continue to grow and thrive in the future.

Medical Improv Boosts Healthcare Communication, Quality, Safety, & Patient Satisfaction


Health practitioners are increasingly being evaluated for their ability to accept feedback, adapt to change, handle stressful situations and establish rapport. Medical Improv builds the skills needed to handle these difficult situations, interact with diverse cultures, and become sensitive to ever changing healthcare environments.

The medical industry is also faced with data measurement that assesses the quality and cost of care in order to determine reimbursement rates. This ongoing trend is pushing organizations and practitioners to improve their interpersonal relationship skills in order to create positive patient experiences at every level.Assisting Organizations

Preparing for unpredictability is the paradox shared between health care practitioners and improvisers. Improvisational theater teaches every professional to accept uncertainty and ambiguity as conditions of performance, rather than trying to enforce order on something that hasn’t happened yet. Participants are told they have all the information needed for a scene, and no one is “wrong”. Risk-taking is supported and applauded as the improvisers  step into the abyss of the unknown!

It’s probable that most people think of improv as comedy, so the term “Medical Improv” can be confusing. Comedy is focused on humor, whereas improvisational theater is focused on honesty and spontaneity. What makes improv so enjoyable is how the participants behave, which in turn makes us laugh! That’s why Medical Improv is considered “serious play”… the method is fun, but the content is serious. Listening, observing, and being emotionally present are essential. It’s an art form and a skill set, a performance and a practice. The chosen Medical Improv exercises develop self-esteem, spontaneity, problem solving, empathy, collaboration and professionalism…..all the attributes needed to create productive, open, and trusting partnerships.

The core principles of Improvisation include:

  • “Yes, and”, rather than “Yes, but” or “No”. Denying another person’s idea can stop a scene dead in its tracks. Build on your partner’s suggestion by affirming, rather than negating.
  • To be “present” for others with the gift of mindful listening.
  • The need to surrender individual “plans” in order to co-create together.
  • To see “failure” as opportunity…to learn, be human, forgive, and help.

Healthcare may be structured, but it can’t be scripted. By reinforcing the skills of listening, observing, cooperating and adapting through the “serious play” of applied improvisation, safe, quality patient care becomes a reality!

Stephanie Frederick, RN, M.Ed., received Medical Improv training at Northwestern University’s Feinberg School of Medicine in Chicago, Illinois.  She is CEO of Improv to Improve Healthcare!, and offers presentations, workshops, and consultations throughout the U.S. and Canada.  Visit, and contact Stephanie at to arrange an initial free consultation to discuss your organization’s needs.



Developing the Soft Skills for Emotional Intelligence

An example of the necessary “soft skills” is the direct correlation between health professionals’ poor communication and medical errors. Emotional intelligence is required for leadership, critical thinking, communication, teamwork, and professionalism. They are skills that can be learned, and most importantly must be practiced. It’s been obvious in my Medical Improv workshops that professionals who practice together, succeed together.

Soft Skills Crucial To Landing Your Dream Job

Guy Berger

Earlier this year, we published a list of the 25 most in-demand skills — like mobile development, channel marketing, and economics. As you may have noticed, all of the skills on the list are “hard skills,” or specific skills required to do a job that can be learned.

That’s why we were surprised when recruiters started telling us that they were having a hard time finding people with the right “soft skills,” or personal attributes that help people interact effectively with others – like communication, teamwork and critical thinking. Hard skills vary based on the job, but soft skills are required for every job. For example, a cook must be able to finely dice vegetables, but a server doesn’t. But both must be team players and communicate effectively for the restaurant they work in to succeed. That makes soft skills extremely valuable, and the growing lack of them provides professionals like you with an opportunity to stand out from the pack!

That’s why we tapped into the Economic Graph to see what we could uncover on soft skills. Our research led to the development of Master In-Demand Professional Soft Skills — this is a new Learning Path designed to help people learn the most in-demand soft skills. It’s free for everyone for the next 30 days, so check it out!

Here’s what we uncovered:

Soft skills are hard to come by

We asked 291 U.S. hiring managers how hard it was to find candidates with the right soft skills for each of the jobs they were hiring for. They said it’s hard to find people with the right soft skills for fifty-nine percent of their open jobs.

Top 10 most sought after soft skills

To find the most sought after soft skills, we analyzed the soft skills listed on the profiles of members who job-hopped (defined as a member changing their employer on their LinkedIn profile) between June 2014 and June 2015 to identify the most sought-after soft skills among employers.

How to Apply Medical Improv Principles in Your Healthcare Organization

Improv to Improv(e) Healthcare!

Applied “Medical” Improv is focused on honesty and spontaneity (“serious play”), rather than comedy.  It’s an art form and it develops communication.  Most importantly, it’s FUN!  It can be designed to increase self-awareness, problem solving, empathy, collaboration and professionalism.  Building teamwork empowers productive, open, and trusting partnerships to expand and flourish.

It’s no longer a secret that the U.S. medical system needs help in several critical areas:  questionable healthcare quality, increasing medical errors, burned employees, and poor patient experiences.  Top administrators, support staff, and direct caregivers all need to keep their “soft skills” sharpened.  A positive attitude, empathy, and self-awareness, along with excellent communication, team building, and problem solving are all necessary for facing today’s workplace (healthcare) challenges.

Additionally, preventable adverse events (PAE’s) cause 400,000 people to die each year, making it the #3 cause of death in the U.S. (2013, Centers for Disease Control and Prevention statistics).  The Joint Commission has identified Leadership, Communication, and Human Factors as the top 3 causes of PAE’s, and there’s growing interest in using applied Improv principles to offer new and innovative solutions to these ongoing, critical problems.

What are the principles of Applied “Medical” Improv?

  • “Yes and…” (to affirm and add, rather than negate)
  • A need to surrender individual “plans” and co-create together
  • To see “failure” as opportunity (to learn, be human, forgive, help)
  • To be “present” for others with mindful listening
  • Affirm and grow your team’s ideas
  • Realize that you have everything that’s needed to support and collaborate together

A free initial consultation is available to discuss your organization’s interests, goals and budget.  A planning meeting via conference call or on-site will be arranged, and a program proposal delivered.

The workshop process usually includes:

  • Administration, support staff, and direct caregivers are encouraged to attend the on-site workshops.
  • Each workshop “part” is offered over 2-3 hours to each group, with varied times and dates to reach all members of the healthcare organization.
  • An appropriate number of Improv facilitators are present, depending on participant numbers.
  • Follow-up sessions with initial workshop attendees can be arranged to introduce additional exercises and support already implemented principles.
  • Optional monthly meetings for ongoing staff education, shared experiences, support of the new Improv “culture”, and (eventual) staff-led “train the improviser” programs.

In summary, Improv to Improv(e) Healthcare! addresses:

  • Listening… words aren’t even necessary; body posture, emotions and disposition are powerful communicators
  • Cooperation… it’s a “team sport” that celebrates dialog and shared respect
  • Observation… the ability to process large amounts of crucial information and translate it into action
  • Adaptability… letting go of preconceived notions and being open to new ideas

“Medical Improv” has fairly new roots in the U.S., and there are approximately 50 professionals that have attended “train the trainer” workshops. As one of those trainers, my team and I have presented workshops for a variety of healthcare organizations looking for new, innovative ways to address patient safety, quality of care, employee retention, and medical errors.  Some of the organizations who have benefited from our workshops include hospitals, home health agencies, public health programs, professional associations, academic programs, private physician groups, and others.  Contact me today to find out how your organization can benefit from Improv to Improv(e) Healthcare! workshops!

Stephanie Frederick, M.Ed., RN


Stephanie Frederick, M.Ed., RN is passionate about providing positive patient and staff experiences throughout the organization by improving communication.  She attended the first Medical Improv “Train the Trainer” intensive, taught by Katie Watson, JD in June, 2013 at the Chicago’s Northwestern University’s Feinberg School of Medicine.

Watson, K. “Perspective: Serious Play: Teaching Medical Skills With Improvisational Theater Techniques”

Katie Watson has been teaching this popular course to first year medical students since 2002.  In 2013 she and Belinda Fu, M.D., launched the first Medical Improv “Train the Trainer” course intensive for medical professionals.  I am honored to have been a participant in that class, and understand the wonderful gift this program can be for improving communication and collaboration in our medical and healthcare communities.  

Watson, K. “Perspective: Serious Play: Teaching Medical Skills With Improvisational Theater Techniques,” Acad Med. 2011 Oct;86(10):1260-5.


Campbell, C., “Improv to Improve Interprofessional Communication, Team Building, Patient Safety, and Patient Satisfaction”

Candace Campbell’s DNP project is similar to Improv to Improve Healthcare! workshops for health professionals.  Our (separate) post-workshop surveys have shown enthusiasm for these fun, applied improvisational exercises.  These trainings help to bridge the healthcare communication gap, and ultimately improve patient safety and satisfaction.