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Assessment and analysis of direct care community worker training: addressing social determinants of health in the home care setting

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Assessment and analysis of direct care community worker training: addressing social determinants of health in the home care setting

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Content Running head: DIRECT CARE COMMUNITY WORKER 1
Assessment and Analysis of Direct Care Community Worker Training
Addressing Social Determinants of Health in the Home Care Setting
Martha E. Trudeau
University of Southern California
Doctor of Social Work
Suzanne Dworak-Peck School of Social Work
SOWK 722: Grand Challenge Capstone
Dr. Analisa Enrile
May 2020
Direct Care Community Worker 2

Executive Summary
MET Healthcare Innovations, LLC is a for-profit company founded in 2019 to support
the roll-out of the Direct Care Community Worker (DCCW) Training, which has the overarching
goals of helping to close the health gap and reduce economic inequality. The training program
focuses on identifying and resolving Negative Social Determinants of Health (NSDH) which are
aspects of where and how people live that adversely impact health. Currently, there is no formal
mechanism in place to routinely address NSDH found in the homes of Medicaid consumers
receiving home care services. These unmet needs can lead to preventable healthcare utilization,
adverse outcomes, and death.
Clients served by this pilot training are older, dual eligible Medicaid/Medicare or Veteran
consumers with long-term, disabling conditions living in Philadelphia and receiving personal
care services from Direct Care Workers (DCWs). Services are predominantly funded by the
Pennsylvania Medicaid managed care system with a smaller portion of client services funded by
the Department of Veterans Affairs. For this project, all clients receive services through
BAYADA Home Health Care, a large agency with a strong presence in Philadelphia and
providing DCW services to over 500 Medicaid clients and approximately 80 Veteran clients.
BAYADA has committed multiple resources to the pilot project, including students who will be
drawn from BAYADA’s current field staff for the pilot training. Other community resources
will collaborate on resolution pathways. Such collaborations will be the backbone of the project.
Direct Care Workers (DCWs) are trusted, yet untapped resources for tackling social
issues because their training does not include sufficient information about this topic. Community
Health Workers (CHWs), on the other hand, are familiar with social issues but do not provide
personal care, are with their clients intermittently, and lack sufficient staff to see all the clients
Direct Care Community Worker 3

who might need their assistance. The DCCW Training creates a hybrid position which combines
DCW and CHW duties. Training includes instruction on the use of the DCCW Observation Tool
which serves to identify needs and focus care. This project aims to prepare a cadre of DCCWs
focused on closing the health gap by addressing NSDH and thus helping to decrease morbidity,
mortality, healthcare utilization, and cost for home care clients. By providing a living wage for
the DCCWs, the project also helps to reduce economic inequality which may bring others into
this understaffed field that addresses ever-growing needs.
Philadelphia is the initial market area which includes 133,000 older Medicaid consumers
covered by the Community Health Choices managed Medicaid program. Although older
consumers make up only 38% of the PA Medicaid population, they account for 79% of the
expenditures. After the pilot, the geographic market area will expand, and training will
additionally be available to other agencies, family caregivers, DCW administrative staff
(supervisors, schedulers, etc.), and others with identified or expressed knowledge deficits.
Multiple marketing methods will promote three messages: NSDH are too expensive not
to fix; DCCWs provide a new way to address NSDH; the DCCW position provides a living
wage. DCCW Training will be supported by home care agencies viewing the role as a new
revenue stream. Because of the potential for decreased healthcare utilization, Medicaid health
plans will reimburse home care agencies a higher rate for the DCCWs.
A thorough literature review indicates the DCCW role has not been previously
implemented, although many organizations throughout the U.S. are successfully implementing
SDH remediation programs while realizing significant returns on investment. Each should be
recognized for what it can accomplish. The DCCW position adds a new, hybrid role which
provides an additional tool to address issues in the home care setting.
Direct Care Community Worker 4

DCCW duties include routine completion of an Observation Tool which will provide data
to identify client needs, develop policies, procedures, and pathways for resolving NSDH;
formulate a standard of care regarding SDH, and inform community health initiatives. While
improving quality of life and decreasing morbidity for clients, this role provides a career
trajectory for DCWs, many of whom are Medicaid consumers as working poor parents. All
duties of the DCCWs are consistent with regulations and home care practice standards.
Multiple funding sources are focusing on ways to address NSDH (Centers for Medicare
and Medicaid, Department of Veterans Affairs, American Association of Retired People, Robert
Wood Johnson Foundation) and will be tapped for financial support. Approximately $200,000
will be needed for the pilot period. During this time, partnerships will be solidified and may
include the Centers for Medicare and Medicaid, Medicaid health plans, home care agencies, and
government and private social resources. Data will be collected during the pilot period to
confirm the training program is an effective teaching tool and that the new skills can successfully
improve client care. Ultimately, these activities will lead to the development of a standard for
home care which includes a Community Failure to Rescue quality indicator. This indicator will
help ensure that negative social elements are addressed for home care clients.

Direct Care Community Worker 5

Assessment and Analysis of Direct Care Community Worker Training
Negative Social Determinants of Health (NSDH) include elements of where and how
people live that may adversely impact health. The American Hospital Association (AHA, 2019)
notes that these factors represent 80% of what drives health, with access and quality of care
contributing 20%. Despite this knowledge, there are no formal mechanisms to routinely observe,
remediate, or report these elements in the homes of Philadelphia’s Medicaid recipients 60 years
and older who are receiving home care due to long term disabling conditions. For this project,
home care should not be mistaken for home health care with includes more advanced services
from licensed providers like social workers, nurses, and other therapists. Home care is high-
touch, low-tech services from unlicensed caregivers. Philadelphia’s Medicaid beneficiaries of
home care services have limited resources while living in the poorest large city in the U.S. (U.S.
Census Bureau, 2017). Poverty is expressed in a variety of ways such as food insecurity (Hunger
Free America, 2018; Lubrano, 2018) and mortality disparities (Center on Society and Health,
2018). Given the descriptive statistics, it is likely this population is experiencing significant
difficulties, yet there is no certainty because individual-level data are not routinely collected. In
other words, it is not known precisely who needs what.
These Medicaid consumers receive home care services from Direct Care Workers
(DCWs) who generally receive from 40-80 hours of training (nursinglicensure.org, 2019) which
includes minimal information about potential social problems. Although they are in the homes
routinely, they are unprepared to tackle social issues, such as limited mobility, utility security,
necessary transportation; food and hydration security, physical and emotional safety, and other
environmental and social factors. The primary problem addressed by this project is that such
unresolved difficulties broaden the health gap, leading to hospitalization, adverse outcomes, and
Direct Care Community Worker 6

death. A secondary problem relates to the DCWs, who as working poor parents, may be
Medicaid consumers themselves. The salary they receive is not a living wage which contributes
to extreme economic inequality. Both the health gap and economic inequality are considered
Grand Challenges for Social Work as defined by Fong, Lubben, & Barth (2018).
Project Conceptual Framework
Summary of the current environment. Much of well-being is related to places where
people live, making the home environment the primary location to promote health. This is
particularly true for older Medicaid consumers who are receiving home care services due to long
term illnesses. Their poor health and lack of resources support their Medicaid eligibility and
indicate a high likelihood that they are living with inequities that may be amenable to
improvement. Currently, this is a missed opportunity because the DCWs providing personal care
are not prepared to address NSDH, even though they are with clients frequently as known and
trusted caregivers.
In 2014, AcademyHealth (2018) sponsored a policy conference entitled, “Hoping for
Frailty: The Policy Crisis in US Elder Care” (Weiner, 2014). Panelists brought focus to the
inequitable ratio between social and health expenditures as a percent of Gross Domestic Product
(GDP). The consensus was that people will be able to age in place only if home health services
are combined with remediation of negative social factors (Weiner, 2014). This thinking is
moving the locus of healthcare activities away from hospital systems.
Many organizations recognize the impact of NSDH and are focusing on ways to address
them. A search of the United Nations web site (2020) reveals nearly two million articles under
the topic. Since 2005, the World Health Organization has had the Commission on Social
Determinants of Health from which was identified the need for leadership and participation from
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across many communities, with action taking place at all levels (Marmot & Bell, 2009). Major
organizations are taking on this focus such as the World Health Organization (WHO, 2019);
American Association of Retired People (AARP, 2016); the Institute for Healthcare
Improvement (IHI, 2019); and the Centers for Disease Control (CDC, 2020).
In order to optimize health in the home environment, individual needs must be
specifically identified. Hospitals try to uncover these needs through complex electronic health
record reviews and data abstraction (Institute of Medicine, 2015). Natural Language Processing
(NLP) has been used as a more efficient way to identify information in physician notes,
uncovering fall risk, poor social support, tobacco use, and risk factors associated with hospital
readmission (Navathe et al., 2017). This indicates that without complex data abstraction, there
are NSDH generally missed by hospital staff prior to discharge and so left unaddressed.
Navathe et al. (2017) note that NLP of medical records was used to gather data because
point-of-care surveys are not automated, nor scalable. This suggests that if a survey is automated
and scalable, it would be a better way to obtain relevant information. This would be particularly
true if the point-of-care is the client’s home and electronic information transfer is available as it
is through Medicaid mandated Electronic Visit Verification (EVV, Medicaid, 2020). Of
importance, actions in the home may be initiated promptly to resolve identified negative factors.
The National Academies of Sciences, Engineering and Medicine (2019) recently released
an evidence-based consensus report concerning the impact of social determinants on health. In
this report, activities requiring systems level changes were identified and lead to goals relating to
designing health care delivery that integrates social and health care. Goals relevant to this project
include building an appropriate workforce; developing an accommodating digital infrastructure;
developing inclusive financing options; and promoting research and evaluation methods to gauge
Direct Care Community Worker 8

effectiveness of social care in health care settings. This study notes the new level of awareness of
SDH includes recognition that improved health is partially dependent on improving social
conditions and decreasing social vulnerability. As this consensus report is further disseminated it
may strongly impact related future activities. Of relevance to this project, the report includes
home health aides (aka DCWs) in the list of disciplines needed to impact SDH.
The Centers for Medicare and Medicaid Services (CMS, 2017) recently instituted the
Hospital Readmission Reduction Program, a payment system that aims to keep people out of
hospitals. This was mandated through the 21
st
Century Cures Act and will incorporate
socioeconomic status toward readmission penalties for patients who are covered by Medicare
and Medicaid. The aim is to improve the coordination of services for dual eligible consumers and
decrease health care utilization (Remington, 2018). Keeping people out of hospitals is a reason to
expect an increased use of home care options which will shed light on and exert pressure to
remediate NSDH. Acknowledging the importance of identifying unmet social needs in order to
connect individuals with appropriate services, CMS is testing different models of gathering this
information (Billioux, Verlander, Anthony, & Alley, 2017). Advanced home health service
providers are included (Social Work, Nursing, etc.) in these efforts, but not DCWs. This suggests
that high-touch, low-tech care providers will remain untapped resources if new ways are not
developed to include them.
Bruce Broussard, CEO and president of Humana Inc., identifies advances in home-based
care and addressing SDH for older and chronically ill populations as some of “the most
impactful” influences on the U.S. health care system (Holly, 2019, ¶1). Broussard notes that
these areas impact downstream use of services by preventing negative outcomes (Holly, 2019).
The Humana Chief Medical Officer, Roy Beveridge, supports these suppositions by noting that
Direct Care Community Worker 9

site of care is moving from institution based to less expensive home- and digital-based care
which he identifies as an “uninstitutionalized” focus (Holly, 2019, ¶ 7).
Jacobs (2017) concurs that home-based resources are underutilized. He notes that the
shift to the home health model enhances opportunities to resolve SDH in many ways.
Further, he notes the need for policies to help home health providers integrate care to include
such things as transportation, food insecurity, education; utility needs, interpersonal violence,
income; and family and social supports. All these points are consistent with the DCCW project
except that his focus is the professional or home health side of home-based services rather than
the home care side. He refers to Medicare services which rarely included DCWs, the truly
underutilized resource and most frequently seen provider in the home setting.
There are many examples of organizations successfully taking healthcare out of hospitals
and into communities. Hennepin Health, a Minnesota (MN) county based Accountable Care
Organization, uses a collaborative effort to address NSDH in a Medicaid demonstration project.
Partnerships are used to improve the workforce and care coordination of physical, behavioral,
social and economic care for Medicaid consumers. Two years after implementation there was an
increase of 3.3% in outpatient visits and a decrease of almost 10% in emergency room (ER)
visits (Sandberg et al., 2014). Client approval was seen in an 87% satisfaction rating (Sandberg
et al., 2014), and clinical care improvements were seen in diabetes care (MN Community
Measurement (MCM), 2014a), vascular care (MCM, 2014b), and asthma care (MCM, 2014c).
These efforts included CHWs but did not have a position like the DCCW who could promote an
even greater impact with more routine reinforcement of positive behaviors.
Kaiser Permanente (KP) in California focuses on the costliest patients for their pilot
program. Efforts concentrate on 1% of the membership that represents 23% of total health care
Direct Care Community Worker 10

spending (Shah, Rogers, & Kanter, 2016). They developed a scalable model to target SDH with
a holistic, three-prong approach for high cost, high need patients which includes partnering with
existing resources, identifying gaps in accessing resources, and demonstrating the value of
addressing SDH (Shah et al., 2016). Members of the KP team acknowledge that the definition of
health care is expanding to include SDH and they continue work on developing scalable
interventions (Shah, et al., 2016). These efforts have not included a DCCW-like role.
The Center for Health Care Strategies, Inc. (CHCS) promotes innovations focused on
publicly funded health care. Their Transforming Complex Care initiative supported by the
Robert Wood Johnson Foundation (RWJF) is important because of the public funding focus,
efforts are addressing needs comparable to the DCCW project population, and they follow the
CHCS core tenets (CHCS, 2018) of entrepreneurship, big-picture thinking, communication;
attending to nuance, embracing ambiguity, continuously improving; collaboration, being a
trusted partner, and investing in people (CHCS, 2018). Hospital based CHWs are utilized and
there is no role equivalent to the DCCW.
Health IT Analytics (2019) found that addressing social determinants at home brought
about an 11% reduction in cost to health plans. This amounted to an average of $2,601 reduction
in cost for the year after service referrals. Those who did not have the same social needs met saw
a reduction of 1% during the same time frame. Having just one social need met brought about a
reduction of 7% in costs to health plans.
Particularly relevant to the DCCW project is a report by the Council of Large Public
Housing Authorities which indicates that their membership views housing as a SDH as well as a
platform for services that improve outcomes (Jaspen, 2018). For this reason, they are working
with the health care sector as an effective way to meet the needs of those in public housing.
Direct Care Community Worker 11

Specific to Philadelphia, the Health Enterprise Zone (HEZ) was launched in 2016 with an
aim to improve the region’s health by joining the forces of hospitals, schools, and community
groups (Schweich, 2018). The geographic focus for these efforts is North Philadelphia, a densely
populated area where 13% of the state’s Medicaid recipients reside and 31% of the residents live
below the poverty level. The Pennsylvania Department of Health and Governor Tom Wolf
allocated almost $12 million to the HEZ to focus their efforts on health, community, education,
and technology. This geographic area includes the DCCW pilot project population. HEZ
representatives have been informed about this project and currently they are not utilizing a role
like the DCCW. Their funds are allocated for this year, but they have expressed interest in future
collaboration. Conversations with representatives of the Medicaid health plans and the PA
Healthcare Association also indicate interest in this project.
Health plans and health systems are implementing Community Health Worker programs
to help address non-clinical issues as a way to decrease hospitalizations. Community Health
Workers (CHWs) take solutions to the communities where they are most needed and look for
root causes of problems to help prevent recurring symptoms. The services they provide are
needed and successful, but they see the clients intermittently, do not provide personal care, and
there are not enough CHWs available to see all the home care clients who might need their
services. The Bureau of Labor Statistics (BLS) reports that there are three million DCWs in the
U.S. (BLS, 2018a; BLS, 2018b) compared to 56,000 CHWs (BLS, 2018c).
Kangovi & Asch (2018) describe the Community Health Worker environment as a
“Boom” (p. 1) which is opening the door to activities supported by research and the development
of best practices for provision of community care. The DCCW can add to the “Boom” by
expanding the scale of CHW services and bringing into the home a new way of thinking and
Direct Care Community Worker 12

innovatively solving problems. DCWs who have personally experienced Medicaid assistance as
working poor parents, will have a practical understanding of the needs of their clients as they
deal with the service system to help resolve NSDH. The DCCW role may also improve their
circumstances by providing a living wage for the work they perform.
Disrupting a norm. A long-held norm that social determinants of health are too
expensive to fix must be disrupted. Norms develop in many ways and the norm that SDH are too
expensive to address may have been influenced by, among other things, the Black Report
released in the U.K (Black Report, 1980). It was named after Sir Douglas Black who chaired the
Work Group. The Report brought to light the extent to which inequalities exist and the impact
they have on health and mortality. Rather than attributing poor health to health systems, the
Black Report attributed it to social inequalities such as income, housing, work conditions, and
diet (Black Report, 1980). Included in the Report were social policy recommendations that were
not accepted by the Secretary of State for Social Services. The estimated cost of implementing
the recommendations was £2 billion/year (Black Report, 1980), translating into approximately
$1 billion then or $3 billion now (Pounds Sterling Live, 2019). This report could have been a
call to action but instead it promoted a norm that SDH are expensive to address, providing a
rationale for inaction.
Forty years after the Report, the DCCW program addresses these important
recommendations (Socialist Health Association, 1980):
For disabled people, to reduce the risks of early death, to improve the quality of
life whether in the community or in institutions, and as far as possible to reduce
the need for the latter.
The functions of home help should be extended to permit a lot more work on
behalf of disabled people; short courses of training, specialization of functions…

Direct Care Community Worker 13

… evaluation research and statistical and information units. The object would be
both to provide special help to redress the undeniable disadvantages of people
living in those areas but also to permit special experiments to reduce ill-health and
mortality and provide better support for disabled people.

It may be ill-received to broadly note that the Report and plans came out of a Socialist
environment, but importantly, current literature reveals many U.S. projects that are consistent
with these recommendations and successfully address SDH. Examples of significant returns on
investment from such projects will provide support for the DCCW program.
Vast healthcare expenditures also provide rationale for this project, particularly with
predictions of ever-increasing costs, and given what is known about the impact of social
determinants on health (AHA, 2019.) Costs of healthcare are projected to grow 1% faster than
the GDP at an average rate of 5.5% per year, resulting in expenditures of $5.7 trillion by 2026
(CMS, 2018). Medicaid represents 17% of the total National Health Expenditures (CMS, 2018).
In Pennsylvania, Medicaid enrollment is 62% adults and children, and 38% elderly and disabled,
yet expenditures are 79% for elderly and disabled (Kaiser Family Foundation, 2018). These
Medicaid funds provide services to the DCCW Training program population with needs that may
be amenable to remediation that could ultimately decrease health resource utilization. Safely
decreasing consumption of finite resources through NSDH remediation has the potential to
improve consumers’ lives while decreasing health care utilization and expenditures. Information
such as this will provide important rationale for an increased reimbursement rate for the new
DCCW role and support the new norm that SDH are too expensive not to address.
Problems of Practice and Innovative Solution
The project mission is to provide Medicaid home care consumers who are experiencing
multiple health-impacting inequities with the opportunity to live healthier lives by addressing
Direct Care Community Worker 14

negative elements that may be contributing to poor health. This will lead to more appropriate
health care utilization and decreased costs. It also allows the potential for an increased salary and
career trajectory for DCWs, who may also be Medicaid recipients as working poor parents.
These activities will help to address the Social Work Grand Challenge of closing the health gap
as well as related priority areas identified by Fong, Lubben, & Barth (2018) relating to research
on social determinants of health inequities; improving the conditions of daily life; and advancing
community empowerment for sustainable health. By increasing the wages for DCW, this project
will also help to decrease economic inequality.
The DCCW training is motivated by the values of compassion, fiscal intelligence, and
empowerment, and includes methods to solve social-based problems at their core. A review of
current and related activities throughout the country suggests this project is embedded in an
environment that is ripe for addressing SDH. Direct Care Workers are available in significant
numbers, are in clients’ homes routinely, often daily, and can observe the environment first-
hand. They represent a large force which could provide a great deal of assistance in resolving
social issues for the neediest citizens - if they know how to do it. The goal of this project is to
train DCWs to add duties generally attributed to CHWs which creates a new, hybrid position of
Direct Care Community Worker. The DCCW Training aims to take advantage of their presence
in homes as primary caregivers by preparing them to observe, report, and remediate negative
social elements. This will allow them to complete personal care, create a positive milieu for
productive assisted decision-making, and provide a more encompassing care experience.
First-hand observations made by in-home workers allow accurate assurances that social
needs are met, or they measure the burden of unmet needs which can inform policies and
procedures aimed at remediation actions that help close the health gap for these clients. Further,
Direct Care Community Worker 15

Sevilla-Cazes, et al. (2017) suggest that focusing on patient centered factors in the home might
show better health and utilization results than focusing on methods to reduce hospital
readmissions. This is a subtle difference yet one that allows a more precise focus of care.
Additionally, they identify key areas of home care client difficulties which focus on
uncertainties, disconnections between behaviors and symptoms, decision making limitations;
hopelessness, despair, and ultimately a sense that the hospital is the safest place rather than a
negative outcome. For this project these elements are defined as a Cycle of Struggles
(Attachment A).
Older Medicaid consumers who are receiving DCW services may experience the same
difficulties noted above, coupled with additional negative social factors found in their lives that
add to their Cycles of Struggles. The home care setting with frequent and ongoing interactions
from appropriately trained DCCWs lends itself to a compassionate, client centered focus so the
Cycle of Struggles can be interrupted, leading to positive adaptation and adherence in a Cycle of
Successes (Attachment B). NSDH can be observed using the DCCW Observation Tool
(Attachment C), discussed with the client through Motivational Interviewing (Flynn, 2016), and
resolved with assisted decision-making and Trauma Informed Care (CDC, 2018; Substance
Abuse and Mental Health Services Administration (SAMHSA), 2014; Adyanthaya, 2014).
Elements of Positive Affect Induction (Isen, Lewis, Haviland-Jones, & Barrett, 2008;
Fredrickson & Branigan, 2005), Attribution Retraining (Haynes, Perry, Stupnisky, & Daniels,
2009; Landau, 2003; Weiner, 1972; Heider, 1958), and connecting with services bring evidence-
based contributions and care coordination to create a positive milieu. Oversight is provided by
appropriate licensed staff.
Direct Care Community Worker 16

Four activity groupings noted in Table 1, counteract the struggles and create a Cycle of
Successes (Attachment B).
Table 1
Cycle of Successes
1. A. Review discharge paperwork or
care plan with client
B. Assist with answering or obtaining
answers to questions
C. Observe social determinants of
health (SDH)
D. Positive Affect Induction
3. A. Assisted decision-making with
Attribution Retraining
B. Assisted implementation

2. A. Continue to observe SDH
B. Reinforce education
C. Connect health to behaviors
D. Consider methods to resolve NSDH
4. A. Initiate service connections
B. Address barriers and enhance
facilitators

Based on the Bureau of Labor Statistics (2018a; 2018b; 2018c), nationwide, CHWs earn
significantly more than DCWs ($21.76/hour vs. $12.29/hour) so while improving care, the
hybrid position presents the potential to provide a living wage for workers. Healthcare funders
will realize cost savings from more appropriate healthcare utilization which will offset the
increased reimbursement rate required to sustain the position and the funds needed to resolve
problems. Several examples have been reviewed to showcase successful resolution efforts
resulting in significant returns on investments (Health IT Analytics, 2019; Center for Health Care
Strategies, 2018; Morse, 2018; Shah, Rogers & Kanter, 2016; Sandburg et al., 2014; Lorig, et al.,
1999). This project is also supported by the research of Trzeciak (2018) who has identified the
positive impact of compassionate care on resource use, quality, errors, compliance, stress and
pain. He also notes that it decreases burn-out for care providers. Financial support for the DCCW
position from the legislature, CMS, Medicaid health plans, other government entities, and
community organizations will bring the week-long training program and the position to fruition
and sustain it into the future. In the long run it could improve population health, save health care
Direct Care Community Worker 17

dollars, provide a career trajectory for low wage DCWs, decrease turnover and draw new
workers into the caregiving field for which there is an ever-growing need. Many activities are
helping to improve social issues that lead to poor health. The DCCW position is one more tool.
Theories supporting the training program. The DCCW Training elements are
modified from the Community Health Worker Performance Measurement Framework (CHWPF,
Attachment D) developed through iterative consultations, supported by the Bill & Melinda Gates
Foundation, and in partnership with USAID and UNICEF (Agarwal et al., 2019). Theoretical
support for program elements focuses on the two most involved participants; the DCW and the
client. Because the DCWs are experienced and mature, Adult Learning Principles (Teaching
Excellence in Adult Literacy (TEAL), 2011) have been considered in training program
development. This pilot will determine, through pre- and post-testing (Attachment E), if students
learn from the program. Client behavior change is supported by The Ecological Theory (National
Cancer Institute (NCI, 2005) and the NCI Health Belief Model (HBM, 2005). These elements are
consistent with the project Theory of Change (Attachment F). Outcomes measures, assessed 12-
18 months post-implementation, will include client satisfaction, primary care visits, emergency
room visits, hospital admissions and days, and intensive care unit admissions and days.
Student behavior change.
CHWPMF. This framework (Agarwal et al., 2019) informs the DCCW training program
elements, the logistics for implementation, and outcomes. Because the DCCW program is a
hybrid position it does not follow all the conventions of a pure CHW program. Elements of the
CHWPMF (Attachment D) may be compared with the DCCW Logic Model (Attachment G). For
example, the DCCW is neither hospital focused nor based so the requirement of a strong
familiarity with hospital systems is replaced with a strong familiarity and collaboration with
Direct Care Community Worker 18

home care and community systems. Data collection on a community level is replaced by
individual level data collection that prompts rapid action. Electronic data collection will be an
add-on to information already obtained via Electronic Visit Verification (EVV) as required by
Medicaid (Medicaid, 2020). Although data will be aggregated periodically to steer the program,
it may also be used to assist with population health initiatives. Staff transportation is not a
concern because the DCCW role is an add-on to current DCW transportation processes.
Adult Learning Principles. These Principles are used to define characteristics of
appropriate DCCW candidates, course content, and teaching methods. The training participants
are DCWs with at least two years of home care experience. Supervisors identify candidates who
have shown themselves to be exemplary, compassionate employees with excellent skills and
work ethic. Personal care skills are learned in DCW training (Attachment H) and are not
addressed in the DCCW training. Based on learning aptitude qualities defined by Galbraith,
Downey, & Kates (2002) the candidates show agility in key areas, including the mental capacity
to think through problems, comfort with complexity, and succeeding despite tough conditions;
self-awareness, respect for others, and an understanding of how systems work; curiosity,
resilience, and willingness to experiment.
There are a variety of assumptions, explanations, and models that make up Adult
Learning Principles. Transformational Learning Theory (TL) best describes the methods and
outcomes for this training as it promotes a shift in consciousness for the students in how they
view themselves and the world around them (TEAL, 2011). This shift is prompted by advancing
from a low-paying and often considered dead-end position to a new role with added
responsibilities, earning potential, and a career trajectory. Further, the training allows practice on
an observation-based data collection tool and provides skills to address observed problems that
Direct Care Community Worker 19

have previously been insurmountable due to a lack of knowledge. For TL to take place, Taylor
(2000) recommends an environment that is trusting, empathetic, caring, authentic and sincere.
Taylor (2000) also notes that students need to receive rapid feedback and to work on activities
that allow autonomy, participation and collaboration; with exploration of alternative
perspectives, problem-solving, and reflection (1998). To explore different points of view,
Cranton (2002) recommends using films and short stories, brief writing assignments with follow-
up discussions, critical incident or experience sharing; and entry/exit slips which could be helpful
in gauging understanding and interest. The DCCW training addresses these points by providing
an open classroom milieu, using discussions following brief lectures, short writing assignments
which are shared in class; sharing of real life examples from students to supplement materials,
sessions focused on problem-solving, use of videos and short stories; and a daily post-class
assessment.
Client behavior change.
The Ecological Theory. Medicaid clients will experience three levels of influence included
in this theory: intrapersonal characteristics including knowledge, personality, and beliefs;
interpersonal interactions with family, friends, and social groups; and community factors like
norms, regulations, and policies (NCI, 2005). Each level can influence client outcomes and a
DCCW can exert a strong influence on the intrapersonal and interpersonal elements by
performing the tasks addressed in the Cycle of Successes, which are within regulatory
boundaries (Legal Information Institute, 2019; Nursinglicensure.org, 2019). These activities have
the advantage of being multilevel in that they address environmental and behavioral influences.
For example, the DCCW may ensure nutritious foods are available in the home, which will
promote a behavioral change to healthy eating habits.
Direct Care Community Worker 20

HBM. Importantly, the DCCW is available to the client on a regular basis and can
reinforce health education, prescription compliance, and recommendations provided by
clinicians while providing ongoing encouragement, success recognition, and a positive milieu.
These activities support key client beliefs that promote behavior change described by the HBM
(NCI, 2005):
Clients believe they have health conditions or are susceptible to conditions.
Clients believe the conditions are serious.
Clients believe there are actions that reduce their risks.
Clients believe costs (barriers) are outweighed by the benefits.
Clients are exposed to factors that prompt actions.
Clients are confident in their ability to perform an action.

The DCCW can provide ongoing, frequent reminders and encouragement to clients coupled with
observation, reporting and assisted decision-making to help empower clients, and assist with
efforts to resolve problems.
Project Structure and Communication Methods
BAYADA Home Health Care (BAYADA.com, 2020), one of the larger home care
companies in Philadelphia, will be the pilot site for this project which has been reviewed by
leadership. There is clear organizational interest in addressing SDH and the new hybrid position
of DCCW is viewed as a potential business line that could improve care, bring in additional
revenue, and introduce a career trajectory for current DCWs. BAYADA leadership has expressed
concerns about methods to pay for the pilot and there are options available.
This innovation is a training program which combines the duties of a Direct Care Worker
and a Community Health Worker, creating the hybrid position of Direct Care Community
Worker. The DCCWs will continue to provide routine personal care to their clients and will add
Direct Care Community Worker 21

SDH observation and when necessary, remediation of negative elements. Each training session
will include up to six students who will participate in the 40-hour program. A pre-test will be
administered prior to class to assess current knowledge. A post-test will be administered at the
end of the week to assess if learning took place. Students must receive at least 80% on the post-
test to be considered DCCWs. MSWs or RNs will provide the training, oversight, and mentoring.
Because of the disparity between the DCW salary and that of a Community Health
Worker (Bureau of Labor Statistics, 2018a; 2018b), by taking on these added duties, the DCWs
have the potential to significantly increase their salaries. The higher pay rate may decrease DCW
turnover and also draw people into the short-staffed caregiving field. DCW benefits translate into
better client care. A higher salary will be supported by a higher reimbursement rate from the
service funders who will realize a significant return on this investment through more appropriate
and less costly healthcare utilization.
Although DCWs and Medicaid clients are most personally impacted by this training
program, they are not the people to whom a marketing campaign will be focused. In order to
implement this new training program there are two groups that must be convinced of its benefits
and viability; Philadelphia home care agencies that employ DCWs and the government entities
that reimburse providers for the DCW services. A multiprong approach will be implemented by
MET Healthcare Innovations, LLC (MHI, 2020) under the auspices of which the DCCW
program was created in 2019. The training program is fully developed but there has been no
formal marketing campaign to advance it. Initial efforts will focus on raising awareness of this
new health services role, the potential for improved quality of life for clients, decreased
preventable healthcare utilization and cost, and a career trajectory for DCWs. Methods will
include face-to-face meetings, articles in newspapers and relevant journals, attending networking
Direct Care Community Worker 22

events; presenting at conferences, podcast interviews, and developing a social media presence
through Facebook, Linkedin, a web site (met-healthcare-innovations.com), and a blog; applying
for grants (VA, AARP, RWJF) and taking advantage of the subsequent press opportunities.
Home care agencies and their funders are linked because the agencies have expressed
interest in the program but will not move forward without assurances that the funders will pay a
higher reimbursement for the DCCW services. Without a higher reimbursement there is limited
value to the care providers. There are hundreds of homecare providers in the Philadelphia market
who may participate after the initial pilot period indicates training success and improved
outcomes for clients. This training is modular so it may be used to addressed specific knowledge
gaps. It may also serve as a template to be modified for different geographic locations.
The Medicaid program in Pennsylvania (PA) has undergone a major change. January
2019 completed the roll-out of Community Health Choices (CHC), the PA managed Medicaid
program focused on dual eligible consumers covered under Medicaid and Medicare (CHC,
2018). Covered under this program are 133,000 people in Philadelphia. Some are covered
because of their long-term care needs but 94% are in the dual eligible category receiving non-
institutional care (Burling, 2019). Members of this group will be the beneficiaries of the DCCW
services. CHC has three approved health plans which have been provided and will continue to
receive information about this project. Because of the new managed care program, cost has taken
on immediate importance. The potential to decrease health care utilization through remediation
of NSDH could compel them to be active stakeholders in order to relieve the burden in their
consumer populations. Meetings with health plan representatives revealed a high level of interest
in SDH remediation. They are looking for options but are without solid plans on how to move
forward. As a new program, the DCCW program provides an option to them, but because it has
Direct Care Community Worker 23

not been included in previous budgets, discretionary funds or other budget changes must be
made to accommodate an increased reimbursement rate until the anticipated return on that
investment is realized. The DCCW Training marketing plan must help them believe that positive
change is possible and cost effective. They must be convinced that the program values of
compassion, fiscal intelligence, and empowerment are more than just words. If health plan
support is not immediately forthcoming, other funding sources (VA, AARP, RWJF) will be
accessed in order to complete a pilot that will provide data showing a solid return on investment.
East (2014) notes that positive Word of Mouth (WOM) is more likely to occur than
negative WOM and the marketing plan will help ensure this by providing accurate information to
a large swath of people. The industry is looking for viable methods to address SDH and a solid
marketing plan will ensure the DCCW program is discussed as one potential option. Broad
messaging will capitalize on “the mere-exposure effect” (Dyer, Furr, & Lefrandt, 2019, p 89).
With this effect people prefer something they have heard about, seen or with which they are
somehow familiar. Although the DCCW program is new, if marketing is successful, when the
program is discussed, people might feel like it is familiar even if they are not completely
knowledgeable about it.
“Going viral” was initially used in the medical field but is now used to describe reaching
a large swath of people. Garey & Johnstone (2015) describe the digital idea of going viral as
breaking down boundaries that allow ideas to “flow” (p 3) between people. Going viral has
become a ubiquitous term in current culture and for this project, it is used to describe the goal for
a multi-method campaign involving more than digital media. The six themes identified by Garey
& Johnstone (2015) are relevant for any marketing campaign that aims to enhance the likelihood
of going viral: entice the audience, keep it short, create an emotional connection; use visuals to
Direct Care Community Worker 24

engage, encourage self-identification, and allow the audience to engage and take part. These
themes will be implemented by using the methods previously described.
Waters (2017) notes that successful innovation requires a clear vision, so all involved are
going in the same direction. The first materials produced for the DCCW Training were Mission,
Vision, and Values (Attachment I). They are the primary touchstones and messages. If any
activity does not fit with the Mission, Vision, and Values then it is not the right activity for this
project. If any message is inconsistent then it is not honest. Pieces of those defining ideas are
used to describe the DCCW program in order to ensure a consistent and clear message.
Waters (2017) additionally described four models for effective innovation: disruptive
innovation; design-led innovation; customer-led innovation; and brand-led innovation. All four
have relevance to this project and may be highlighted in marketing language. This project is
disruptive in that it will dispel the belief that social determinants of health are too expensive to
fix. This may be the most frequently encountered concern since the goal of initial marketing is to
obtain financial backing. Empathy towards clients’ problems animates the training program as is
customary with design-led innovation. Empathy is a feeling about something that prompts
compassion which is an action and a key project value. Stakeholders will be asked to act
compassionately which will also be fiscally intelligent. Although Medicaid consumers were not
formally queried during the development phase as might happen with customer-lead innovation,
their input was obtained through informal conversations and concerned observations. As a
“customer expert” (Water’s, 2017, p 4) these observations are considered informed and customer
driven. Since MHI is a new company there is currently no brand recognition and building that is
a key component of the marketing plan. The DCCW title is also new so it will need to be
branded as well. Despite this, the company has taken on some of the qualities of a Brand-led
Direct Care Community Worker 25

organization in that it starts with a vision and sense of purpose and promotes an understanding of
what is core. Feeding America research (ARF Ogilvy Awards, 2019) revealed that supporters
may be more likely to fund projects that address their hearts and minds. The values of
Compassion and Fiscal Intelligence motivate this project, are specifically related to hearts and
minds, and ongoing references to them will be reminders of the core of this program.
Intervention phases. Upon receiving BAYADA approval, supervisors will identify the
first group of up to six students. If acceptable to all parties, the first pilot training will be held in
November 2020. It will include a pre- post-test assessment of knowledge (Attachment E). A
post-test score of at least 80% for individuals will be required to qualify as a DCCW and an
average class score of 85% will confirm program effectiveness. A level of improvement score
will be completed to ensure the training improves students’ knowledge. BAYADA HR and
Contracting Directors will be involved in negotiating with previously identified funders. In 2021,
service offices will begin participation in the program roll-out by assigning the DCCWs to
clients. Train-the-trainer classes will begin when more than three classes per month are required
to meet demand.
Program expansion will begin after a start-up phase of 12-18 months. By then there will
be sufficient program and outcomes data to aggregate and review to modify the program as
indicated, expand program presence, and support population health initiatives. Expansion may be
accomplished geographically or by identifying new student populations such as family
caregivers or administrative staff from provider agencies. Ultimately the manual will be
templated to address different locations and modular to address specific training needs.
This project is currently considered a quality improvement project approved by
BAYADA internal management, so IRB approval was not obtained. If a research tract makes
Direct Care Community Worker 26

sense at a later date, then IRB approval will be obtained. Client services will not be withheld nor
diminished because of this project and DCCW client assignments will be based on the same
criteria as DCW assignments. Assignments are routinely made based on client need, client and
caregiver schedules, and client and caregiver geographic locations. Over time this could be
modified based on funders’ requests or other factors.
Units of service. One unit of service will be the completion of a 40-hour DCCW training.
The output of the training will be six newly trained DCCWs. After the pilot training, the
Philadelphia training schedule will be based on demand. As a cadre of DCCWs is in place, the
service offices unit of service will be one hour of DCCW care which may be provided in
increments of 2 – 24 hours per day. For non-training weeks, a unit of service for instructors will
include 15 minutes of oversight or mentoring of DCCWs in the field
Assessment methods. Two key areas of assessment will be considered; elements related
to the DCCWs and elements related to their clients. For both groups a pre/post implementation
methodology will be used. Prior to beginning the training, the candidates will be given a pre-test
(Attachment E) to gauge their level of knowledge on the topics covered in the training. This will
serve as a comparison to the post-test at the end of the course and as a guide for the instructor to
add focus to areas for which students have a very low level of understanding. A post-test score of
at least 80% will be necessary to become a DCCW. Test scores will also inform needed
modifications to the training manual and methods. The impacts for the DCCWs will be enhanced
skills, increased salary, and improved satisfaction which will be seen in the annual BAYADA
employee satisfaction survey, and further evidenced by a decreased turnover rate compared to
non-DCCW staff. By one-year post-implementation, there will be sufficient comparative
administrative data to evaluate changes in salary amounts, turnover rates, attendance, and job
Direct Care Community Worker 27

satisfaction for employees. The outcomes for clients will be measured after 12-18 months and
will include improved client satisfaction which will be noted in the BAYADA client satisfaction
survey. Data from the funder(s) will be used to determine an increased use of primary care and a
decrease of at least 10% in emergency room visits, hospital admissions and days, and intensive
care unit admissions and days. Impacts for clients will be improved quality of life and better
health. For both DCCWs and clients, comparisons will be made with data from the year prior to
implementation.
Budget. With or without rapid acceptance and financial support of the program from
Medicaid health plans, alternative or additional funding sources will be sought. Governor Wolf’s
(D-PA) budget includes $1.2 million to educate consumer directed care providers (Wolf, 2020).
These are clients’ family or friends who are reimbursed for providing care. There has been little
control about who performs these duties and what their skills are. The Governor hopes to provide
education as a quality control measure and the DCCW training could be part of that training.
This program will be submitted either with BAYADA or as a stand-alone when the request for
proposals opens.
The Department of Veterans Affairs (VA) has released a Request for Application (RFA)
for Service Directed Research on Social Determinants of Health. The goal of the pilot funding is
to generate data to establish the feasibility of further research, establish a new partnership with
an outside organization, or answer a question of value. The RFA notes that SDH contribute to
health outcomes and health disparities and so the funding should be used to identify, evaluate,
and/or implement evidence-based practices to integrate social care and health care in order to
mitigate Veterans’ unmet social needs. There is a strong focus on community efforts to resolve
NSDH. The DCCW project will be the focus of a submission with VA, University of
Direct Care Community Worker 28

Pennsylvania, and BAYADA Home Health Care as partners. A project team is in place and the
submission deadline is June 1, 2020. If funded, the project will start January 2021. Prior to that
start date, the project will go through IRB review. VA IRB will not review until funding is
assured.
AARP and RWJF have funding foci consistent with this project. AARP (2020) provides
grants geared towards sustainable, scalable, evidence-based, and practical solutions to address
challenges facing low-income older adults. RWJF (2020) recognizes the importance of state
leaders in using the Medicaid program to improve consumers and communities. The web site
specifically notes the Medicaid programs are looking to address outcomes, not simply pay for
services rendered and this may require connecting individuals to needed services and expanding
on allowable services. This is consistent with the DCCW Training.
A significant benefit of collaborating with BAYADA is their ongoing relationship with
the Philadelphia Office of Workforce Development (POWD). The POWD will be an important
relationship because it focuses on funding the key areas of education and training, policy and
strategy, and business engagement; and coordinating efforts among partners who prepare
individuals for jobs in Philadelphia (Philadelphia, Department of Commerce, 2019). Because
BAYADA trains and hires so many employees, POWD subsidizes hiring and training processes,
and will support this training and immediate post-training salaries.
A Line Item Budget format will align with the BAYADA fiscal year (calendar year).
Two budgets will be considered at this time (Attachments J and K); the pilot budget representing
July 1 – December 31, 2020, and the first full year operating budget representing January 1 –
December 31, 2021. Anticipated revenue sources for both budgets will include BAYADA,
POWD, at least one Medicaid health plan, and AARP grant funds. Additional funding sources
Direct Care Community Worker 29

being considered are VA (2020) which recently released a Request for Application on the topic
of SDH resolution in the community; the RWJF (2020) which also has SDH as a focal area; and
additional funding from AARP. Based on Funding Models described by Foster, Kim, &
Christiansen (2009), a blended model will be used that includes the Public Provider model based
on Medicaid service contracts, and the Policy Innovator model with funds from the BAYADA
Business Development, POWD to develop and implement a plan to enhance DCW training, and
AARP to help provide services to older home care clients. Funds from RWJF and VA are
representative of the Policy Innovator model.
Revenue projections. Revenue sources were noted above. Medicaid health plans, PA
Health and Wellness, AmeriHealth Caritas, and UPMC Community Health Choices are
important stakeholders and function under the auspices of the PA Medicaid managed care
program, Community Health Choices (CHC, 2019). For the pilot, POWD will provide funds to
cover the pilot training. These funds may be used for salaries, training materials, or any pilot
related costs. For three months following the training, POWD will support 25% of the new
DCCW salaries. The first month of this support is seen in December 2020. The remainder of the
December salaries will be covered by the health plans for services rendered. For two years after
the pilot period, POWD will pay the salaries for DCWs to attend the training and will provide
25% of new DCCWs salaries for three months following each training. This is consistent with
their commitment to BAYADA for other training programs (Conversation with Bonnie Kelly,
Division Director of Human Resources, BAYADA, June 21, 2019). POWD funds will be
contingent on the health plans committing to an increased reimbursement rate for individuals
working in this new position which explains why these relationships are so important and why
Direct Care Community Worker 30

they are being nurtured during the pilot phase. BAYADA is supporting training classes with
funds to support elements not covered by other sources.
The Bureau of Labor Statistics (BLS, 2018a) shows a mean hourly rate in Philadelphia of
$12.29 or $25,570 annually for DCWs. BLS shows CHWs receiving a mean hourly rate in
Philadelphia of $21.76 or $45,260 annually (2018c). With these numbers in mind and
considering that the DCCW encompasses the duties of two positions, an hourly pay of $22 will
be requested for DCCWs. This will require a reimbursement rate of $33/hr. to cover benefits and
administration. All project funds will pass through BAYADA via service contracts or grants.
Staffing plans. An important benefit of working with BAYADA as the primary project
site is that the personnel and built infrastructures are already in place. The DCCWs will simply
be added to the array of services already being deployed by over 300 offices (BAYADA.com,
2019). For the pilot, the Director of the DCCW Program will complete all trainings. The Director
position will require .6 FTE plus 50% for benefits and administrative costs which are included
in all staff salaries. While DCWs are in the one week training they will be paid their routine
hourly rate of $10.66. For the first year, eight classes of six students each are anticipated with
training salary covered by POWD. The budget will be modified if additional classes are needed.
Following training, the DCCW salaries will be covered by the health plans’ service contracts
except for the first three-month intervals during which POWD is covering 25%.
Additional staff FTE starting the first full year will include a data analyst and
administrative support. The analyst, who is part of BAYADA’s Research, Analytics, &
Innovation Department, will provide .1 FTE for data analysis. The analyst will format and
analyze data to determine client and DCCW outcomes and impacts. Although reliable data will
not be available immediately, the analyst will complete practice data aggregation and analysis to
Direct Care Community Worker 31

refine analytic methods. Administrative support of .25 FTE will be needed for scheduling classes
and other logistics.
Financial resources. With generous support from BAYADA, POWD, AARP, and health
plan service contracts the revenues and costs for the pilot and first year budgets are perfectly
aligned. Outcomes data will be important to rationalize continuation of the program. Although
client satisfaction and quality of life are important impacts, reduced health resource utilization
will provide the financial rationale for program continuation. If resource utilization reduction of
over 15% or greater is realized, the reimbursement rate may be re-negotiated, or other forms of
financial backing will be requested from the health plans to further support the program.
Additionally, funds will be sought from other stakeholders including city and state governments,
utility companies, foundations, and other organizations that may provide financial and/or in-kind
services needed for remediation efforts.
If budget cuts are needed, an option would be to share administrative support with
another department and cut the requested hours, with the Director taking over some of the duties.
Additionally, the DCCW salary can be reduced by $2/hr. and still maintain a living wage that is
almost double the rate for DCWs. Finally, it is not possible to prospectively gauge the total
number of DCCWs needed in the Philadelphia market. Once a critical mass is achieved (all
DCCWs are functioning at full capacity and there is no additional demand) then routine classes
in Philadelphia will cease and training will be scheduled only when there are at least six
openings. The program will then start the process over in new markets.
Complicating factors and constraints. The biggest concern is the receptivity of the
funders to pay more than the current DCW reimbursement. There is reason for optimism found
throughout the health care environment as previously described. There is convincing evidence
Direct Care Community Worker 32

that the DCCW would help funders realize cost savings through reduced healthcare resource
utilization. If one or more of the health plans agree to the higher reimbursement, then POWD
will support the program as described because of the potential for providing a living wage to
those who have not previously received it. The number of health plans involved will determine
the number of DCCWs to be trained and this may alter the number of training classes and
trainers needed. If the health plans are not on board, then additional grant funding will be secured
from AARP, RWJF, or VA to cover costs of a small-scale program until persuasive outcomes
and impacts data are available.
Other funding sources will be considered based on what data show as key areas of need.
For example, if data show that heating and/or air conditioning concerns are frequently found,
those industry leaders will be approached to assist with in-kind or financial participation. The
same will be true with food, transportation, or other frequently identified needs. These additional
funding sources will help offset costs for BAYADA and the funders while helping to assure
rapid responses to needed remediation. Because BAYADA is a non-profit entity it opens the
door to additional funding sources. These additional sources are essential but not yet secured.
Future implications
As part of the career trajectory, DCCWs may be groomed to take on supervisory roles in
the program. This will be based on the success of the program and the interest of DCCWs in
taking on further responsibilities. The program may also be tailored for additional groups, for
example, family caregivers or administrative staff associated with DCCWs (in-office schedulers,
supervisors, etc.), or other social agencies. Certain parts of the training may be templated to
address different geographic locations or client populations, or it may be presented in modules
for groups with specific knowledge gaps.
Direct Care Community Worker 33

Experts have called for the recognition of the community health system as its own,
unique healthcare sub-system, articulating a need to standardize the way performance and
success is measured (Schneider & Lehmann, 2016). This project leads to the development of an
industry standard of care. The observation tool developed for the DCCW use promotes
observation of key social problems recognized by Alley et al. (2016). Ultimately, such
observations and subsequent resolution efforts will become a standard of care known as
Community Failure to Rescue (CFTR). Developed for hospital use, a premise of FTR as it was
originally framed is that Medicare-aged people enter the hospital ready to have complications
and so the measure of quality is whether staff members are prepared to handle this inevitable
occurrence (Silber et al., 2007). Death following a complication is considered a Failure to
Rescue. In the home care setting people are equally complicated, fragile, and vulnerable. In
many communities, clients live in environments riddled with health-impacting insecurities. If
these practical insecurities are not addressed, then a Community Failure to Rescue has occurred
because people have been left in vulnerable situations dealing with negative elements that may
be amenable to improvement.
CFTR represents people at home, an environment that lacks regulations and supports
found in hospitals. Care providers should be ready to handle the same inevitable complications
found in the hospital, in addition to the unpredictable and possibly profound complications of life
that consumers experience and that impact health care utilization, morbidity and mortality.
DCWs know when to report physical problems. DCCW training prepares caregivers to observe,
report and resolve social problems, providing a more complete care experience.
Without assurances that negative social elements are being addressed, it can be assumed
that the system is failing to rescue people in vulnerable situations. Routine individualized data
Direct Care Community Worker 34

collection assures that needs are met or measures the burden of unmet needs. The observation
tool would be self-validating; if one sees that the air conditioner does not work, then it does not
work. It is the same for heat, running water, dangerous structures, or other problems. Since the
older Medicaid population is known to be vulnerable simply by virtue of their service eligibility,
then observations of SDH should be documented for all of them, otherwise that is CFTR1. For
those with identified NSDH, then resolution efforts should be attempted. If not, that is CFTR2.
Conversely, Community Rescue 1 and 2 would indicate the standard was met. Fulfilling this
standard would subvert the ethical dilemma of being aware of a high likelihood for NSDH but
doing nothing about it. The need for action has taken on new urgency because of an awareness of
the personal and financial implications of SDH. Sources of resolution efforts are many and the
DCCW is one discipline that can help address issues where health begins - at home.

Direct Care Community Worker 35

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Direct Care Community Worker 46

Attachment A

Direct Care Community Worker 47

Attachment B
Cycle of Successes

Direct Care Community Worker 48

Appendix C Please contact author for details
Direct Care Community Worker Observation Tool with Instructions
Attachment D
Community Health Worker Performance Measurement Framework
(Agarwal et al., 2019, Open Access).

Direct Care Community Worker 49

Appendix E
Direct Care Community Worker
Pre-/Post-Test Training Evaluation Answer Key Please contact author for details

Attachment F
Theory of Change

Direct Care Community Worker 50

Attachment G
Direct Care Community Worker Logic Model
Context/Assumptions
*Health begins at home. *Home-based care is a health system existing in parallel with the hospital-based system.
*Information is lacking regarding the individual burden of negative social determinants of health (NSDH) affecting
Medicaid home care consumers. Although population data exist, individual needs identification can be difficult.
Without assurances that NSDH are being addressed, providers may fail to rescue older Medicaid consumers in
vulnerable situations which can lead to high healthcare utilization, poor outcomes, and death. In-home observations
can measure the burden of unmet needs which can inform policies and procedures aimed at resolution. Direct Care
Workers (DCWs), routinely in these homes, are untapped resources for identifying and resolving these issues and
this training will prepare them to do so in the new, hybrid position of Direct Care Community Worker (DCCW).

Key: DCW = Direct Care Worker (Home Health Aide) CHW = Community Health Worker
DCCW = Direct Care Community Worker
Inputs Activities Outputs Intermediate
Outcomes
Long-term
Outcomes
*Grant support
for program
development and
implementation

*Community
Partners
(Medicaid health
plans, Social
resources, home
care providers)

*Training
Instructor
*Experienced
DCWs

*Training
manuals and
supplies

*Training space

*Increased
reimbursement
for DCCWs

*Inform state
legislators and
Medicaid health
plans of potential
benefits of DCCW

*Develop
partnerships for
funding &
resolution
pathways

*Pilot DCCW
training/proof of
concept

*Mentoring
follow-up of
DCCWs

*DCCWs begin to
observe, resolve
and report NSDH
found in clients’
homes

*Develop
Community
Failure to Rescue
(CFTR)
calculations
*Collaborations
developed with
health plans and
community
services

*DCCW training
manual completed
including use of
Observation Tool

*DCCW training
piloted and widely
implemented

*Students score at
least 80% on
training post-test
creating a cadre of
DCCWs

*Fully developed
CFTR evaluation
tool
*DCCW
Decreased turnover
Increased salary
Improved
attendance
Improved
Satisfaction
Survey results

*Client
Decreased ED use
Increased primary
care visits
Improved
Satisfaction
Survey results

*Data available for
CFTR calculations
testing and
implementation
*Continuation of all
Intermediate Outcomes

*DCCW
Increase in new hires
Decreased turnover

*Client
Decreased hospital
admissions and
hospital days

*Medicaid Health Plans
Decreased health plan
Costs producing a
100% ROI
supporting
increased
reimbursement

*CFTR evaluation will
be standard for home
care and all clients w/
DCCW will have
documented SDH
observations and all with
NSDH will have
remediation activities

Direct Care Community Worker 51

Appendix H
Direct Care Worker Training Topics (not addressed in DCCW Training)
Client Rights, HIPAA Requirements
Infection Prevention
Basic Communication with Clients
Basic Physiologic Parameters
Abuse and Neglect (physical, emotional, financial)
What they are
Reporting Requirements
Safety Awareness for Client and Caregiver
Medication Assistance Limitations
Understanding and Working with Older Clients
Body Changes
Contracture Prevention/Range of Motion Exercises
Dementia
Mental Health
Nutrition
Death and Dying
Professional Boundaries
Personal Care Skills
Bathing and General Cleanliness
Skin Care, Pressure Ulcer Prevention and Reporting
Assistance with Toileting
Proper Body Mechanics for Client and Caregiver
Transferring Clients, Assisting with Ambulation

Direct Care Community Worker 52

Appendix I
Direct Care Community Worker Motto, Mission, Vision, and Values

Motto: Think straight, plan carefully, act boldly. – Clara Barton

Mission
To provide Medicaid consumers who are >60 and receiving home care services, with the
opportunity to live healthier lives by relieving them of at least some of the burden of negative
social elements in their environment.

To develop training, tools, and a career trajectory for Direct Care Workers which will enable
them to take on the new hybrid role of Direct Care Community Worker.
To provide financially engaged stakeholders with the opportunity to act compassionately and
with fiscal intelligence.
Vision
Consumers will have fewer illnesses, appropriate use of healthcare resources, and high
satisfaction ratings with their in-home care providers, health plans, and other service providers.

Funders will have a 100% return on remediation investment because of decreased resource use.

The new Direct Care Community Workers will receive a living wage. This position will serve as
a step on a career trajectory and will bring others into the field of direct caregiving.

Values
This program maintains the blended values of Compassion, Empowerment, and Fiscal
Intelligence, with Compassion and Empowerment focusing on Medicaid consumers and
caregivers, and Fiscal Intelligence focusing on service providing agencies and Medicaid health
plans.

Home Care is the most basic form of health care delivery, presents the most reliable information
about the presence or absence of negative social determinants of health, and allows immediate
remediation opportunities. Home Health Care is a health system existing in parallel with the
Hospital health system.

This Photo by Unknown Author
is licensed under CC BY-SA

Direct Care Community Worker 53

Appendix J
Direct Care Community Worker Pilot Budget – Pilot Phase
Please contact author for details marti.trudeau@met-healthcare-innovations.com

Appendix K
Budget – FY 2021 (January 1 – December 31, 2021) Please contact author for details

Direct Care Community Worker 54

Attachment L

GANTT CHART

Task Spring
2020
Summer
2020
Fall
2020
Winter
2020
Spring
2021
Summer
2021
Manuals completed
(Instructor & Student)

Final project
defense

Identify students for pilot
training

Pilot Training
Review pilot results with
BAYADA

Begin rollout/assign
DCCW to clients

Submit grant apps to VA,
AARP, RWJF

Marketing Plan

Meet with
stakeholders

Update web site,
Blog, & other soc media

Submit articles
to journal

First podcast interview
Develop Community
Failure to Rescue quality
indicator

Hire analyst & admin
support

Direct Care Community Worker 55

Attachment M
MET Healthcare Innovations, LLC
Direct Care Community Worker Training Executive Summary
Contact: Marti Trudeau, RN, MPA, CPHQ, DSW (c), Founder and CEO
marti.trudeau@met-healthcare-innovations.com
Company Description: MET Healthcare Innovations, LLC (MHI) was founded by Marti
Trudeau in 2019, to support the roll-out of her doctoral project, the Direct Care Community
Worker Training (DCCW), which has the overarching goal of helping to close the health gap.
Problem: Negative Social Determinants of Health (NSDH) are aspects of where and how people
live that adversely impact health. There is no formal mechanism in place to routinely observe or
resolve NSDH found in the homes of Medicaid consumers receiving home care services. These
unmet needs can lead to preventable healthcare utilization, adverse outcomes, and death.
Clients: During the start-up/pilot phase, clients will be older, dual eligible Medicaid/Medicare
consumers with long-term, disabling conditions living in Philadelphia and receiving personal
care services from Direct Care Workers (DCWs). Their services are funded by the Pennsylvania
Medicaid managed care system and provided by home care agencies.
Solution: DCWs are trusted, yet untapped resources for tackling social issues. The DCCW
Training, creates a hybrid position, combining DCW and Community Health Worker (CHW)
duties. The Training Manual includes an Observation Tool used to identify needs and focus care.
This DCW career trajectory will provide a living wage and may attract others into the
understaffed caregiving field.

Goals: Prepare a cadre of DCCWs who receive a living wage while closing the health gap by
helping to decrease morbidity, mortality, healthcare utilization, and cost for Medicaid home care
clients. Create a career trajectory for DCWs which provides a living wage.

Market: The Philadelphia pilot market includes 133,000 Medicaid consumers covered by the
Community Health Choices managed Medicaid program. Although older consumers make up
only 38% of the PA Medicaid population, they account for 79% of the expenditures. After the
pilot, the geographic market area will expand, and training will additionally be available to
family caregivers, DCW administrative staff (supervisors, schedulers), and others.

Marketing: Multiple methods will promote three messages: NSDH are too expensive not to fix;
DCCWs provide one way to address NSDH; The DCCW position provides a living wage.
Revenue Model: DCCW Training will be supported by home care agencies viewing the role as a
new revenue stream. Because of the potential for decreased healthcare utilization, Medicaid
health plans will reimburse home care agencies a higher rate for the DCCWs. Other training
requests will be fee-for-service.
Direct Care Community Worker 56

Competitors: A thorough literature review indicates the DCCW is a unique position. There are
many organizations trying to address NSDH and each should be recognized for what it can
accomplish. The DCCW role adds a new, hybrid role which provides an additional tool to
address issues in the home care setting.
Team: MHI includes the Founder/CEO. BAYADA Home Health Care has committed multiple
resources to the pilot project. Many community resources will collaborate on resolution
pathways.
Strengths: Many organizations are implementing successful SDH remediation programs while
realizing significant returns on investment.
DCCW duties include routine completion of an Observation Tool which will provide data to
identify client needs, develop policies, procedures, and pathways for resolving NSDH; formulate
a standard of care regarding SDH, and inform community health initiatives.
While improving quality of life and decreasing morbidity for clients, this role provides a career
trajectory for DCWs, many of whom are Medicaid consumers as working poor parents.
Following the start-up phase, the training may be templated to address similar concerns in other
geographic areas; provided to family caregivers and to others on the periphery of caregiving
(supervisors, schedulers, etc.); presented as modules covering requested content areas.
DCCW Training is consistent with regulations and home care practice standards.

Multiple funding sources are focusing on ways to address NSDH (Department of Veterans
Affairs, American Association of Retired People, Robert Wood Johnson Foundation).

Weaknesses There are risks inherent in developing and implementing a new training program
which creates a new, hybrid health services position.
An increased reimbursement rate from the Centers for Medicare and Medicaid Services
(CMS)/Medicaid health plans for the DCCW role has not been secured.
Once NSDH are found, there must be mechanisms in place for resolving the issues for benefits to
be realized and to avoid ethical dilemmas. The training provides a summary of available
resources, but additional collaborations will be necessary to develop resolution pathways.

Direct Care Community Worker 57

Attachment N

Short Summary
Direct Care Community Worker

This company is a start-up with the goal of enhancing home care services to address Social
Determinants of Health (SDH) which are factors of normal life that can impact health. Funders
and providers of home care services often lack information about the burden of these factors in
the homes of people receiving personal care services. The Direct Care Community Worker
program adds skills of a community health worker to those of a direct care worker so social
problems and personal care will be addressed. The funding and implementation of this program
will have a significant impact on client morbidity and quality of life resulting in cost savings
from more appropriate healthcare utilization.

Direct Care Community Worker 58

Attachment O Direct Care Community Worker Brief
Social Determinants of Health (SDH) are factors of normal life that can impact health.
Funders and providers of home care services often lack information about the burden of negative
social determinants of health (NSDH) in the home care setting. This creates a void that permits
inaction that is consequential. Without assurances that NSDH are being addressed, it could be
assumed that providers are failing to rescue people in vulnerable situations. In-home observation
is an efficient way to either assure that needs are met or to measure the burden of unmet needs
which can inform policies and procedures aimed at remediation actions.
The target beneficiaries of this pilot program are older adult Medicaid recipients or
Veterans living in Philadelphia and receiving home care services. These services include routine
visits from Direct Care Workers (DCWs) to assist with activities of daily living, but the DCWs
are not prepared to address NSDH. Community Health Workers (CHWs), on the other hand, can
address NSDH but do not provide personal care, are not as frequently in these homes, and lack
the staff to see all home care clients. The goal of this program is to provide DCW training that
leads to a hybrid health services position, the Direct Care Community Worker (DCCW). These
caregivers will provide personal care and address social issues. Pathways for use by the DCCWs
are being developed collaboratively with funders and service agencies. Such an approach could
help clients be healthier while reducing health resource utilization and cost. Additionally, the
position provides a potential career trajectory for DCWs which could increase their current low-
wage salaries to lift them out of poverty, decrease staff turnover, and bring other caregivers into
the field. This program is motivated by the blended values of compassion and fiscal
intelligence. After the pilot phase, the program may be reproduced for broader use. Over time,
data will inform the new home care quality indicator of Community Failure to Rescue.
Direct Care Community Worker 59

Attachment P DCCW Training Program Demo

DIRECT CARE COMMUNITY WORKER TRAINING
PROGRAM DEMO

To help Close the Health Gap

Healthcare with Compassion and Fiscal Intelligence

Martha Trudeau, RN, MPA, CPHQ, DSW
marti.trudeau@met-healthcare-innovations.com

© Martha Trudeau, 2020. Any use of this book, including reproduction, modification,
distribution or republication, without the prior written consent of the author, is strictly
prohibited.
Instructor
Manual

Direct Care Community Worker 60

Preface
This training is designed for Direct Care Workers (aka DCW, Home Health Aide, HHA,
Home Care Worker, Certified Nurse Aide) with the goal of providing enhanced training and
tools to help them develop skills routinely identified with Community Health Workers (CHWs).
Upon successful completion of this program, participants will be prepared to serve in the hybrid
position of Direct Care Community Worker (DCCW). In addition to providing personal care, the
DCCW will be equipped to recognize and address negative social determinants of health
(NSDH), while enhancing their clients’ abilities to resolve such issues and to self-advocate. The
aim is to improve clients’ quality of life and decrease preventable health care utilization and cost.
This training provides the knowledge, skills, and tools to observe, resolve, and report negative
social elements found in clients’ homes and to identify when additional help is needed for
complex or clinical issues. This new position will allow a career trajectory for DCWs that could
provide a living wage which may also draw people into the field of direct caregiving. Funders
will realize cost savings from decreased health care utilization which will offset a higher
reimbursement rate for these specialized caregivers.
Because they know their clients and are with them regularly, DCWs are in a trusted
position to help resolve NSDH. This type of assistance is within their abilities and standards of
practice which include observing, reporting and documenting; and maintaining a clean, safe, and
healthy environment (Legal Information Institute, 2019; Pennsylvania Department of Health,
2019). This training will provide resources to immediately address many social problems. Given
the importance of these issues, it is sensible to utilize the potential of this workforce which until
now has been an untapped resource.
Direct Care Community Worker 61

In Pennsylvania, the Department of Health (PA DoH) identifies core competencies for
CHWs as communication skills, interpersonal skills, knowledge of the community/specific
health issues/health and social service systems; service coordination skills, capacity building
skills, advocacy skills; teaching skills and organizational skills (National Academy for State
Health Policy, 2015). The PA DoH further defines in-home services provided by CHWs to
include nutrition education, home health and safety assessments, and prevention education
(National Academy for State Health Policy, 2015). Combining these skills with those of DCWs
will most efficiently provide an encompassing care experience for in-home clients.
This project is driven by the values and key strategies of Compassion and Fiscal
Intelligence. Compassion focuses on Medicaid consumers and DCWs while Fiscal Intelligence
focuses on service providers and funders. This blended strategy leads to remediation efforts that
will improve quality of life and reduce costs. Stephen Trzeciak, MD, of Cooper University
Health Care in Camden, N.J., uses the term “compassionomics” to depict the economic element
of compassion (Trzeciak, 2018). He points out that client-focused, compassionate care is
associated with lower resource use and higher quality, fewer errors, and better compliance, as
well as positive physiologic changes like stress and pain reduction for patients, and less burn-out
for care providers (2018). More recently he found that compassionate care can help prevent post-
traumatic stress disorder (Burling, 2019). In brief, compassion promotes fiscal intelligence.
Recent successful efforts to resolve NSDH are found in various locations around the U.S.
(Morse, 2018; Sandburg et al., 2014; Shah, Rogers, & Kanter, 2016). Such efforts should be
appreciated for what they have accomplished, and a home care focus should be added to the
array of options to impact social problems at their core. The CHW role has been identified as an
essential element of a broad health promotion campaign and is described as, “…community
Direct Care Community Worker 62

members who are trained to bridge the gap between healthcare providers and patients.”
(Kangovi, Grande &Trinh-Shevrin, 2015, p. 2277). With this training, DCWs, who are trained to
provide personal care, will add CHW duties to become DCCWs with the skills to bridge the gaps
between consumers and health systems, society, and better health. DCCWs will be trained as
observers who strive to understand consumers and their environments in order to appreciate how
to help them be happy and healthy. This process will help pinpoint problems, identify them as
relevant to the consumer, and develop remediation actions.
Kangovi & Asch describe CHWs as a human resource innovation and emphasize the
importance of hiring the right people (2018). A great DCW does not necessarily equate to a
great CHW or DCCW. Considering this, selection criteria have been developed and will be
confirmed by supervisors. DCWs must be:
✓ experienced with at least two years of verifiable work with home care clients,
✓ reliable with exemplary attendance and excellent evaluation records,
✓ compassionate, competent, and ethical.

Based on learning aptitude qualities defined by Galbraith, Downey, & Kates (2002) DCWs will:
✓ be task oriented and self-directed,
✓ have the mental capacity to think through problems,
✓ be comfortable with complexity and will get results despite tough conditions,
✓ be experimenters with curiosity and resilience.

Benefits of this group as DCCWs are that they see their clients on a very regular basis and are
part of and share demographics with the community. DCCWs will become experts in topics like
health education reinforcement, goal setting and realization support, cultural interpretation, and
compassionate communication.
Learning objectives include S.M.A.R.T. goals, originally described by Doran (1981).
Training materials have the overarching goals to provide discussion, activities, and role playing
balanced by a theoretical understanding of concepts. The expertise of each experienced caregiver
Direct Care Community Worker 63

promotes significant group learning opportunities. Computer-based resource research, in-class
presentations, and field observations will inform class discussions and advance practical skills.
Topic redundancy is built into the program to reinforce learning. A pre-/post-training assessment
will be used to determine the extent of learning. A post-training score of >80% will be necessary
to be considered a Direct Care Community Worker.
Information gathering relating to NSDH will be critical to determine clients’ needs and
initiate resolution efforts. This will be accomplished with The Direct Care Community
Worker Observation Tool which was developed for this program. Tablets or smart phones
may be used to document problems and resolution outcomes. The observations may be added to
information already being entered so the technology learning curve will be negligible. Other
administratively approved and HIPAA compliant methods may be used to allow the DCCW to
inform the service office of problem resolution or to request assistance for clinical or complex
issues. Basic Health Information is covered in DCW training and is not addressed in this
training. Please see Appendix A for a list of topics covered in DCW training. The DCCW
training was originally developed for the Philadelphia home care market. As the poorest large
city in the U.S., Philadelphia likely represents the worst-case scenario. This training may be
templated or used as modules to address needs in other locations.
The training manuals are available in two formats to accommodate Kindle users and those
who will need hard copy publications.

Acknowledgements. This work represents the author’s doctoral work at the University of
Southern California Suzanne Dworak-Peck School of Social Work and addresses needs noted
while working as a Registered Nurse with older Medicaid home care consumers in Philadelphia.
Direct Care Community Worker 64

Motto: Think straight, plan carefully, act boldly. – Clara Barton

Mission
To provide Medicaid consumers who are >60 and receiving home care services, with the
opportunity to live healthier lives by relieving them of at least some of the burden of negative
social elements in their environment.

To develop training, tools, and a career trajectory for Direct Care Workers which will enable
them to take on the new hybrid role of Direct Care Community Worker.
To provide financially engaged stakeholders with the opportunity to act compassionately and
with fiscal intelligence.
Vision
Consumers will have fewer illnesses, appropriate use of healthcare resources, and high
satisfaction ratings with their in-home care providers, health plans, and other service providers.

Funders will have a 100% return on remediation investment because of decreased resource use.

The new Direct Care Community Workers will receive a living wage. This position will serve as
a step on a career trajectory and will bring others into the field of direct caregiving.

Values
This program maintains the blended values of Compassion and Fiscal Intelligence, with
Compassion focusing on Medicaid consumers and caregivers, and Fiscal Intelligence focusing on
service providing agencies and Medicaid health plans.

Home Care is the most basic form of health care delivery, presents the most reliable information
about the presence or absence of negative social determinants of health, and allows immediate
remediation opportunities. Home Health Care is a health system existing in parallel with the
Hospital health system.
Empowerment is a key aspect of this program. DCWs will be empowered with enhanced
knowledge and the redefined role of Direct Care Community Worker. They will, in turn,
empower their clients to live healthier lives.

This Photo by Unknown Author
is licensed under CC BY-SA

Direct Care Community Worker 65

TABLE of CONTENTS
Preface
Acknowledgements
Format Introduction
Lesson 1: Overarching Themes
Motto, Mission, Vision, and Values
Upbeat vs. Beat up (Attitude)
Promoting Client Self-determination (Control)
Lesson 2: Definition of Terms and Abbreviations
Compassion and Compassion Informed Care
Compassionomics
Social Determinants of Health/Negative Social Determinants of Health (SDH/NSDH)
Upstreamism
Post-Traumatic Stress Disorder
Community Health Worker (CHW)
Direct Care Community Worker (DCCW)
Lesson 3: Practice, Patience, Presence

Tips for Interviewing
Motivational Interviewing
Identifying and Validating Needs and Feelings
Self-Advocacy and Empowerment (Who is in Charge Here?)
Cultural Awareness, Support, Proficiency, and Humility
Goal Setting to Problem Solve and Promote Healthy Behaviors
Self-Care
Lesson 4: Direct Care Community Worker Observation and Reporting Tool

Review and Practice Observation Questions and Instructions
Documenting Observations

Lesson 5: Trauma Informed Care

DCCWs do not assess, diagnose or treat any conditions
Post-Traumatic Stress Disorder and Specific Observations
De-escalation
Self-harm and Suicide Threats
Hoarding

Direct Care Community Worker 66

Lesson 6: Decision-making Skills to Promote Change
Assisted Decision-making Frameworks
Decision Flow
EPIS – Explore, Prepare, Implement, Sustain
Attribution Retraining
Positive Affect Induction

Changing a Cycle of Struggles to a Cycle of Successes

Lesson 7: Integrative Care and Building Bridges
Navigating Home Care as a Health System (Care Integration)
Bridging Activities to Support Decisions
Resource List

Lesson 8: Making a Difference
Organizations making NSDH a priority
Successful NSDH Remediation Activities

References
APPENDICES
Appendix A: Direct Care Worker Training and Annual Inservice Topics
Appendix B: DCCW Job Description and Performance Evaluation
Appendix C: Scenario examples for discussion
Appendix D: Center for Nonviolent Communication (CNC) List of Universal Needs
Appendix E: CNC Feelings when your needs are satisfied
Appendix F: CNC Feelings when your needs are not satisfied
Appendix G: 10 Steps to Peace (Examples of self-care options)
Appendix H: Diagnostic Criteria for PTSD based on DSM-5 from VA/DoD Clinical
Practice Guideline for the Management of PTSD – Pocket Card (2017)
(Not to be used for diagnosis or treatment by DCCW but to help observe
behaviors requiring additional clinical help.)
Appendix I: Facilitator and Barrier Table for EPIS framework
Appendix J: Philadelphia Hoarding Task Force Pathways to a Healthy & Safe House
Appendix K: Daily Training Review form
Appendix L: Pre-/Post-Test Training Evaluation
Appendix M: Pre-/Post Test Answer Key
Appendix N: Resource List for Philadelphia
Direct Care Community Worker 67

No documented observations. No resolution efforts. Revolving door of costly hospitalizations and early death.
(modified from Silber, Romano, & Rosen, 2007)

Community Rescue (CR) 1. Observations documented 2. Resolution initiated
(modified from Silber, Romano, & Rosen, 2007)

Direct Care Community Worker 68

Break the Cycle of Struggles
The home care setting with frequent and ongoing interactions lends itself to a
compassionate, client centered focus so the negative Cycle of Struggles can be interrupted,
leading to positive adaptation and adherence in a Cycle of Successes. NSDH can easily be
observed, discussed, and resolution options initiated. Positive Affect Induction, Attribution
Retraining, and Bridging Activities bring evidence-based contributions to an environment
of Positivity.
Remind students that oversight is provided by appropriate licensed providers.
Direct Care Community Worker 69

Cycles of Successes

Direct Care Community Worker 70

Attachment Q
Additional information
Podcast interview may be accessed through:
http://www.beyondmedsurgnursingpodcast.com/765221/2968219-how-working-in-home-care-
inspired-marti-trudeau-to-get-a-doctorate-in-social-work

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Asset Metadata

Creator Trudeau, Martha E. (author)

Core Title Assessment and analysis of direct care community worker training: addressing social determinants of health in the home care setting

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 06/08/2020

Defense Date 04/15/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag community health worker,direct care worker,home care,OAI-PMH Harvest,social determinants of health

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Enrile, Annalisa V. (committee chair), Feuerborn, William (committee member), Gosh, Subharati (committee member)

Creator Email metrudeau@yahoo.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-317494

Unique identifier UC11664329

Identifier etd-TrudeauMar-8573.pdf (filename),usctheses-c89-317494 (legacy record id)

Legacy Identifier etd-TrudeauMar-8573.pdf

Dmrecord 317494

Document Type Capstone project

Rights Trudeau, Martha E.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA