Red Flags for Rising Acuity in Home Care

Private duty home care offers many vital services for seniors who need services to age in place. But what happens when clients have a change in health and need more support?

Private duty caregivers are often the first lines of defense against rising acuity levels, but there are some signs when a client needs more advanced care.

Home Health Care News reached out to home care companies to get their insights on how they keep an eye out for this situation—and how they handle it when it arises.


The Tipping Point

Knowing when clients should receive more care, such as skilled nursing or other institutional care, shouldn’t put home care providers in a tough place. In other words, when it’s clear patients need more care, private duty providers shouldn’t be tempted to hold onto clients longer than they should.

“One temptation in our industry is to take cases that cross the line of what a caregiver can or can’t do because of the revenue,” Gavin Ward, regional director of strategy and partnerships at Los Angeles-based 24Hr HomeCare, told Home Health Care News.


24Hr HomeCare, which has 3,000 employees and locations in California, Arizona and Dallas, provides personal care, transportation, light housekeeping and medication reminders.

But skilled care, wound care specialty care and medication administration are outside the company’s scope, Ward told HHCN. Clients with higher acuity can sometimes need additional services in the future.

In most cases, home care, with the support of other services, can surpass that of assisted living or skilled nursing care, Lynn Gardini, president of Home Helpers of Central Pennsylvania in Altoona, told HHCN. Home Helpers, a home care franchisor, is based in Cincinnati and has more than 325 offices.

Even with support, there are some instances where a client may need to transition from home care to more intensive services.

“Whenever the needs become so great that it’s taking a mental and physical toll on the family is really the tipping point,” Gardini explained.

Some general indications that clients likely need more advanced care, include wandering, aggression and medical fragility, according to Gardini.

Vital signs

Home care providers, in general, tend to look for vital signs of increased risks when thinking about if clients need more advanced care, according to Wendy Raney, who owns a Homewatch CareGivers office in Texas. Homewatch CareGivers is based in Greenwood Village, Colorado, and has more than 100 franchise partners.

“I think No. 1 about the safety of the individual,” Raney told HHCN.

Raney’s agency monitors a range of indicators, including signs of depressions, falls, activities of daily living (ADLs), grooming and medication management. It also uses the General Practitioner assessment of Cognition (GPCOG), a screening tool for dementia, to track clients’ cognitive ability.

Clinical nurses on staff also perform clinical evaluations, though she noted the protocol for rising acuity varies from case to case. When more advanced care is needed, a conversation then takes place with family members or the client.

“Once our nursing staff takes a look at that situation… we then go back to the decision-makers,” she said. “Sometimes that’s family, sometimes they have a guardian, and sometimes it’s the individual, and those are the most difficult conversations.”

Rising acuity

Home care providers may be getting used to having these kinds of conversation, or at least expect more of them in the future, as higher acuity levels have generally been observed across the industry.

“We’re starting to see patients with higher acuity situations that we’ve seen in the past,” Ward told HHCN. “We’re seeing patients that may come directly from the hospital more often now than we did a couple years ago. The way reimbursement is happening right now, there’s that incentive to send them home.”

To address this, 24Hr has boosted staff training, particularly on care coordination, to ensure proper communication with every person who has a role in caring for the client.

Raney, for her part, has seen more patients from skilled nursing facilities (SNF) and rehabilitation facilities. In addition to a variety of training for Homewatch’s caregivers, she stressed the importance of staying on top of clients who cannot be left alone, and documenting any changes.  

“We’re making sure that we’re staying in constant communication with the family, that they know what’s going on,” she said. “At any time they’re wanting something different from what we’re providing, we can let them know.”

This observation is complicated by the overwhelming desire by clients to remain in their home as they age.

“[A]s they decline, their preference is certainly to stay at home, and while their decline continues their preference to stay at home stays the same,” Gardini said.

Communication, presence are paramount 

As home care providers continue to deal with rising acuity levels in clients, communication is emerging as the cornerstone of continuing the relationship, providers told HHCN.

Clear and candid conversations between caregivers and clients and family members are crucial to prevent being blindsided if needs increase.

“You must set forth your expections to the family and to the individual for what can be provided in the home and what cannot be provided,” Gardini said. 

And in the midst of communicating with family and doctors, the client should not be forgotten.

“It’s very important that the client participate in the discussion whenever possible, because it is their life,” Gardini said.

Written by Maggie Flynn

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