Fall 2014
Supervision in Care Management: Managing Quality

Care Managers Supervising Caregivers: A Power Team

About the Author

Phyllis Mensh Brostoff is the CEO and co-founder of Stowell Associates in Milwaukee, Wisconsin, providing geriatric care management and care managed home care services to the elderly, disabled adults, and their families since 1983.  She received her master’s degree in social work from the University of Maryland in 1970, and immediately began working with the elderly.  Phyllis is certified by the state of Wisconsin as a Certified Independent Social Worker (CISW), the National Association of Social Workers Academy of Certified Social Workers (ACSW) and the National Academy of Certified Care Managers (CMC).  She taught at the University of Wisconsin-Milwaukee School of Social Welfare from 1971-1977.  She was a founding member of the NAPGCM and was the President of the National Board in 2009 and President of the Midwest Chapter Board 2006-2008.  She has given numerous speeches, workshops, and presentations throughout the country on care management, assessment, ethical issues, the care of the chronically ill, and how to grow a business to social workers, nurses, attorneys, trust officers, financial planners, and the general public.

Phyllis Mensh Brostoff, CISW, CMC
Stowell Associates
4485 N Oakland Avenue
Milwaukee WI  53211
email
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414 963-2600

Phyllis Mensh Brostoff, CISW, CMC

Summary

Care managers are often called upon to supervise paid caregivers working with their clients but may not have been specifically trained in how to do so.  This article provides a theoretical framework for care managers to understand how their own preferences and motivations differ from those of the paid caregivers with whom they interact, and direct application of an approach to supervision through an integrative coaching model.  The goal of this model is to foster a team approach to enhance the quality of care and life for their mutual client.

Introduction

The great majority of care managers work with clients living in their own homes, and these clients often receive assistance, or need assistance, from a paid caregiver who is not a family member.  Care managers provide oversight and support, if not direct supervision to these paid caregivers.  Some care managers have a group of privately paid caregivers with whom they share cases, which may continue over many years.  Other care managers employ their own paid caregivers which gives them the direct responsibility to hire, train, supervise, and discipline, up to and including firing the caregivers.  The majority of care managers may direct caregivers through a home care or licensed home health agency. This poses the challenge of supervising a caregiver who is actually the employee of another agency.

How many care managers have been formally trained to provide any supervision to paid caregivers, (formal or informal, direct or indirect) and does this relationship require a different type of supervision than the one the care manager has experienced? Since there are many different types of supervisory models, starting with a basic definition of supervision may be useful in understanding this role:  Supervision is  considered to entail “a critical watching and directing” (https://www.merriam-webster.com/dictionary/supervision), whereas in social work literature, supervision is defined as “the relationship between the supervisor and supervisee, in which the responsibility and accountability for the development of competence, demeanor, and ethical practice takes place” (NASW Standards).

The nursing profession refers to “clinical” supervision primarily between similarly educated professionals, and not necessarily between a highly educated professional care manager and a caregiver who may have only the most rudimentary education beyond high school.   While many caregivers do have formal training as certified nursing aides or assistants, many have not received specific training in working in the home setting, and many have never worked with a care manager or understand the supervisory role involved.

The nursing profession also uses the word “delegation” to define the relationship between the professional nurse and nursing assistants who perform specific care tasks delegated by the nurse.  Although each state defines “nursing delegation” in detail within its licensing rules and through the Board of Nursing, there is a consistent use of the definition of delegation: “the transfer, at the discretion of the nurse, of authority for the performance of a task of client care from the licensed nurse with authority to perform the task to someone who does not otherwise have such authority”
https://www.nh.gov/nursing/nursing-assistant/documents/delegation-cc.pdf (Delegation:  Know Your Responsibility) https://www.nh.gov/nursing/nurse-practice-act/ (Nurse Practice Act) https://www.ncsbn.org/1625.htm  (National Council State Board of Nursing:  Regulations and Delegation).

Furthermore, The “Five Rights of Delegation” (National Council of State Boards of Nursing, (1997) The Five Rights of Delegation https://www.ncsbn.org/fiverights.pdf ) concisely captures the specific expectations of delegation/supervision and the flavor of the relationship between the professional RN and the nursing assistant:

  1. The Right Task: “right for the client and for the nursing assistant’s knowledge and experience.”
  2. The Right Circumstances: “type of setting, supervision offered, available resources, and the condition of the client.”
  3. The Right Person: “the nursing assistant should have been taught to perform the task and competency should be assessed.”
  4. The Right Direction and Communication: “clear, concise information [about]…what task is to be performed and for whom, when the task is expected to be performed and …conditions to report to the nurse…during…[and] once the task is completed.”
  5. The Right Supervision: “Supervision should include ensuring that the nursing assistant is competent to perform the task and understands the request of the task. Supervision also includes assisting with problems/concerns during the task and follow-up after to ensure the desired result and documentation occur.”

The many disparities between the care manager and a caregiver of education, background, and power (to mention a few) can pose a significant challenge – providing many opportunities for misunderstanding, confusion, possibly anger, and despair, but also for a wonderful, fun, and fruitful collaboration as well as great service to our mutual clients.  Good communication between the care manager and the caregiver should lead to the fulfillment of mutually agreed upon goals based upon the needs of the client as well as an enhanced quality of life for the client.  This collaboration may lend itself to a sense of satisfaction for both the caregiver and the care manager in a job well done.

Facing the Challenges

How do you forge a respectful working relationship with someone whom you see only periodically?  The caregiver knows the client in the most intimate way, spends far more time with him or her than you do, may have a very different cultural background, and may believe she/he does not necessarily need your “critical watching and directing.” In fact, your delegation of doing things the “right” way may be perceived as merely bossy. The situation is further compounded by the caregiver’s need to find the “right” balance between two (or more) bosses: you, the client, and possibly the employing agency.  Communication of roles and expectations in the nascent stages of this relationship is key and must be tailored towards a working relationship.

To this end, supervision may take a different tack from “critical” and “bossy”: it can use a coaching approach, focusing on ongoing mentorship and guidance, identifying specific targets of skill and knowledge required for the job, and identifying the practice that leads to improvement and excellence.  Coaching necessarily requires observation, listening, reflecting, revising, refocusing, and of course, the presence of explicit rules -that need to be followed.  These rules are often written in a formal caregiver care plan by the care manager, identifying details of what the caregiver is supposed to do regarding the client’s personal hygiene, food preparation, housekeeping and oversight, and companionship of the client.

Home care agencies may require caregivers to keep some type of documentation, using forms or notebooks, which care managers can read during their visits to the client’s home.  If no formal, written notes are required, the care manager may request that notes be written to document patient changes on a daily basis, otherwise the care manager has to rely on observation of the condition of the client, the home, and the caregiver’s report of the client (mood, sleep, appetite, ambulation, continence, etc.) during the care manager’s routine monitoring visit.

Utilization of Predictive Index

In 2008, my agency utilized The Predictive Index Management Information System (PI) to improve our understanding of how to provide the best supervision to our care managers and caregivers (including home care as well as care management services). Steve Barlam of LivHome had initially introduced the PI at an NAPGCM Advanced Practice Retreat.  He reviewed the PIs for both care managers and caregivers with our organization based on the adjectives that best describe the jobs of the care manager and caregiver. An explanation of The Predictive Index from the PI training program Reference Manual is referenced below:

The Predictive Index (PI) was developed and administered experimentally by Arnold S. Daniels during the period 1953 and 1954. It is one of a class of objective assessment techniques based on certain fundamental assumptions of behavioral psychology, the first being that work/social behavior is primarily an expression in activity of a variety of responses to environmental stimuli, recognizable as consistently expressed personality traits. 

The Predictive Index adjective checklist is essentially a symbolic environment, the individual will respond to them in a manner consistent with the ways in which s/he responds to the actual environmental stimuli that the words in the checklist symbolize. The measurements made by the Predictive Index establish for each individual the location or magnitude on the continuums of the six drives, which when integrated, provide a specific description and prediction of the individual’s work-related behavior. The present norms are based on a total N of over 8000 persons in the industrial/commercial population.

A Normative Reliability Investigation of the Predictive Index Organization Survey Checklist” (N=2546), reporting the results of a statistical analysis completed in April, 1996, again confirms the soundness of the measurements of individual behavior and potential provided by the Predictive Index. Numerous studies of the criterion-related validity of the Predictive Index have consistently confirmed its work-relatedness and accuracy…it is thus possible to use the Predictive Index to objectively assess and describe individual behavior and job demands in the same terms,….[of course] managers must recognize, understand, and deal with all of their people as individuals.

In summary, the PI is based on the concept that human behavior is an individual’s response to stimulus, a response that we are either born with or have learned.  Since most people behave in a consistent, predictable way, their motivations can be understood, and therefore influenced in a positive direction, when the person doing the influencing (i.e. the supervisor) understands their motivation.  The PI identifies four major personality traits, which each individual has on a continuum from high to low:

  1. Dominance: desire for control (from unassuming to assertive);
  2. Extroversion: desire to be liked (from reserved to sociable);
  3. Patience: interest in stability (from driving/intense to relaxed); and
  4. Formality: interest in getting things right (from independent to conforming).Graphic1_Care Managers Supervising Caregivers, A Power Team

The PI of the care manager job fits the pattern that is defined as “Altruistic Service,” and the list of the statements about that pattern of behavior does describe a “typical” care manager.  The care manager PI has a high B, representing extroversion; a middle A, identifying cooperativeness; a low C, identifying the need for variety and a change of pace at work; and a middle D, a focus on knowledge and rules.

The Altruist is a specialist who needs structure, is cooperative, collaborative, congenial, open and receptive to ideas, input, suggestions, and has a positive response to pressure.  They are empathetic, extroverted, enthusiastic, fast, intense, efficient, and precise and detailed in follow-up.  The Altruist asks, “What can I do to help you?”

The PI of a caregiver is different: it is “Diligence.”  The caregiver job requires a high D and C — a stabilizing pattern identifying a person who is patient and exact; and a low A and B for a person who is agreeable and matter of fact.  This job requires an individual who is skillful at detail work, precise, wants to do the right thing, needs strong structure and rules to go by, respects and seeks direction, and a plan to go by from a professional they trust as an expert.  Graphic2_Care Managers Supervising Caregivers, A Power TeamThe Diligent person works harmoniously with the group, helps others, is unselfish and approachable but at the same time shy with strangers, opening up in familiar circumstances.  The Diligent person is patient, steady, and has a high tolerance for repetitive work.

In considering how best to influence the Diligent caregiver, the Altruistic care manager can focus on the caregiver’s desire to have certainty and understand what the rules are and what specific knowledge is needed to do the job.  For example, if the care manager is introducing the caregiver to a new client, the  focus may be on specific details of the client (i.e. she likes her shower in the mornings, not the evenings), details of the home (the knick knacks must be dusted on a Monday), scheduling or preference of the meals (she wants her meals at exactly 8am, noon, and 5:30pm), and other details that may help the caregiver achieve success as soon as possible (bring slippers to the home to walk in and take your shoes off as soon as you enter the door, turn the TV on only at 4pm to listen to Jeopardy, and on and on).  This is why having a written care plan can be very useful – however, the Diligent caregiver prefers to receive information initially by hearing it, (not reading it), so that a precise, detailed review is necessary in the form of a phone call, an initial meeting at the client’s home or in the care manager’s office.

Direct observation of on-going care by a caregiver with the client can provide the supervising care manager with the information that is pertinent to crafting a recommendation when improvement is needed. The caregiver may best be coached by the care manager listening carefully to concerns about the client, the home, the family, or the facility.  The care manager can then develop approaches with specific direction and guidance which can be observed in subsequent visits.  The Diligent caregiver needs encouragement and recognition, and may respond best to “modeling” changes needed in behavior by the care manager demonstrating the new behavior that is desired.  For example, the care manager may show the caregiver that the client with dementia responds better to her if the caregiver is not “in her face” but a short distance away in a space that may appear less threatening to the client.  In addition, the care manager’s use of body language and tone/volume of voice can also be helpful to model the desired behavior for the caregiver.

Through the use of the PI tool, the care manager who is supervising a caregiver can consider the “typical” behaviors and needs of the job and the specific individual they are supervising who is doing that particular job.  Of course, this is based on the belief that the caregiver is actually suited by her own individual needs and typical behaviors to this job (not an assumption that can always be made).  However, if the caregiver does like his/her job, and the care manager believes in his/her ability to take the approach of a “coach” who observes and suggests, maintains a consistent, clear, respectful, and responsive style, supervision of caregivers by care managers can be managed very well.  If you are able to forge a positive working relationship with the caregiver, the client will understand that you are working together to provide the best care and hopefully not sabotage your plan.  This truly makes the care manager and caregiver a powerful team!

Note: The author wishes to thank Steve Barlam, LivHome, for introducing her to the PI and preparing a PI “Pro” report with her recently for the jobs of care manager and caregiver.

References

Graphs and Charts

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