The 7 Secrets of a Highly Effective Home Health Agency


A focused, visionary, ideological culture drives effective organizations. The Home Health Agency (HHA) is not simply an organization with an owner, some skilled nurses, an administrator, a corporate charter from the state and a Medicare license. The employees, nurses, billers, and owners/management, are members of the particular HHA "tribe", and are members which function within the agency team. Since prehistoric times, the basic human organic structure is tribal**. An HHA which operates as a tribe is a well led organism which exudes confidence, competence and proficiency in its behavior. Highly effective HHA's have these cultural components present in order to thrive in technical nursing, point of care skill and professionalism, administrative competence, and in communication of a shared vision.  Many of the same or similar characteristics of tribes are inherent in what is known as "a learning organization". These concepts, when strategically applied can yield highly effective practices that result in successful, effective home health agency operations. The characteristics of learning organizations in this essay are presented first, but not in order of priority.  The Learning Organization framework gives meaning to all aspects of effective HHA's.

Following are 7 secrets of Highly Effective HHA's

1. Effective Home Health Agencies are Learning Organizations*

Agencies which teach and encourage shared vision and corporate learning, over time become true "learning organizations". The learning organization concept was introduced by Dr. Peter Senge, of M.I.T.'s Center for Organizational Learning in Cambridge, MA, and author of "The Fifth Discipline, The Art and Practice of the Learning Organization".  Dr. Senge identified that a learning organization exhibits five main characteristics: Systems Thinking, Personal Mastery, understanding Mental Models, a Shared Vision, and Team Learning.

  • The idea of the learning organization developed from a body of work called Systems Thinking.  This is a conceptual framework that allows people to study businesses (home health agencies are businesses) as bounded objects, like cellular organisms. Learning organizations use this method of thinking when assessing their company and have information systems that measure the performance of the organization as a whole and of its various components (metrics). Systems thinking involves all the characteristics that must be appear in an organization for it to be a learning organization.  If some of these characteristics are missing, then the organization will fall short of its goal of being fully effective.
  • An individual's commitment to the process of learning and professional proficiency is known as Personal Mastery.  There is a competitive advantage for a Home Health Agency organization whose workforce learns and implements quicker than the workforce of other organizations. Individual learning is acquired through staff training and development, and credentialed formal education. However eventual learning cannot be forced upon an individual who is not receptive to learning. Effective agencies know the importance of the development of a culture where personal mastery is encouraged and practiced in each member's daily work-life. The effective HHA must employ agreed upon mechanisms to encourage individual learning to be transferred into organizational learning.
  • The assumptions held by individuals and organizations are called Mental Models. To become an effective agency which is growing as a learning organization, these models must be challenged. Individuals tend to espouse theories, which are what they intend to follow, and theories-in-use, which are what they actually do. Similarly, organizations tend to have 'memories' which preserve certain behaviors, norms and values.  In creating a learning environment for the effective Home Health Agency, it is important to replace confrontational attitudes with an open culture that promotes inquiry and trust. Unwanted assumptions, norms and misaligned values need to be discarded in a process called 'unlearning'. It is the responsibility of each agency to identify the flawed mental models of its members. These should be dealt with discretion and in a considerate, humble manner.
  • The development of a Shared Vision is important in motivating the HHA staff to understand the shared vision of excellent, quality patient care as being the overriding cultural value can energize the tribe. In some agencies the agreed upon shared vision is often to succeed against a competitor; however, these are transitory goals.  The shared vision should reflect a long term goal that is intrinsic within the company, such as the vision of excellent patient care.
  • The benefit of Team Learning is that staff members grow more quickly and the problem solving capacity and agility of the organization is improved through better access to knowledge and expertise.  Team learning requires individuals to engage in dialogue and discussion; therefore team members must develop open communication, shared meaning, and shared understanding.  (Tribunals aid in developing this capacity.)

*For more in-depth information on the theory and practice of Learning Organizations, please refer to the work of Dr. Peter Senge and the Society for Organizational Learning www.solonline.org

**Many of the ideas that are contained in this essay have their root in Tribes, a book by Seth Godin, published in 2003.

2. Effective agencies know the "why" behind their agency-an authentic desire to care for their patients, and their members

Every hire, every promotion, every training exercise, every cost and expenditure, every effort to maintain regulatory compliance, and every seminar or conference, are driven by the shared vision of the agency

Certainly the choice of the agency operating platform is guided by the HHA's shared vision, that being a focus on delivery of high quality care for their patients.

In the effective HHA, patient care must be the top priority. If all other characteristics are present, yet the agency is not patient focused, the agency will be less than highly effective. Care for patients is the "why" behind everything that is done. The effective agency's "lifeblood" is quality patient care, and in that highly effective agencies share a common cultural ideology. Together HHA staff members believe that care for patients is something we are called to do.

Helping others should come naturally to us as individuals, and together we aspire to this cultural norm as a living company, an organism, a tribe. No members of our agency staff are to be hired unless they can agree and agree to learn to espouse the agency's shared cultural operational vision. Owners and managers who are unable and unwilling to be open and to submit to this shared vision/teamwork oriented concept and agree to grow towards operating in this way are acknowledging that they will accept something less than becoming highly effective as an agency. Leaders are very aware that they must constantly praise and encourage the members of the tribe to continue learning, initiating and growing in personal mastery. The agency without a focus primarily on quality patient and member care, empowering its employees/members to act as "care agents" in the field, are not able to achieve anything similar to the effectiveness of those HHA's that do.

3. Effective agencies are proficient in skilled nursing and therapeutic care

Skilled Nursing Proficiency is also a non-negotiable cultural norm of the effective HHA. Highly effective agencies know that skilled staff members working in the areas of patient admissions, charting, case management, therapy deployment, regulatory/billing & compliance, and RN accreditation are necessary in order to become more and more effective in operation. The highest professional standards for skilled nursing care, nursing licensing, and knowledgeable, well-designed workflows and well-trained administrative staff are high return targets for each HHA. Decisions regarding software platforms and operating systems for the agency should include methodologies for tracking and maintaining the necessary ongoing training necessary for always current professional nursing licensing.  Effective tribal agency leaders have a constant eye on the professional standards maintained by the nursing staff.

4. Effective agencies achieve a growing competence in Regulatory Compliance

The most important reason for choosing a software platform is to provide a methodology for maintenance of regulatory compliance in skilled care of patients, and billing & reporting those patient episodes. In the current environment the home health industry is regulated by our primary payment source, the Center for Medicare Services.
If you utilize paper documents to operate your agency, then suffice it to say that highly effective operations are not possible for your agency on a large scale.

The effectiveness of the agency in billing and overall compliance is directly attributable to the accuracy achieved in preparation of the Outcome and Assessment Set documentation (the OASIS). Also the 485 summary report to be signed by the Physician in charge of the patients care must be accurate and in compliance. The technologically superior and constantly improving updated software platform* is the driver for this accuracy and completeness in the effective HHA.  Because of the sophistication of operational platforms maintaining the home health agency on paper forms, while still possible, is now impractical and counterproductive. The time required in generating paper charts and billing submission documents in order to maintain regulatory standards for OASIS and 485 submissions is clearly cost prohibitive.

*Note: Axxess' Agencycore® is the leading state-of-the-art Point-of-Care and Operations based software platform in the US. A rapidly growing number of prominent and effective Home Health Agencies utilize Agencycore® to enhance their ability to achieve highly effective and productive operations. To the writer's knowledge, no other platform available in the marketplace today can compare to Axxess in the enablement of highly effective agency operations.

5. Effective agencies act with wisdom regarding expenditures

Are the agency's costs and expenditures aligned with the agency's shared vision of excellent patient care?

Generosity with patients and with staff brings about the joy of working, of having fun with one's co-workers and the patients in the field. Cost containment managed wisely means being generous with patients and the pay scale for agency staff, because these factors drive greater returns, more referral generation and more expansive revenues. Cost containment is non-negotiable; however, the effective HHA is wise in strategically deciding on how costs are linked to productivity. Additionally, effective agencies utilize productivity and performance metrics as motivational drivers towards greater productivity. Personal productivity and team productivity can effectively be managed in an open facilitative manner, appropriate to the adaptive, learning organization based tribal culture.

6. Effective agencies are Ideological and Visionary in Nature

Tribes are a prehistoric way of organic alignment of like-minded people working together collaboratively for a common goal or shared vision. An authentic desire to provide quality patient care is an excellent example of a shared vision. The effective agency is a living organism, a tribe, whose culture must be guided and disciplined by its shared vision and its collaboration. Each member is expected to seek Personal Mastery of his or her role in the tribal organism. This recognizes the skilled nurse, the aide, the social worker, the billing and administration personnel, the ownership and management, as being highly proficient and ever-learning, ever-growing-in-knowledge and proficient in their assigned duties. The age old "guild" interrelationship between the master and the apprentice is a guiding principle in an effective home health agency. Knowledge is not hoarded for personal advantage. Teaching and learning is encouraged between team members and between care givers and patients.

7. The effective tribal/organic agency is protective of its collaborative culture

Tribes have strong, visionary, focused and competent leadership.  Effective "Tribal HHA's" are focused on 'the why' behind what they do, so that every member acts in accomplishment of the shared vision of the tribe.  For effective HHA's it has to do with excellence in patient care. Tribal organisms are quick to identify the mental models (or flawed assumptions) that are not aligned with the agency's vision. Left unattended, flawed mental models can harm an agency's shared culture, and can in turn do harm to its ongoing business success.  The effective HHA acts and initiates based on its best knowledge and shared learning.  The effective agency is always creating, initiating, evolving. This creative action and initiation has the effect of causing others in the market to react. Most HHA's are not aware of tribal organic operational culture, so tribal cultures can move stealthily within their local markets, to quietly and forthrightly accomplish their goals and objectives, and move closer to their shared vision. In doing so, they are lethal competitors.

Because effective agencies are learning organizations, and every member is encouraged to act in accordance with a shared
Tip: A shared vision is best accomplished by operating the agency with a regularly scheduled "tribunal". Most well-tuned agencies have these tribunals once a week, or at least once every month. In a tribal organism, tribal leadership encourages learning by exhibiting open communication and humility towards the members of the tribe.

vision, creative solutions and methods are constantly being tried and implemented. Like a tribe in the wilderness, it constantly adapts and is agile as a team.

An effective HHA recognizes its organic nature, in that tribal culture is the fundamental unit of human activity. Everyone knows and understands his or her role and is expected to do his or her job because each member is committed to achieving an ever growing sense of personal mastery and is fulfilled in his or her role. He or she is being encouraged to grow in their role, and is praised when they achieve new attributes. This mastery and the encouragement of leaders can assist each member in making their assigned work become "fun".

Let's have fun! "Having fun" and achieving positive feedback at work creates a work environment in which members enjoy participating. Once organic concepts and learning organization cultural standards are implemented in the HHA, more effective workflows in operations result, because the team members are enjoying their work and working together towards a common goal. Why not try these concepts? You might become more effective! Not only that, you might begin to have fun at work.