“Caregiving is Teamwork…” Information Sharing in Home Care for Older Adults with Disabilities Living in the Community

Abstract

Aim:

We examined information sharing between direct care workers, family caregivers, and clinicians involved in the care of older adults with disabilities.

Methods:

Semi-structured interviews with N=11 representatives of home care agencies (“residential service agencies” in Maryland).

Results:

Work system and process characteristics relevant to information sharing included: (1) using electronic management systems and patient portals to communicate within agencies and with clinicians, (2) implementing tools to gather information about client goals, preferences, and routines, and (3) relying on family members for information about clients’ needs. Participants did not report differences in dementia-related care coordination; however, dementia-related adaptations involved additional considerations for navigating relationships with family and standardizing processes to communicate with clinicians.

Conclusion:

Findings highlight care demands experienced by direct care workers and support calls to better coordinate information sharing between interdisciplinary care teams.

Introduction

Older adults living in the community with disabilities commonly rely on home and community-based long-term services and supports (LTSS) delivered by direct care workers who provide hands on assistance to older adults with physical and cognitive disabilities with daily activities, such as bathing and dressing.^1,2 Given their intimate knowledge about older adults’ daily routines, preferences, and changes in health status, direct care workers are well positioned to recognize and share information about care gaps and changes in function and behaviors that may affect the appropriateness of care plans but are often viewed as unskilled and excluded from clinical care team interactions.^3–5 Information sharing, which is central to health care encounters and includes the sharing of knowledge about clients’ health, values, preferences, and treatments, ^6,7 is typically unstructured and disorganized among direct care workers, family caregivers and home care clinical care teams (consisting of nurses, administrators, etc).^8,9 Direct care workers also often report being excluded from the assessment and care planning process.^10,11 While these challenges may be relevant for many older adults living with disabilities and receiving home care, they are particularly concerning for the care delivered to older adults living with dementia, who represent a substantial share of older adults needing home care services, and who often rely on direct care workers navigating complex family dynamics as well as dementia-related behaviors (e.g., agitation, hallucinations).^12,13

In addition to sharing information about changes that take place in the home, direct care workers often provide assistance to older adults during medical appointments, and recent work demonstrates that they also assist with tasks such as viewing sections of the patient portal.^14,15 Still, limited guidance exists on whether and/or how direct care workers should leverage their expertise to improve information sharing.^15,16 Direct care workers are actively engaged in receiving and sharing information using different technologies – as evidenced by tools such as electronic visit verification systems, virtual training programs, and innovative methods to facilitate within-agency communication.^17,18 Nevertheless, the current paradigm too often leaves direct care workers ill equipped for their role, and may adversely affect care quality, care efficiencies, and potentially avoidable services use.^4,5 The participation of direct care workers in information sharing with families and clinicians, and the degree to which they are supported within care delivery systems is poorly defined and understood.¹⁵ For older adults with dementia, the consequences may be more severe, given impaired recall and judgement that motivates the need for assistance as the disease progresses in severity.^13,19

Direct care workers may be contracted in several settings - including skilled home health as well as independent home care agencies.²⁰ In Maryland, non-Medicare participating home care agencies, “residential service agencies” are defined as providing at least one home health care service (e.g., nursing, personal care, durable medical equipment) for compensation to individuals with disabilities.²¹ As is the case around the country, in Maryland, the direct care workforce is in high demand – between 2014 to 2024 an estimated 40% more direct care workers will be needed to meet growing LTSS needs² due in part to prioritization of community- based LTSS over institutional care, and higher acuity of those receiving care.²² As a result, direct care workers carry new responsibilities and require additional technical and interpersonal competencies that were not previously part of their role,²² motivating the need for innovative strategies to better support this workforce. Further, because non-Medicare participating residential service agencies are minimally regulated, there is mystery surrounding activities such as information sharing, which may be supported or hindered by available tools and technologies, the agency and home environment, and the quality of collaborations between direct care workers, older adults and family caregivers, and clinical care teams.²³ Beyond federal and state regulation, information sharing practices in residential service agencies may differ from Medicare home health agencies and institutional settings given the need individuals’ to adapt to the continuity of LTSS (versus temporary post-acute care) as well as receiving and delivering care in personal homes (versus nursing homes). As a result, research that goes beyond simply describing workflow processes by centering the strengths, weaknesses, and capabilities of individuals in understanding information sharing practices is needed.

Given the complex nature of home care delivery, existing challenges with information sharing and communication, and the integral role direct care workers play in supporting older adults in the community, the present study aimed to (1) assess current information sharing practices in home care as well as whether they vary for older adults living with dementia, and (2) understand potential opportunities to better engage direct care worker in information sharing. We propose that residential service agencies make adaptations specific to caring for older adults living with dementia. Recent policy recommendations targeting supporting quality of life for persons living with dementia, direct care workers, and family caregivers make these aims especially salient.^24,25

Methods

Data collection

We conducted semi-structured interviews with residential service agency administrators, nurses/social workers, and direct care workers in Maryland. The study was reviewed and approved by the institutional review board of the Advarra Institutional Review Board (IRB# Pro00057844). Residential service agency administrators previously engaged in a separate study were invited to participate in qualitative interviews ²⁶. Participant eligibility included the residential service agency employer having been in operation for at least 1 year and serving older adults living with dementia. Participants must have been employed in their role for at least six months. The research team contacted a total thirty-four residential service agency administrators to invite them and/or agency staff to participate in the study between June 2022 and September 2022. Administrators were contacted by phone up to three times. Ten administrators were unable to be reached (i.e., three attempts and/or no return call), four reported that they did not serve clients with dementia, and fifteen refused participation. Five administrators provided informed consent and completed interviews. Residential service agency nurses/social workers and direct care workers (i.e., personal care aides, home health aides) were recruited following enrollment of administrators using snowball sampling methods. These participants received information from participating administrators about the study and those who were interested contacted the research team via email or phone. As a result, the research team was contacted by and consented three nurses/social workers and three direct care workers. Interviews were completed virtually and at a time most convenient for participants, typically during business hours. Upon obtaining oral consent, trained research team members conducted interviews which lasted 45–60 minutes. Participants received $25 gift cards as a token of appreciation.

Interview guides, tailored to each role, were developed by the study team and iteratively revised (see Appendices A and B). At the beginning of each interview, self-reported measures of role (agency administrators, nurse, direct care worker), age, sex, race, and role tenure (1–4 years, 5–9 years, 10 or more years) were collected. Interview questions probed residential service agency practices used to share information within agencies, as well as between direct care workers, families, and clinicians.

Data analysis

Interviews were recorded, transcribed, then coded using NVivo, a collaborative qualitative software program.²⁶ Two research team members independently inductively and deductively coded each interview transcript. A working codebook was iteratively developed. Following individual coding, the research team met weekly and reviewed transcripts together, refined coding definitions, discussed any discrepancies, and reached consensus on how to best address discrepancies, enhancing trustworthiness and confirmability.²⁶ The constant comparative method was used to refine themes by moving iteratively between data and codes.²⁷ This process generated 54 codes. The team determined that saturation was met when no new codes emerged.²⁸ Upon completion of inductive coding of all transcripts, the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model, a human factors model, was a useful model to frame the results (Figure 1). The SEIPS 2.0 model was originally designed to improve patient safety in clinical settings and was adapted here for the context of dementia caregiving.³⁰ The model further identifies pathways by which organizational structures (work systems) affect the provision of care (work process).³⁰ Themes were categorized and labeled by the first author, using broad constructs in the SEIPS theory. QSR International NVivo 12 was used for all analyses.

Figure 1.

Conceptual Framework describing Information Sharing in Home Care based on SEIPS 2.0 Model

Results

Eleven interviews were conducted with administrators (n=5), nurses/social workers (n=3), and direct care workers (n=3) employed at licensed residential service agencies in Maryland (Table 1). Average age of participants was 48 years old (SD, 13.5). All but one participant self-reported as being female. Participants were racially diverse – 45.5% were White, 55.5% were Black. Nearly half (45.5%) reported being employed at their agency for 1–4 years while more than one quarter (27.3%) reported being employed with their agency for ten or more years. Emerging themes are categorized across the SEIPS 2.0 model as an organizing framework. Emblematic quotes for each SEIPS 2.0 element are presented in Table 2.

Table 1.

Participant Characteristics (N=11)

Role (%, n)
Agency Administrator	45.5 (5)
Nurse	27.3 (3)
Direct care worker	27.3 (3)
Age (M, SD)	48 (13.5)
Sex (%, n)
Male	9.1 (1)
Female	90.9 (10)
Race (%, n)
White	45.5 (5)
Black	55.5 (6)
Tenure* (%, n)
1– 4 years	45.5 (5)
5–9 years	18.2 (2)
10+ years	27.3 (3)

^*Note. Tenure is missing n=1.

Table 2.

Themes with example quotes from older adults, family caregivers, and direct care workers.

Work system	Tasks -Agency and family communication -Observing and reporting changes in client functions and behaviors -Communication with clinicians	Everything is done within the home with the client, so if the client needs a doctor’s appointment made, or needs to reach a doctor, the caregiver might call the doctor for them, have them on speakerphone, and kind of walk them through what they need. (Administrator 2)
	Tools and technology -Electronic management systems -Patient portal -Paper	It’s [sharing information about client’s care] done-- with the family, it’s done by email. It’s done in the care log notes and it’s done verbally with the family. With the agency, it is done through the care log and verbally… we [also] have an app that is updated daily and with the physician, we usually send messages to the physician. (DCW 3) The only time I have done it through the portal is with the family’s permission… in whatever [portal] notes I send, I do say “On behalf of this person, I am doing-- I’m updating you on these events or observation or activity,” or whatever. (DCW 8) I’ve never assisted them in-- I might direct them to their MyChart so that they can get a prescription refill or pay their bill, but I would just advise them of that, or advise them of how they can go about setting up their MyChart. But the only thing that I would be doing would be using it just-- review their chart, their history, and then use it to communicate to their medical team if necessary. (Nurse 3)
	Organizational factors related to information sharing -Assessments -Client profiles -Care plans	So initially when we get the client, there’s an assessment that’s done. So the administrator of the agency goes out and physically meets with the client and the family and gathers as much information as is needed while in the home, you know, we’re taking the time now to get to know the client, what they like, what their needs are, what they would, you know, would like (DCW 3)
	Internal environment -Home characteristics	So the first point of contact is whenever, you know, we either get a referral or a person schedules a personal home visit. In that situation the owner would go out and conduct the home visit and that will tell us any safety issues, or you know, entry and surrounding ways to get into the home, see if they need anything done to their home to make it safe on their level. (Administrator 3).
	External environment -Care systems and state level policies	…whatever insurance the individual has. Some of them have Medical Assistance. Some of them have Medicare, Medicaid.. so it’s whoever they have we interact with (Administrator 4) They (long-term care insurance provider) send us referrals and they are, like, one of our partners. So most of them, they send us referrals. Their patients also find us. And we service their patients and we send the invoices to them and they pay us. (Administrator 5)
Processes  -Includes work and collaboration among and between residential service agency staff, medical providers (e.g., clinicians), clients and family caregivers.		I had one client that liked to chew on the hearing aids and the family would say, “He always loses these hearing aids and we find them all chewed up.” So, I would actually put on that care plan, “Be mindful to be sure the client has both hearing aids and one is not in his mouth.” Things like that. (DCW 1) I initially hear their preferences from the family but then I start to learn them myself to know their likes and their dislikes. (DCW 2) If there are two CNAs on the team, let’s brainstorm ideas and talk to them amongst each other and hand off and things like that. So, I feel the majority of the time, we don’t have like 24-hour services or if there’s a handoff, we’re in there for a time period and then we return the next day. So, it’s just one of us. If there are multiple workers, make sure they’re interacting and communicating with each other as well
Dementia-related adaptations		The actual care plan would be built around dementia, with all of the safety aspects that come along with a client with dementia. But I think the actual-- the workflow and communication and reporting of information has the exact same workflow, dementia versus non-dementia. (Nurse 3) We work with the families, for us caregiving is teamwork, we like to meet the need, it is essential to meet the need mostly with dementia patients. If you really want to get their mood stable, you have to work with their preferences. So we will ask the family member their preferences what they like, the games they like, what the best activities they like.” (Administrator 5) We see that over and over again with family members, the resistance to talking about it, to acknowledging it, and that makes it hard I think for the caregivers too, our staff as well as family caregivers, when there’s not the acknowledgement so then you can actually put things in place, so you end up just going ahead and trying to put things in place, but there’s not an acceptance of it. (Administrator 1)

Work system

Persons.

Family caregivers and older adults were identified as being involved in information sharing with direct care workers due to their intimate knowledge of client goals, preferences, medical care, and changes in health status that might impact the care plan. Residential service agency staff also spoke about sharing information with each other. One nurse highlighted the value of direct care workers.

I rely on my [direct care workers] to give me feedback. Are the things in the care plan accurate? Are they still needed? Have things changed? It’s very, very important and I strongly encourage my direct care workers to report back to me any changes in the clients, and help me modify the care plan to make it most appropriate for any changes or improvement in patient status, or decline in patient status… because they’re with them every day. I’m not (Nurse 3).

Tasks.

Information sharing tasks involving direct care workers included communication with family and observing and reporting changes in older adult functions and behaviors.

Normally you call the family… and you just let them know, like, “Hey, I noticed so and so is starting to do this. That’s something he hasn’t done before, and I just wanted to give you a heads up. I am going to report this to the nurse so she’s aware of the changes. (Direct Care Worker 2)

Participants reported that direct care workers have limited interactions with clinicians and mainly facilitate transportation for clients to medical appointments. One direct care worker spoke about steps taken to prepare for appointments to be able to share family or agency concerns with clinicians.

If I’m attending the doctor’s appointment with them, there’s normally an envelope I take with me [with] all the patient’s demographics, past medical history, XYZ… They put any information given from the doctor into the envelope and I bring it back to the family. (Direct Care Worker 2)

Tools and Technology.

Tools used to share information between and within residential service agencies, clinicians, and families included email, phone, speaking in person, and written communication. One direct care worker spoke about the benefit of emailing families rather than relying solely on oral communication.

“A lot of families are…They become overwhelmed… it’s a lot for them to listen to.… I say to them, ‘Okay, so I’m going to send the information in an email and once you get the email, please reach out to me and we can discuss it.’… I do follow-up with them, you know, verbally just to confirm that they got the email and, you know, to ask if there’s anything that they need for us to address. (Direct Care Worker 3)

Electronic management systems were consistently identified as being used by agencies as a documentation tool, for flagging urgent matters related to client health or behavior changes, and/or allowing direct care workers to log their daily activities and tasks performed for a given client.

The care plan is uploaded into this encrypted app. So, they use that app to clock in, check off on the task that was completed on that care plan. If a task was not completed, there’s a drop-down box, so they can add their documentation as to why, even if it’s something as simple as, “The client refused to shower to today,” that has to be documented. (Direct Care Worker 1)

One nurse suggested adding messaging capabilities within-agency electronic management systems as another means to stay in contact with direct care workers.

“We’ve managed to get scheduling to be directly confirmed via email, but all other communication, your best bet is to go through a text message… maybe if there was a means of communication through our [electronic health management] system that could almost instant message them through the [phone application], then they would realize it was directly related to their work and patient care, maybe that would be something interesting to try out.”(Nurse 3).

Participants expressed variable practices in accessing, assisting with, and using patient portals for clients. Some participants reported not using patient portals or communicating with clinicians, at all. One administrator emphasized the difficulty in engaging with electronic health records - noting that patient portals are set up for individuals, rather than teams. Still, a nurse and a direct care worker both reported using patient portals for activities that included refilling medications and sending messages to clinicians. One direct care worker stated:

If there’s a way that we can access appointments or if there’s a way… for example, [medical provider] sends a text message, but it only sends it to a specific person that is listed, but if it could be sent to everyone, maybe in the future, they’ll be able to do that. (Direct Care Worker 3)

Organizational factors related to information sharing.

Participants noted that standard assessments are conducted to evaluate client function and health (e.g., medications). Outside of these standard timed assessments, staff use other methods to collect information about clients, including ad-hoc reassessments, which often reflect emerging care needs that initiate changes to the care plan. In speaking about collecting information about client preferences (e.g., preferred activities) one administrator noted that personal information is often documented outside of the care plan as a client profile or in open text fields.

The [direct care worker supervisor] is the one who mainly develops the profile. She goes out with whichever [nurse] is admitting a new patient… during the assessment she takes notes like… this is a retired man from the Navy. His hobbies are model trains and… he likes to read and take walks… she gives a little description about himself, his family, his interests. And that helps the [direct care worker], you know, just get to know them a little better (Administrator 1).

Internal Environment.

Participants widely commented that agencies collected relevant information during initial assessments about each living situation and surrounding environment to orient direct care workers and other residential service agency staff to the home context.

So we’ll let them know everything, you know how to get in, if they have pets, if there are smokers in the house, how many people live at the home, you know, so they’re not walking into a situation where it’s, you know, five people in there, and you’re only supported to be caring for grandma and, you know, things could go crazy in this industry (Administrator 3)

External Environment.

Residential service agency staff reported collaborating with outside organizations like the Alzheimer’s Association or state agencies to connect clients and caregivers to outside resources – as well as the Veteran’s Administration, Medicaid, and long-term care insurance providers to facilitate reimbursement.

Most [insurance providers] are pretty easy to deal with. Most of it is done directly online. By the time we usually have to deal with the long-term care [insurance] plans the families have already initiated everything. Sometimes we have elderly couples that have no clue, so we’ll have to help them initiate just the use of the long-term care [insurance] plans. (Administrator 3)

Work Processes

Family members often supported clients by helping agency staff (particularly direct care workers) understand client needs, preferences, and behaviors. A few direct care workers noted that relying on family for medical information about the client (versus communicating with clinicians) may result in knowledge gaps regarding clients’ health conditions and medical needs, and, in some cases, pose a challenge to the accuracy of information shared.

And I can say that a lot of times and more often than not, when we ask, “What are your diagnoses?” the family doesn’t even actually really know all the diagnoses for it. So, [nurse] may say, “Can I see your medication list?” And she’ll go over the medication list and say, “Well, they’re taking this. If they’re taking this, that means they have this.” You know, and then have to look into do some further digging once they become a client of ours…” (Direct Care Worker 1)

In recognition of the role of families as often being primary sources of information, participants identified personalized check-ins and conversations to overcome barriers to information exchange.

Our nurse supervisor, she reaches out to every client.…at least every 2 to 3 weeks, just to see “How’s it going? How’s care going?” Sometimes it’s a quick little “All’s well.” Sometimes it’s more lengthy. Not like an assessment, just like “How are things going?”… That’s how I feel like we get most information, is just asking questions. If a caregiver wants to call us, tell us that they’re going to a doctor’s appointment, we’ll call and say, “How did the doctor’s appointment go?” Just being personable with them. (Administrator 2)

While family members and residential service agency staff often collaborated to coordinate care for clients, one direct care worker discussed instances when they did not feel included in the care team.

Sometimes the family is going to decide on what they want… [and] the agency could possibly feel as though the person no longer needs [home care]… But I could feel like in some areas they may not and then some areas they do. I’ve had situations where home care has been discontinued for a person because they felt like, “Oh, he’s back to normal. He can do things on his own.” And I’m like, “Not really.” (Direct Care Worker 3)

Dementia-related Adaptations.

Participants stated that there were few or no differences in protocols and approaches guiding care delivery for older adults with dementia versus those without (e.g., frequency of assessments), but that there were distinct considerations. For example, dementia family caregivers’ relationships with residential service agencies required greater effort:

“Families of people with dementia…they’re always anxious, they’re always wanting to know. If you have somebody with just companionship, or a different type of care, they don’t really care about the day to day. Whereas people with dementia, they want to know everything…” (Administrator 1)

Participants also described collaborations between family caregivers of people with dementia and residential service agency staff:

“…if the family doesn’t have anything in place, maybe we can brainstorm some ideas, put in place maybe a camera, maybe an alarm on the door, or try and identify what the issue is there and try to make a recommendation for that client. (Nurse 1)”

Discussion

Our findings emphasize the value of direct care workers delivering care in the community and highlight the many moving parts in home care. The fragmentation in communication between direct care workers, families, and clinicians has been documented,³¹ but less is known about direct care worker participation in information sharing as well as how residential service agencies support them. As the demand for home care increases, it is becoming increasingly important to close gaps resulting in communication breakdowns, impacts on job quality and satisfaction, and negative care experiences for older adults and family caregivers. We present new information demonstrating variability in the use of patient portals and other technologies among direct care workers, as well as adaptations that direct care workers and other residential service agency staff must undergo when working with clients with dementia. These findings are best framed by our adapted version of the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model, a human factors model,²⁹ which was applied following data analysis. Our study provides a critical first step in understanding residential service agency staff practices related to information sharing and potential modifiable factors.

Electronic management systems were used as a hub for information sharing for direct care workers to sign in and out of a shift as well as document changes in client health or behaviors. The use of these systems in home care have received limited attention, despite the increasing use of technology,^32,33 and positive experiences among home care providers.³⁴ Direct care workers do not regularly communicate with clinical care teams,³³ but the use of electronic management systems could potentially close this gap. This technology might improve communication between direct care workers, who often experience inefficiencies in “hand-offs” between each other when providing services to the same client.³³ The expansion in the innovative utilization of current technologies to incorporate agency and clinician messaging capabilities might also be a worthwhile investment to solve issues related to miscommunication and avoidable health service utilization as well as enable direct care workers to better advocate for their clients when needed. For example, a pilot test in New York state demonstrated the feasibility and utility of direct care workers electronically tracking client activities and well-being beyond the intended purpose of risk prediction and clinical alerts – for direct care worker retention and satisfaction of both direct care workers and the clients they serve.¹⁸

Currently, there is a lack of consensus on the degree to which direct care workers should be involved in medical appointments, and what level of responsibility they should have in communicating with clinicians. We find that direct care workers often take steps to prepare for appointments and relay information between clinicians, families, and clients. These results align with prior work highlighting direct care worker involvement in medical appointments.^14,35 In Maryland, by law, direct care workers are restricted from sharing medical information across providers, as well as sharing information between clinical care teams and family members,³⁶ which imposes complex ethical considerations that may be especially challenging when caring for clients with cognitive limitations, such as those living with dementia. State policymakers and program leaders should consider the implications of the direct care workers’ scope of practice as it pertains to their role and facilitating effective and appropriate sharing and receiving of important health information (e.g., changes in health and function).

Our findings surrounding direct care worker use of the patient portal, as well as recommendations from participants to integrate direct care workers into patient portal contact teams are novel, emphasizing that workers may be involved in health-related tasks that are an extension of their traditional responsibilities. Our prior work shows that direct care workers are accessing patient portals.²⁶ Still, direct care worker access to portals has only been recently introduced as a method to improve care team integration, such as in California, where direct care workers were identified in patient portals as part of state-wide training program.¹⁶ Policy and practice are still at the forefront of understanding shared access in portal use for family caregivers, citing ethical concerns as well as organizational and logistical challenges.³⁷ The same considerations are likely relevant for direct care workers, although other issues may reflect turnover of staff and other organizational characteristics. Conversations surrounding portal shared access are timely, especially given the increasing need for telehealth access and utilization in the wake of the COVID-19 pandemic.^{38 39} Despite the challenges, direct care worker access to patient portals may close information gaps between clinicians, residential service agencies, and families, as well as reduce stress related to coordinating medical care, especially for older adults living with dementia.

We find that information sharing in home care requires adaptations for suitability in meeting the needs of older adults living with dementia. The reliance on family caregivers for information can be helpful as well as challenging for direct care workers and other residential service agency staff. In lieu of standardized processes around documenting older adults’ routines and preferences, residential service agency staff were often limited to health information provided by families that may be outdated or inaccurate. As the population of persons living with dementia needing home care continues to grow,⁴⁰ these gaps may be addressed by embedded, pragmatic interventions that aim to improve the transparency and accuracy of information shared within routine care delivery practices.

We acknowledge several limitations. First, we describe the experiences of participants from residential service agency staff in one state. While states differ in the delivery of home care, our study is novel in that we focus on information sharing between direct care workers, family caregivers, and clinicians. Further, the inclusion of staff from non-Medicare residential service agencies present opportunities for LTSS stakeholders to intervene in both private-pay and Medicaid-funded settings. Second, we acknowledge our small sample size, although six to twelve interviews may generate enough information to reach theme saturation, particularly among samples that are relatively homogenous.^41,42 Despite these limitations, findings yield important information for better understanding information sharing in home care delivery.

Our findings support calls to improve direct care worker involvement in care coordination and increase their engagement with interdisciplinary care teams. Results point to potential modifiable tools and technologies, as well as suggested work process-relevant opportunities for intervention (e.g., electronic management systems, patient portals). Given the growing number of older adults relying on home care services to age in the community, devising residential service agency level strategies are a natural next step in addressing fragmentation in information sharing and supporting direct care workers in the essential work that they do.

Highlights.

• Strategies are needed to better integrate direct care workers into interdisciplinary care teams.

• Electronic management systems and patient portals may be platforms for home care interventions.

• Considerations should be made for supporting direct care workers caring for those with dementia.