Risks to home care workers: Professional perspectives

Care at home is fundamental to community care policy, but the simultaneous growth of health and safety regulation has implications for home care services because of the duty of employers towards home care workers. This grounded theory study set in Northern Ireland used data from 19 focus groups and nine semi-structured interviews with a range of health and social services professionals and managers to explore perspectives on planning long term care for older people. Home care workers faced a wide range of hazards in the homes of clients, who themselves were faced with adapting their living habits due to their changing health and care needs and ‘risks.’ Creative approaches were used to ensure the health and safety of home care workers and simultaneously to meet the choices of clients. Staff experienced feelings of conflict when they judged it necessary to impose their way of providing home care and thus impose their values on clients to create a safe working environment. There was variation between and within organizations in terms of the staff focus on client needs or on their employer responsibility towards home care workers. The planning of home care services must take account of both the choices of clients and the hazards facing home care staff.     

Acute health care service use among elderly home care clients

Utilization of acute health care services accounts for a substantial proportion of health expenditures in Canada, and is associated with compromised health and autonomy for older persons. Using the Resident Assessment Instrument for Home Care (RAI-HC), this cross-sectional study of 683 elderly home care recipients sought to distinguish clients who were more likely to use acute health care services; i.e., hospital admissions, emergency room visits. Clients with nutritional problems were 2.58 times more likely to have used acute health care services than clients without nutritional problems. Among clients with a poor social support system, those with nutrition problems were 5.95 times as likely to have used acute health care services. Poor self-rated health, and greater functional dependency were also signif- icantly associated with acute health care use. This study provides a profile of elderly home care clients who are at risk of using acute health care services, which may facilitate targeted efforts to prevent unplanned acute health care use.     

Self-direction in home care for older people: a consumer's perspective

Interest among elder home care consumers in playing a stronger role in planning and supervising their own care was examined. Elder home care consumers were surveyed to determine their willingness to assume more responsibility for their home care such as in the hiring, paying, scheduling, supervising and/or firing of their home care worker. Telephone interviews were conducted of 883 home care clients in the Massachusetts Home Care Program which is administered through 27 local, private, non-profit Home Care Corporations (HCC) and which currently serves 33,000 clients. Respondents reported high levels of satisfaction with their home care services and home care worker. However, a substantial minority of respondents reported a willingness to assume more responsibility for their own home care services. A quarter to a third of the respondents indicated that they could take greater responsibility for supervising a home care worker and needed less assistance from a case manager. Multiple regression analyses revealed that prior experience in directing an in-home worker, greater length of receipt of home care services, greater current involvement in directing a home care worker, and lower levels of satisfaction with home care services were associated with a willingness to assume responsibility for directing a home care worker. Pilot projects are needed that develop and test options for older people with disabilities to exercise greater control over their own personal assistance.     

Home alone: unmet need for formal support services among home health clients

In order to remain in the home without family or other informal support, home health clients must have access to essential formal services such as nutritional support and homemaking chores to supplement medical and nursing care. In this study, we looked at client-related factors associated with the need for formal support services, and factors associated with whether those needs are adequately met. Data were collected from 2,013 home health clients in Massachusetts. According to the assessment of the skilled nurses treating them, 85 percent of the clients needed one or more support services; some or all needs were not adequately met in nearly half. Significant factors contributing to unmet need included: being non-white, having Medicaid as payer, being in a health maintenance organization, having AIDS, receiving maternal/child health services, and having an acute condition. This research suggests that even clients receiving skilled nursing care may not have many or most of their supportive needs met, and that there are identifiable factors which decrease the likelihood of having adequate care provided.     

How state-funded home care programs respond to changes in Medicare home health care: resource allocation decisions on the front line

OBJECTIVE: To examine how case managers in a state-funded home care program allocate home care services in response to information about a client's Medicare home health care status, with particular attention to the influence of work environment. DATA SOURCES/STUDY SETTING: Primary data collected on 355 case managers and 26 agency directors employed in June 1999 by 26 of the 27 regional agencies administering the Massachusetts Home Care Program for low-income elders. STUDY DESIGN: Data were collected in a cross-sectional survey study design. A case manager survey included measures of work environment, demographics, and factorial survey vignette clients (N = 2,054), for which case managers assessed service eligibility levels. An agency director survey included measures of management practices. DATA COLLECTION/EXTRACTION METHODS: Hierarchical linear models estimated the effects of work environment on the relationship between client receipt of Medicare home health care and care plan levels while controlling for case-mix differences in agencies' clients. PRINCIPAL FINDINGS: Case managers did not supplement extant Medicare home health services, but did allocate more generous service plans to clients who have had Medicare home health care services recently terminated. This finding persisted when controlling for case mix and did not vary by work environment. Work environment affected overall care plan levels. CONCLUSIONS: Study findings indicate systematic patterns of frontline resource allocation shaping the relationships among community-based long-term care payment sources. Further, results illustrate how nonuniform implementation of upper-level initiatives may be partially attributed to work environment characteristics.     

Characteristics of elderly home health care users: data from the 1996 National Home and Hospice Care Survey

OBJECTIVE: This report presents demographic characteristics, service utilization, and primary admission diagnoses of elderly users of home health care services. Included are home health care services used by both current and discharged clients (called patients). These services are provided by home health care agencies and hospices. The focus of the report is on services used by both current patients and discharges aged 65 years and over. METHODS: The data used for this report are from the National Center for Health Statistics 1996 National Home and Hospice Care Survey's (NHHCS) sample of current patients and discharges. The 1996 NHHCS is the fourth survey of home health care agencies and hospices and their current patients and discharges. RESULTS: The overall results of the survey indicate that, as in previous years, the elderly current patients and discharges were predominantly women, 75-84 years old, white, non-Hispanic, widowed, and most often lived in a private residence with members of their family. For elderly men and women, the most commonly used home health care service was skilled nursing services and the primary admission diagnosis was diseases of the circulatory system, including heart disease.     

Why I became a home support worker: recruitment in the home health sector

Home care is considered an essential pillar of the health care systems in many industrialized countries. With an increased demand for home health workers, there has been growing interest in examining recruitment and retention of these workers. With a focus on recruitment of home support workers, in this study we draw on data from interviews with 57 home support workers in three Canadian provinces, to examine the factors that attract individuals to employment in this sector. These factors include: previous experience, financial considerations, and enjoying working with people. Understanding these overlapping factors can aide in the recruitment of future workers.     

Transitions from home to nursing home in a capitated long-term care program: the role of individual support systems.

OBJECTIVE. This study calculated the risk of nursing home admission for clients receiving home- and community-based (HCB) care in a capitated long-term care system. DATA SOURCES. Program administrative data for non-institutionalized elderly and physically disabled (EPD) clients who had an HCB long-term care placement in the Arizona Long-Term Care System (ALTCS) during the period from January 1989 through December 1991. STUDY DESIGN. The program experience of clients who were initially placed in HCB care (N = 2,923) was tracked from the date on which they entered the program until the end of December 1992. DATA EXTRACTION METHODS. Program administrative data were used to create spans of program experience for each client. Cox proportional hazards regression models were then used to assess the individual factors associated with the risk of nursing home entry during the study period. PRINCIPAL FINDINGS. The greatest risk of nursing home entry was observed for those who were older or white, and for those clients with Alzheimer's disease. Little significant effect was observed for support system variables. CONCLUSIONS. Study results suggest that efforts to prevent nursing home entry may be most productive if they focus on the point at which clients are first assessed for placement into the ALTCS program. Once in HCB care, subsequent risk of nursing home placement may be more related to the client's health and frailty than to support system factors.     

"I'm satisfied … but": clients' and families' contingent responses about home care

Home care service organizations need a means of gaining useful feedback about satisfaction with care from clients and their families. Interviews were conducted with 82 older adult clients and 52 family members about their satisfaction with home care. A subgroup of participants (n = 39) provided "contingent" satisfaction responses. Contingent responses reflect the duality of perceptions that clients and families convey about services. Three themes emerged as critical to understanding these types of responses: adept versus inept staff, predictable versus precarious scheduling, and responsive versus restrictive care plans. Understanding the reasons for contingent responses could help home care agencies to target quality improvement initiatives for individual clients and families.     

我国居家老人对社区三类健康服务需求的影响因素分析

目的 综合分析我国居家老人对社区保健知识、精神蔚籍和上门看病送药三类健康服务需求的影响因素。方法 利用CLHLS2017—2018调查数据,运用SPSS 23.0软件进行统计分析,采用二元logistic回归分析方法,探寻我国居家老人对社区三类健康服务需求的影响因素。结果 我国居家老人社区三类健康服务（保健知识:χ2 = 935.263,P＜0.001;精神蔚籍:χ2 = 406.578,P＜0.001;上门看病送药:χ2 = 325.448,P＜0.001）的需求与供给差异显著;除居住地、退休前职业、地区和抑郁程度是影响居家老人对三类健康服务需求的共同因素之外,两周患病（否:OR = 1.282,95%CI:1.072～1.534,P = 0.007）、每年体检（是:OR = 1.19,95%CI:1.021～1.387,P = 0.026）以及高血压诊断（否:OR = 1.224,95%CI:1.045～1.433,P = 0.012）等也影响居家老人对保健知识的需求,居住方式（独居:OR = 1.321,95%CI:1.094～1.594,P = 0.004）也影响居家老人对精神蔚籍的需求,年龄（70～79岁:OR = 0.792,95%CI:0.649～0.966,P = 0.022）和每年体检（是:OR = 0.821,95%CI:0.716～0.941,P = 0.005）也影响居家老人对上门看病送药的需求。结论 建议社区卫生机构全方位开展对健康居家老人的保健知识宣传;重视对独居和抑郁居家老人的心理健康服务;权衡自身资源和居家老人的实际情况,逐步推进上门看病送药服务。     

Establishing interfaces between community- and hospital-based service systems for the elderly

The gerontological service delivery system often fails to integrate the different types of services needed at different times by older clients. Social workers need to address the urgent and increasing need for communication among acute care hospitals that are diversifying into areas previously the domain of community-based providers of services for the aged. Coordinated care case management programs were developed in seven hospitals to determine whether hospitals could serve as a logical entry point of frail elderly persons into the system. Examination of the experiences of these hospitals illustrated the need for models of service integration and resulted in several approaches to comprehensive service delivery and coordination. Social work professionals in both acute and long-term care settings need to understand all aspects of the service delivery system to ensure that elderly clients receive appropriate levels and continuity of care in a complex and constantly changing system.     

Who are those most likely to be institutionalized,the elderly who receive comprehensive home care services or those who do not?

Three samples of clients aged 65 and over from three different home care and homemaker programs are compared to elderly persons with a risk of institutionalization chosen from three random samples of people aged 65 and over living in the catchment areas of the three programs. The most important differences between the clienteles and the populations with a risk of institutionalization appear when examining the availability of help. The populations at risk generally have access to a source of help living with the elderly person while the clienteles of comprehensive home care programs depend on outside help. Home care and homemaker programs therefore replace in-home services with out-of-home services. These services will be effective insofar as they succeed in reproducing some of the essential characteristics of in-home care.     

Home health and home care in Massachusetts after the Balanced Budget Act of 1997: implications of cost containment pressures for service authorizations

This paper explores the response of the Massachusetts state-funded home care program for the elderly when its clients encountered barriers to the receipt of home health services because of HMO enrollment and the implementation of the Balanced Budget Act of 1997. Clients of three regional case management agencies serving the Massachusetts state home care program whose home care services were interrupted because of hospitalization between January 1 and April 30, 1999 and whose services were resumed after they returned home were studied. Detailed data are reported that show how the long-term personal assistance services provided through the state program were often complemented by temporary home health services after elders returned home. The multivariate analysis revealed that the authorization of state-funded personal care services was keyed to the status of home health aide services. After hospitalization, the presence of a home health aide reduced the likelihood of authorization of personal care. At final assessment, the situation was reversed, that is, the withdrawal of a home health aide increased the likelihood of authorization of personal care. The findings suggest that more restrictive Medicare reimbursement policies for home health services led to greater state expenditures for personal care services. In other words, less generous Medicare financing shifted a greater portion of the burden of financing home care to the state of Massachusetts. These findings raise important policy questions about the balance of responsibility between the federal government and states to provide financing of home care services for the elderly.     

Self-Direction in Home Care for Older People: A Consumer's Perspective

ABSTRACT

Interest among elder home care consumers in playing a stronger role in planning and supervising their own care was examined. Elder home care consumers were surveyed to determine their willingness to assume more responsibility for their home care such as in the hiring, paying, scheduling, supervising and/or firing of their home care worker.

Telephone interviews were conducted of 883 home care clients in the Massachusetts Home Care Program which is administered through 27 local, private, non-profit Home Care Corporations (HCC) and which currently serves 33,000 clients. Respondents reported high levels of satisfaction with their home care services and home care worker. However, a substantial minority of respondents reported a willingness to assume more responsibility for their own home care services. A quarter to a third of the respondents indicated that they could take greater responsibility for supervising a home care worker and needed less assistance from a case manager, Multiple regression analyses revealed that prior experience in directing an in-home worker, greater length of receipt of home care services, greater current involvement in directing a home care worker, and lower levels of satisfaction with home care services were associated with a willingness to assume responsibility for directing a home care worker. Pilot projects are needed that develop and test options for older people with disabilities to exercise greater control over their own personal assistance.     

Formative Evaluation of Home Visitors' Role in Addressing Poor Mental Health,Domestic Violence,and Substance Abuse Among Low-Income Pregnant and Parenting Women

Objectives: This research assessed home visitor effectiveness in communicating about and responding to poor mental health, domestic violence, and substance abuse among pregnant and parenting women home visited as part of a comprehensive family support strategy in seven urban communities. Methods: Cross-sectional studies were conducted with mothers (n = 189) actively engaged in home visitation programs and home visitors (n = 45). Maternal interviews assessed need for and receipt of mental health, domestic violence, and substance abuse services, and home visitor discussion of these risk areas. Home visitor surveys assessed perceived adequacy of training and personal effectiveness in addressing these risk areas. Results: Over half of mothers needed mental health, domestic violence, or substance abuse services; however, only 27% of mothers in need of service received services. Most mothers reported having communicated with their home visitor about the three risk areas, but there were no differences in communication frequency based on whether services were needed. Most home visitors perceived themselves as effective in communicating about and responding to these risk factors but rated the training they had received in these areas as less than adequate. Conclusions: Home visitors could benefit from more intensive training in the formal assessment of risks and the protocols for communication about those risks with their clients. Home visitors could also receive support from and work in collaboration with professionals in addressing client risks. Further research on home visit content is needed to determine which strategies facilitate home visitors' ability to effectively communicate about and address client risks.     

Economic analysis of home vs hospital-based parenteral nutrition in Ontario, Canada

BACKGROUND: Advances in technology and infrastructure have facilitated transfer of complex services from acute care hospitals to the home. This increases the burden on community resources but may provide net savings to the health care system. We undertook a retrospective cohort study of patients transferred from hospital to home while receiving home parenteral nutrition (PN) to assess their costs of care. METHODS: A detailed review of medical records was undertaken for all patients managed by the Hamilton Health Sciences Home PN Program between 1996 and 2001 whose PN was initiated in hospital. Mean per diem direct medical costs were estimated from the perspective of the provincial Ministry of Health for 3 periods: the last 2 weeks before discharge and the first month after discharge. Costs were compared among time intervals and among patients subgroups defined by age and underlying disease. RESULTS: Twenty-nine eligible subjects were identified. Common indications for PN included malignancy (n = 12), inflammatory bowel disease (n = 6), and intestinal ischemia (n = 4). Mean per diem costs in the last week of hospitalization were higher than those in the first month after discharge (dollars 567 vs dollars 405, p < .0001). Acute care resources accounted for <10% of the overall costs on home PN. The estimated monthly savings per patient maintained on home PN were dollars 4860 (95% confidence interval dollars 2700-dollars 7000). Savings were even greater among patients with underlying malignancy and advanced age. CONCLUSIONS: Home PN is cost saving when compared with hospital-based PN. Neither age nor underlying malignancy should pose a barrier to receipt of home PN.     

Utilization of home care among people with HIV infection.

OBJECTIVE: To examine factors affecting the utilization of formal and informal home care services by people with HIV infection. DATA SOURCES AND STUDY SETTING: Study participants are adults with HIV infection receiving services at major providers of medical care in ten U.S. cities. Six interviews were conducted over an 18-month period (March 1991 to September 1992). DATA COLLECTION METHODS: Data on home care utilization, personal background characteristics, insurance status, and functional status are based on self-report. Disease stage is based on medical record data. STUDY DESIGN: This is an observational study using a panel survey design. Cross-tabular and longitudinal regression analyses (N = 1,727) were conducted to determine the effects of sociodemographic factors, functional status, disease stage, and insurance status on the receipt of home care from nurses, paraprofessionals, other professional providers, household residents, nonresident family and friends, and volunteers. PRINCIPAL FINDINGS: Over a 12-month period, 16 percent of respondents received home nursing visits; 11 percent received paraprofessional care (e.g., nurse's aides, helpers); 4 percent received help from volunteers; 11 percent from non-resident family or friends, and 21 percent from household members. Among the subgroup with AIDS (n = 837), corresponding percentages were 29, 20, 7, 17, and 29 percent for each provider type. In multivariate analyses, illness stage and functional status had strong effects on odds of utilization. Blacks and Hispanics were less likely than whites to have nursing care, but racial/ethnic group did not affect receipt of informal care. CONCLUSIONS: Home care utilization is concentrated among people with AIDS, compared to those at less advanced disease stages. In addition to functional limitations, fatigue is associated with the use of home care. Nursing and non-nursing home care have somewhat different correlates. Medicaid may provide better coverage of personal care services than private insurance.     

Factors explaining the referral of the elderly to home nursing or home help.

Factors explaining the referral of the elderly to home nursing or home help or both were studied in a population (n = 1358) aged 60 years or over and living in the commune of Aht?ri, a semi-industrialized community in middle-western Finland, using social and health care registers and questionnaires in collecting data. The clients of home nursing and of combined home nursing and home help were predominantly women, whereas men were in the majority among those referred to home help. A stepwise regression analysis showed old age, living alone, low self-perceived health, low education and few visiting contacts to explain home nursing or home help among men. Among women, the most important variables explaining home nursing or home help in the regression model were old age, low self-perceived health, low standard of housing, high amount of symptoms and lowered functional capacity. The poor availability of social support is more important a factor explaining the referral to home care among elderly men than among women. On the other hand, low health status and poor functional capacity, as well as poor availability of physical support are more important factors among women than men.