In Their Own Words: The Challenges Experienced by Certified Nursing Assistants and Administrators During the COVID-19 Pandemic

This qualitative study aimed to provide an in-depth understanding of the challenges experienced by certified nursing assistants and administrators during the unprecedented COVID-19 crisis. We conducted 6 administrator interviews and 10 remote focus groups with day and evening CNAs at 5 nursing homes (N = 56) in downstate New York. Content analysis was conducted, and emerging themes were identified across sites and roles. Results showed numerous challenges for both CNAs and administrators including many that were personal. These personal challenges included feeling helpless, anxious, or fearful; experience of COVID illness; and balancing high concurrent demands of work and family. There were also many operational challenges such as a lack of COVID testing capacity, information, and consistent guidance and support, staffing and equipment. Understanding these challenges can facilitate goals to promote future safety, skill refinement, and enhanced resilience in the workforce.

Perspectives of certified nursing assistants and administrators on staffing the nursing home frontline during the COVID-19 pandemic

Objective

To identify best practices to support and grow the frontline nursing home workforce based on the lived experience of certified nursing assistants (CNAs) and administrators during COVID‐19.

Study setting

Primary data collection with CNAs and administrators in six New York metro area nursing homes during fall 2020.

Study design

Semi‐structured interviews and focus groups exploring staffing challenges during COVID‐19, strategies used to address them, and recommendations moving forward.

Data collection

We conducted interviews with 6 administrators and held 10 focus groups with day and evening shift CNAs (n = 56) at 6 nursing homes. Data were recorded and transcribed verbatim and analyzed through directed content analysis using a combined inductive and deductive approach to compare perceptions across sites and roles.

Principal findings

CNAs and administrators identified chronic staffing shortages that affected resident care and staff burnout as a primary concern moving forward. CNAs who felt most supported and confident in their continued ability to manage their work and the pandemic described leadership efforts to support workers' emotional health and work–life balance, teamwork across staff and management, and accessible and responsive leadership. However, not all CNAs felt these strategies were in place.

Conclusions

Based on priorities identified by CNAs and administrators, we recommend several organizational/industry and policy‐level practices to support retention for this workforce. Practices to stabilize the workforce should include 1) teamwork and person‐centered operational practices including transparent communication; 2) increasing permanent staff to avoid shortages; and 3) evaluating and building on successful COVID‐related innovations (self‐managed teams and flexible benefits). Policy and regulatory changes to promote these efforts are necessary to developing industry‐wide structural practices that target CNA recruitment and retention.

Improving Patient Activation among Older Veterans: Results from a Social Worker-Led Care Transitions Intervention

Older veterans enrolled in the Veterans Health Administration (VHA) often use both VHA and non-VHA providers for their care. This dual use, especially around an inpatient visit, can lead to fragmented care during the time of transition post-discharge. Interventions that target patient activation may be valuable ways to help veterans manage complex medication regimens and care plans from multiple providers. The Care Transitions Intervention (CTI) is an evidence-based model that helps older adults gain confidence and skills to achieve their health goals post-discharge. Our study examined the impact of CTI upon patient activation for veterans discharged from non-VHA hospitals. In total, 158 interventions were conducted for 87 veterans. From baseline to follow-up there was a significant 1.7-point increase in patient activation scores, from 5.4 to 7.1. This association was only found among those who completed the intervention. The most common barriers to completion were difficulty reaching the veteran by phone, patient declining the intervention, and rehospitalization during the 30 days post-discharge. Care transitions guided by social workers may be a promising way to improve patient activation. However, future research and practice should address barriers to completion and examine the impact of increased patient activation on health outcomes.

The Psychological Impact of COVID-19 on Home Based Primary Care Providers in New York: A Qualitative Study

Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in the New York including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.

Challenges Reported by Certified Nursing Assistants During COVID-19: A Qualitative Study

Certified nursing assistants (CNAs) who care for vulnerable nursing home residents faced unprecedented circumstances due to the COVID-19 pandemic. While staff and PPE shortages were ubiquitous and widely known, the focus of this qualitative work was to gain a broader understanding of the numerous challenges they faced. We conducted 10 remote focus groups with CNAs at 5 nursing homes (N=56) in downstate New York. Content analysis was conducted, and emerging themes identified. Results showed a myriad of emotional challenges including helplessness, fear and anxiety. Operational challenges focused on lack of COVID testing capacity, information, and consistent guidance and support, in addition to staff and equipment. Individual challenges included personal experience of COVID illness and that of colleagues, and balancing high concurrent demands of work and family. These results are discussed in the context of developing recommendations to promote future safety, skill refinement and enhanced resilience in the workforce moving forward.

Providers’ Perceptions of Telehealth Barriers Among Homebound Adults in in a Home-Based Primary Care Practice

The COVID-19 pandemic resulted in a dramatic shift to video-based telehealth use in home-based primary care. We conducted an online 11-item survey exploring provider perceptions of patients’ experience with and barriers to telehealth in a large HBPC program in New York City. More than one-third (35%) of patients (mean age of 82.7; 46.6% with dementia; mean of 4 comorbidities/patient) engaged in first-time video-based telehealth encounters between April and June 2020. The majority (82%) required assistance from a family member and/or paid caregiver. Among patients who had not used telehealth, providers deemed 27% (n=153) “unable to interact over video” for reasons including cognitive or sensory ability. Fourteen percent lacked caregivers. Physicians were not knowledgeable about patients’ internet connectivity, ability to pay for cellular plans, and video-capable device access. These findings highlight the need for novel approaches to facilitating telehealth and systematic data collection before targeted interventions to increase video-based telehealth use.

Disruptions and Adaptations in End-of-Life Care Delivery for Homebound Patients During COVID-19

The initial COVID-19 pandemic surge in New York City caused widespread delays and disruption in end-of-life services. This study examined the impact of disruptions among homebound adults in an HBPC practice who died between March-June 2020. Through an in-depth mixed-methods chart review, we identified 113 patient deaths (mean age: 87, 73% female, 67% with dementia). Forty-nine (43%) of deaths occurred in April 2020. Through a content analysis of clinician notes, we identified key COVID-related themes, including a shift to intensive phone-based care and to a lesser degree, telehealth; delays in hospice referrals and admissions; and an increase in treatment for behavioral symptoms. Our analysis also demonstrated the central role of family and paid caregivers in coordinating care, and efforts by patients, caregivers and providers to avoid hospital admissions. These findings demonstrate the importance of care coordination across medical, home and community partners to support end-of-life care in emergencies and beyond.

Provider Perceptions of Video Telehealth in Home-Based Primary Care During COVID-19

The COVID-19 pandemic accelerated the adoption of virtual care. In this qualitative study, we sought to determine provider perceptions of video telehealth during the first wave of COVID-19 in NYC to inform practice for home-based primary care providers nationwide. We conducted semi-structured interviews with clinical directors, program managers, nurse practitioners, nurse managers, and social workers at 6 NYC practices (N=13) in spring 2020. We used combined open and focused coding to identify themes. Participants employed both hospital-supported and commercial technological platforms to maintain care during COVID-19. Benefits of video telehealth included improved efficiency, capacity and collaboration between providers. Barriers included patients’ physical, cognitive or technological abilities, dependence on caregivers and aides to facilitate video visits, challenges establishing trust with new patients and addressing sensitive topics over video, and concerns over missing important patient information. Considering patient, clinical, and technological conditions can help optimize telehealth implementation among older homebound adults.

It Was Trial by Fire: Recommendations for Building a Stronger Nursing Home Workforce After COVID-19

The COVID-19 crisis showed the urgent need for a unified, well-supported nursing home workforce. The objective of this qualitative study was to examine the lived experience of certified nursing assistants (CNAs) and administrators during COVID-19 to identify best practices moving forward. Six administrator interviews and 10 remote focus groups with CNAs at 5 nursing homes (N=56) were examined through directed content analysis. Based on priorities identified by CNAs and administrators, the following practices may be most impactful: 1) ongoing and responsive staff training; 2) transparent, direct, and two-way communication channels; 3) prioritizing hiring permanent staff to avoid shortages and reliance on agency staff; 4) building collaborative staff-management relationships; 5) providing flexible job benefits; 6) providing staff-centered emotional support resources; and 7) appraising COVID-19 innovations. Our results suggest that rather than returning to “business as usual,” nursing homes can draw on these lessons to build a more sustainable workforce and industry.

Navigating COVID-19: Communication and Coordination Between Home Care Agencies and Aides Caring for Older Veterans

Home health aides are essential members of the home care team, but often report limited communication with agency supervisors. To explore the impact of COVID-19 on these dynamics, we conducted semi-structured interviews with providers (n=9), contracted home health agencies (n=6), and aides caring for veterans (n=8) at an urban Veterans Affairs medical center. Data were analyzed through thematic analysis. Agencies relied on aides to observe and report on patients’ conditions, including COVID-19 symptoms, but aides were not always aware of follow-up and wanted more information about their patients’ health and COVID-19 status. Agencies also reported providing personal protective equipment (PPE) and infection prevention guidance to aides; however, some aides reported purchasing their own PPE and seeking out private COVID-19 testing. Supporting aides by providing needed training and protective resources, and engaging them more collaboratively in medical care, may help improve job satisfaction and quality of care.

"I felt useless": a qualitative examination of COVID-19's impact on home-based primary care providers in New York

Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.

"There Is Something Very Personal About Seeing Someone's Face": Provider Perceptions of Video Visits in Home-Based Primary Care During COVID-19

The rapid deployment of video visits during COVID-19 may have posed unique challenges for home-based primary care (HBPC) practices due to their hands-on model of care and older adult population. This qualitative study examined provider perceptions of video visits during the first wave of the COVID-19 crisis in New York City (NYC) through interviews with HBPC clinical/medical directors, program managers, nurse practitioners/nurse managers, and social work managers (n = 13) at six NYC-area practices. Providers reported a combination of commercial (health system-supported) and consumer (e.g., FaceTime) technological platforms was essential. Video visit benefits included triaging patient needs, collecting patient information, and increasing scheduling capacity. Barriers included cognitive and sensory abilities, technology access, reliance on caregivers and aides, addressing sensitive topics, and incomplete exams. Effectively integrating video visits requires considering how technology can be proactively integrated into practice. A policy that promotes platform flexibility will be crucial in fostering video integration.

COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic from a National Survey

Objectives

Approximately 7.5 million US adults are homebound or have difficulty accessing office-based primary care. Home-based primary care (HBPC) provides such patients access to longitudinal medical care at home. The purpose of this study was to describe the challenges and adaptations by HBPC practices made during the first surge of the COVID-19 pandemic.

Design

Mixed-methods national survey.

Setting and Participants

HBPC practices identified as members of the American Academy of Homecare Medicine (AAHCM) or participants of Home-Centered Care Institute (HCCI) training programs.

Methods

Online survey regarding practice responses to COVID-19 surges, COVID-19 testing, the use of telemedicine, practice challenges due to COVID-19, and adaptations to address these challenges. Descriptive statistics and t tests described frequency distributions of nominal and categorical data; qualitative content analysis was used to summarize responses to the open-ended questions.

Results

Seventy-nine practices across 29 states were included in the final analyses. Eighty-five percent of practices continued to provide in-person care and nearly half cared for COVID-19 patients. Most practices pivoted to new use of video visits (76.3%). The most common challenges were as follows: patient lack of familiarity with telemedicine (81.9%), patient anxiety (77.8%), clinician anxiety (69.4%), technical difficulties reaching patients (66.7%), and supply shortages including masks, gown, and disinfecting materials (55.6%). Top adaptive strategies included using telemedicine (95.8%), reducing in-person visits (81.9%), providing resources for patients (52.8%), and staff training in PPE use and COVID testing (52.8%).

Conclusions and Implications

HBPC practices experienced a wide array of COVID-19–related challenges. Most continued to see patients in the home, augmented visits with telemedicine and creatively adapted to the challenges. An increased recognition of the need for in-home care by health systems who observed its critical role in caring for fragile older adults may serve as a silver lining to the otherwise dark sky of the COVID-19 pandemic.

Perceptions of event notification following discharge to improve geriatric care: qualitative interviews of care team members from a 2-site cluster randomized trial

OBJECTIVE

To assess primary care teams' perceptions of a health information exchange (HIE) event notification intervention for geriatric patients in 2 Veterans Health Administration (VHA) medical centers.

MATERIALS AND METHODS

We conducted a qualitative evaluation of an event notification alerting primary care teams to non-VHA hospital admissions and emergency department visits. Data were collected through semistructured interviews (n = 23) of primary care team physicians, nurses and medical assistants. Study design and analysis were guided by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Team members found the alerts necessary, helpful for filling information gaps, and effective in supporting timely follow-up care, although some expressed concern over scheduling capacity and distinguishing alerts from other VHA notices. Participants also suggested improvements including additional data on patients' diagnosis and discharge instructions, timing alerts to patients' discharge (including clear next steps), including additional team members to ensure alerts were acted upon, and implementing a single sign-on.

DISCUSSION

Primary care team members perceived timely event notification of non-VHA emergency department visits and hospital admissions as potentially improving post-discharge follow-up and patient outcomes. However, they were sometimes unsure of next steps and suggested the alerts and platform could be streamlined for easier use.

CONCLUSIONS

Event notifications may be a valuable tool in coordinating care for high-risk older patients. Future intervention research should explore the optimal amount and types of information and delivery method across sites and test the integration of alerts into broader care coordination efforts.

Paid Caregivers in the Community-Based Dementia Care Team: Do Family Caregivers Benefit?

PURPOSE

Older adults with dementia often rely on both paid caregivers (ie, home health aides, personal care attendants, other direct care workers) and family caregivers (ie, spouses, children, other unpaid individuals) to remain in the community. This study conceptualizes paid caregivers as part of the collaborative dementia care team and examines the association between receipt of paid care and primary family caregiver experience.

METHODS

Using data from 3 waves (2011, 2015, and 2017) of the National Health and Aging Trends Study linked to the National Study of Caregiving, community-dwelling Medicare beneficiaries aged ≥67 years with advanced dementia (n = 338 observations) were identified. Primary family caregiver experiences were compared among those with zero, part-time (<40 hours/week), and full-time (≥40 hours/week) paid care, and multivariable models were used to evaluate the associations between full-time paid care and family caregiver strain (eg, being overwhelmed due to caregiving) and activity restriction (eg, being unable to work for pay due to caregiving).

FINDINGS

About one half of the community-dwelling older adults with advanced dementia received paid care: 30% had part-time paid care and 18% had full-time paid care. The experiences of family caregivers of those receiving part-time and no paid care were not significantly different. After adjusting for family caregiver and care recipient characteristics, receipt of full-time paid care was associated with a nearly 70% reduced odds of having activity restrictions due to caregiving (odds ratio, 0.31; P = 0.01) and a reduction in mean caregiver strain score (-0.73; P = 0.04). There was no statistically significantly association between the odds of high caregiver strain (score ≥5) and receipt of paid care (odds ratio, 0.65; P = 0.33).

IMPLICATIONS

The provision of paid care for individuals with dementia in the community may benefit family caregivers. Future work should acknowledge the important ways that paid caregivers contribute to outcomes for all members of the collaborative dementia care team.

Barriers to telehealth access among homebound older adults

Background/Objectives

To identify major barriers to video‐based telehealth use among homebound older adults.

Design

Cross‐sectional survey.

Setting

A large home‐based primary care (HBPC) program in New York City (NYC) serving 873 homebound patients living in the community.

Participants

Sixteen primary care physicians.

Measurements

An 11‐item assessment of provider perceptions of patients' experience with and barriers to telehealth.

Results

According to physicians in the HBPC program, more than one‐third (35%) of homebound patients (mean age of 82.7; 46.6% with dementia; mean of 4 comorbidities/patient) engaged in first‐time video‐based telehealth encounters between April and June 2020 during the first COVID‐19 surge in NYC. The majority (82%) required assistance from a family member and/or paid caregiver to complete the visit. Among patients who had not used telehealth, providers deemed 27% (n = 153) “unable to interact over video” for reasons including cognitive or sensory impairment and 14% lacked access to a caregiver to assist them with technology. Physicians were not knowledgeable of their patients' internet connectivity, ability to pay for cellular plans, or video‐capable device access.

Conclusion

The COVID‐19 pandemic resulted in a large and dramatic shift to video‐based telehealth use in home‐based primary care. However, 4 months into the pandemic a majority of patients had not participated in a video‐based telehealth encounter due to a number of barriers. Patients lacking caregiver support to assist with technology may benefit from novel approaches such as the deployment of community health workers to assist with device setup. Physicians may not be able to identify potentially modifiable barriers to telehealth use among their patients, highlighting the need for better systematic data collection before targeted interventions to increase video‐based telehealth use.

Interventions to Reduce the Impact of Client Death on Home Care Aides: Employers' Perspectives

For home care agencies and aides, the death of clients has important, yet often unrecognized, workforce implications. While research demonstrates that client death can cause grief and job insecurity for aides, we currently lack home care agencies' perspectives on this issue and approaches to addressing it. This study uses key informant interviews with leaders from a diverse sample of eight New York City home care agencies to explore facilitators and barriers to agency action. We found that agencies engaged primarily in a range of informal, reactive practices related to client death, and relatively few targeted and proactive efforts to support aides around client death. While leaders generally acknowledged a need for greater aide support, they pointed to a lack of sustainable home care financing and policy resources to fund this. We recommend increased funding to support wages, paid time off, and supportive services, and discuss implications for future research.

"At Home, with Care": Lessons from New York City Home-based Primary Care Practices Managing COVID-19

BACKGROUND/OBJECTIVES

COVID-19 required rapid innovation throughout the healthcare system. Home-based primary care (HBPC) practices faced unique challenges maintaining services for medically complex older populations for whom they needed to adapt a traditionally hands-on, model of care to accommodate restrictions on in-person contact. Our aim was to determine strategies used by New York City (NYC)-area HBPC practices to provide patient care during the first wave of the COVID-19 pandemic with the goal of informing planning and preparation for home-based practices nationwide.

DESIGN

Cross-sectional qualitative design using semi-structured interviews.

SETTING

HBPC practices in the NYC metro area during spring 2020.

PARTICIPANTS

HBPC leadership including clinical/medical directors, program managers, nurse practitioners/nursing coordinators, and social workers/social work coordinators (n = 13) at 6 NYC-area practices.

MEASUREMENTS

Semi-structured interviews explored HBPC practices' COVID-19 care delivery challenges, adaptations, and advice for providers. Interviewers probed patient care, end-of-life care, telehealth, community-based services and staffing. Interviews were recorded and transcribed. Data were analyzed through a combined inductive and deductive thematic approach.

RESULTS

Participants described care delivery and operational adaptations similar to those universally adopted across healthcare settings during COVID-19, such as patient outreach and telehealth. HBPC-specific adaptations included mental health services for patients experiencing depression and isolation, using multiple modalities of patient interactions to balance virtual care with necessary in-person contact, strategies to maintain patient trust, and supporting team connection of staff through daily huddles and emotional support during the surge of deaths among long-standing patients.

CONCLUSION

NYC-area HBPC providers adapted care delivery and operations rapidly during the height of the COVID-19 pandemic. Keeping older, medically complex patients safe in their homes required considerable flexibility, transparency, teamwork, and partnerships with outside providers. As the pandemic continues to surge around the United States, HBPC providers may apply these lessons and consider resources needed to prepare for future challenges.

Care Team Members’ Perceptions of an Informatics Intervention to Improve Geriatric Care Across Multiple sites

Electronic health information exchange (HIE) may improve care for geriatric patients receiving care across multiple sites by reducing test duplication, medication prescribing errors, and adverse events. This project evaluated the implementation of an HIE intervention at two VA medical centers offering VA providers real-time notification of non-VA inpatient or ED use, followed by post-hospital geriatric care coordination. We interviewed 23 providers (physicians, nurses, social workers and other care team staff) about their experiences with the program. Interviews were analyzed using the Consolidated Framework for Implementation Research (CFIR) to examine 1) goals and expectations for notifications and transitional care; 2) barriers to effective use of notifications and coordination; and 3) suggestions for improvement. Overall, care team members were positive about the intervention, noting it cut down on time searching for outside medical records and that care coordination visits were helpful in answering patients’ questions and clarifying discharge instructions. However, some providers were not aware of the alerts, found the HIE interface challenging to use, or were concerned that expanding the program would create workflow issues. Suggestions for improvements included sharing information about newly prescribed medications, lab and radiological tests, and progress alerts during the episode of care; and including non-VA providers to facilitate care coordination. Social workers also asked to be included on alerts to improve follow-up. Our findings suggest HIE can be a useful tool for coordinating care across sites, provided information can be easily shared between all care team members and HIE interfaces are streamlined to reduce additional work.

We Treat Them Better Than the Family They Have: Negotiating Aide-Family Relationships in the Home Care Setting

Unpaid and paid care in the home are closely intertwined, but a lack of outside supervision and support often forces family and non-family caregivers to negotiate care tasks and boundaries alone, leading to role conflict and role ambiguity. This analysis drew on two qualitative studies of home health aides (S1 n = 27, S2 n =26) to explore 1) aides’ perception of their caretaking role; 2) aides’ experiences co-producing care with family members; and 3) factors affecting these relationships. Data were analyzed through grounded theory and discourse analysis. We identified three relationship dynamics between aides and family members: independent, where aides and families provided care separately; competitive, where aides and families struggled over control of care tasks; and carative, where aides considered family part of the unit of care. We propose strategies for employer agencies to better support paid and unpaid caregivers in negotiating boundaries and co-producing care.

Dementia care providers’ delivery of family caregiver support during COVID-19

Family caregiver support is a cornerstone of dementia care. Yet the transition to virtual care during COVID raised questions about the ability of dementia care teams to maintain caregiver support services. We surveyed Veterans Affairs clinicians about dementia caregiver support delivery following the COVID surge in the six New England states. 38 out of 68 (55%) clinicians from 6 states responded in June and July 2020. We found: 1) Clinicians continued providing the same types of support services for family caregivers before and after COVID, with over 50% of providers interacting with caregivers daily or multiple times per week. The most prevalent services were caregiver needs assessments, information and referrals, and assistance with accessing services. Two-thirds reported continuing to offer caregiver skills training and counseling, including peer support groups. 2) Caregiver support modality changed, most frequently through the combined use of phone and video, followed by only phone, and rarely, by only video. 3) Providers indicated that phone, more than video, increased to replace in-person interactions, because of multiple factors: caregivers (who continued to call for support on an as-needed basis but declined video encounters), providers (who began to provide group support via phone), and service factors (ad hoc versus scheduled encounters). Results suggest clinicians continued providing caregiver support despite suspension of in-person interactions, but future research is needed to assess the impacts of caregiver support delivery mostly by phone and factors underlying the limited use of video in delivering caregiver support.

What Is Important at the End of Life? Perspectives From Experienced Home Care Workers

Home care workers (HCWs) make up a large and rapidly growing sector of the American health care workforce serving older adults. This study focuses on a common but understudied feature of home care labor: workers’ thoughts around what makes a "good" or "bad" patient death. While researchers have investigated patients’, families’, physicians’, and other care providers’ perspectives on this issue, the perspectives of HCWs, who contribute substantially to home-based care at the end of life, have yet to be explored. We conducted 40 in-depth interviews with HCWs in New York City on their experiences with and reflections on patient death. We used a inductive, iterative approach to analyze data on what HCWs believe is important for dying patients. HCWs described EOL values that align well with the views held in common by patients, families, and other care providers, like the importance of not being alone when dying and being physically comfortable (not in pain and not suffering). In particular, HCWs conceptualized a detailed role for themselves when providing EOL care near the time of death. HCWs’ sustained presence and relationships with patients may uniquely position them to assist in the attainment of patients’ EOL goals, particularly when HCWs understand what these goals are. HCWs’ potential for playing this role, however, is jeopardized by a lack of training in EOL care and by the limited information they receive about a patient’s health status.

Rationale and Design of Distance-Based Training to Persuade Local Health Department Employees that Addressing Social Determinants of Health Is Their Job, Too

Public health workers in local health departments frequently rate skills needed to address social determinants of health among their top training needs. These workers have the ability to impact social determinants of health, but many may believe this responsibility is not part of their job description or that they do not have the necessary skills or resources. Guided by the Elaboration Likelihood Model of Persuasion and employing the case study method of instruction, the Region 2 Public Health Training Center designed a 45-minute, self-paced, online training module, titled Strategies to Advance Health Equity: How Health Departments Can Promote Living Wages, to persuade public health workers that addressing social determinants of health, especially those related to income disparities, is part of their day-to-day responsibilities. This article describes the module design, promising preliminary assessment data, and the formal evaluation plan.

Professional, friend or family?: How home care companies sell emotional care

While there is a growing literature on home care workers, less is known about how home care companies market their services. Through a content analysis of the 19 largest U.S. home care and home health providers' websites, we examined how companies describe services, desired outcomes of care, and job responsibilities and qualifications. Companies actively market family-like relationships as central to "good care". However, companies' emphasis on unmeasurable skills such as compassion and warmth may also create exploitative work environments. Supporting "good care" requires improved data collection, industry oversight, and policy change to recognize socio-emotional care and protect a marginalized workforce.