Social work services in home health care: challenges for the new prospective payment system era

Violations of workers' rights and exposure to work-related abuse of live-in migrant and live-out local home care workers - a preliminary study: implications for health policy and practice

BACKGROUND

Home care workers work in an isolated environment, with limited supervision and guidance which makes them more prone to abuse and exploitation. While past research focused mostly on the well-being of care recipients, this study aimed to shed light on the care workers' daily reality and explore if and how boundaries of professional care work are blurred. Our primary aim was to assess the working conditions and the prevalence of abuse and exploitation among live-in migrant home care workers and live-out local home care workers.

METHODS

A random stratified sample of Israeli older adults aged over 70, who are entitled by law to home care services was used to recruit 338 migrant live-in home care workers and 185 local live-out home care workers to a face-to-face survey. The participants were asked about their relationship with the care recipient and their exposure to violations of workers' rights and work-related abuse.

RESULTS

Almost all the participants reported exposure to certain workers' rights violations. Among the migrant live-in care workers, it was found that 58% of them did not receive any vacation days besides the weekly day-off, about 30% reported not get even a weekly day-off on a regular basis, and 79% did not get paid sick days. Local live-out care workers also suffered from a high prevalence of exploitation - 58% did not get any vacation days besides the weekly day-off, and 66% did not get paid sick leave. 20% of the local live-out care workers, and 15% of the migrant live-in care workers did not receive a signed contract. A smaller portion (7.4% among migrant care workers, 2.5% among local care workers) reported work-related abuse. When compared to local workers, migrant home care workers were more vulnerable to some worker's rights violations, as well as emotional abuse.

CONCLUSION

These findings are disturbing, as work-related abuse and exploitation affect not only the well-being of the care worker but also the health of the care recipients, as the quality of care provided deteriorates. At the public policy level, more significant attention and regulation of the home care industry is needed. The frequency and the nature of home visits made by home care agencies must be changed. Also, home care workers should be offered emotional support.

The Myriad Roles of the Home Care Social Worker

The home care social worker has many roles to play within the treatment milieu. This article briefly describes the primary roles of the home care social worker. Some of the roles are mandated by Medicare, and other roles are indigenous to the field of social work. The roles include direct service provider, advocate, community organizer, team educator, team consultant, and one who helps reduce health care costs.

Rural-urban differences in end-of-life care: implications for practice

Most older adults with advanced illnesses express the wish to die at home. Home-based care from home health and hospice agencies makes this possible, but there are great geographic variations in utilization. Interviews and focus groups with key constituents in home health and hospice agencies across the 8-county region of Western New York State were used to explore how rural-urban location and agency type (home health or hospice) influence variations in end-of-life care. Emergent themes were: Rural-Urban Differences (geographic challenges, market forces, and programming issues) and End-of-life Care Issues (macrosocial, mezzosocial, and microsocial factors). Implications for social work practice are discussed.

Psychosocial Care in Home Health Policy

As of summer 2008, health care reform has become an important part of the 2008 presidential election. However, long-term care has been absent in the discussion of health care reform by presidential candidates. This article examines policies that govern the payers of long-term care, specifically home health care (HHC). HHC is the fastest growing industry within long-term care, as there is a growing number of older adults in need of both skilled and unskilled home care. Medicare and Medicaid are the two major payers of HHC; yet these payers do not address the psychological and social needs of the patients. Furthermore, there is a long-term care disconnect between Medicare and Medicaid that creates even larger problems for older adults in need of long-term care.

Revaluing Social Work in Home Care: Lessons From Innovators, Rebels, and Hospice

The Medicare and Medicaid home health benefits are extensive programs covering more than 4 million persons, costing $13 billion annually. However, these benefits have limited social work coverage, representing only 1% to 2% of all Medicare and Medicaid home health visits, and social work is not a required service under Medicaid. There has been limited research addressing home care social workers' frustrations with unmet patient needs but no research on coping strategies social workers use to deal with the devalued status of social work in home care. This article presents the results of an interview-based pilot study of the topic, using a convenience sample of 14 home care social workers in New York City interviewed in 2006. Policy makers and practitioners should take guidance from the innovator and rebel social work types and from the Hospice Medicare Benefit and create a more robust social work—based psychosocial care component in Medicare and Medicaid home health care.

Actualizing “Professional Altruism”

The Medicare home health benefit and the Medicare Hospice Benefit (HMB) differ significantly in social work coverage, with social work being only 1%-2% of national Medicare home health visits compared to about 10% of national HMB visits. There has been some research on the frustrations of home care and hospice social workers. However, there is no research that compares home care and hospice social workers. The article presents results of convenience sample interviews of 34 home care social workers and 42 hospice social workers in New York City from August 2006 to October 2007. The analysis finds that, in contrast to home health social workers, hospice social workers feel more able to actualize their altruism professionally; their professional training is more relevant to actual practice; their patients and caregivers have fewer unmet psychosocial needs; and their care is less constrained, and actually enhanced to a great extent, by payer requirements.

Advancing the evidence base for social work in long-term care: the disconnect between practice and research

This article reviews the research literature relative to social work practice in geriatric long-term care (LTC) settings with the aim of determining the state of the evidence base for practice. Overall, this body of research supports the efficacy of social work services within the context of community-based case management and interdisciplinary models of geriatric intervention; however, there is less evidence of a discipline-specific contribution, particularly in institutional health care settings (e.g., nursing homes and hospitals) where a great number of gerontological social workers are employed. Implications of this review include the need to prioritize research within gerontological social work in order to enhance best practice knowledge and skills in settings where it is most needed.

The unmet needs of the elderly with diabetes in home health care

The implementation of the Prospective Payment System (PPS) in Medicare home health care has raised concern about health outcomes of elderly patients since its intention is to curb spending. This study examines the unmet needs of older diabetic patients while receiving home health care and post-discharge from home health care (N = 129) in order to explore any effects of PPS on patients' need. The study found that a higher proportion of elders had unmet needs 30 days post-discharge compared with while receiving home health care. The specific unmet needs identified by the elderly diabetic patients included social work services, home health aide, homemaker services, and need for medical equipment. The study explores the role of social work to better manage the unmet needs of diabetic elders who live in the community.

Unmet patient need in home care under managed care

Social workers in home care agencies obtained through a national random sample responded to a mail questionnaire that examined the relationship between the frequency of discharge with unmet patient need and patient/family characteristics, agency auspice, and practice activities when social workers' assessment of patient needs and managed care payment limits conflict. Regression analysis found that the importance of social work financial planning with clients and intra-agency advocacy were significant negative contributors, and patient cognitive impairment, inadequate family care, and agency auspice were significant positive contributors to a regression model explaining 31 percent of the variance in the frequency of discharge with unmet need. Implications for practice, education, and research are discussed.

Managed care in home health: social work practice and unmet client needs

Findings from a sample (n = 117) obtained through a survey mailed to a random sampling of social workers in home health agencies nation-wide suggest that the characteristics of patients discharged with unmet needs were psychosocial. Social work practice activities targeted transferring responsibility for care for patients from agencies and government/commercial third party payers to informal caregivers and community resources. Desired continuing education topics evidence the emphasis on effective interventions that facilitate discharge, interdisciplinary collaboration and practice evaluation.

Home Health Outcomes: A Systems Perspective

This article describes barriers to successful patient outcomes in home health care from a systems perspective and provides suggestions to remove these barriers. The barriers that are discussed include processes for collecting assessment data, referral procedures for patient access to medical social services, and changes in Medicare’s home health funding structure.