As the locus of long-term care for an aging population shifts from institutions to the community, older adults are increasingly reliant on home care workers for everything from their physical health to social needs to psychological well-being. Yet little is known about how the home care experience affects patient outcomes, as detailed information is rarely collected and synthesized into clinical studies.
The Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai is helping to fill that void with a comprehensive new study offering important insights into the critical role home care worker continuity plays in enabling older adults to successfully age in place.
The study, published in Innovation in Aging this past February, calls for enhanced training and a “reconceptualization” of the essential role these paraprofessionals play in providing psychosocial and other forms of support to individuals under their care, many of them with severe cognitive and functional impairment.
“We need a reconceptualization of paid caregivers not as interchangeable paraprofessionals, but as key members of the care team whose support profoundly affects the health and well-being of the clients they serve,” says Jennifer Reckrey, MD, Associate Professor, Brookdale Department of Geriatrics and Palliative Medicine. “They should be recognized and valued for the daily contributions they make, which goes beyond the realm of just personal care.”
“Our study found that receiving long-term care from the same home-based workers over time may be a key contributor to better health and well-being for older adults,” says lead author Jennifer Reckrey, MD, Associate Professor in the Brookdale Department, who has conducted extensive research into the changing role of paid caregivers such as home health aides and personal care attendants. “Greater worker continuity was associated with better client outcomes, including fewer falls, greater improvement and stabilization in daily activities, and fewer depressive symptoms.”
For their retrospective study, researchers reviewed records for 3,864 individuals living in New York City whose long-term home care was funded by Medicaid. They found particularly disconcerting that cognitive impairment was associated with discontinuity of care; patients with cognitive issues may be less able to direct new home care workers to perform needed tasks and more susceptible to negative outcomes when usual routines are altered.
“Continuity strengthens therapeutic relationships by allowing providers to earn the trust of their clients and increase their knowledge of the patient’s health and daily care needs,” says Dr. Reckrey. “If a new person is brought onboard, the relationship has to be built from scratch since the rhythm is broken, and mistakes can be made and important care cues missed.”
There are an estimated 2.8 million paid home care workers in the United States, roughly half of them government-funded (primarily by Medicaid) and the remainder through private sources. Training of this sector’s employees by the licensed agencies that typically hire them is minimal, and the annual turnover is around 65 percent, according to the Home Care Association of America. Factors contributing to this extraordinary churn include low wages, few or no benefits, an itinerant workforce, and the considerable challenge of caring for individuals who often have dementia and exhibit behavioral symptoms such as agitation, aggression, and confusion.
Against that backdrop, Dr. Reckrey and her team called for a basic reframing of the way we think about and value the work of home care workers.
“We need a reconceptualization of paid caregivers not as interchangeable paraprofessionals, but as key members of the care team whose support profoundly affects the health and well-being of the clients they serve,” she says. “They should be recognized and valued for the daily contributions they make, which goes beyond the realm of just personal care.”
The role of the home-based caregiver is becoming increasingly vital to an aging population as its members become sicker and, at the same time, more committed to living their final years at home. Which is why the home care field needs to pay much greater attention to promoting psychosocial care in terms of research, practice, and skills training that is more rigorous and ongoing, according to Dr. Reckrey.
“If we want older adults to live in the community longer, then it will require more and more meaningful relationships with caregivers,” she says. “When the home care worker is engaged with the client in meaningful activities, it affects in a very positive way depression, loneliness, and other psychological outcomes. As our study makes clear, we simply can’t afford to ignore the human factor.”