"It's Like They Forget That the Word 'Health' Is in 'Home Health Aide'": Understanding the Perspectives of Home Care Workers Who Care for Adults With Heart Failure

Having a Say in Patient Care: Factors Associated with High and Low Voice among Home Care Workers

OBJECTIVES

To identify factors associated with high and low "voice"-or level of input in patient care decisions-among home care workers (HCWs), an often marginalized workforce that provides care in the home to older adults and those with chronic conditions.

DESIGN

We conducted a secondary analysis of data from a cross-sectional survey assessing experiences of HCWs in caring for adults with heart failure. The survey measured HCWs' voice using a validated, 5-item instrument.

SETTING AND PARTICIPANTS

The survey was conducted virtually from June 2020 to July 2021 in partnership with the 1199 Service Employees International Union (1199SEIU) Training and Employment Funds, a union labor management fund. English- or Spanish-speaking HCWs employed by a certified or licensed home care agency in New York, NY, were eligible.

METHODS

HCW voice was the main outcome of interest, which we assessed by tertiles (low, medium, and high, with medium as the referent group). Using multinominal logistic regression, we calculated odds ratios (ORs) and 95% CIs for the relationship between participant characteristics and low and high levels of voice.

RESULTS

The 261 HCWs had a mean age of 48.4 years (SD 11.9), 96.6% were female, and 44.2% identified as Hispanic. A total of 38.7% had low voice, 37.9% had medium voice, and 23.4% had high voice. In the adjusted model, factors associated with low voice included Spanish as a primary language (OR 3.71, P = .001), depersonalization-related burnout (OR 1.14, P = .04), and knowing which doctor to call (OR 0.19, P < .001). Factors associated with high voice included Spanish as a primary language (OR 2.61, P = .04) and job satisfaction (OR 1.22, P = .001).

CONCLUSIONS AND IMPLICATIONS

Organizational factors such as team communication practices-including among non-English speakers-may play an important role in HCW voice. Improving HCW voice may help retain HCWs in the workforce, but future research is needed to evaluate this.

"I'll fill in the gaps": perspectives of HHAs on promoting aging in place for older adults with low incomes

Older adults with low incomes experience disproportionate rates of cognitive and functional impairment and an elevated risk of nursing home admission. Home health aides (HHAs) may have insight into how to optimize aging in place for this population, yet little is known about HHAs' perspectives on this topic. We conducted 6 focus groups with 21 English-speaking and 10 Spanish-speaking HHAs in Pennsylvania and New Jersey. Transcripts were analyzed using qualitative thematic analysis, and three themes emerged. First, HHAs described the uniqueness of their role within multidisciplinary care teams. Second, HHAs shared concrete interventions they employ to help their clients improve their function at home. Third, HHAs discussed barriers they face when helping clients age in place. Our findings suggest that HHAs have important insights into improving aging in place for older adults with low incomes and that their perspectives should be incorporated into care planning and intervention delivery.

Paid Care for People with Functional Impairment and Serious Illness: Results from the Health and Retirement Study

BACKGROUND

Paid caregivers (e.g., home health aides) care for individuals living at home with functional impairment and serious illnesses (health conditions with high risk of mortality that impact function and quality of life).

OBJECTIVE

To characterize those who receive paid care and identify factors associated with receipt of paid care in the context of serious illness and socioeconomic status.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Community-dwelling participants ≥ 65 years enrolled in the Health and Retirement Study (HRS) between 1998 and 2018 with new-onset functional impairment (e.g., bathing, dressing) and linked fee-for-service Medicare claims (n = 2521).

MAIN MEASURES

Dementia was identified using HRS responses and non-dementia serious illness (e.g., advanced cancer, end-stage renal disease) was identified using Medicare claims. Paid care support was identified using HRS survey report of paid help with functional tasks.

KEY RESULTS

While about 27% of the sample received paid care, those with both dementia and non-dementia serious illnesses in addition to functional impairment received the most paid care (41.7% received ≥ 40 h of paid care per week). In multivariable models, those with Medicaid were more likely to receive any paid care (p < 0.001), but those in the highest income quartile received more hours of paid care (p = 0.05) when paid care was present. Those with non-dementia serious illness were more likely to receive any paid care (p < 0.001), but those with dementia received more hours of care (p < 0.001) when paid care was present.

CONCLUSIONS

Paid caregivers play a significant role in meeting the care needs of those with functional impairment and serious illness and high paid care hours are common among those with dementia in particular. Future work should explore how paid caregivers can collaborate with families and healthcare teams to improve the health and well-being of the seriously ill throughout the income spectrum.

Having a Say Matters: The Association Between Home Health Aides' Voice and Job Satisfaction

Purpose

Despite a rapidly growing need for home health aides (HHAs), turnover rates are high. While this is driven in large part by the demanding nature of their work and low wages, another factor may be that HHAs are often not considered part of the medical team which can leave them feeling unheard by other healthcare professionals. We sought to determine whether this concept, or HHAs' perceived voice, was associated with job satisfaction.

Methods and Design

This cross-sectional survey of English- and Spanish-speaking HHAs caring for adults with heart failure (HF) was conducted from June 2020 to July 2021 in New York, NY in partnership with a labor management fund of a large healthcare union that provides benefits and training to HHAs. Voice was assessed with a validated 5-item scale (total score range 5 to 25). Job Satisfaction was assessed with the 5-item Work Domain Satisfaction Scale (total score range 5 to 35). Multivariable linear regression analysis was used to examine the association between voice and job satisfaction.

Results

A total of 413 HHAs employed by 56 unique home care agencies completed the survey; they had a mean age of 48 years, 97.6% were female, 60.2% were Hispanic, and they worked as HHAs for a median of 10 years (IQR, 5, 17). They had a median Voice score of 18 (IQR 15-20) and mean job satisfaction score of 26.4 (SD 5.6). Higher levels of voice (1.75 [0.46-3.04]) were associated with greater job satisfaction (p=0.008). When adjusting for Race/Ethnicity, HF training, and HF knowledge, the association between Voice and job satisfaction remained significant ((1.77 [0.40-3.13]).

Conclusion

HHAs with a voice in the care of their patients experienced greater job satisfaction. Voice may be an important target for interventions aiming to improve HHAs' retention in the field.

Home Health Care Workers' Interactions with Medical Providers, Home Care Agencies, and Family Members for Patients with Heart Failure

BACKGROUND

Despite providing frequent care to heart failure (HF) patients, home health care workers (HHWs) are generally considered neither part of the health care team nor the family, and their clinical observations are often overlooked. To better understand this workforce's involvement in care, we quantified HHWs' scope of interactions with clinicians, health systems, and family caregivers.

METHODS

Community-partnered cross-sectional survey of English- and Spanish-speaking HHWs who cared for a HF patient in the last year. The survey included 6 open-ended questions about aspects of care coordination, alongside demographic and employment characteristics. Descriptive statistics were performed.

RESULTS

Three hundred ninety-one HHWs employed by 56 unique home care agencies completed the survey. HHWs took HF patients to a median of 3 doctor appointments in the last year with 21.9% of them taking patients to ≥ 7 doctor appointments. Nearly a quarter of HHWs reported that these appointments were in ≥ 3 different health systems. A third of HHWs organized care for their HF patient with ≥ 2 family caregivers.

CONCLUSIONS

HHWs' scope of health-related interactions is large, indicating that there may be novel opportunities to leverage HHWs' experiences to improve health care delivery and patient care in HF.

"I Depend on Her for Everything": A Retrospective Chart Review of Home Care Worker Service Disruptions for Homebound Older Adults During the COVID-19 Pandemic

Home care workers played critical roles in meeting the complex medical and social needs of homebound adults during COVID-19, yet their contributions remain underappreciated. This study characterizes home care workers' roles during COVID-19 and examines how home care disruptions impacted homebound individuals and caregivers. Using a qualitative analysis of electronic medical records among a randomly sampled subset of homebound patients in a home-based primary care practice, we found that home care workers were essential in meeting existing and new needs of homebound individuals. Insufficient home care worker services, including unstable schedules and inadequate hours of paid care, became particularly disruptive, leading to risks for patients and their caregivers. Given their integral role on care teams, home care workers must be a policy focus to prepare for emergent situations and ensure that homebound individuals have access to high quality, stable home care.

Making a Bad Situation Worse: Examining the Challenges Facing Rural Home Care Workers

This study examines the unique challenges facing rural home care workers. Semi-structured interviews were undertaken between July 2021 and February 2022 with 23 participants that have experience in rural home care delivery. The major challenge confronting rural home care workers involved distance and transportation. This challenge emerged due to long distance between clients, unreliable vehicles, inadequate reimbursement, and inclement weather. In turn, this challenge exacerbated three other types of challenges facing rural home care workers: workforce challenges that consisted of a persistent labor shortage and shorter visits that forced workers to rush through tasks, client isolation due to the social and physical seclusion of households, and the poor working conditions of home care work more broadly. Without policy interventions that respond to these particular challenges, the care gap in rural areas can be expected to grow.

The Need for Stability in Paid Dementia Care: Family Caregiver Perspectives

Paid caregivers (e.g., home health aides, home care workers) provide essential care to people with dementia living at home; this study explored family caregiver perspectives on the role and impact of paid caregivers in home-based dementia care. We conducted semi-structured interviews with family caregivers (n = 15) of people with advanced dementia who received long-term paid care at home in New York between October 2020 and December 2020. We found that given the vulnerability resulting from advanced dementia, family caregivers prioritized finding the "right" paid caregivers and valued continuity in the individual providing care. The stable paid care that resulted improved outcomes for both the person with advanced dementia (e.g., eating better) and their family (e.g., ability to work). Those advocating for high quality, person-centered dementia care should partner with policymakers and home care agencies to promote the stability of well-matched paid caregivers for people with advanced dementia living at home.

Better Preparation and Training Determine Home Care Workers' Self-Efficacy in Contributing to Heart Failure Self-Care

OBJECTIVE

Identify determinants of home care workers' (HCW) self-efficacy in contributing to heart failure (HF) self-care.

METHODS

Secondary analysis of a survey (n = 328) examining characteristics of HCWs caring for adults with HF in New York. Self-efficacy assessed using Caregiver Self-Efficacy in Contributing to Self-Care Scale. Standardized scores range 0-100; ≥ 70 points indicate adequate self-efficacy. Characteristics determined by self-efficacy (low vs. adequate). Prevalence ratios with 95% confidence intervals (PR [95% CI]) were estimated using multivariable Poisson regression with robust standard errors.

RESULTS

Home care workers with adequate self-efficacy had at least some prior HF training (55% vs. 17%, p < .001) and greater job satisfaction (90% vs. 77%, p = .003). Significant determinants for adequate self-efficacy were employment length (1.02 [1.00-1.03], p = .027), preparation for caregiving (3.10 [2.42-3.96], p < .001), and HF training (1.48 [1.20-1.84], p < .001).

CONCLUSION

Home care agencies and policy-makers can target caregiving preparation and HF training to improve HCWs' confidence in caring for adult HF patients.

Does Connectedness Matter? The Association Between Mutuality and Job Satisfaction Among Home Health Aides Caring for Adults With Heart Failure

Home health aides (HHAs) provide care to many adults with heart failure (HF) in the home. As the demand for HHAs increases, there is a need to promote HHAs' job satisfaction and retention. In this cross-sectional community-partnered study, we examined whether mutuality (e.g., quality of the HHA-patient relationship), is associated with job satisfaction among HHAs caring for adults with HF. Mutuality was assessed with the Mutuality Scale, which measures overall mutuality and its four domains (reciprocity, love and affection, shared pleasurable activities, and shared values). Our final sample of 200 HHAs was primarily female. The mean overall mutuality score was 2.92 out of 4 (SD 0.79). In our final model, overall mutuality and each of the four domains were associated with increased job satisfaction; however, only the shared pleasurable activities domain was significant (aPR: 1.15 [1.03-1.32]). Overall, mutuality may play a role in promoting job satisfaction among HHAs.

Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care

BACKGROUND

Older adults see multiple outpatient providers and increasingly use home health care (HHC) services. Previous studies attempting to draw inferences about the association between HHC use and patient outcomes have been mixed. Whether HHC is associated with care coordination and how both influence outcomes are unknown. In addition, prior studies have not taken the patient perspective into account. We examined the association between receiving HHC and self-reported gaps in care coordination and separately, preventable adverse outcomes.

METHODS

The analysis for this cross-sectional study was conducted between October 2021 and June 2022, using data on 4296 Medicare beneficiaries from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who completed a survey on care coordination from 2017 to 2018. The associations between the receipt of HHC and two outcomes (a gap in care coordination, and separately, a preventable adverse event) were examined with Poisson models with robust standard errors. Potential confounders were accounted for through propensity score-based inverse probability weighting.

RESULTS

Among 4296 participants, 430 (10%) received HHC and they were older and had more comorbidities and ambulatory visits than those without HHC. HHC was not associated with differences in self-reported gaps in care coordination (33.3% HHC vs. 32.5% no-HHC, p = 0.70). HHC recipients reported more preventable drug-drug interactions (9.1% vs. 4.0%, p < 0.001) but not more preventable ED visits or hospital admissions. In IPW-adjusted models, HHC was not associated with gaps in care coordination (p = 0.60) but was associated with double the risk of a preventable adverse outcome (aRR 2.06; CI: 1.37, 3.10, p < 0.001).

CONCLUSIONS

HHC recipients were significantly more likely (than those without HHC) to report a potentially preventable adverse event (particularly a drug-drug interaction), suggesting an opportunity to improve patient safety by leveraging the observations of older adults receiving HHC.

Development and Piloting of a Community-Partnered Heart Failure Training Course for Home Health Care Workers

BACKGROUND

Despite their unique contributions to heart failure (HF) care, home healthcare workers (HHWs) have unmet educational needs and many lack HF caregiving self-efficacy. To address this, we used a community-partnered approach to develop and pilot a HF training course for HHWs.

METHODS

We partnered with the Training and Employment Fund, a benefit fund of the largest healthcare union in the United States, to develop a 2-hour virtual HF training course that met HHWs' job-specific needs. English and Spanish-speaking HHWs interested in HF training, with access to Zoom, were eligible. We used a mixed methods design with pre/postsurveys and semi-structured interviews to evaluate the course: (a) feasibility, (b) acceptability, and (c) effectiveness (change in knowledge [Dutch Heart Failure Knowledge Scale range 0-15] and caregiving self-efficacy [HF Caregiver Self-efficacy Scale range 0-100]).

RESULTS

Of the 210 HHWs approached, 100 were eligible and agreed, and 70 enrolled. Of them, 53 (employed by 15 different home care agencies) participated. Posttraining data showed significant improvements (pretraining mean [SD] versus posttraining mean [SD]; P value) in HF knowledge (11.21 [1.90] versus 12.21 [1.85]; P=0.0000) and HF caregiving self-efficacy (75.21 [16.57] versus 82.29 [16.49]; P=0.0017); the greatest gains occurred among those with the lowest pre-training scores. Participants found the course engaging, technically feasible, and highly relevant to their scope of care.

CONCLUSIONS

We developed and piloted the first HF training course for HHWs, which was feasible, acceptable, and improved their HF knowledge and caregiving self-efficacy. Our findings warrant scalability to the workforce at large with a train-the-trainer model.

Addressing the Home Care Shortage: Predictors of Willingness to Provide Paid Home Care in New York

OBJECTIVES

To determine the prevalence and predictors of willingness to consider becoming a paid home care worker.

DESIGN

Cross-sectional telephone-based survey study.

SETTING AND PARTICIPANTS

800 adult residents of New York State participating in the 2020 Empire State Poll, an annual survey conducted in English and Spanish using random-digit dialing.

METHODS

Willingness to consider working as a paid home care worker was analyzed as the main outcome. Survey questions also involved demographics and unpaid caregiving experience. We used multinomial logistic regression to examine associations between participant characteristics and willingness to be a paid caregiver.

RESULTS

Participants had a mean age of 47.7 years (95% CI 45.4-50.0). Demographic information included 51.1% female gender, 65.4% White race, 13.4% Black race, 6.4% Asian or Pacific Islander, 14.8% another race, 19.1% Hispanic/Latino ethnicity, and 43.0% household income below $50,000 per year. A weighted 25.4% of participants would consider becoming a paid home care worker. In an adjusted model, willingness to be a paid home care worker was associated with younger age [odds ratio (OR) 0.98, 95% CI 0.96-1.00, P = .032], female gender (OR 2.46, 95% CI 1.35-4.46, P = .003), Black or other race (OR 2.40, 95% CI 1.11-5.17, P = .026, and OR 3.13, 95% CI 1.30-7.54, P = .011, respectively), Hispanic ethnicity (OR 2.26, 95% CI 1.06-4.81, P = .035), household income below $50,000 per year (OR 2.00, 95% CI 1.03-3.88, P = .040), and having provided unpaid family caregiving (OR 2.08, 95% CI 1.15-3.76, P = .016).

CONCLUSIONS AND IMPLICATIONS

A quarter of New Yorkers would consider working as a paid home care worker. Willingness to consider this occupation was associated with the demographic characteristics disproportionately represented in the current home care workforce. Improved working conditions and compensation could help attract and retain home care workers, thereby addressing the rising need for home care in the United States.

"I found myself alone" - A phenomenological study of the home care workers' experience during the COVID-19 pandemic

Home care workers (HCWs) are a highly heterogeneous population in Italy in terms of their professional qualifications. HCWs play an important role in helping patients affected by chronic diseases and their families. Although many investigators have studied the lived experiences of family caregivers, few have been conducted "to give a voice" to HCWs and even fewer have examined the experiences of HCWs during the present COVID-19 pandemic. We investigated the lived experiences of HCWs during the first wave of the pandemic in Italy. Cohen's phenomenological research approach was used to conduct this study. In our study, we enrolled and interviewed 19 HCWs who were female, and most were married, with an average age of 52 years. The participants were enrolled from September 2020 to November 2020, after the first COVID-19 wave in Italy. Four main themes emerged from the analysis of the data: (1) "I found myself alone"; (2) from invisibility to visibility; (3) a fear of getting sick and infecting others; and (4) "Health or work? That is the question." Understanding HCWs' lived experiences, especially those related to the COVID-19 pandemic, is a first step in giving a voice to this important but vulnerable population in the healthcare workforce.

Home Health Aides' Increased Role in Supporting Older Veterans and Primary Healthcare Teams During COVID-19: a Qualitative Analysis

BACKGROUND

Home health aides are important but often overlooked members of care teams, providing functional and emotional support to patients. These services became increasingly important during the COVID-19 pandemic as older adults faced disruptions in in-person medical services and family caregiving. Understanding how aides supported healthcare teams is important for informing emergency planning and better integrating home health services with primary care.

OBJECTIVE

To describe aides' roles in supporting veterans and working with primary care teams during COVID-19 and identify COVID-related changes in tasks.

DESIGN

Semi-structured interviews.

PARTICIPANTS

Eight home health aides, 6 home health agency administrators, and 9 primary care team members (3 RNs, 3 social workers, 3 MDs) serving veterans at a large, urban, Veterans Affairs medical center.

APPROACH

Combined deductive and inductive analysis to identify a priori concepts (aide roles; changes in tasks and new tasks during COVID-19) and emergent ideas. Aide, administrator, and provider interviews were analyzed separately and compared and contrasted to highlight emergent themes and divergent perspectives.

KEY RESULTS

Participants reported an increase in the volume and intensity of tasks that aides performed during the pandemic, as well as the shifting of some tasks from the medical care team and family caregivers to the aide. Four main themes emerged around aides' roles in the care team during COVID-19: (1) aides as physically present "boots on the ground" during medical and caregiving disruptions, (2) aides as care coordination support, (3) aides as mental health support, and (4) intensification of aides' work.

CONCLUSIONS

Home health aides played a central role in coordinating care during the COVID-19 pandemic, providing hands-on functional, medical, and emotional support. Integrating aides more formally into healthcare teams and expanding their scope of practice in times of crisis and beyond may improve care coordination for older veterans.

Eliciting the educational priorities of home care workers caring for adults with heart failure

BACKGROUND

Although home care workers (HCWs) are increasingly caring for adults with heart failure (HF), many feel unprepared and lack HF training. To serve as the foundation for a future educational intervention, we aimed to elicit HCWs' HF educational needs.

METHODS

We partnered with the largest healthcare union in the US to recruit 41 HCWs employed by 17 home care agencies. Using the nominal group technique, we asked HCWs to respond to three questions: When caring for an HF patient: (1) What information do you want? (2) What symptoms worry you? (3) What situations do you struggle with? Participants ranked their responses by priority. Data were consolidated by question.

RESULTS

For question 1, participants ranked HF signs and symptoms most highly, followed by HF treatment and medications. For question 2, chest pain was most worrisome, followed by neurologic changes and shortness of breath. For question 3, participants struggled with encouraging patients to follow a heart-specific diet.

CONCLUSIONS

HCWs expressed a need to learn more about signs and symptoms of HF and ways to assist patients with HF self-care. These findings can inform the development of an HF training program for HCWs that specifically addresses their expressed needs.

Utilization, Contributions, and Perceptions of Paid Home Care Workers among Households in New York State

Background and Objectives

While family caregivers have traditionally provided care for older adults with chronic conditions and disabilities, the demand for paid home care workers has increased in the last decade. Although typically thought to assist with personal care, emerging data suggest that paid home care workers assist with a wider scope of care. However, the extent and quality of the care they deliver remains poorly understood.

Research Design and Methods

Using the Empire State Poll, a telephone-based cross-sectional survey of 800 adults in New York State, we characterized the types of care that paid home care workers provided and the perceived value of that care.

Results

Of 800 participants surveyed, 274 reported that they or an immediate family member received care from a paid home care worker (34.3%). Of these, the majority (73.9%) reported that paid home care workers provided emotional and/or medical care, in addition to personal care. In adjusted models, providing emotional and medical care (compared to personal care alone) was associated with nearly a twofold greater perception of importance and experience by the care recipients.

Discussion and Implications

Our findings provide additional data on how paid home care workers contribute to patient care, from the perspective of the care recipient(s). The type of care provided is associated with varying magnitudes of perceived quality. Although limited to New York, these findings have implications for paid home care workers’ training and compensation. Future studies are warranted to investigate the specific factors that mediate the association between types of care provided and their perceived value.

Barriers and Benefits of Information Communication Technologies Used by Health Care Aides

BACKGROUND

Although information and communication technologies (ICT) are becoming more common among health care providers, there is little evidence on how ICT can support health care aides. Health care aides, also known as personal care workers, are unlicensed service providers who encompass the second largest workforce, next to nurses, that provide care to older adults in Canada.

OBJECTIVE

The purpose of this literature review is to examine the range and extent of barriers and benefits of ICT used by health care workers to manage and coordinate the care-delivery workflow for their clients.

METHODS

We conducted a literature review to examine the range and extent of ICT used by health care aides to manage and coordinate their care delivery, workflow, and activities. We identified 8,958 studies of which 40 were included for descriptive analyses.

RESULTS

We distinguished the following five different purposes for the use and implementation of ICT by health care aides: (1) improve everyday work, (2) access electronic health records for home care, (3) facilitate client assessment and care planning, (4) enhance communication, and (5) provide care remotely. We identified 128 barriers and 130 benefits related to adopting ICT. Most of the barriers referred to incomplete hardware and software features, time-consuming ICT adoption, heavy or increased workloads, perceived lack of usefulness of ICT, cost or budget restrictions, security and privacy concerns, and lack of integration with technologies. The benefits for health care aides' adoption of ICT were improvements in communication, support to workflows and processes, improvements in resource planning and health care aides' services, and improvements in access to information and documentation.

CONCLUSION

Health care aides are an essential part of the health care system. They provide one-on-one care to their clients in everyday tasks. Despite the scarce information related to health care aides, we identified many benefits of ICT adoption.

The Influence of Preparedness, Mutuality, and Self-efficacy on Home Care Workers' Contribution to Self-care in Heart Failure: A Structural Equation Modeling Analysis

BACKGROUND

Home care workers (HCWs) are increasingly caring for patients with heart failure (HF). Previous studies have shown that they contribute to HF patients' care, but how their preparedness and their relationship with patients (mutuality) influence caregiving is unknown, as well as the role of HCWs' self-efficacy.

OBJECTIVE

Guided by the Situation-Specific Theory of Caregiver Contribution to HF Self-Care, we investigated the influence of HCWs' preparedness and mutuality on HCWs' contribution to HF self-care and the mediating effect of HCWs' self-efficacy in the process.

METHODS

We conducted a cross-sectional survey of HCWs who cared for patients with HF. The survey included the Caregiver Preparedness Scale, Mutuality Scale, Caregiver Contribution to Self-Care of HF Index, and Caregiver Self-Efficacy in Contributing to Self-Care Scale. We performed structural equation modeling and a mediation analysis.

RESULTS

A total of 317 HCWs employed by 22 unique home care agencies across New York, NY, completed the survey. They had a median age of 50 years, 94% were women, and 44% were non-Hispanic Black. Results demonstrated that mutuality had a direct influence on HCW contribution to self-care and preparedness influenced their contribution to self-care, but only through the mediation of self-efficacy.

CONCLUSION

Home care workers' preparedness, mutuality, and self-efficacy have important roles in influencing their contribution to HF self-care. As a workforce increasingly involved in the care of patients with HF, knowing the mechanisms underpinning HCWs' contribution to self-care may illuminate future interventions aimed at improving their contributions and HF patient outcomes.

Family assistants' living and working conditions and their interaction with patient and family caregiver variables

BACKGROUND AND AIM

The progressive and constant aging of the global population together with the economy crises and the social variations within family contexts increasingly leads to the use of external resources (Home Care Workers, HCWs) for health care within one's own family of origin. Purpose of the study is to describe Italian Home Care Workers' (HCWs) living and working conditions and understand the interactions with outcomes of the patients and informal caregiver.

METHODS

Observational study with cross sectional design to evaluate the interaction of HCWs without specific training on patients and informal caregivers' outcomes.

RESULTS

understand Italian HCWs' condition and interaction between these conditions and outcomes of patients and informal caregiver.

CONCLUSIONS

understanding how HCWs' conditions can affect outcome about patient and informal caregivers, represents a fundamental step in order to increase QoL of these families.

Family Caregiver Perspectives on Benefits and Challenges of Caring for Older Adults With Paid Caregivers

BACKGROUND

Many older adults receive help from both family caregivers and home care workers. We aimed to understand family caregivers' perspectives on home care workers.

METHODS

This qualitative study took place at an academic medical center in New York, N.Y. We interviewed family caregivers of community-dwelling older adults about their experiences with home care workers. We analyzed transcripts thematically.

RESULTS

We interviewed 17 family caregivers and identified four major themes: (a) home care workers provide functional and emotional support; (b) home care is logistically challenging; (c) finding the right fit between home care workers, older adults, and families is essential; and (d) home care workers and family caregivers coordinate care well beyond the initiation of home care.

CONCLUSION

Despite its logistical challenges, home care benefits patients and family caregivers. Given the growing prevalence of caregiving, clinicians and family caregivers might benefit from training and support about working with home care workers.

Home health aide perceived information needs for dementia-specific care plans

Home health aides (HHAs) are a vital workforce essential to meet the complex care needs of the persons living with dementia (PLWD) who remain at home. Care plans for PLWD in the home healthcare setting should incorporate HHAs perspectives. We sought to understand HHAs' perspectives about their information needs in caring for PLWD, from June to August 2020, semi-structured interviews telephone interviews (n = 25) with English and Spanish-speaking HHAs with limited English proficiency in the New York metropolitan area. Interviews were audio-recorded, transcribed verbatim and transcripts were analyzed using conventional content analysis. Four key themes emerged reflective of information needs of HHAs caring for PLWD: (1) ambiguities of scope of HHA tasks related to medication management; (2) clinical information needs of HHAs; (3) dementia-related concerns; and (4) going above and beyond. Findings from this research can guide efforts to develop dementia-specific care plans, and training to support the HHA workforce caring for the growing population of PLWD.

All alone: A qualitative study of home health aides' experiences during the COVID-19 pandemic in New York

BACKGROUND

Despite their integral role, Home Health Aides (HHAs) are largely unrecognized as essential to implementing effective infection prevention and control practices in the home healthcare setting. We sought to understand the infection prevention and control needs and challenges associated with caring for patients during the pandemic from the perspective of HHAs.

METHODS

From June to August 2020, data were collected from HHAs in the New York metropolitan area using semi-structured qualitative interviews by telephone; 12 HHAs were interviewed in Spanish. Audio-recorded interviews were transcribed, translated and analyzed using conventional content analysis.

RESULTS

In total, 25 HHAs employed by 4 unique home care agencies participated. HHAs had a mean age of 49.8 (± 9.1), 24 (97%) female, 11 (44%) Black, 12 (48%) Hispanic. Three major themes related to the experience of HHA's working during the COVID-19 pandemic emerged: (1) all alone, (2) limited access to information and resources, and (3) dilemmas related to enhanced COVID-19 precautions. Hispanic HHAs with limited English proficiency faced additional difficulties related to communication.

CONCLUSIONS

We found that HHA communication with nursing staff, plays a key role in infection control efforts in home care. Efforts to manage COVID-19 in home care should include improving communication between HHAs and nursing staff.

Eliciting the educational needs and priorities of home care workers on end-of-life care for patients with heart failure using nominal group technique

BACKGROUND

Home care workers, as paid caregivers, assist with many aspects of home-based heart failure care. However, most home care workers do not receive systematic training on end-of-life care for heart failure patients.

AIM

To elicit the educational needs and priorities of home care workers caring for community- dwelling adults with heart failure at the end-of-life.

DESIGN

Nominal group technique involving a semi-quantitative structured group process and point rating system was used to designate the importance of priorities elicited from home care workers. Individual responses to the question, "If you have ever cared for a heart failure patient who was dying (or receiving end-of-life care on hospice), what are some of the challenges you faced?", were aggregated into categories using directed content analysis methods.

SETTING/PARTICIPANTS

Forty-one home care workers were recruited from a non-profit training and education organization in New York City.

RESULTS

Individual responses to the question were aggregated into five categories: (1) how to cope and grieve; (2) assisting patients with behavior changes, (3) supporting patients to improve their quality of life, (4) assisting patients with physical symptom management, and (5) symptom recognition and assessment.

CONCLUSIONS

Our findings confirm the need for the formal development and evaluation of an educational program for home care workers to improve the care of heart failure patients at the end-of-life. There is also a need for research on integrating home care workers into the interprofessional healthcare team to support optimal health outcomes for patients with heart failure.

Filling a gap in standardized nursing terminology. Development of a new nursing diagnosis proposal on heart failure self-care

PURPOSE

Heart failure is a highly prevalent chronic health problem associated with poor quality-of-life and negative outcomes. Self-care is a cornerstone in patients suffering from heart failure. Nurses are commonly engaged in enhancing patients' self-care behaviors, but the specific condition of deficit on self-care is not clearly identified by nurses. No nursing diagnoses focused on self-care of heart failure patients is currently available. This study aimed to develop a new nursing diagnosis that focuses on self-care in heart failure patients.

DATA SOURCES

A concept and content analysis were used. Some steps of the concept analysis were performed through an integrative literature review conducted searching in PUBMED and CINAHL databases to identify attributes, antecedents, and consequences of the diagnosis. Forty-five articles were selected from the 1450 studies found. Then, the content analysis was performed by an international panel of 29 experts. Two Delphi rounds were used to achieve consensus and an item content validity index was calculated for each diagnostic element.

DATA SYNTHESIS

Integrative review proposed four diagnostic labels, two definitions, 15 defining characteristics, and 44 related factors. After the two Delphi rounds a consensus was reached for each diagnostic indicator with a content validity index ranging from 82.8% to 100%. The nursing diagnosis-labeled heart failure self-care deficit-was validated with a definition, eight defining characteristics, 15 related factors, and five at-risk populations.

CONCLUSIONS

This diagnosis allows nurses to document patients' self-care in daily clinical practice through a standard nursing terminology, by naming this health problem, describing its etiology, and clinical manifestations.

IMPLICATIONS FOR NURSING PRACTICE

This new diagnosis is expected to assist nursing clinicians, educators, and students in clinical reasoning with the aim to improve diagnostic accuracy in identifying patients with a heart failure self-care deficit, to select the most appropriate interventions and pursue better outcomes.

Experiences of Home Health Care Workers in New York City During the Coronavirus Disease 2019 Pandemic: A Qualitative Analysis

IMPORTANCE

Home health care workers care for community-dwelling adults and play an important role in supporting patients with confirmed and suspected coronavirus disease 2019 (COVID-19) who remain at home. These workers are mostly middle-aged women and racial/ethnic minorities who typically earn low wages. Despite being integral to patient care, these workers are often neglected by the medical community and society at large; thus, developing a health care system capable of addressing the COVID-19 crisis and future pandemics requires a better understanding of the experiences of home health care workers.

OBJECTIVE

To understand the experiences of home health care workers caring for patients in New York City during the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

From March to April 2020, a qualitative study with 1-to-1 semistructured interviews of 33 home health care workers in New York City was conducted in partnership with the 1199SEIU Home Care Industry Education Fund, a benefit fund of the 1199 Service Employees International Union United Healthcare Workers East, the largest health care union in the US. Purposeful sampling was used to identify and recruit home health care workers.

MAIN OUTCOMES AND MEASURES

Audio-recorded interviews were professionally transcribed and analyzed using grounded theory. Major themes and subthemes were identified.

RESULTS

In total, 33 home health care workers employed by 24 unique home care agencies across the 5 boroughs of New York City participated. Participants had a mean (SD) age of 47.6 (14.0) years, 32 (97%) were women, 21 (64%) were Black participants, and 6 (18%) were Hispanic participants. Five major themes emerged: home health care workers (1) were on the front lines of the COVID-19 pandemic but felt invisible; (2) reported a heightened risk for virus transmission; (3) received varying amounts of information, supplies, and training from their home care agencies; (4) relied on nonagency alternatives for support, including information and supplies; and (5) were forced to make difficult trade-offs in their work and personal lives.

CONCLUSIONS AND RELEVANCE

In this qualitative analysis, home health care workers reported providing frontline essential care, often at personal risk, during the COVID-19 pandemic. They experienced challenges that exacerbated the inequities they face as a marginalized workforce. Interventions and policies to better support these frontline health care professionals are urgently needed.

Heart Failure Training and Job Satisfaction: A Survey of Home Care Workers Caring for Adults with Heart Failure in New York City

Background

Home care workers (HCWs), who include home health aides and personal care attendants, frequently care for adults with heart failure (HF). Despite substantial involvement in HF care, prior qualitative studies have found that HCWs lack training and confidence, which creates challenges for this workforce and potentially for patient care. Herein, we quantified the prevalence of HF training among HCWs and determined its association with job satisfaction.

Methods

We conducted a cross-sectional survey of agency-employed HCWs caring for HF patients across New York, NY from 2018-2019. HF training was assessed with, "Have you received prior HF training?" Job satisfaction was assessed with, "How satisfied are you with your job?" The association between HF training and job satisfaction was determined with robust poisson regression.

Results

323 HCWs from 23 agencies participated; their median age was 50 years (IQR: 37,58), 94% were women, 44% were non-Hispanic Black, 23% were Hispanic, 78% completed ≥ high school education, and 72% were foreign-born. They had been caregiving for a median of 8.5 years (IQR: 4,15) and 73% had cared for 1-5 HF patients. Two-thirds received none/a little HF training and 82% felt satisfied with their job. In a fully adjusted model, HCWs with some/a lot of HF training had 14% higher job satisfaction than those with none/a little HF training (aPR 1.14; 95% CI 1.03-1.27).

Conclusions

The majority of HCWs have not received HF training. HF training was associated with higher job satisfaction, suggesting that HF training programs may improve HCWs' experience caring for this patient population.

Understanding the Workflow of Home Health Care for Patients with Heart Failure: Challenges and Opportunities

BACKGROUND

Readmission rates are high among heart failure (HF) patients who require home health care (HHC) after hospitalization. Although HF patients who require HHC are often sicker than those who do not, HHC delivery itself may also be suboptimal.

OBJECTIVE

We aimed to describe the workflow of HHC among adults discharged home after a HF hospitalization, including the roles of various stakeholders, and to determine where along these workflow challenges and opportunities for improvement exist.

DESIGN AND PARTICIPANTS

In this qualitative study, we used purposeful sampling to approach and recruit a variety of key stakeholders including home health aides, nurses, HF patients, family caregivers, physicians, social workers, home care agency leaders, and policy experts. The study took place in New York, NY, from March to October 2018.

APPROACH

Using a semi-structured topic guide, we elicited participants' experiences with HHC in HF through a combination of one-on-one interviews and focus groups. Data were recorded, transcribed, and analyzed thematically. We also asked selected participants to depict in a drawing their understanding of HHC workflow after hospitalization for HF patients. We synthesized the drawings into a final image.

KEY RESULTS

Study participants (N = 80) described HHC for HF patients occurring in 6 steps, with home health aides playing a main role: (1) transitioning from hospital to home; (2) recognizing clinical changes; (3) making decisions; (4) managing symptoms; (5) asking for help; and (6) calling 911. Participants identified challenges and opportunities for improvement for each step.

CONCLUSIONS

Our findings suggest that HHC for HF patients occurs in discrete steps, each with different challenges. Rather than a one-size-fits-all approach, various interventions may be required to optimize HHC delivery for HF patients in the post-discharge period.

Paid Caregiver Communication With Homebound Older Adults, Their Families, and the Health Care Team

BACKGROUND AND OBJECTIVES

Although paid caregivers (e.g., home health aides and home care workers) provide essential care for homebound older adults with serious illness in their homes, little is known about how and to whom paid caregivers communicate about the health needs they encounter. This study explored how paid caregivers (i) communicate when older adults experience symptoms or clinical changes and (ii) interact with the health care team.

RESEARCH DESIGN AND METHODS

We conducted separate one-on-one, semi-structured interviews (n = 30) lasting 40-60 min with homebound older adults (or their proxies if they had cognitive impairment) and their paid caregivers (provided they had worked with the older adult for ≥8 hr per week for ≥6 months). Interviews were audio-recorded, transcribed, and coded.

RESULTS

Thematic analysis identified four themes: (i) older adults or their families were the gatekeepers to paid caregiver communication with the health care team; (ii) communication between older adults, their families, and paid caregivers was enhanced when close relationships were present; (iii) paid caregivers responded to health care team inquiries but rarely communicated proactively; and (4) most older adults, families, and paid caregivers were satisfied with existing paid caregiver communication with the health care team.

DISCUSSION AND IMPLICATIONS

Rather than discuss concerns with the health care team, paid caregivers communicated directly with older adults or their families about the health needs they encounter. Understanding how communication occurs in the home is the first step to maximizing the potentially positive impact of paid caregivers on the health of older adults living at home.

Home care workers caring for adults with heart failure need better access to training and technology: A role for implementation science

Although highly involved in heart failure (HF) patients' care, home care workers (HCWs) lack HF training and are poorly integrated into the healthcare team. For its potential to address these challenges, we examined the role of technology among HCWs caring for HF patients. We conducted 38 interviews with key stakeholders. Overall, four themes emerged. Participants reported that technology is critical for HF care, but existing systems are outdated and ineffective. HCWs also have limited access to electronic resources. Technology, training, and principles of implementation science can be leveraged to improve HCWs' experience in caring for HF patients and home healthcare delivery.

"It's Like They Forget That the Word 'Health' Is in 'Home Health Aide'": Understanding the Perspectives of Home Care Workers Who Care for Adults With Heart Failure

Background

Home care workers (HCWs) increasingly provide long‐term and posthospitalization care for community‐dwelling adults with heart failure (HF). They observe, assist, and advise these patients, yet few studies have examined their role in HF. As the foundation for future interventions, we sought to understand the perspectives of HCWs caring for adults with HF.

Methods and Results

We conducted 8 focus groups in partnership with the Home Care Industry Education Fund, a benefit fund of the 1199 Service Employees International Union United Healthcare Workers East, the largest healthcare union in the United States. English‐ and Spanish‐speaking HCWs with HF clients were eligible to participate. Data were analyzed thematically. Forty‐six HCWs employed by 21 unique home care agencies participated. General and HF‐specific themes emerged. Generally, HCWs (1) feel overworked and undervalued; (2) find communication and care to be fragmented; (3) are dedicated to clients and families but are caught in the middle; and, despite this, (4) love their job. With respect to HF, HCWs (1) find it frightening and unpredictable; (2) are involved in HF self‐care without any HF training; and (3) find the care plan problematic.

Conclusions

Although frequently involved in HF self‐care, most HCWs have not received HF training. In addition, many felt poorly supported by other healthcare providers and the care plan, especially when their clients’ symptoms worsened. Interventions that provide HF‐specific training and aim to improve communication between members of the home health care team may enhance HCWs’ ability to care for adults with HF and potentially lead to better patient outcomes.

Application of self-care based on full-course individualized health education in patients with chronic heart failure and its influencing factors

BACKGROUND

The treatment of heart failure not only needs to relieve the clinical symptoms and improve the quality of life for patients but also needs to select scientific and reasonable ways to prevent or delay the progression of the disease, thus reducing the mortality and hospitalization rate. Although the previous regimen can effectively relieve symptoms in the early stage of treatment, long-term use may cause adverse events, such as arrhythmia, and even increase mortality. Therefore, conventional treatment cannot meet the actual health needs of patients, and scientific nursing intervention is very necessary.

AIM

To investigate the application of self-care based on full-course individualized health education (FCIHE) and its influencing factors in patients with chronic heart failure (CHF).

METHODS

We enrolled CHF patients who were admitted to our center between September 2015 and June 2016 and divided them into an intervention group (n = 50) and control group (n = 50) using a random number table. Routine nursing care was applied to the control group, and FCIHE was offered to the intervention group. The self-care behavior, 6-min walking distance (6MWD), and 36-item short form health survey (SF-36) scores were compared between the two groups. The influencing factors of the self-care were also analyzed.

RESULTS

The 6MWD was not significantly different between the two groups at admission (P > 0.05); however, at 3 and 6 mo after discharge, 6MWD was significantly increased, and it was significantly longer in the intervention group (P < 0.05). The scores for self-care behavior showed no significant difference at admission between the two groups (P > 0.05); however, at 3 and 6 mo after discharge, the total scores for self-care maintenance, management, confidence, and behavior of the intervention group were significantly higher than those of the control group (P < 0.05). There were no significant differences in the SF-36 scores at admission (P > 0.05); however, at 3 mo and 6 mo after discharge, the scores for all eight subscales, including physical functioning, role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role-limitations due to emotional problems, and mental health, were significantly higher in the intervention group (P < 0.05). As shown by logistic regression analysis, the influencing factors of self-care mainly included age, cardiac function class, and education background (odds ratio > 1; all P < 0.05).

CONCLUSION

FCIHE improved self-care behavior and cardiac function in CHF patients. Age, cardiac function, and education level affected the implementation of self-care among CHF patients.

Factors Associated With Live Discharge of Heart Failure Patients From Hospice: A Multimethod Study

OBJECTIVES

This study identified sociodemographic and clinical factors that predicted live discharge among home hospice patients with heart failure, and related these findings to perspectives among health care providers about challenges to caring for these patients.

BACKGROUND

Hospice patients with heart failure are frequently discharged from hospice before death ("live discharge"). However, little is known about the factors and circumstances associated with live discharge among patients with heart failure.

METHODS

Quantitative analyses of patient medical records (N = 1,498) and qualitative interviews were performed with health care providers (n = 19) at a not-for-profit hospice agency in New York City.

RESULTS

Thirty percent of home hospice patients with heart failure experienced a live discharge, most frequently due to 911 calls that led to acute hospitalization. The odds of acute hospitalization were higher for younger patients (age 18 to 74 years: adjusted odds ratio [AOR]: 2.10; 95% confidence interval [CI]: 1.34 to 3.28), African American (AOR: 2.06; 95% CI: 1.31 to 3.24) or Hispanic (AOR: 2.99; 95% CI: 1.99 to 4.50) patients, and higher functioning patients (Palliative Performance Scores of 50% to 70%; AOR: 5.68; 95% CI: 3.66 to 8.79). Qualitative interviews with health care providers highlighted the unique characteristics of heart failure (e.g., sudden changes in patients' condition), the importance of patients' understanding of hospice and their own prognosis, and the role of sociocultural and family context in precipitating and potentially preventing live discharge (e.g., absence of social supports in the home).

CONCLUSIONS

Live discharge from hospice, especially due to acute hospitalization, is common with heart failure. Greater attention is needed for patients' knowledge of and readiness for hospice care, especially among younger and diverse populations, and for factors related to the social and family context in which hospice care is provided.