This collection of research has been updated since it was originally posted in November 2018.
As baby boomers age, the demands placed on the country’s health care system are increasing. That includes the home health care industry, which is undergoing changes to accommodate a growing senior population.
Home health care services allow people who require extra care to remain in their homes, reducing the burden otherwise shouldered by health care facilities, assisted living centers and nursing homes. The services also can be less expensive than these other facilities.
According to the most recently available data from the U.S. Centers for Disease Control and Prevention, 4.5 million adult patients received home health care at some point in 2015. Federal data indicate that number is expected to grow in the next decade. The Bureau of Labor Statistics projects employment of home health aides and personal care aides to grow 41 percent from 2016 to 2026, outpacing average growth for other occupations.
Home health aides are distinct from visiting registered nurses or licensed practical nurses in that they are not required to have specialized education beyond a high school degree, are not licensed as nurses, and in many cases do not provide assistance with medical tasks. Per the Bureau of Labor Statistics, “Home health aides and personal care aides help people with disabilities, chronic illnesses, or cognitive impairment by assisting in their daily living activities. They often help older adults who need assistance. In some states, home health aides may be able to give a client medication or check the client’s vital signs under the direction of a nurse or other healthcare practitioner.”
Home health care services are typically run through agencies. The most recently available CDC data estimates that 12,200 such agencies were operating in the U.S. in 2016. According to this analysis, 80.6 percent of these agencies were for profit, while 14.8 percent were non-profit and 4.6 percent were government owned.
Despite the demand for home health aides, the compensation remains low – median pay in 2017 was $11.12 an hour. By contrast, other jobs in the healthcare field that typically require the same entry-level education (high school diploma or equivalent), such as optician and pharmacy technician pay more — $17.43 and $15.26 per hour, respectively. Assisting the disabled, elderly and chronically ill with the everyday tasks of living — the work of home health care — can be physically and emotionally taxing. Turnover is common in the field, which can impact the quality of care received by clients.
This research roundup looks at home health care from a variety of angles. It identifies geographic and demographic trends in the availability and provision of home health care in the United States. Featured research also points to reasons why the industry experiences such rapid churn and to potential solutions, from new training programs to on-the-job exercise programs that benefit clients and workers alike.
Trends in home health care
Care for America’s Elderly and Disabled People Relies on Immigrant Labor
Zallman, Leah; et al. Health Affairs, June 2019.
This study analyzes nationally representative survey data collected on 180,084 people in 2017 to better understand the composition of the direct care workforce. The data came from the annual social and economic supplement of the 2018 Current Population Survey, conducted by the Census Bureau and the Bureau of Labor Statistics. The researchers defined direct care occupations as personal and home care or home health aides, as well as nursing and psychiatric aides. For the purposes of their analysis, respondents who were born outside of the U.S. were considered immigrants. The survey did not collect information about documentation status, so the researchers used a method that has been applied previously to this dataset in labor economics and health care research to estimate proportions of unauthorized immigrants.
Key findings:
- In 2017, over one fourth of direct care workers — 27.5% — were immigrants.
- Immigrants with legal noncitizen status accounted for 9.0% of direct care workers, naturalized citizens made up 13.9% of direct care workers and unauthorized immigrants totaled 4.3% of direct care workers. For reference, the paper cites the following statistics: immigrants with legal noncitizen status comprise 5.2% of the U.S. population, naturalized citizens make up 6.8%, and unauthorized immigrants account for 3.6%.
- Immigrant health care workers were more likely than US-born workers to be employed in home health agencies (13.1% vs. 7.9%) and in nonformal settings (such as private households and residential facilities that do not have nursing services).
- The authors write that these findings emphasize immigrants’ disproportionate role in providing health care support for people in the U.S. “In light of current shortages, high turnover rates, low retention rates, growing demand for direct care workers, and immigrants’ already disproportionate role in filling such jobs, policies that curtail immigration are likely to compromise the availability of care,” the authors write. “Moreover, the anti-immigrant rhetoric and policies that restrict immigration threaten the health and well-being of immigrants who are entrusted with the care of the nation’s elderly and disabled people.”
“National Trends and Geographic Variation in Availability of Home Health Care: 2002-2015”
Wang, Yun; et al. Journal of the American Geriatrics Society, July 2017.
How does home health care vary across the country? This study maps the number of home health agencies in every county in the U.S. from 2002 to 2015.
Key findings:
- The average number of Medicare-certified home health agencies per county increased from 14.7 per 100,000 people to 21.8 per 100,000 in the time studied.
- The coasts had lower home health care availability than the center of the country.
- Counties with a higher median income and larger senior populations were likely to have more home health care agencies.
“Invisible No More: A Scoping Review of the Health Care Aide Workforce Literature”
Hewko, Sarah J.; et al. BMC Nursing, December 2015.
For this review, researchers screened 5,045 papers on various aspects of the health care aide workforce to identify 82 relevant studies. The synthesis of these papers led to the following findings about health care aide education, supply, use, demand, injury and illness.
Key findings:
- The average health care aide was female, 36-45 years old and had a high school education or less.
- Health care aides were at a higher risk of injury than registered nurses and licensed practical nurses.
- Home health care aides were distinct from other health care aides in that they were more likely to be older and immigrants.
- The research suggests that given the high turnover among health care aides, coupled with projected increases in demand, there will be shortages of health care aides in the future.
- Home health care aides had lower job stability, earned less, were less likely to have fringe benefits and worked fewer hours than health care aides who worked in hospitals and nursing homes.
Mental and physical health of home care workers
“Health-Related Quality of Life Among U.S. Workers: Variability Across Occupation Groups”
Shockey, Taylor M.; et al. American Journal of Public Health, August 2017.
This study compares self-rated health, reports of frequent physical and mental distress, frequent overall unhealthy days and frequent activity limitation (defined as 14 days or more in the past month in which poor physical or mental health kept respondents from doing their usual activities) among workers in 22 standard occupation groups. The study compared survey responses collected from over 155,000 workers.
Key findings:
- “Health care support occupations, with the most female workers of the occupation groups, have one of the highest adjusted prevalence of frequent activity limitation among all occupation groups. According to the U.S. Bureau of Labor Statistics, nursing, psychiatric, and home health aides, who account for approximately two thirds of all health care support occupations, ranked over a 10-year period among the top of occupation groups reporting the most cases of workplace injuries and illnesses. Health care support occupations also experience the highest risks of musculoskeletal disorders.”
“‘Who’s Caring for Us?’: Understanding and Addressing the Effects of Emotional Labor on Home Health Aides’ Well-Being”
Franzosa, Emily; et al. The Gerontologist, August 2018.
“Interventions to strengthen the home care workforce focus on workers’ economic and physical well-being, without acknowledging the caring labor affecting emotional well-being. Our study examined workers’ perceptions of the emotional effects of caring work, coping mechanisms, and desired support,” the researchers write. They conducted focus groups with 27 home care workers.
Key findings:
- The factors that were important to home health aides’ emotional well-being were: close relationships with clients, work-life balance, positive relationships with clients’ families and agency supervisors and feeling like their work was valued.
- “Aides were largely alone in managing job stressors and desired more communication, connection, and support from supervisors and peers.”
- The authors suggest policy makers and agencies adjust reimbursement systems and job descriptions to reflect the emotional labor required of the role and to improve communication, training, support and mental health benefits for home care workers.
“Safety Risks Associated with Physical Interactions between Patients and Caregivers During Treatment and Care Delivery in Home Care Settings: A Systematic Review”
Hignett, Sue; et al. International Journal of Nursing Studies, July 2016.
This review identifies research that highlights the safety risks associated with home care work.
Key findings:
- Risks backed up by strong evidence from at least two papers include: “awkward [physical] working positions, social environment issues (additional tasks and distractions), abuse and violence [from patients and their family], inadequate team (peer) support, problems with workload planning, needle stick injuries and physical workload (moving and handling patients).”
- The authors suggest that policy, design and system-level interventions can promote the safety of caregivers and patients.
“Determinants of Occupational Injury for U.S. Home Health Aides Reporting One or More Work-Related Injuries”
Hamadi, Hanadi; et al. Injury Prevention, October 2018.
This study uses the same dataset as the April 2016 paper published in the Gerontologist to look more closely at the factors associated with increased injury risk for home health aides.
Key findings:
- Home health aides who did not consistently care for the same patients had decreased injury risk.
- Home health aides who “reported not needing any other devices for job safety,” such as lifting devices, were also at a lower risk of injury.
Those who leave and those who sta
“Predictors of Intent to Leave the Job Among Home Health Workers: Analysis of the National Home Health Aide Survey”
Stone, Robyn; et al. The Gerontologist, April 2016.
What are the factors associated with home health workers who plan to stay in their jobs? What factors are common among those who want to leave? This study analyzes data collected from 3,377 Medicare- and Medicaid-certified home health workers to answer these questions.
Key findings:
- The following factors were associated with lower intent to leave home health work: job satisfaction, consistent patient assignment (being assigned the same patients each week) and provision of health insurance.
- The following factors were associated with a greater intent to leave home health work: insufficient work hours, on-the-job injuries, African American race and a higher household income.
- “The findings suggest that intention to leave the job may be reduced through policies that prevent injuries, improve consistency of client assignment, improve experiences among African American workers, and offer sufficient hours to workers who want them.”
“Characteristics of Home Care Workers Who Leave Their Jobs: A Cross-Sectional Study of Job Satisfaction and Turnover in Washington State”
Banijamali, Sahar; Jacoby, Daniel; Hagopian, Amy. Home Health Care Service Quarterly, June 2014.
This study surveyed 402 former home care workers in Washington State and compared their responses with those still in the field.
Key findings:
- People who left home care work were: “more highly educated, had higher household income, and were more likely to be White.”
- Home care workers who left the field and found new jobs reported better benefits, wages, hours, and career mobility than they had previously.
- “The low status and poor pay of home care workers may result in the inability of the profession to retain those who face better prospects.”
Successful Interventions
“Building Health Promotion into the Job of Home Care Aides: Transformation of the Workplace Health Environment”
Muramatsu, Naoko; et al. International Journal of Environmental Research and Public Health, April 2017.
Tasking 46 home care workers with leading their clients through a “gentle physical activity program” benefited the aides as well as the clients, according to this pilot study of a workplace health promotion program called “Healthy Moves.”
Key findings:
- Almost all — 98 percent — of home care aides reported being satisfied with the program. Ninety percent said they strongly agreed or agreed that the program helped them motivate their clients to be active, and 95 percent felt the training increased their knowledge about physical activity and helped them facilitate safe exercise for their clients.
- Through surveys and focus groups, the home care aides described an improved “psychosocial work environment.” “The most frequently mentioned reason why [health care aides] were satisfied with conducting Healthy Moves with their clients was that it was beneficial for both the clients and the [health care aides] themselves.”
“The Homecare Aide Workforce Initiative: Implementation and Outcomes”
Feldman, Penny H.; et al. Journal of Applied Gerontology, April 2017.
“Improved training and support are thought to improve retention among direct care workers. However, few studies have examined actual retention. This study examined satisfaction and retention among home health aides enrolled in the ‘Homecare Aide Workforce Initiative’ (HAWI) at three New York agencies,” the authors write. HAWI is a grant-funded program that provides training, mentoring and case management support for workers. The study looks at a sample of 228 home health aides who completed the training and were still on the job after three months.
Key findings:
- “Three months after hire, 91 percent of HAWI hires reported they were ‘very satisfied’ or ‘satisfied’ with the job; 57 percent reported they were ‘not at all likely’ to leave their job in the coming year.”
- “At 365 days, 60 percent were still working.”
- The authors predicted through their analysis that the odds of home health care workers remaining in their jobs at 3, 6 and 12 months after starting work were significantly higher among HAWI graduates than non-HAWI employees.
“Ergonomic and Safety Risk Factors in Home Health Care: Exploration and Assessment of Alternative Interventions”
Czuba, Laura Rae; Sommerich, Carolyn M.; Lavender, Steven A. Work, 2012.
For this study, researchers analyzed injury data for home health care workers and observed them on the job to identify the risk factors that lead to injury. They found that aides who worked with patients with greater physical needs (i.e., patients who need assistance being transferred from wheelchair to shower or bed) were more likely to report end-of-shift exhaustion and pain.
Conclusion:
- “Home health care companies may find that developing a scheduling system that manages the exposure of their aides to higher needs patients may be a feasible and effective method for reducing the aides’ exposure to risk factors for musculoskeletal injuries.”