Home Care: A Worker’s Perspective

Homecare is touted as the panacea for care of our frail elders. It is more cost effective than residential settings such as assisted living or nursing home care and it speaks to the wishes of many older adults who want to remain in their own homes preserving a sense of independence, familiarity and continuity.

Our discussion of homecare, from the worker’s perspective, was one of the most interesting and far reaching conversations we have had at the Round Table. We were well represented by supervisors – one from a publicly funded home care agency and one from a private pay agency; by several of us who are both professionals and daughters who are caring for our own aging mothers in various degrees of decline; one home care worker; and one social worker who has limited experience accessing home care. From our different perspectives, we discussed the complications of an aide entering the privacy of someone’s home: the adult client has had a recent change in independence perhaps affecting her sense of self; family members may be urging, even forcing her to accept services; a family system has long-standing dynamics and unique patterns of interactions. And the home care worker’s expectations and assigned job is “to help.” Inevitably there is ample room for miscommunication, problematic relationships and troubles with boundaries. The success of an agency will lie in its ability to make a good match between an aide and the family by defining and clarifying expectations.

While there were ample case examples of difficult situations, overstepping boundaries and power struggles, one of our supervisors skillfully portrayed a picture of homecare services that works well more times than not. She described the bell-curve of good care and the good matches that evolve between homecare workers and their clients. Unfortunately it is the tails of the curve that we hear about most frequently, about which we worry. These are the complex instances involving clients with mental illness, dementia with an aggressive and agitated component, family members who intrude in care, not always in the best interests of the frail elder, or the problems with melding and understanding cultural differences.

I’ve never been a great proponent of home care having worked in a nursing home that provided excellent care. I understand the intent but have been concerned about the isolation of homecare workers who are expected to be the eyes and ears of some very complicated social, mental health and medical/nursing needs. My concern has been for both the elder and for the homecare worker. The discussion though, allowed me to shift my perceptions. I was persuaded by the argument that in-home care, if done well, can be more flexible and individualized for older adults and can actually support and encourage greater independence in ADLs, which is not an insignificant accomplishment. Too often in congregate care settings, independence is forfeited for adherence to schedules and efficiency.

That said, there are still many pitfalls that seem to coalesce in the area of communication and boundaries. One set of confusions sets in when a certain comfort level and good relationship has been established. Expectations can then begin to shift either because the homecare worker has become too attached and cares so much she is willing to do more than the assigned tasks primarily because she doesn’t want to see the older adult in need. Or from the client’s perspective, he or she might begin treating the worker as a family member. In either case, boundaries get blurry.

One supervisor had an aha! moment. She recounted this scenario: Homecare worker walks into a home, newly assigned, and asks, “Show me what you’d like me to do.” The supervisor then gets a phone call from the family member who complains, “Do you know, you’re caregiver didn’t even know what to do!” What a set of miscommunications! The homecare worker, new to this family, thought she was being respectful and not intrusive, while the family’s expectations were for her to come in and efficiently do the job as requested.

Two of us spoke about our mothers, both of whom recently agreed, cautiously, to use home care services. One woman refers to her worker as a personal companion; the other has reluctantly agreed to have an aide do her laundry, and “by-the-way, sometimes she brings me delicious things to eat that are so interesting from her culture.” These two elderly women, both still very cognitively intact, expressed the alternate side of the relationship: they feel they are doing a favor for the home care worker. When “Mother” visits with her companion, she feels she is being a good listener and can help her solve her problems by listening and being the voice of experience. And “Mom” knows that her aide works hard to support many family members and feels that she is remunerating her with a fair income. She also has expressed a certain amount of discomfort in being in an employer/employee relationship and the hierarchy of power that it implies. She mitigates this discomfort by engaging her aide in discussions about her family both here and at home in Haiti, letting her know that she values and respects her as a person, not merely an employee. Both these women have found a sense of purpose and of being useful instead of being just the recipient of care.

I was urged to write a check list of recommendations – one for agencies and one for families – that would help clarify expectations. But the intention here was to illuminate the many faceted dynamics of this service. I am confident that most agencies adequately explain their services. Families however are wanting or needing or desiring that their older adult be as protected as possible. Homecare is not a perfect solution but when it works its’ strengths lie in developing and maintaining personal connections and understanding the uniqueness of human relationships.

The Round Table Discussion Group meets monthly for an interdisciplinary conversation with experienced professionals in the field of aging.  Each conversation uses one or two journal articles as reference points.  The article read for this discussion was:

• Worker’s Experiences of Crises in the Delivery of Home Support Services to Older Clients:   A Qualitative Study, Joanie Sims-Gould, et al, Journal of Applied Gerontology 32 (1) 31-30