Understanding Racial/Ethnic Disparities in Home Health Care Outcomes: The Clinical Practice Factors

Background and Purpose: Disparities in health outcomes are well documented in the literature. Likewise, recent studies point to disparate outcomes for minority recipients of home healthcare. However, there is a critical lack of understanding regarding the contributing factors to such disparities, in particular the role that practice factors play in home health disparities. In this study, we conducted focus group interviews with home health agency staff to explore clinical practice factors that influence the relationship between race/ethnicity and home health outcomes. Ultimately, the goal of this research is to alleviate disparities and improve health outcomes by enhancing our understanding of practice factors. Methods: Three focus group interviews were conducted with 23 home health agency staff. Agency staff were recruited from a list of all agencies in a tri-state metropolitan region. We obtained a convenience sample of staff from a variety of home health agencies and representing the various disciplines (e.g. social work, nursing, therapy), races/ethnicities and gender as well as professional and paraprofessional staff. Focus group interviews were facilitated by a racially diverse team in a convenient and anonymous site. The interviews were digitally recorded and transcribed by a professional transcriptionist. Data analysis was conducted using Nvivo software with a grounded theory framework. Results: This work explores agency staff's unique and intimate perspectives on caring for the elderly in their homes and explores the complex, often unarticulated, practice factors that may contribute to disparate health outcomes. The staff reported multiple levels of influence in the home health setting, including patient (e.g. health literacy, income, patient/family caregiving capacity and environment), staff (e.g. staff discretion, staff-patient cultural, racial and ethnic barriers, staff bias, and physical, geographic and logistic barriers to providing consistent, quality care), agency (e.g. staff assignments, lack of staff diversity, poor area coverage, and cost control practices), and system factors (e.g. insurance coverage, reimbursement cuts, and out of pocket costs) which influence the relationship between race/ethnicity and outcomes. We also compare and contrast the perspectives of professionals and paraprofessionals in order to explore the multidimensional nature of home healthcare. Conclusions and Implications: Results from this study highlight the relationship between access to care, quality care and outcomes. Likewise this also provides evidence for the intersection of race and class in influencing outcomes of care. Finally, the role of staff discretion, bias and institutional forms of racism are highlighted in these results. Additional research is needed to verify these results, and to identify other potential contributing factors; we propose a conceptual framework to guide future research. The researchers also make recommendations related to quality assurance procedures for home health care with a focus on vulnerable groups. Finally, implications for social work practice and the social worker's role in reducing disparities in the home health setting will be discussed.