Rethinking Instability In Home Care of Older Adults: Using Ethnographic Research to Explore Continuity of Worker-Recipient Pairings In Publicly- and Privately- Funded Home Care

PURPOSE: Home care is one of the fastest growing occupations in the United States (BLS 2010), and deeply influences quality of life for millions of older adults, family members and home care workers (Montgomery et al. 2005). However, the industry remains challenged by instability, including endemically high rates of turnover which hinder the delivery of quality care (Castle et al 2007; Harrington et al 2000). Current research has primarily focused on agency-level turnover, finding that factors including low wages, lack of benefits, and for-profit ownership contribute to high turnover rates (Dill & Cagle 2010). This paper expands analyses of home care turnover to include the reassignment of workers to different clients within agencies, which may also have a substantial impact on care quality. This paper compares how funding structures, organizational level policies and supervisors' everyday practices in publicly- and privately- funded home care agencies contribute to instability.

METHOD: Ethnographic research was conducted in one privately funded and one publicly funded home care agency in Chicago, Illinois. Within each agency, a nested sample was constructed consisting of worker-client pairs (n=14), agency supervisors and administrators. At each agency, data collection included 4-6 weeks of daily observations of agency supervisors, and 6-8 months of weekly observations with older adults and workers. Data collection also included semi-structured interviews, document review and observations of public hearings. Fieldnotes, transcripts and documents were coded using HyperResearch© qualitative software. Following inductive qualitative research practice, data were continuously analyzed over the collection period to identify key themes and patterns.

RESULTS: Continuity of home care worker/recipient pairings was related to home care recipients' evaluations of care quality. Disruptions in care were stressful for older adults, impeded critical relationship development and led elders to overlook concerns about workers in order to avoid disruption and the possibility of being assigned even less acceptable workers. External turnover resulted from inadequate sick- and family-leave and illicit exchanges, though departing workers often intended to find new employment in direct care. Older adults had a greater sense of continuity at the privately funded agency, where lower supervisor caseloads, detailed intake procedures and careful consideration of worker-client matches worked to minimize instability. In publicly funded care, policies separated case management from worker supervision, while high supervisor caseloads, and lack of contact between recipients and supervisors limited supervisors' ability to consider individual factors in matching workers and clients, contributing to high levels of instability.

IMPLICATIONS: This ethnographic research suggests that continuity should be considered a component of quality care. In publicly-funded care, greater economic allowances for administrative overhead, combined with requirements for lower supervisory caseloads, more detailed intake procedures and careful matching of workers with clients might improve continuity of care. Ethnographic methods linking policy, management and service delivery are particularly useful in decentralized contexts, in this case highlighting that institutional-level analyses of turnover inadequately address issues continuity in home care. Further multivariate research using larger cross-section of agencies is recommended to further specify how continuity is related to care quality and factors which contribute to continuity.