Home Health Care Patients and Safety Hazards

in the Home: Preliminary Findings

Robyn R.M. Gershon, MT, MHS, DrPH; Monika Pogorzelska, MPH;

Kristine A. Qureshi, RN, DNSc; Patricia W. Stone, PhD; Allison N. Canton, BA;
Stephanie M. Samar, BA; Leah J. Westra, BA; Marc R. Damsky, MPH; Martin Sherman, PhD

Abstract
Introduction: Home health care is the fastest growing sector in the health care industry, with an
anticipated growth of 66 percent over the next 10 years and with over 7 million patients served
each year. With the increasing acuteness of care provided in home health care and the increasing
number of frail elderly that make up this patient population, it is important to identify risk factors
that affect patient health and safety in this setting. Methods: A convenience sample of 1,561
home health aides, attendants, and personal care workers completed a risk assessment survey.
Items addressed personal, patient, and home characteristics and health hazards. All activities had
prior Institutional Review Board approval. Preliminary Results: Ninety-five percent of home
health care workers (HHCWs) were female with an average of 8 years experience. The majority
of clients were elderly, with a smaller percentage of adult (26 percent) and pediatric (7 percent)
cases. HHCWs reported the following exposures at their clients’ homes: cockroaches (33
percent), cigarette smoke (30 percent), vermin (23 percent), irritating chemicals (17 percent), and
peeling paint (15 percent). The following conditions were also described: clutter (17 percent),
temperature extremes (9 percent), unsanitary (12 percent) and unsafe (6 percent) conditions in
the home, neighborhood violence/crime (11 percent), and aggressive pets (6 percent). Two
percent of respondents reported the presence of guns in the home. Additionally, 12 percent of
HHCWs reported signs of abuse of their clients. Conclusion: Both HHCWs and home care
patients appear to be at potential risk due to a variety of health hazards/exposures in the clients’
homes. Given the growing population of both HHCWs and recipients, it is important to
document this risk as an important first step in prevention and management.

Introduction
The home care setting is a challenging work environment in terms of patient safety for a number
of reasons. First, residential settings may present household-related hazards (e.g., poor indoor air
quality, lead paint, toxic substances) that are associated with numerous negative health
effects. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 Second, many of the same well-defined hazards related to health
care—such as spread of nosocomial infections, development of resistant organisms, medication
errors, and others—are also found in home care settings. 13, 14, 15 Third, home care may be
delivered under conditions that may be uncontrolled. Fourth, health care providers may have
limited training or expertise in the area of patient safety and often have little or no direct

1
supervision. 16, 17, 18, 19 Finally, risk management is especially problematic in home care because
each home is, in essence, a “worksite,” yet all the necessary health care workplace protections
for both workers and patients may not be in place or readily available. 20

For these reasons, controlling hazards in home care can be difficult. Although we continually add
to our knowledge base of patient safety in the acute care setting, our understanding of the health
and safety hazards associated with home care is limited and highly reliant on anecdotal and
qualitative reports, even though these hazards have important implications for the health and
well-being of home care patients. Importantly, an unsafe household can adversely affect not only
the patient, but also home health care providers and household caregivers. To address these
concerns, risk assessment data are needed to develop evidence-based strategies to reduce risk,
including strategies that may require tailoring to this unique health care setting.

As a step in closing the research gap in home care, a large cross-sectional survey of New York
City-based home health aides and personal assistants was conducted to assess home health care-
associated potential health and safety hazards.

Home Health Care Sector

Home health care is the fastest growing sector in the health care industry, with 66 percent growth
projected over the next 10 years. 21 The sector is large, employing over 1.3 million workers in a
variety of occupations, including roughly 1.2 million aides and personal assistants.21 Most
growth occurred after the enactment of Medicare in 1965, although the agencies were first
established in the late nineteenth century. Even more dramatic growth occurred after the 1987
revisions to Medicare, which led to facilitated reimbursement to home care agencies. 22 By 2005,
over 20 thousand home care agencies were providing care to an estimated 8 million individuals.
This likely represents only a fraction of the true number of home care patients, since many
receive informal care through non-Medicare-certified agencies or individuals.22

In general, there are three types of home care agencies: (1) certified home health agencies
(CHHAs), (2) long-term home health care programs (LTHHCPs), and (3) licensed home care
services agencies (LHCSAs). CHHAs are authorized to serve both Medicare and Medicaid
recipients in need of short-term skilled nursing care and to provide nursing, home health aide,
personal care, and homemaker and housekeeper services. LTHHCPs, also known as “nursing
homes without walls,” provide services that enable individuals eligible for nursing homes to
remain at home. They operate under a Federal waiver for home and community-based services
and are required to provide all the services provided by a CHHA, as well as case management.
Finally, LHCSAs provide at least one of the following services, either directly or through
contracts with another program: nursing care, home health aides, personal care, private duty
nursing, homemakers, and physical/occupational and speech therapies.

Most formal home care is provided by freestanding proprietary agencies (55 percent), followed
by hospital-based agencies (24 percent), with nonprofit public health agencies and nonprofit
private agencies providing a smaller portion of home care. 23 Another large and growing type of
home care is home hospice care. Since 1983, when Medicare added hospice benefits to the plan,
the number of certified hospices grew from 31 to 2,444.22, 23 The actual size of the informal,
uncertified, and unlicensed home care network is not known, but it is believed to be nearly as
large as the formal network.

2
In addition to over 110,000 registered nurses providing skilled nursing care or supervision in
home care, a large workforce, comprising home health aides, home attendants, and personal care
workers, provides the bulk of day-to-day care in the home care setting. 24 Under medical
direction, although without direct supervision, home health aides provide basic medical services
that allow patients to convalesce outside of the traditional hospital and hospice setting. They
check patients’ vital signs, conduct physical therapy, change dressings, and assist with the use of
medical equipment. In addition, they may provide other services that neither patients nor their
families are able to provide on their own, such as assistance with ambulation, bathing, and
grooming the patient. Home health aides may also be asked to perform light housekeeping.24

Personal care workers and home care attendants, commonly referred to as “personal assistants,”
provide more personal care assistance to patients in the home setting. Their responsibilities
primarily focus on activities of daily living (e.g., bathing, grooming, dressing, feeding),
housekeeping, and transportation. Such responsibilities usually do not entail providing medical
or nursing care, although in practice this is not always the case. Personal care workers and home
care attendants may also provide advice about nutrition and hygiene to patients and their
families. 25

A high school diploma is not generally required for employment as a home health aide or
personal assistant. However, home health aides working for agencies that receive funding from
the Federal Government must pass a competency test. Additionally, the National Association for
Home Care and Hospice offers a national certification for home care aides, which evaluates
home health care workers (HHCWs) on 17 unique skills. Training and other certification
requirements may vary from State to State for personal assistants and home health care aides.24,
25, 26, 27

It is important to note that HHCWs have an increased incidence of injury compared to other
health care and human services workers.19, 28 A review by Galinsky, et al., provided exhaustive
documentation of overexertion injuries in HHCWs. 29 They found that forceful exertions and
awkward postures during patient care, especially lifting and shifting patients, were the main risk
factors for musculoskeletal disorders in this workgroup. The impact of these types of injuries and
the relationship between HHCW health and safety in general, and the safety of patients (e.g.,
patient falls), have not been assessed. Such an assessment is clearly needed, especially in light of
the growing prominence of home care.

With the annual U.S. expenditures for home health care in excess of $40 billion per year, the
scope of home care is broad and, as noted, covers a wide range of services, from assistance with
daily living activities to providing the more complex care required by postsurgical or chronically
ill patients. 30 Even with the increasing acuity of care that is provided in the home setting, the cost
per day of home care is significantly lower than that of a nursing home or an inpatient hospital
stay ($109 vs. $3,838, respectively) and is increasingly more desirable by both patients and their
families.22

Home Care Patients

The patient population served by home health care is large, growing, and increasingly frail and
elderly. The increase in home care is being driven by continued efforts at medical cost saving24
that began in the late 1980s when a nationwide campaign to reduce medical costs led to

3
decreased length of hospital stays and the early discharge of many patients to home care. For
example, in 2003, patients were discharged from hospitals after 4.8 days on average; in 1990, the
average hospital stay was 6.4 days 31 ; in 2000, 48 percent of discharged Medicare patients were
discharged to home care. 32

Perhaps the most significant factor affecting home care is the aging post-World War II (“baby-
boomers”) cohort. The first wave of the cohort will reach age 65 in 2012, and by 2032, the
cohort will have reached age 85, 33 resulting in a dramatic increase in the number of older
Americans. For example, in 1960, 16.2 million people in the United States were aged 65 or
older; by 2000, that number had increased to 35 million, and by 2030 this number is projected to
increase to 72 million.33

An even greater magnitude of growth is projected for the extremely elderly cohort. In 1960, less
than 1 million Americans were 85 years or older; by 2000, this number had increased to 4.2
million, and it is anticipated that by 2030, nearly 10 million Americans will be 85 years or
older.31 These shifts are due not only to sweeping demographic changes in the population, but
also to reductions in U.S. mortality rates. Combined, the result will strain the services provided
to the elderly, including home care services. Even though the home care workforce is large, with
an estimated 1.3 million workers overall, the projected need is great, with perhaps twice as many
home care employees needed by 2030. 34 This is especially problematic given that the workforce
itself is undergoing similar demographic age shifts and, as is the case with the nursing
profession, is steadily experiencing increasing shortages for a variety of reasons.

These demographic changes in the U.S. population can also be seen acutely in the home care
patient population. For example, in 2000, almost 70 percent of the Nation’s 8 million patients
receiving formal home care were 65 years or older, and 17 percent were 85 years or older. By
2012, this is expected to increase substantially as the baby boomer cohort ages, with perhaps as
many as 20 million or more patients needing home care.22

Other shifts in home care are noted as well. For example, while currently about half of home care
patients aged 64 or younger are female, there are nearly twice as many females in the 65 years
and older age group.22 Although the vast majority of home care patients receiving formal care are
white (90 percent), this is expected to change as a reflection of the increased growth in minority
populations.22

There are also current and projected changes related to the health condition of home care
patients. A large proportion of current home care patients have heart disease diagnoses (47
percent), followed by injuries (16 percent), osteoarthritis (14 percent), and respiratory ailments
(12 percent),22 and increasingly frail and vulnerable patients continue to enter home care with
many highly complex medical problems and multiple diagnoses, thus requiring a greater
intensity of care.

All these trends suggest that home care will become even more challenging and that the
expectations placed upon the sector, including the caregivers, will most likely become more
demanding. By increasing our awareness and understanding of the health hazards inherent in the
home care environment, it may be possible to reduce the risk of injury and illness to the home
care patient and to improve the quality of work life for the caregiver.

4
Health and Safety Hazards Associated with Home Health Care
Most of our information regarding home health hazards comes from anecdotal or qualitative
reports, and only a few surveys have been conducted. Although there is a wide range of hazards,
the hazards generally fall into two major categories: those related to violence or the threat of
violence and those related to unsanitary household conditions.

A good overview of the scope of home hazards is provided in a recently published qualitative
study by Markkanen, et al. 35 Data on occupational hazards were collected from HHCWs
participating in focus groups and in-depth interviews. They identified general security/personal
safety hazards that could present a threat to patient safety, including unsafe neighborhoods,
violent or unstable patients and family members, and potentially dangerous pets. The study
participants also raised environmental concerns, including overheated room temperatures, poor
indoor air quality, and unsanitary conditions, such as the presence of insects and rodents.

Unsanitary conditions are a special concern, since the spread of infectious disease within the
household is well documented, and various procedures in home care could present a risk of
infection. Cross-contamination (e.g., transfer of pathogens through direct and indirect contact
with raw foods, animals, and contaminated inanimate objects) can place the frail elderly and
others at risk. One household area of potential concern in this regard is the bathroom. Gerba, et
al., tested the spread and survivability of microbes in household toilets and found that droplets
formed during flushing could result in the spread of organisms on various bathroom surfaces and
that the droplets remained airborne and viable for extended periods. 36 This may become a
concern in special cases, such as where the number of enteric pathogenic organisms is high and
when hosts are especially vulnerable. Household laundry is also a concern because it has been
shown to be a route for the spread of disease. For example, spread of Staphylococcus aureus via
laundry has been documented. 37 A review on domestic hygiene noted that changes in household
laundry practices—such as lower temperatures, less use of household bleach, and lower water
volume—had an adverse impact on laundry hygiene in general. 38 These changes could place
home care patients at increased risk of infection.

Studies have also documented the survivability and spread of microbes in the kitchen. Pathogens
associated with raw or undercooked food items, such as poultry, have caused disease in
household members, including those who are especially vulnerable due to age or immune
status. 39 For example, cases of salmonellosis related to this type of contamination have been
reported.39 Dirty kitchen surfaces, rags, sponges, mops, etc., are potential sources of cross-
contamination and can spread disease causing microorganisms in the home care setting.

Mismanagement of medical waste may also be a cause for concern in the home care environment
because it can be a source of pathogenic microbes. Although each State regulates the
transportation, storage, and disposal of biomedical waste, usually via individual health
departments, the home care setting is not easily regulated. Anecdotal reports of improperly
disposed sharps (e.g., using empty food containers) are common and can lead to needlestick
injuries in caregivers, patients, household members, and sanitation workers. In a recent pilot
study of HHCWs, Gershon, et al., found that 13 percent of home health care nurses (N = 72)
experienced a needlestick injury in the 12-month period preceding the self-administered survey,

5
and most of these were disposal-related. 40 Other authors have documented needlesticks
associated with home care, although the studies usually have targeted home health nurses. 41, 42, 43

Another area of concern is the reuse of certain single-use disposable items. For example, it has
been reported that many diabetes patients repeatedly reuse insulin syringes, without disinfection,
until the needle is no longer sharp. 44 Similarly, in the home care setting, drainage bags may be
disinfected and reused, a practice that rarely occurs in the hospital setting. 45

Urinary drainage systems, normally kept intact for patients with indwelling catheters, may be
breeched when the home care patient needs to use a leg bag.45 Indwelling devices in general,
which are the greatest predictors of nosocomial infection, are increasingly prevalent in home care
patients. 46 Between 1993 and 1995, the Centers for Disease Control and Prevention (CDC)
investigated three outbreaks of bloodstream infections in patients receiving home infusion
therapy.13, 14, 15 Inappropriate disinfection of semi-critical items (e.g., reusable thermometers) is
reportedly common.

The issue of home hygiene, including disinfection practices, needs addressing. Unfortunately, we
still do not yet have a national surveillance system in place in the United States for health care-
associated infections in home care settings, even though this has been suggested.46 Specific CDC
guidelines for infection control practices for home care have not yet been published, although a
number of thorough reviews of home infection control practices and guidance have been
provided by national and State organizations.44, 45 Although the reviews are somewhat dated,
much of the advice remains sound and is currently in practice. The CDC Web site also provides
useful references in this regard. 47

Finally, a topic of special concern in home care, especially urban home care, is the issue of crime
and violence. A recent article by Geiger-Brown, et al., includes a thorough review of the risks
and risk factors for violence in home care.20 The few studies that have explored this issue have
found that verbal abuse was the most commonly reported form of abuse; 48, 49 in one study, the
prevalence was as high as 52 percent.49 Other forms of violence or the threat of violence have
been reported, with dangerous neighborhoods, family members, and patients most often cited as
threatening. 50, 51 In a small survey by Kendra, et al., administrators and staff were asked to rank
factors associated with high-risk assignments with respect to the personal safety of staff
members. 52 Both groups gave similar responses: geographic location, high crime areas,
inappropriate patient or caregiver behavior, the threat of infectious diseases, and evening
assignments (with only staff reporting this last risk factor).

Methods
Survey Design
In 2006-2007, a health and safety survey was constructed following extensive developmental
steps, including in-depth interviews, focus groups, cognitive interviews, and pilot testing. The
survey was designed to assess the health hazards associated with the delivery of home health
care. Two versions of the survey were prepared, one targeting home health aides, home
attendants, and personal care workers, here referred to collectively as “aides”; and the other

6
targeting home health care registered nurses. This paper focuses on the aides’ survey instrument.
The 58-item survey included items that addressed the following: demographics of the HHCW,
description of the client’s residence, level/type of care provided, potential occupational health
hazards, potential home health hazards, and use and training on safety devices. The survey was
designed to be completed within 30 minutes and was prepared in English at a sixth-grade reading
level to facilitate rapid completion. The survey responses were primarily categorical, although
some items had 4- to 5-point Likert-type scale response choices, and several items were open-
ended. The survey and codebook are available by contacting the corresponding author.

Survey Distribution
Although the survey was anonymous, each participant was asked to sign an informed consent
form, and all procedures involving subject participation had the prior approval of the Columbia
University Institutional Review Board. A brief one-page document describing the study was
provided to potential participants. Because of the well-established difficulty in surveying
HHCWs in general, and the additional challenges in recruitment of individuals for whom English
may be a second language (as is the case for many home health aides), an in-person recruitment
strategy was employed. To facilitate this, a collaborative relationship was formed with an
occupational health organization that conducts mandatory health assessments and screenings for
home care agencies throughout New York City.

Recruitment of participants took place in the organizations’ waiting rooms, conveniently located
in offices that were easily accessible to the New York City-based research team. Participants
could complete the study survey in private areas located adjacent to the waiting rooms. In some
cases, the data collector helped to facilitate the survey administration by reading the questions
out loud, although generally, data were collected through self-administration. Data collection
days were held until the targeted goal of a convenience sample of 1,500 aides was reached.
Participating aides represented numerous agencies. The incentive for participation was a single
$1 scratch-off lottery ticket and enrollment in a lottery drawing for a $25 gift card prize (chance
of winning: 1:100).

Data Analysis
All completed surveys were returned to the study office where they were checked for legibility
and completion. Surveys missing substantial amounts of data were not included in the data
analysis. All data were double-entered into a database and then reviewed by a data manager to
ensure accuracy. Data editing, including recoding and collapsing of variables and the formation
of new variables, was followed by basic descriptive analysis of the data, including the calculation
of means, medians, percentages, proportions, and standard deviations. All analyses were
conducted using SPSS® (SPSS, Inc., Chicago IL: SPSS Inc.).

Results
Demographic information is provided in Table 1. The sample of participants was predominantly
middle-aged women (mean age, 43.5 years, range 18-82). Most aides (83 percent) reported that

7
English was spoken at their own Table 1. Description of the sample, home health
home. Participants were more care aides, and personal assistants:
likely to report that they worked New York City, 2007 (N = 1,561)
as a home health aide rather Characteristics Value [N (%)]
than as a personal assistant, and a
Sex [N (%)]
nearly 15 percent reported that
Female 1,438 (95.1)
they performed both jobs.
Male 74 (4.9)
Most participants had worked in Age [mean years (±SD)] 43.5 (±11.8)
a
the home care sector for slightly Language spoken [N (%)]
more than 8 years, but some had English 1,298 (83.2)
worked in the field for as many Spanish 341 (21.8)
as 35 years. The sample was Russian 39 (2.5)
predominantly unionized (67 Chinese 8 (0.5)
percent). The vast majority of Other 174 (11.1)
the sample (91 percent) Job title [N (%)]a
commuted to and from work Home health aide 965 (61.8)
(i.e., home visits) using public Personal care worker/home attendant 672 (43.0)
transportation, with an average Both 42 (9.5)
daily travel time of 2.2 hours.
Tenure (years) as a home health aide/attendant
8.3 (±6.7)
[mean (±SD)]
Most aides provided care for a
Hours worked in home care (per week)
single patient, although some 34.1 (±17.9)
[mean (±SD)]
aides had as many as 10 or more Clients seen per week [mean (±SD)] 2.1 (±4.3)
patients in a typical week. The a
Union affiliation [N (%)]
majority of the participants’
Union member 1,016 (67)
patients lived in apartment
Non-union member 501 (33)
buildings (71 percent), with the
Daily commute time (hours) [mean (±SD)] 2.2 (1.8)
remainder living in houses
a
(29 percent), assisted living Client residence type [N (%)]
facilities (15 percent), or group Apartment building 1,107 (70.9)
homes or shelters (2 percent). House 449 (28.8)
Typically, patients were elderly Assisted living/senior housing/
234 (15.0)
(64 percent), long-term patients nursing home
(83 percent), although adults Group home/ shelter 33 (2.1)
(26 percent) in long-term care Other 45 (2.9)
(77 percent) constituted a Client residence setting [N (%)]a
sizeable portion of their patient Urban 1,177 (91.5)
population. Children (7 percent) Suburban 88 (6.8)
were also provided care, Rural 22 (1.7)
generally on a long-term basis Client makeup [N (%)]
a

(66 percent). Elderly 1006 (64.4)

Adults 403 (25.8)
As expected, the job duties Children 111 (7.1)
consisted primarily of assisting a Column numbers may not add to 1,561 due to missing values.
with activities of daily living
(Table 2), including bathing,

8
toileting, dressing, etc. Although
24 percent of participants reported Table 2. Provision of care, activities
that they provided wound care, only performed, reported by home health
a small proportion (13 percent) care aides/personal assistants
reported using needles. Performing (N = 1,561)
household chores was common:
Activity Number (%) reporting
mainly cooking, light housekeeping,
and washing laundry. Participants Personal care
reported activities with the potential Assist client with bathing 153 (13.0)
for back injuries and muscle strain, Assist client with dressing 1,385 (94.2)
such as transferring patients Toileting care 1,437 (94.9)
(77 percent), walking and Oral hygiene 1,236 (85.2)
ambulating patients (87 percent), Record vital signs 1,138 (79.2)
and turning and positioning patients
Provide urinary
(68 percent). 556 (44.8)
catheter/ostomy care
Provide wound care 371 (30.6)
Infection Control Use needles or other sharps 285 (24.2)

Practices and Safety Activities

Equipment and Supplies Cook meals 1,422 (95.1)

Take clients to appointments 1,305 (92.1)
Self-reported compliance with
Walk or ambulate clients 1,191 (86.6)
infection control measures was
Transfer clients 1,027 (76.8)
generally good. For example, most
of the aides (92 percent) reported Turn and position clients 907 (67.7)
the use of gloves when the Feed clients 908 (67.6)
possibility of contact with blood Household duties
and other bodily fluids was present. Perform light housekeeping 1,461 (97.7)
Frequent handwashing was very Change linens 1,433 (96.7)
common (97 percent), as was the Wash laundry 1,418 (94.7)
use of hand gels or foams (83
Run errands 1,362 (94.1)
percent). Many aides (79 percent)
used protective aprons as a clothing
barrier. Nearly all participants (92 percent) reported quickly cleaning up blood or bodily fluid
spills. While most aides (79 percent) avoided eating or drinking in areas where the client
received care, a sizeable percentage (21 percent), nevertheless, reported that this sometimes did
occur. Poor compliance was noted for handling of contaminated needles, with 66 percent of aides
reporting that they usually recapped needles. Sharps containers were used by 80 percent of the
sample.

Personal protective gear, gowns, or aprons were reportedly available to just over half
(57 percent) of aides. Other protective gear, such as eye goggles and face masks, were only
available to 18 percent and 34 percent of aides, respectively. Disposable gloves were the most
commonly available item of personal protective gear; 89 percent of aides reported that these
were readily available to them.

9
Eight percent of the aides
Table 3. Health and safety hazards in patients’
reported that they felt they
households, as reported by home health
were at risk of exposure to
care aides/personal assistants (N = 1,561)
contagious diseases.
However, self-reported Health and safety risk factors Number (%) reporting
hepatitis B virus (HBV) Violence and psychosocial factor
vaccine rates were Verbal abuse 436 (27.9)
suboptimal; only 57 percent
Neighborhood violence/crime 168 (10.8)
of participants reported that
Racial or ethnic discrimination from
they had received all three the client or client’s family
134 (8.6)
doses, and 10 percent Threat of physical harm 128 (8.2)
received only one or two Drug use in the home 77 (4.9)
doses; 2 percent reported Client’s neighbors 65 (4.2)
that they had not been Guns in home 29 (1.9)
vaccinated, because they a
Perceived threats
were HBV antibody-
Threatening neighbors 214 (55.4)
positive. The majority of
Threatening client’s family members 147 (38.1)
aides reported tuberculin
Threatening clients 121 (31.3)
skin testing (i.e., PPD), with
67 percent reporting annual Threatening pets 67 (17.4)

testing, 19 percent reporting Slips/trips/falls hazards

twice-yearly testing, and Messy home/clutter (e.g., loose rugs) 259 (16.6)
only 2 percent reporting that Poor lighting in the home setting 78 (5.0)
they were never tested. Environmental hazards
Animal hair 332 (21.3)
Hazardous Home Excessive dust 301 (19.3)
Conditions Peeling paint 228 (14.6)
Mold/dampness 156 (10.0)
Potential health hazards in
Air pollution 150 (9.6)
the home (Table 3) were
Temperature extremes at client’s home 140 (9.0)
frequently reported. Most
Unsafe conditions in the home 92 (5.9)
commonly reported hazards
Loud/irritating noise in the home setting 64 (4.1)
were unsanitary conditions
(e.g., insects, rodents) and Potential chemical hazards
air pollutants (e.g., animal Irritating chemicals
258 (16.5)
(e.g., bleach, cleaning agents)
hair, dust, peeling paint,
cigarette smoke, mold). Unsanitary conditions

Violence, threats of Cockroaches 512 (32.8)

violence, and abuse were Mice/rats 360 (23.1)
also commonly perceived Unsanitary conditions in the home setting
193 (12.4)
(e.g., dirty toilets)
threats, with threatening
a Reported by a subset of employees (N = 386), who said they felt threatened.
neighbors most frequently
reported (55 percent),
followed by threatening family members (38 percent), threatening patients (31 percent), and
aggressive pets (17 percent). Twenty-eight percent of participants reported verbal abuse, and 9
percent of the aides reported racial or ethnic discrimination. Other potential personal safety
hazards included evidence of drug use in the home (5 percent) and guns in the home (2 percent).

10
Signs of patient abuse (e.g., by the patient’s family) were noted by 12 percent of the aides. When
noted, 77 percent reported this to their supervisor, but 13 percent did not, and the remainder
stated that they sometimes reported the abuse.

Practices that could result in harm to both the caregiver and the patient were reported by most of
the respondents, for example, turning and positioning, walking and ambulating the client, and
transferring and lifting the client. Yet only a small proportion of respondents reported access to
safe lifting devices such as Hoyer lifts (20 percent) and/or transfer boards (9 percent). Reports of
hazards that could lead to slips, trips, and falls—such as excessive clutter, loose rags, etc.—were
not infrequent (17 percent). Poor lighting, which could also result in injuries, was also noted (5
percent).

Other potential health hazards included exposure to irritating chemicals, which were mainly used
for cleaning spills. Diluted bleach was most commonly used (51 percent), followed by full
strength bleach (9 percent) and bleach mixed with other chemicals (8 percent).

Health and Safety Training

Almost all aides (90 percent) reported training in workplace health and safety. This included
training on safe lifting (83 percent); the proper use of Hoyer lifts (73 percent); electrical safety
(58 percent); fire safety and evacuation (81 percent); personal safety (74 percent); respiratory
protection (52 percent); slip, trip, and fall prevention (73 percent); and standard precautions and
infection control (78 percent). However, in the past 12 months, 6 percent said they did not
receive any safety training, and 53 percent reported receiving only one to two sessions of safety-
related training, including infection control. Roughly one-third (36 percent) of the aides reported
receiving three or more safety-related training sessions in the previous 12 months.

Discussion
These results document a high prevalence of a number of health and safety hazards associated
with home care. They generally support earlier, primarily qualitative findings on home health
hazards and establish that home care patients and HHCWs may be at risk of exposure to a range
of unsafe conditions. While this large data set was limited to just one geographic area, it is
representative of the New York City home care aides population and is most likely representative
of any large urban area in the United States.

Several aspects of these findings deserve special mention. First, the infection control practices,
although generally acceptable, were suboptimal in certain areas. The lack of availability of even
the most basic personal protective equipment, such as gloves (11 percent) and aprons (43
percent), is worrisome. In some cases, sharps handling and disposal practices were not in
compliance with the Occupational Safety and Health Administration (OSHA) Bloodborne
Pathogen Standard. 53 While aides are not supposed to handle needles, anecdotal reports from
focus groups that were held in the development phase of this study suggest that this is very
common when clients have been prescribed injectable insulin. These needles are often left for
disposal by the aide. If sharps containers are not provided, aides recap before discarding them in
the regular trash or, in some cases, into household containers. Given the fact that more than 50
percent of the aides received safety-related training only once or twice a year or less, additional

11
training, specifically on infection control, appears warranted. Agencies should not only ensure
that aides have all the necessary equipment and supplies, but also that they are trained in their
proper use. This is especially true for safe transfer equipment, such as Hoyer lifts, which can be
difficult to use. However, very few aides actually had these available to them.

Unsanitary conditions were quite common. During questionnaire development, the study team
conducted field observations and, almost uniformly, observed clutter, unhygienic practices, poor
lighting, overheating, and loose rugs. The quantitative data presented here confirm these
observations. These conditions may result from the inability of patients—many of whom are
infirm and elderly and often live alone with few resources—to maintain a safe and orderly
household. In some cases, the personal care attendant does perform household chores and thus
has more control over the situation. However, in cases where other household members perform
these chores, additional training or support may be required. Policies and procedures for
addressing this issue should be the subject of further inquiry and interventional studies. This is
important, not only in terms of the risk that unsanitary conditions present for the transmission of
infectious disease, but also because some of these hazards increase the risk of injury (e.g., falls),
and some conditions (e.g., excessive clutter) are fire safety hazards.

Hepatitis B vaccination rates were generally lower than recently published rates for other health
care work groups. A large sample of nonhospital-based registered nurses had an 84 percent rate
of complete series. 54 Slightly more than 50 percent of the aides in our sample reported receiving
all three doses. Under the Bloodborne Pathogens Standard, home health aides would be
classified as having potential risk of exposure to blood and potentially infectious materials.
Therefore, the hepatitis B vaccine and annual bloodborne pathogen training must be offered to
them at no cost.53 However, some aides are not employed by a single agency full time and, thus,
might not be eligible for this coverage. Given the close personal contact with patients and body
fluids, such low rates of HBV vaccine coverage are a concern. Since infected aides might also
present a risk of HBV transmission to their patients, universal vaccination should be encouraged
and supported.

The perception of risk of personal injury was high. Threatening neighbors, clients, and family
members; dangerous neighborhoods; and the presence of illicit drugs and guns in the home
increased this perception. As noted in earlier studies, verbal abuse was common. A large
proportion of our HHCW sample (68 percent) reported that they can refuse a case, and 65
percent said that they had done so in the past. These results are somewhat lower than those
reported by Kendra, et al., in a small sample of home care staff, where 85 percent of staff
reported that they could refuse a high safety risk assignment.52 However, their sample of 62 staff
members might have included full-time registered nurses who may have been more willing to
decline than a part-time aide. It was telling that, while all administrators in the Kendra, et al.,
study said that no negative ramifications would result from refusal, only 37 percent of staff
agreed, with the remainder leaving this question blank. The potential adverse impact on patients
who were refused was acknowledged by both administrators and staff in that study. In our
sample, in cases where aides refused to provide care, it is unknown how this affected their
employment or the provision or quality of the care their patients received.

Agencies and staff have implemented several strategies to improve the safety of home health
care staff. These include extensive preplanning, personal escorts, frequent communication,

12
providing cell phones, additional training, and encouraging staff to carry chemical spray and
weapons. Other strategies that have been considered include alternative care sites, early morning
visits, and reliance on local police for protection.52 The implementation rate or efficacy of these
strategies is not known.

This study had several strengths and limitations. As noted, the sample was confined to one
geographic area, although aides were employed by many different agencies, and the sample
demographics were representative of New York City aides as a whole. Because the survey was
available only in English, there may have been response bias. However, in instances where it was
requested, the questions were read out loud, which may have mitigated this bias to some extent.
Also, in order to be employed in New York State, aides were required to have at least a basic
understanding of the English language.

Another potential concern is that aides may have given socially desirable responses to some of
the sensitive questions (e.g., those on patient abuse). However, the surveys were anonymous, and
there was no evidence that certain questions were left largely unanswered.

In summary, this study presented evidence from a large sample of home health aides indicating a
high prevalence for certain home care-associated health hazards, many of which might be
amenable to intervention. Much more research is needed in this understudied health care sector.
Additional risk assessment studies, especially targeting home care patients, and intervention-type
studies are especially warranted.

Conclusion
The underlying question of these home care-associated hazards is the extent to which they
adversely impact patient quality of care. When staff are concerned about personal risk and are at
risk of exposure to numerous and varied health hazards, quality of care may be compromised.
Unaddressed household health hazards also present a direct risk to the health and safety of the
patient and other household members.

The financial constraints currently imposed on agencies are significant and may only increase
with time. Agencies need to be reimbursed adequately so that aides can be hired as full-time
employees with eligibility for benefits, including health care benefits. Training time, both for
trainers and trainees, must also be reimbursed so that training does not impose a financial
hardship. Adequate funding is also needed for appropriate safety equipment and supplies. The
impetus for improvements for reimbursement is made clear in a timely article on the pathways to
improvement in the health of the U.S. population. 55 The authors suggest that the United States
should focus its attention on the most vulnerable segment of the population—in most cases the
very population served by home care agencies. In order to improve the health and well being of
home care populations, these larger issues will require policy changes at the highest levels.

Author Affiliations
Mailman School of Public Health, Columbia University, New York, NY (Dr. Gershon, Ms.
Pogorzelska, Ms. Canton, Ms. Westra); School of Nursing, University of Hawaii, Honolulu, HI

13
(Ms. Qureshi); School of Nursing, Columbia University, New York, NY (Dr. Stone);
Department of Psychology, New York University, New York, NY (Ms.Samar); Mobile Health
Management Services, Inc, New York, NY (Mr. Damsky); Department of Psychology, Loyola
College, Baltimore, MD (Dr. Sherman).

Address correspondence to: Robyn R.M. Gershon, MHS, DrPH, Mailman School of Public
Health, Columbia University, 722 W. 168th Street, Suite 1003, New York, NY 10032;
telephone: 212-305-1186; fax: 212-305-8284; e-mail: Rg405@columbia.edu.

References
10. Phipatanakul W, Eggleston PA, Wright EC, et al.
Mouse allergen. II. The relationship of mouse allergen
1. Brunekreef B, Dockery DW, Speizer FE, et al. Home exposure to mouse sensitization and asthma morbidity
dampness and respiratory morbidity in children. Am in inner-city children with asthma. J Allergy Clin
Rev Respir Dis 1989; 140: 1363-1367. Immunol 2000; 106: 1075-1080.

2. Dales RE, Burnett R, Zwanenburg H. Adverse health 11. Saegart S, Klitzman S, Freudenberg N, et al. Healthy
effects among adults exposed to home dampness and housing: A structured review of published evaluations
molds. Am Rev Respir Dis 1991; 143: 505-509. of U.S. interventions to improve health by modifying
housing in the United States 1990-2001. Am J Public
3. Dales RE, Zwanenburg H, Burnett R, et al. Health 2003; 98: 1471-1477.
Respiratory health effects of home dampness and
molds among Canadian children. Am J Epidemiol 12. Klitzman S, Caravanos J, Deitcher D, et al. Prevalence
1991; 134: 196-203. and predictors of residential health hazards: A Pilot
Study. J Occup Environ Hyg 2005; 2: 293-301.
4. The healthy homes initiative: A preliminary plan.
Washington, DC: Department of Housing and Urban 13. Danzig LE, Short LJ, Collins K, et al. Bloodstream
Development, Office of Lead Hazard Control; 1999. infections associated with a needleless intravenous
Available at: infusion system in patients receiving home infusion
www.hud.gov/offices/lead/library/hhi/HHIFull.pdf. therapy. JAMA 1995; 273: 1862-1864.
Accessed April 18, 2008. 14. Do AN, Ray B, Banerjee S, et al. Bloodstream
5. Dowd MD. Childhood injury prevention at home and infection associated with needleless device use and the
play. Curr Opin Pediatr 1999; 11: 578-582. importance of infection-control practices in the home
health care setting. J Infect Dis 1999; 179: 442-448.
6. Jacob B, Ritz B, Gehring U, et al. Indoor exposure to
molds and allergic sensitization. Environ Health 15. Kellerman S, Shay DK, Howard J, et al. Bloodstream
Perspect 2002; 110: 647-653. infections in home infusion patients: The influence of
race and needless intravascular access devices. J
7. Leaderer BP, Belanger K, Triche E, et al. Dust mite, Pediatr 1996; 129: 711-717.
cockroach, cat, and dog allergen concentrations in
homes of asthmatic children in the northeastern United 16. Cohen MA, Tumlinson A. Understanding the state
States: Impact of socioeconomic factors and variation in Medicare home health care: The impact of
population density. Environ Health Perspect 2002; Medicaid program characteristics, state policy, and
110: 419-425. provider attributes. Med Care 1997; 35: 618-633.

8. Litonjua AA, Carey VJ, Burge HA, et al. Exposure to 17. Hayashi R, Gibson JW, Weatherly RA. Working
cockroach allergen in the home is associated with conditions in home care: A survey of Washington
incident doctor-diagnosed asthma and recurrent state's home care workers. Home Health Care Serv Q
wheezing. J Allergy Clin Immunol 2001; 107: 41-47. 1994; 14: 37-48.

9. Matte TD, Jacobs DE. Housing and health: Current 18. Meyer JD, Muntaner C. Injuries in home health care
issues and implications for research and programs. J workers: An analysis of occupational morbidity from a
Urban Health 2000; 77: 7-25. State compensation database. Am J Ind M 1999; 35:
295-301.

14
19. Myers A, Jensen RC, Nestor D, et al. Low back 32. Medicare home health community beneficiaries 2001.
injuries among home health aides compared with Washington, DC: Department of Health and Human
hospital nursing aides. Home Health Care Serv Q Services, Office of the Inspector General; 2001.
1993; 14: 149-155. Report No. OEI-02-01-00070. Available at:
www.oig.hhs.gov/oei/reports/oei-02-01-00070.pdf.
20. Geiger-Brown J, Muntaner C, McPhaul K, et al. Accessed April 18, 2008.
Abuse and violence during home care work as a
predictor of worker depression. Home Health Care 33. Federal interagency forum on aging-related statistics.
Serv Q 2007; 26: 59-77. Older Americans update 2006: Key indicators of well-
being . Washington, DC: U.S. Government Printing
21. Bureau of Labor Statistics, U.S. Department of Labor. Office; 2006. Available at:
Career guide to industries, 2006-2007 edition. digitalcommons.ilr.cornell.edu/key_workplace/283/.
Available at: http://www.bls.gov/oco/cg/cgs035.htm. Accessed April 18, 2008.
Accessed April 12, 2008.
34. Markkanen P, Quinn M, Galligan C, et al. There's no
22. National Association for Home Care & Hospice. Basic place like home: A qualitative study of the working
statistics about home care. 2008. Available at: conditions of home health care providers. J Occup
www.homecareaware.org. Accessed July 10, 2008. Environ Med 2007; 49: 327-337.
23. Home Care Association of New York State. Home 35. Markkanen P, Quinn M, Galligan C, et al. There’s no
care aware. Available at: place like home: A qualitative study of the working
http://www.homecareaware.org. Accessed April 12, conditions of home health care providers. J Occup
2008. Environ Med 2007; 49(3): 327-337.
24. Bureau of Labor Statistics, U.S. Department of Labor. 36. Gerba CP, Wallis C, Melnick JL. Microbiological
Nursing, psychiatric, and home health aides. Available hazards of household toilets: Droplet production and
at: www.bls.gov/oco/ocos165.htm. Accessed April 12, the fate of residual organisms. Appl Microbiol 1975;
2008. 30: 229-237.
25. Bureau of Labor Statistics, U.S. Department of Labor. 37. Kundsin RB. Staphylococcal disease in the home. Clin
Personal and home care aides. Available at: Med 1966; 3: 27-29.
http://www.bls.gov/oco/ocos173.htm. Accessed April
12, 2008. 38. Terpstra PMJ. Domestic and institutional hygiene in
relation to sustainability: Historical, social and
26. Office of Administrative Law Judges, U.S. environmental implications. Int Biodeterior
Department of Labor. Dictionary of occupational Biodegradation 1998; 41: 169-175.
titles. Available at:
http://www.oalj.dol.gov/libdot.htm. Accessed April 39. Mead PS, Slutsker L, Dietz V, et al. Food related
12, 2008. illness and death in the United States. Emerg Infect
Dis 1999; 5: 607-625.
27. National Association for Home Care & Hospice.
Educational opportunities. Available at: 40. Gershon R, Pogorzelska M, Qureshi K, et al. Home
www.nahc.org/education/home.htm. Accessed April health care registered nurses and the risk of
18, 2008. percutaneous injuries: A pilot study. Am J Infect
Control 2008; 36: 165-172.
28. Ono Y, Lagerstrom M, Hagberg M, et al. Reports of
work related musculoskeletal injury among home care 41. Backinger CL, Koustenis GH. Analysis of needlestick
service workers compared to nursery school workers injuries to health care workers providing home care.
and the general population of employed women in Am J Infect Control 1994; 22: 300-306.
Sweden. Occup Environ Med 1995; 52: 686-693.
42. Beltrami EM, McArthur MA, McGerr A, et al. The
29. Galinsky T, Waters T, Malit B. Overexertion injuries nature and frequency of blood contacts among home
in home health care workers and the need for healthcare workers. Infect Control Hosp Epidemiol
ergonomics. Home Health Care Serv Q 2001; 20: 2000; 21: 765-770.
57-73.
43. Perry J, Parker G, Jagger J. Percutaneous injuries in
30. Centers for Medicare & Medicaid Services. Office of home healthcare settings. Home Healthc Nurse 2001;
the Actuary. Available at: 19: 342-344.
www.cms.hhs.gov/ReportsTrustFunds/. Accessed June
9, 2008. 44. Simmons B, Trusler M, Roccaforte J, et al. Infection
control for home health. Infect Control Hosp
31. DeFrances CJ, Hall MJ, Podgornik MN. National Epidemiol 1990; 11: 362-370.
hospital discharge survey; 2003. Available at:
www.cdc.gov/nchs/data/ad/ad359.pdf. Accessed April 45. Rhinehart E. Infection control in home care. Emerg
12, 2008. Infect Dis 2001; 7: 208-211.

15
46. Manangan LP, Pearson ML, Tokars JI, et al. 51. Loveless LE. Workplace violence: A report to the
Feasibility of national surveillance of health care nation. Iowa City: University of Iowa, Iowa Injury
associated infections in home care settings. Emerg Prevention Research Center; 2001.
Infect Dis 2002; 8: 233-236.
52 . Kendra MA, Weiker A, Simon S, et al. Safety
47. Guidelines for infection control in home care settings. concerns affecting delivery of home health care.
Division of Healthcare Quality Promotion, Centers for Public Health Nurs 1996; 13: 83-89.
Disease Control and Prevention. Available at:
www.cdc.gov/ncidod/dhqp/gl_home_care.html. 53. Occupational exposure to bloodborne pathogens –
Accessed April 15, 2008. OSHA. Final rule. Fed Register 1991; 56: 64175-
64182.
48. Barling J, Rogers AG, Kelloway EK. Behind closed
doors: In-home workers' experience of sexual 54. Gershon RM, Qureshi KA, Pogorzelska M, et al. Non-
harassment and workplace violence. J Occup Health hospital based registered nurses and the risk of
Psychol 2001; 6: 255-269. bloodborne pathogen exposure. Ind Health 2007; 45:
1-10.
49. Sylvester BJ, Reisener L. Scared to go to work: A
home care performance improvement initiative. J Nurs 55. Schroeder SA. We can do better - improving the
Care Qual 2002; 17: 71-82. health of the American people. N Engl J Med 2007;
357: 1221-1228.
50. Fazzone PA, Barloon LF, McConnell SJ, et al.
Personal safety, violence, and home health. Public
Health Nurs 2000; 17: 43-52.

16