The different forms of exploitation in homecare work

Taiwan implemented its first National 10-Year Long-Term Care Plan in 2008 and its second in 2017. Over the first 10 years, the number of home care workers grew too slowly to meet demand. To increase the home care workforce, the government introduced 2 new payment mechanisms in 2018. This study assesses these mechanisms' impact on growth in numbers of home care workers and use of home care services in Taiwan. Data were collected from the Ministry of Health and Welfare (2014-2019) and the Division of Long-Term Care (2017-2019). Generalized estimating equations compared rates of growth in the number of home care, institutional care, and foreign care workers and the number of care recipients receiving care from each group before and after 2018. Before 2018, rates of growth in all three groups of care workers increased slowly. After 2018, the rate of growth for home care workers increased to 31.8% from 9%, while growth in the other two groups remained stable. While there was greater workforce growth among home care than institutional care workers post-implementation of the payment mechanisms (p < .05), the number of home care recipients (p < .05) and monthly home care visits (p < .05) also increased. The new payment mechanisms improved home care workers' autonomy and salaries and appear to have contributed to immediate increased recruitment and retention. Whether this increase continues over the long run will need to be determined.

Background: Paid home care workers (HCWs) represent one of the fastest growing sectors of the US workforce and healthcare industry. They are increasingly utilized by home-dwelling adults with heart failure (HF) for long term assistance and post-acute care. Yet, little is known about the perspectives of HCWs regarding their role in HF management and as part of the healthcare team. Objective: We sought to understand the perspectives of HCWs who take care of adults with HF as the foundation for the development of future intervention(s). Methods: We conducted 8 focus groups with English and Spanish-speaking HCWs at the 1199SEIU’s Home Care Industry Education Fund, a non-profit organization that oversees the training of 65,000 HCWs from 50 home care agencies across NYC. Eligibility criteria included taking care of a client with HF within the last year and being a HCW for at least 2 years. Purposeful sampling ensured equal representation of English and Spanish speaking HCWs. Focus groups were audio recorded and professionally transcribed. Data were organized using qualitative software and analyzed using grounded theory. Results: The 46 participants were mean age of 49 years (SD 10), 45 (98%) were female, 17 (37%) were Black, 25 (54%) were Hispanic, and 42 (91%) had at least a high school education. Participants had been HCWs for 16 years (8.4 SD) and spent 3.5 days per week (1.8 SD) with HF clients. Seven major themes emerged: 1. HF has an unpredictable disease course, which is frightening to HCWs. “One minute we’re watching TV and the next, he crumps.” 2. HCWs often assist with HF management , although most have not received HF training. “Over time, you pick up on the symptoms - the shortness of breath, the swollen legs. But, I’ve never received HF training.” 3. Communication is fragmented. ?No one at the agency picks up the phone, so I just take him to the emergency room instead.? 4. HCWs are ignored by the healthcare team. “We’re with the clients all day, more than anyone else. So why aren’t we included in the conversation?” 5. Role definition is lacking . “The agency doesn’t make clear who we are or what we do. We aren’t just the help!” 6. Delicate family dynamics. “I’m always in the middle and I can’t afford to lose my job.” 7. Social isolation and burnout. “I’m with her all day, and she has Dementia too. It’s hard -- I’ve literally got nobody to talk to.” Conclusions and Implications: Our findings suggest that while HCWs are frequently involved in their clients’ HF management, most have not received formal HF training or resources. Additionally, despite spending so much time caring for their clients, they often feel invisible to healthcare providers. HF-specific training, as well as interventions that aim to integrate HCWs into the healthcare team, may improve HCWs’ HF knowledge and the quality of care delivered to adults with HF.

BackgroundThe demand for home care workers (HCWs) is increasing, but home care services face challenges in recruiting and retaining skilled workers, partly due to hazards in the work environment. Transportation to client visits is an important part of HCWs' working conditions, with various modes (e.g., walking, cycling, driving) being utilized. However, these modes are often implemented without considering HCWs' perceptions of their use. Therefore, our study aimed to understand HCWs’ perceptions and experiences of using different transportation modes at work, and how they may influence health.MethodsFourteen HCWs from a home care unit in Trondheim (Norway) participated in focus group interviews. The interviews were analyzed using a reflexive thematic analysis approach including reflexive journaling. The analytical process was guided by a biopsychosocial understanding of health.ResultsThe analysis showed that when different transportation modes were assigned, predictability of the assignment was important for the HCWs. Both walking and driving were regarded to have both positive and negative health impacts. When walking, informants thought that getting fresh air outdoors and doing physical activity was health-promoting, while bad weather conditions and too much walking could be negative for their health. When driving a car, informants talked about privacy and getting physical rest as positive for their health, while traffic and parking conditions could be stressful. Individual factors such as age, physical health, and strong preferences were highlighted as important to consider when planning HCWs’ transportation modes in an occupational health perspective.ConclusionsWalking now and then between client visits was generally believed by the HCWs to lead to positive health effects compared to only driving a car. Introducing planning of various transportation modes in advance, so that they are predictable, seems important to reduce stress among HCWs. In addition, some individual factors should be considered in the planning, and it should be realized that the planning likely represents a trade-off between promoting the psychosocial work environment when driving a car and potentially enhancing long-term physical health when using active transportation. Thus, biopsychosocial aspects of health should be considered when planning the mode of transport between client visits for HCWs.

Person-centered care for people living with dementia has been associated with improved functional ability and quality of life, yet little is known about person-centered care in the home setting. This study explored home care worker perspectives on providing person-centered care for people living with dementia. Using secondary qualitative analysis of 22 semi-structured interviews with home care workers, we identified themes related to the Dementia Initiative’s person-centered dementia care framework. We found that home care workers frequently acknowledged their client’s personhood and developed meaningful relationships with their clients, implementing individualized strategies to meet client needs. However, barriers to person-centered care included limitations of home care worker scope of practice and challenging dynamics with other home care workers and family caregivers. In addition, home care agencies’ formal care plans sometimes served as a barrier to person-centered care, but home care workers advocated within and around their task-based duties to ensure client needs were met. This analysis highlights the importance of integrating home care workers in person-centered healthcare teams and sustaining the meaningful relationships between home care workers and their clients, family caregivers, and other home care workers. Standardized training of home care workers in the principles and goals of person-centered dementia care could enhance existing person-centered care practices and promote alternatives to disease-centered practices. Recognizing home care workers’ unique role in providing person-centered care is essential to identify and meet the needs of people living with dementia in the community and their family caregivers.

BackgroundDue to the aging population, the need for home care services is increasing in most Western countries, including Norway. However, the highly physical nature of this job could contribute to make recruiting and retaining qualified home care workers (HCWs) challenging. This issue may be overcome by adopting the Goldilocks Work principles, aiming at promoting workers’ physical health by determining a “just right” balance between work demands and recovery periods while maintaining productivity. The aim of this study was to 1) gather suggestions from home care employees on suitable organizational (re)design concepts for promoting HCWs’ physical health and 2) have researchers and managers define actionable behavioral aims for the HCWs for each proposed (re)design concept and evaluate them in the context of the Goldilocks Work principles.MethodsHCWs, safety representatives, and operation coordinators (n = 14) from three Norwegian home care units participated in digital workshops led by a researcher. They suggested, ranked, and discussed redesign concepts aimed at promoting HCWs’ health. The redesign concepts were subsequently operationalized and evaluated by three researchers and three home care managers.ResultsWorkshop participants suggested five redesign concepts, namely "operation coordinators should distribute work lists with different occupational physical activity demands more evenly between HCWs", "operation coordinators should distribute transportation modes more evenly between HCWs", "Managers should facilitate correct use of ergonomic aids and techniques", "HCWs should use the stairs instead of the elevator", and "HCWs should participate in home-based exercise training with clients". Only the first two redesign concepts were considered to be aligned with the Goldilocks Work principles. A corresponding behavioral aim for a “just right” workload was defined: reduce inter-individual differences in occupational physical activity throughout a work week.ConclusionsOperation coordinators could have a key role in health-promoting organizational work redesign based on the Goldilocks Work principles in home care. By reducing the inter-individual differences in occupational physical activity throughout a work week, HCWs’ health may be improved, thus reducing absenteeism and increasing the sustainability of home care services. The two suggested redesign concepts should be considered areas for evaluation and adoption in practice by researchers and home care services in similar settings.

Home care is the preferred care option for most people who need support; yet abuse exists in these settings toward both home care workers and clients. There are no existing reviews that assess the scope of current research on abuse in home care, and tangentially related reviews are dated. For these reasons, a scoping review is warranted to map the current state of research on abuse in home care and examine current interventions in this field. Databases selected for searching were Medline and EMBASE on OVID, Scopus, and the following databases in EBSCOhost: Academic Search Complete, AgeLine, and Cumulative Index to Nursing and Allied Health Literature. Records were included if: (a) they were written in English; (b) the participants were home care workers or clients age 18 years or older; (c) they were published in journals; (d) they undertook empirical research; and (e) they were published within the last 10-year period. Following Graham et al. (2006), the 52 included articles are categorized as either knowledge inquiry or as intervention studies. We find three themes among knowledge inquiry studies: (1) prevalence and types of abuse in home care, (2) abuse in the context of living with dementia, and (3) working conditions and abuse. Analysis from the intervention studies suggest that not all organizations have specific policies and practices to prevent abuse, and no existing interventions to protect the well-being of clients were identified. Findings from this review can inform up-to-date practice and policymaking to improve the health and well-being of home care clients and workers.

This Note looks closely at the issues facing home care workers and the persons with disabilities and older persons who consume that care. It argues that without seriously taking into account the unique intersectional needs of both care providers--predominately low-income women of color--and care consumers--generally persons who have disabilities, are elderly, or both--advocates will fail to create empowering care partnerships. The Note discusses the ways in which a purely feminist or disability rights lens fails to take into account the complex dynamics of the home care relationship, and suggests that scholars who have integrated the needs of care workers and care consumers have provided what should be considered foundational theories for home care empowerment activism. It implores advocates to continue to look to theorists that holistically incorporate feminist scholarship and disability rights scholarship in order to best understand the complex, multidimensional issues facing participants to relationships of care. The Note also examines advocates and organizations already doing this kind of integrated work and argues that they should be promoted and emulated, to the extent that their efforts have been successful. Finally, the Note lays out several possible policy solutions that would serve the needs of home care workers and care consumers, empowering and elevating all care participants, and contends that these should be prioritized in advocacy efforts going forward. INTRODUCTION My [personal assistant] is my right-hand, she s my angel.-Joann Vitiello, care consumer (1) Workers like me face tough decisions all the time--should we pay the tuition bill or fix the oven that broke right before Thanksgiving? Can we put gas in the car to take our consumers to medical appointments or do we need to save that money for groceries? --Alantris Muhammed, home care worker (2) You can't teach compassion. That's why we need a raise--so that people like me can afford to do the work we love. -Liliana Cordero, home care worker (3) A home care worker in Seattle, who juggles paid work as an aide to an elderly woman with dementia with unpaid work for her own son with autism, finds that her paychecks barely cover her basic household expenses. (4) An in-home aide to a child with multiple disabilities in St. Paul, Minnesota recalls how she was only able to take one week off from work after the birth of her own son, as she was unable to afford to miss any more hours. (5) A home care worker in Chicago, without any paid sick leave, must choose between exposing her elderly clients to her cold or flu, and missing out on crucial wages to support her children. (6) An in-home aide in Brainerd, Minnesota estimates that she has logged over two hundred hours of unpaid work since her employer began to cap her hours; she does not want her bedridden clients to go without crucial services in her absence, as they have no one else to whom they can turn for their care needs. (7) These stories are not unusual among home care workers, nor among low-wage women workers in general. With one in seven low-wage women working as a home care aide, (8) this is not only the reality for the home care workers' industry--made up predominately of low-income women of color (9)--but instead represents the lived experience of many working class women in the United States. Home care aides are largely comprised of some of the most vulnerable workers in the United States. Overwhelmingly women, significantly women of color and immigrant women, this population earns among the lowest wages in the service industry, and has historically been excluded from labor and employment protections. (10) Because they work within the home and thus out of the public eye. domestic workers--including home care workers--are at high risk of exploitation and abuse. (11) However, the realities of the home care industry do not only affect the women who provide care to older people and people with disabilities. …

“I Depend on Her for Everything”: Characterizing the Role of Home Care Workers Caring for Seriously Ill Homebound Older Adults During the COVID-19 Pandemic Through a Mixed-Methods Study (RP419)

ObjectivesThe demand for home care services has increased with the growth of the older population. Currently, home care workers (HCWs) are experiencing challenges such as poor working conditions, high turnover, fragmented services and dissatisfied clients, which are indicative of limitations on HCWs’ ability to provide quality integrated home care to older people. Therefore, we conducted a scoping review to identify the key elements that affect the capabilities of the HCWs in providing quality integrated care to older people in their homes.DesignScoping review.Data sourcesPubMed, PsycINFO, Scopus, CINAHL, Cochrane, Analysis & Policy Observatory, Australian Association of Gerontology (Australia), WHO, Trove (Australia), Social Care Online (UK) and Google between January 2014 and August 2025.Eligibility criteria for selecting studiesStudies were included if they focused on the analysis of HCWs’ experience in providing care to older people within home settings and were published in the English language between January 2014 and August 2025.Results19 studies met the inclusion criteria out of 2844 retrieved articles. Most studies were conducted in North America (n=8). Qualitative studies were the most commonly reported (n=16). The findings of the studies were combined and categorised into four themes using a narrative synthesis approach. The four themes identified were HCWs’ capability through (1) collaborative practice, (2) education and training, (3) structural conditions at work and (4) personal attributes.ConclusionThis scoping review on home care for older people highlights four interconnected pillars that shape HCWs’ capabilities. This review provides valuable insights to inform the standards and policies to strengthen HCWs’ capabilities across these domains. Future study is needed to explore the measures taken by agencies to understand and address key elements of HCWs’ capability.

Task shifting, which involves the transfer of care work from regulated health-care professionals to home care workers (HCWs), is a strategy to ensure the efficient delivery of home care services in Canada and internationally. Using a feminist political economy approach, this paper explores the effects of task shifting on HCWs' skills. Task shifting may be understood as a form of downward substitution-and an effort to increase control over workers while minimizing costs-as some of health-care professionals' responsibilities are divided into simpler tasks and transferred to HCWs. Our interviews with 46 home health-care providers in Ontario, which focused explicitly on HCWs' role in care provision, problematize the belief that "low skilled" care workers have little control over their work. HCWs' skills become more complex when they do transferred tasks, and HCWs sometimes gain greater control over their work. This results in increased autonomy and mastery for many HCWs. In turn, this serves to reinforce the intrinsic rewards of care work, despite the fact that it is low paid and undervalued work.

Many people living with dementia (PLWD) wish to continue living at home. The quality of home care services directly influences their ability to stay at home, their quality of life, and can promote independence for PLWD, and reduce burden for the family carer. For high-quality, effective, person-centred community-based dementia care, a knowledgeable and empathetic workforce is crucial. This article presents an up-to-date review and summary of the literature investigating dementia training programmes for community home care professionals and care workers, referred to collectively as home care workers (HCWs). We reviewed the literature between October 2016 and April 2018 on dementia training for HCWs. We found a significant lack of evidence-based, codesigned specialist dementia training programmes for HCWs that address the needs of all stakeholders in home care, and which formally measure outcomes. In order to enable PLWD to maintain living at home in the community, dementia-friendly and knowledgeable HCWs are needed. This review highlights the need for more research into the design and evaluation of evidence-based dementia specialist training programmes for community care.

Home care workers (HCWs) are an important group of frontline workers that deliver essential at-home care services to enable older adults to age in place. Despite their importance in patient care, research has shown that HCWs are an overlooked and undervalued workforce: HCWs work in isolated conditions, are paid low wages, experience high levels of stress and burnout, and more. As a result, despite being motivated to try and be healthy, this essential workforce suffers from poor physical and mental health outcomes. This paper combines data from focus groups, interviews, and a month-long field study with HCWs to investigate the feasibility and utility of using activity tracking devices to provide HCWs with fine-grained awareness and insights into daily activities that affect their health and wellbeing. We explore HCWs' reactions to both their individual and collective data, discussing their efforts towards positive behavior change, but also highlighting systemic and occupational factors that may limit HCWs' agency and control over their own activities. Finally, we discuss the potential for HCWs' collective data to raise awareness about their working conditions and provide data-driven evidence to aid advocacy efforts towards improved policies, better wages, or greater protections for this vital workforce.

Home care workers (HCWs) have played a critical role in keeping homebound older adults safely at home during COVID-19, yet their essential work is often understudied. This study characterized the roles of HCWs during COVID-19 and examined how HCW service disruptions impacted patients and their caregivers. We performed a thematic analysis of medical records from 53 patients with HCWs in a home-based primary care practice in New York City. We abstracted unstructured clinical notes into a priori and emergent categories and identified core themes via team discussion. The following themes emerged: 1) Shifts to remote medical care and changing patient needs led to task shifting and new tasks for HCWs (i.e. getting food for patients experiencing food insecurity), 2) The risks associated with HCW tasks, such as exposure from caring for patients with COVID-19, increased during the pandemic, 3) Patient and family refusal of HCW services to avoid COVID-19 exposure as well as abrupt loss of HCW services due to HCW precarity or COVID-19 exposure left family caregivers with additional caregiving responsibilities, 4) Regulations surrounding return to work following COVID-19 exposure created additional difficulties in reinstating HCWs and left patients without adequate care, putting them at risk of hospitalization. In conclusion, pandemic-related disruptions created barriers to adequate home care, putting both patients and caregivers at risk. This analysis suggests a need for more robust HCW training and established regulations to protect HCW safety as well as a need for policies to support caregivers and ensure continuity of care during emergencies.

BackgroundThe need for home care workers (HCWs) is rapidly growing in Norway due to the increasingly growing elderly population. HCWs are exposed to a number of occupational hazards and physically demanding work tasks. Musculoskeletal disorders, stress, exhaustion, high sick leave rates and a high probability of being granted a disability pension are common challenges. This qualitative study explored the views of HCWs on how working conditions affect their safety, health, and wellbeing.MethodsA descriptive and explorative design was utilised using semi-structured individual interviews with eight HCWs from three home care units in a middle-sized Norwegian city. Interviews were conducted in the Norwegian language, audio-recorded, and transcribed verbatim. The data was analysed by systematic text condensation. Key data quotes were translated into English by the authors.ResultsHCWs reported that meaningful work-related interactions and relationships contributed to their improved wellbeing. Challenging interactions, such as verbal violence by consumers, were deemed stressful. The unpredictable work conditions HCWs encounter in users’ homes contributed to their exposure to environmental hazards and unhealthy physical workloads. This was the case, although the employer promoted ergonomic work practices such as ergonomic body mechanics when mobilising and handling of clients, using safe patient handling equipment. HCWs perceived high level of individual responsibility for complying with company safety policies and practices, representing a health barrier for some. Organisational frameworks created unhealthy work conditions by shift work, time pressure and staffing challenges. Performing tasks in accordance with HCWs professional skills and identity was perceived as health-promoting.ConclusionsThis study suggests that unpredictable working conditions at users’ home can adversely affect the safety, health, and wellbeing of HCWs. The interaction between the unpredictable environment at users’ homes, HCWs’ perceived high level of individual responsibility for complying with company safety policies and practices, and staffing challenges due to sickness-related absences upon the workplace creates tense work conditions with a negative influence on HCWs health.

BackgroundCulturally matched home care workers (HCWs) for immigrants with ADRD face high stress from addressing cultural care needs. While wearables measuring heart rate variability (HRV) show promise as stress indicators, their feasibility and acceptability for daily use in HCWs remain unclear. Focusing on Korean‐American HCWs as an exemplar of an ethnic minority, we presented preliminary findings on using a finger‐worn device for longitudinal stress monitoring.MethodsWe included Korean‐American HCWs (≥6 months of caregiving experience) of Korean immigrants with ADRD who owned a smartphone. HCWs caring for their own family members were excluded. Data collection began in September 2024. Participants wore Ōura rings for 21 consecutive days (7 days for baseline data establishment and 14 days for analysis). We measured recruitment and enrollment rates, completion rates of data collection, HRV data quality (valid data), and participants’ perceived ease of use and comfort (rated on a scale from 1 [very unlikely] to 5 [very likely]). HRV data were accessed through the Ōura application programming interface and analyzed using Python.ResultOf the 27 HCWs referred to the study, 7 (25.93%) were ineligible and 20 (74.07%) were invited. Of those invited, 18 (90.0%) consented to the study. Three (16.67%) dropped out afterward, leaving 15 (83.33%) HCWs who started the study. Fourteen participants completed 21 days of wearing the rings, while one participant remains ongoing. Among the 14 HCWs who completed the study, 8 (57.14%) had valid HRV data for all 14 days, whereas 6 (42.86%) had 1 to 4 invalid data despite completing the study. The average scores for ease of use and comfort of the ring were 4.21 (SD=1.05; range=2‐5) and 3.86 (SD=1.03; range=2‐5), respectively.ConclusionThe study demonstrates the feasibility and acceptability of Ōura for daily HRV monitoring among Korean‐American HCWs caring for Korean immigrants with ADRD. Future studies with larger sample sizes are necessary to validate these findings. Additionally, an in‐depth understanding of the sources of stress and unmet needs in this HCW population is critical to inform culturally tailored interventions.