Aging in America News

| Empowering Workers as Stakeholders 

| Shalini Kathuria Narang

| Millions of Americans rely on home care provided by paid caregivers. With the growing number of older adults in the U.S. seeking to remain in their homes as they age, the demand for quality home care has never been higher.

Home care workers (HCWs), spend more time with patients than any other member of the healthcare team, assisting patients with activities of daily living and aspects of medical care. 

Home Care Cooperatives represent a new approach toward providing quality home care. Unlike traditional home care services, cooperatives are owned and operated by the workers that deliver these services, leading to greater collaboration and a deeper sense of ownership for the participants. Currently, there are 20 such organizations operating in 10 states and Puerto Rico.

A research-backed solution

Research on home care cooperatives has identified key factors that promise to improve the quality of care for patients. The four main drivers of improved care quality at cooperatives include: 

• Incorporation of worker input into care planning 
• Boost in motivation from co-ownership
• Selective hiring of high-performing workers 
• Access to high-quality, hands-on training

“This study identifies specific factors that may improve the quality of home care, a relatively understudied area but one that has major consequences for care recipients and the broader health care system,” says Dr. Geoffrey Gusoff, Assistant Professor of Family Medicine at the David Geffen School of Medicine at UCLA and the study’s lead author. “The care-enhancing practices identified by participants represent testable interventions that have the potential to significantly improve care quality across the home care sector.”

Gussoff adds: “Expanding the home care cooperative model and the adoption of cooperatives’ practices by traditional agencies could contribute to significantly improved home care quality, benefiting both care recipients and the broader healthcare system.”

The Price of Marginalization

HCWs are marginalized within the healthcare system, undermining their ability to provide quality care. 

Despite their crucial role in patient safety and care outcomes, other care team members rarely solicit or act upon the expertise of HCWs’ input. Though HCWs implement care plans across diverse home environments, they generally receive limited training with inconsistent standards. HCWs also work irregular hours with limited benefits, and they earn the lowest wages in healthcare, resulting in annual turnover rates up to 82%.

Agency-level practices such as the exclusion of HCWs from care planning, punitive supervisory approaches, and limited opportunities for additional training all contribute to HCW marginalization and diminished quality.

Profit-driven ownership models in home care and long-term care incentivize investor profits over long-term workforce investments and have been associated with worse care quality and patient outcomes. Additionally, low fee-for-service reimbursement provided by Medicaid, the largest payer of HCW services, translates into low HCW compensation and ignores the value of quality HCW care in preventing costly, unnecessary hospitalizations.

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Further benefits of cooperatives

In previous research, the team focused on how cooperatives can reduce employee turnover through practices such as better compensation, a sense of community, and control. Researchers conducted 32 semi-structured interviews with home care workers and other staff at five cooperatives nationally to identify drivers of care quality.

A key factor for care quality improvement at the cooperatives was found to be the high level of HCW input into patient care decisions, allowing effective response to evolving patient needs including updates to their patient care plans and addressing their safety concerns. Several respondents attributed this to the cooperative structure, “I own a piece of this company, my say counts, and I can communicate and bring back the information that may help the company and help the aides and the clients,” says a HCW.

Another HCW noted that cooperatives’ incorporation of HCW input prevented common safety issues like feeding. “Another caregiver coming in, trying to feed them (patients) solids when they potentially can asphyxiate—you don’t have that,” reports a HCW. This experience contrasts with that of another HCW at a traditional agency, where her warnings of a patient’s fall risk were ignored. “My opinion was absolutely nothing, even though my client was in danger.”

Respondents pointed that care quality at the cooperatives was also improved by the additional motivation that HCWs felt on being co-owners of the business. While many HCWs explained they would aim to provide excellent care for patients even if they were not co-owners, they emphasized that being co-owners of the business led them to, “go the extra mile” and “take it more seriously,” while staff members described co-ownership leading to HCWs, “holding themselves to a higher standard,” and approaching patient care, “wholeheartedly and fully committed.”

For respondents, this “co-ownership motivation” to improve care was both financial and psychological. Providing high-quality care was seen as an important way to increase agency profits that HCWs shared in as co-owners. Others similarly chime in that as co-owners, HCWs take more pride in their work, and want to give better care to be able to give the client a good experience.

Another factor respondents identified contributing to care quality was cooperatives’ preferential selection of HCWs occurring partly through cooperatives’ rigorous interviewing, hiring, and member confirmation processes. At all cooperatives, HCWs become full cooperative members only after a probationary period and vote by other members. 

Finally, respondents described capacity-building opportunities, including formal training, shadowing and peer mentoring, enabling them to develop skills. Respondents noted that large cooperatives tended to provide in-house training, differentiated from traditional agency training by their length, scope, and practical nature. An HCW from a large cooperative described these training sessions as “hands-on” and “really sufficient.” Another HCW contrasted this approach to that of a traditional agency, where, “we only did training for two weeks and it wasn’t hands on the way [the cooperative training] was.”

Several respondents noted that smaller cooperatives also emphasized HCW capacity-building but relied more on training opportunities through state programs and online platforms. While some HCWs reported paying costs for initial certification training, most HCWs and staff reported that the cooperatives covered training costs. 

While highlighting higher HCW care input at cooperatives in comparison to other agencies, some respondents hinted at room for improvement at large cooperatives, where care team communication needs improvement. A staff member at a large cooperative described the creation of a “care navigator” position to enhance the role of HCW input within the care team.

Gussoff concludes: “Quality home care is essential for improving the quality of life of care recipients and reducing unnecessary medical costs, but our current system, which often treats home care workers as low-skilled and easily replaceable, undermines home care quality.” 

Shalini Kathuria Narang is a Bay Area based freelance journalist. She has reported and written on health, wellness, diaspora, travel, technology and trends.