Homecare Worker Safety
Home Healthcare Worker SafetyHome healthcare and hospice organizations focus extensively on the safety of patients and many have adopted safety innovations to reduce risks and prevent injuries such as falls, pressure ulcers and disease exacerbation. As care in the home becomes more complex – and more people are providing home-based care, it is also critical for organizations to consider safety of workers along with safety of patients.
The National Institute for Occupational Safety and Health (NIOSH) says there are almost 4 million home healthcare workers and notes that they often work alone and without many of the typical safety protections available to workers in institutional settings. The objective of this module is to identify information, resources, and best practices to assist home health and hospice organizations to implement strategies to improve safety of their team members. This module identifies many safety risks in the home, along with prevention, mitigation and training strategies to reduce risk to homecare workers. With the demand for homecare expected to increase in the coming decade, agencies may be well served to develop robust safety programs to reduce risk, increase employee satisfaction (a key element of the Quadruple Aim), and improve retention.
This module was developed with input of ElevatingHome/VNAA members. We thank them for their time and ideas!
Who is at Risk When Providing Home Care?
Professional and para-professional staff – including nurses, aides, physical and occupational therapists and supervisors and well as volunteers face occupational risks when providing services in the home. The type of risk depends on the work being done, use of supports, geographic area, and for some, even the season.
What are the Risks?
The risks to homecare workers include those applicable to other healthcare workers along with others unique to the home (or less likely to be reported and managed). These include:
- Infection, including bloodborne and airborne pathogens
- Pests and vermin – including rats, mice, lice, roaches, bedbugs, fleas (may be part of infection control)
- Injuries due to lifting / repetitive motion
- Injuries from pets, guns, acts of nature, mass violence
- Slips, trips and falls
- Verbal or physical abuse, including harassment
- Automobile accidents
While there is no comprehensive source of information on risks and injuries in home care for all at risk workers, a number of sources document the scope of the problem:
- A NIOSH-funded study looking at 2015 data found: 'Home environments are more challenging and variable than other healthcare work environments. In 2015 the Bureau of Labor Statistics reported incidence rates for home health aides and personal care assistants, at 117.9 and 132, respectively, exceeded the average rate of 93.9 cases per 10,000 workers for private industry as a whole."
- A 2008 survey of 1500 home healthcare workers (HHCW) found troubling risks: “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.”
- NIOSH reports that in 2007 27,400 recorded injuries occurred among more than 896,800 home healthcare workers (a rate of 20.5 per 10000). NIOSH found that ‘Home healthcare workers are frequently exposed to a variety of potentially serious or even life-threatening hazards. These dangers include overexertion; stress; guns and other weapons; illegal drugs; verbal abuse and other forms of violence in the home or community; bloodborne pathogens; needlesticks; latex sensitivity; temperature extremes; unhygienic conditions, including lack of water, unclean or hostile animals, and animal waste. Long commutes from worksite to worksite also expose the home healthcare worker to transportation-related risks.’
- A University of Massachusetts-Lowell survey of almost 1000 home health aides found that over 20% report that they have been verbally abused in the past year, and of these, 5% reported threats of physical violence. A meta-analysis by the same research institution reported in the article Risk of Sharps Injuries to Home Care Nurses and Aides found a 5.25% weighted average risk of experiencing at least one sharps injury in the past year while working in home care.
Agency Responsibilities and Best PracticesAgencies are mandated to have an active Safety Program by the Occupational Safety and Health Administration (OSHA): Medicare Conditions of Participation for home health also require an infection control program (COP section §484.70) that describes many aspects of employee safety. OSHA requires covered employers to post information informing workers of their occupational health and safety rights. These regulatory requirements are fairly broad and may not encompass the safety concerns of any specific agency and its staff. In addition to regulators, workers compensation insurers may have requirements (and resources) for managing home care risks.
ElevatingHome / VNAA ‘best practices’ can guide agencies in developing a robust home care safety program for workers that includes required elements and also considers or has capability to encompass known and emerging hazards in the home. Adoption of a robust program incorporating best practices communicates the agency’s commitment to the safety of its employees, contractors and volunteers.
Best Practice: Implement a strategy that emphasizes prevention of harm through understanding of risks to the industry and within your agency's community and patient population. For example:
- Ensure that leadership of the agency understand common risks in home healthcare.
- Conduct a periodic hazard assessment to understand particular risks in your community and patient population - your agency's workers compensation insurer may have tools, and the NIOSH Hazard Review publication 'Occupational Hazards in Home Healthcare' provides a helpful framework.
- Always think about opportunities to prevent risk of harm.
- Regular review of incident reports submitted by staff.
- Developing a program for ‘early warning’ and review of reporting by staff on an emerging concern that does not rise to the level of an incident. Examples of issues that could be identified proactively include unclean environment, individuals in the household who make the employee uncomfortable or aggressive animals.
- Review of state and county data on population health issues that may be encountered in home care, including prevalence of opioid use, firearm ownership, falls due to ice and snow or other issues.
- Periodic employee focus groups or discussions in management meetings
- Inclusion of a safety question on the annual employee experience survey
- Workers compensation carriers may provide local and regional experience and benchmarking data
- National studies to help management understand the scope of safety issues in the home
Best practice: Develop policies relating to safety risks that are consistent with Medicare Conditions of Participation and also assure staff that they have a right to a safe workplace. Examples include:
- A policy/process for staff to request assistive devices in the home to assist with ergonomically safe patient transfers and mobility.
- A policy for reporting of minor incidents (that could signal greater risk or repeat behavior), incidental observations of risk, such as child endangerment, and actual events. Clearly articulating the agency’s openness to learning about concerns can help reduce under-reporting and help to identify risks early.
- A policy on infection control in the home and a separate policy on vermin (This Sample Draft Bedbug Policy From Midwest Clinicians Network could be adapted for home health)
- A policy for systematically escalating safety issues with clients, with clear implications for the client delivered in a professional way. An example is from the US Post Office, which has a 3-step process for communicating with people about securing their animals.
- A policy on verbal and physical harassment or threats from patients or others in the home.
- A policy and process for physical safety that can be activated as needed, for example by having two staff members participate in visits (including overlapping visits) or for hiring of security personnel. The policy should also address what staff-owned physical safety devices such as guns, mace or pepper spray are permitted.
- Conducting a cross-walk of safety policies with mandated emergency preparedness policies to ensure that key topics are addressed and that the agency has policies for in-home worker safety emergencies.
- A policy to guide leadership in for contacting state and federal regulatory agencies and/or referring providers if the agency needs to adjust services due to safety risks.
Best practice: Communicate the agencies’ home safety policies to patients at start of care and explain the process for escalating concerns. Examples include:
- The agency may communicate the expectation that the client maintains a safe environment for workers in the agency's new patient information packet, and might have patient-specific versions of agency policies to use when needed, for example, if the worker has concerns about pets, hygiene in the home or other unsafe conditions.
- For safety concerns in the home, the agency should have a defined process for escalating the concern with the client, outlining the steps the agency will take and the possible implications for services to the patient.
- Ensure that staff are aware of policies and that they are consistently applied so that patients don’t expect workers to make exceptions to safety policies.
- Use empathetic conversations to enlist the patient and family support in mitigating concerns. For example, staff can explain that they use protective gear to prevent spreading infections (or pests) to other patients.
Best Practice: Offer initial and ongoing training on personal safety tailored to the learner’s needs. Examples include:
- Incorporate worker safety policies, procedures, and strategies in the organization’s learning management system or other plan for employee initial orientation and ongoing training program.
- Include review of the agency’s policies and procedures for safety practices and reporting in new staff orientation and annual refreshers.
- Train staff to conduct a quick safety assessment when entering a new home using a checklist. Verify that there are safe entryways, exit paths, smoke alarms, lockboxes for guns, no illegal substances in view, pets secured, etc.
- Add seasonally appropriate trainings and communications to routine staff updates and trainings, for example, offering driver tips for slippery conditions in winter, preventing bee stings and poison ivy in summer.
- Make the agency’s required ‘safety board’ electronic, and post links to training videos from the agency’s learning system or YouTube
- Search YouTube for training in diverse languages and on a variety of topics, to match staff language and learning needs.
- Consider the NIOSH 7-part Training Curriculum for Homecare as one element of your agency’s training (or incorporate ideas from the NIOSH training)
- Include skills building workshops with role play as part of training. For example, staff might use role play to train for de-escalating an interaction with a hostile or threatening caregiver. The Joint Commission's 2019 Quick Safety brief 'De-Escalation in Health Care' offers a number of strategies and case studies.
Best Practice: Collaborate with communities and other VNAs to maximize available resources, and provide direct interventions reduce risks to workers while assisting the clients. Examples include:
- Develop a brief inventory and referral strategy for community agencies or organizations that can help reduce risks, for example by donating equipment, removing pests, offering caregiver respite.
- Provide personal protective equipment relevant to multiple types of safety hazards, for example, ranging from sharps boxes to plastic liners to place under employees’ equipment.
- Develop a relationship with local police to take advantage of any safety training they offer and to include them in the agency's policy relating to providing care where there may be safety risks.
- Provide safety gear to staff, for example, issuing anti-slip footwear devices to home-visiting staff during the winter.
- Use iPhones or other GPS-equipped devices or installing emergency call button apps on staff phones to ensure that the agency can locate staff in emergencies and ensure that staff can contact emergency responders or the agency immediately.
- Share best practice educational resources and online training sessions with regional VNAs or through the state homecare association.
Home Health Care Patients and Safety Hazards in the Home: Preliminary Findings (2008 AHRQ)
- NIOSH Hazard Review (2010): A CDC/NIOSH document that aims to raise awareness and increase understanding of the safety and health risks involved in home healthcare and suggests prevention strategies to reduce the number of injuries, illnesses, and fatalities. Includes Checklists for Employers and Employees
- NIOSH Total Worker Health: CDC/NIOSH offering policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being.
- CDC NIOSH: Caring for Yourself While Caring for Others: Practical Tips for Homecare Workers: CDC publication targeted to home health aids that includes a variety of strategies and checklists to promote personal safety.
- OSHA Safety and Health Topics: Healthcare: includes discussion of hazards to healthcare workers and in the healthcare workplace, and offers information on improving safety for healthcare workers (including inpatient)
- OSHA: Home Healthcare: resources to assist in assessing and reducing home healthcare workers' risks for workplace injury and illness.
- OSHA Compliance Assistant Quick Start, Healthcare Industry: Includes 8 steps outlining major OSHA requirements and guidance materials that apply to health care facilities and a Safety and Health Program Audit Checklist.
Joint Commission: De-Escalation in Health Care - Research and training on strategies to prevent and de-escalate violent behavior in healthcare settings.
Kinnser: Tips for Creating a Home Health Provider Safety Training Program
Ohio Bureau of Workers' Compensation: Safety and Health for the Home Healthcare Industry - includes sample policies and checklists for homecare safety.
U Mass Lowell - Safe Home Care Program: Research and resources on topics related to home care safety
The National Academies Press Resources
- The Future of Home Health Care: Workshop Summary
- Health Care Comes Home: The Human Factors
- The Role of Human Factors in Home Health Care: Workshop Summary
TrainingNIOSH Training Curriculum for Homecare Workers
- Module 1: An Introduction to Homecare Health and Safety
- Module 2: Tips for Reducing Strains, Sprains, and Falls While Doing Housekeeping and Caring for Clients
- Module 3: Tips for Reducing Risks from Environmental Exposures When Providing Homecare
- Module 4: Tips for Reducing Exposure to Bloodborne and Other Infectious Diseases
- Module 5: Tips for Staying Safe When Working with Clients with Dementia
- Module 6: Tips for Setting Healthy and Safe Boundaries to Reduce Stress
- Module 7: Tips for Safely Handling Threatening Behavior When Providing Homecare
NIOSH How to Prevent Driving Injury
NIOSH How to Prevent Exposure in Unsafe Conditions
NIOSH How to Prevent Latex Allergies
NIOSH How to Prevent Musculoskeletal Injuries
NIOSH How to Prevent Needlesticks
NIOSH How to Prevent Exposure in Unsafe Conditions
NIOSH How to Prevent Latex Allergies
NIOSH How to Prevent Musculoskeletal Injuries
NIOSH How to Prevent Needlesticks
American Organization of Nurse Executives and the Emergency Nurses Association Toolkit For Mitigating Violence In The Workplace (2015) and Joint Commission - De-Escalation in Health Care
Ohio Bureau of Workers' Compensation: Safety and Health for the Home Healthcare Industry
Checklists for Employers and Employees adapted from NIOSH
Measures and EvaluationThere are no specific measures of workplace safety for home health. A 2016 report from Press Ganey on nurse perceptions of workplace safety in hospitals suggests that perceptions of safety are correlated to nurse satisfaction and retention, as well as with patient experience.
2016 Nursing Special Report: The Role of Workplace Safety And Surveillance Capacity In Driving Nurse And Patient Outcomes (free download with registration)
Outcome metrics recommended in the American Organization of Nurse Executives and the Emergency Nurses Association Toolkit For Mitigating Violence In The Workplace include:
- Increased reporting of violent incidents
- Measures of interventions in place to reduce escalation and assault
- Tracking of the nature and number of incidents agency-wide
- Some agencies conduct periodic employee surveys to gauge satisfaction and understand perceptions of employees. This is an excellent strategy for assessing workplace safety in home care. Agencies can use this information to prioritize training, programming and employee support to improve home care safety and employee perceptions of safety.
Selected Literature - Abstracts on Home Healthcare Worker Safety
 Henriksen K, Battles JB, Keyes MA, et al., editors. Home Health Care Patients and Safety Hazards in the Home: Preliminary Findings. In Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): Agency for Healthcare Research and Quality; 2008 Aug.
 McCaughey, McGhan G, Kim J, Brannon D, Leroy H, Jablonski R. 2012 Workforce implications of injury among home health workers: evidence from the National Home Health Aide Survey. Gerontologist. Aug;52(4):493-505.