Homecare Worker Safety



Home Healthcare Worker Safety

Home 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
Scope of the Problem
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.”[1]
  • 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 Practices

Agencies 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.
Best practice: Proactively use data from multiple sources to understand risk and incorporate mitigation in your program. Examples of data sources: 
  • 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 example: Use the attached Checklists for Employers and Employees adapted from NIOSH and routinely review the information to identify current and emerging risks. 

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 example:  Low support and training are linked to higher rates of occupational injury for home health aides.[2] Agencies can improve retention and reduce risks by offering a supportive environment backed by agency policy and proactive worker training. See for example the Joint Commission's 'Improving Patient and Worker Safety: Chapter 3 - Activities and Interventions to improve Safety.'

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 example: The Newfound Area Nursing Association (a VNA in New Hampshire) implemented a weapons policy and trains staff to consistently ensure it is followed by staff, patients and caregivers. 
 
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 example: Make training programs short, interesting, and seasonal to engage employee attention.  For example, search for YouTube training resources and include topical issues such as slippery driving training in winter or prevention of bee stings and fleas in summer. 
 
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.
Best Practice example:  VNS Westchester and Westchester Care at Home are partnering to test out personal safety devices for staff visiting unfamiliar areas.  The rapid response device instantly connects staff to emergency responders or office supervisors through a GPS tracking and alert system.
 

Resources

AHRQ:
Home Health Care Patients and Safety Hazards in the Home: Preliminary Findings (2008 AHRQ)

NIOSH  OSHA Joint Commission: Improving Patient and Worker Safety: Chapter 3 - Activities and Interventions to Improve Safety

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  
Quick Guide: Targeted Resources to Address Risks in Home Health
Homecare Risk Resource
Infection, including bloodborne and airborne pathogens OSHA Resources on Infectious Diseases
Ohio Bureau of Workers' Compensation: Safety and Health for the Home Healthcare Industry 
Pests and vermin – mice, rates, bedbugs, fleas, head lice (may be part of an agency’s infection control program or policy) CDC NIOSH: How to Prevent Exposure in Unsafe Conditions
Bed Bug Action Plan for Home Health Care and Social Workers – Virginia Cooperative Extension Service
Sample Draft Bedbug Policy From Midwest Clinicians Network
Musculoskeletal injuries due to lifting / repetitive motion OSHA Resources on Safe Patient Handling
CDC/NIOSH: How to Prevent Musculoskeletal Disorders
Falls CDC/NIOSH Training Module: Tips for Reducing Strains, Sprains, and Falls While Doing Housekeeping and Caring for Clients
Verbal or physical abuse, including harassment and injuries from pets, guns, acts of nature, mass violence OSHA Resources on Workplace Violence
Guidelines for Preventing Workplace Violence for Health Care and Social Services Workers – includes training and assessment checklists
CDC NIOSH: How to Prevent Violence on the Job
CDC/NIOSH: Caring for Yourself While Caring for Others: Practical Tips for Homecare Workers
Joint Commission - De-Escalation in Health Care
Automobile accidents CDC NIOSH: Motor Vehicle Safety at Work
NIOSH Fast Fact: How to Prevent Driving-Related Injuries
   
 

Training

NIOSH Training Curriculum for Homecare Workers Employee Handouts
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 Evaluation

There 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.
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.
An agency's workers compensation insurance carrier may also be a useful source of safety measures and may also have resources to prevent hazards in home care. 

Citations

Selected Literature - Abstracts on Home Healthcare Worker Safety 

 
[1] 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.
 
[2] 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.