Be it for finding help for an elderly family member or transitioning to a career in home health, increasing numbers of nurses are intersecting with the ever-growing elder care industry.
And, though thriving, it's an industry with a lot of recent attention for objectionable practices.
A recent study by Northwestern Medicine in Evanston, IL, and recently published by the American Geriatrics Society revealed many agencies recruit random strangers off Craigslist and place them in the homes of vulnerable elderly people with dementia, don't perform national criminal background checks or drug testing, lie about testing the qualifications of caregivers and don't require any experience or provide real training.
"People have a false sense of security when they hire a caregiver from an agency," said lead study author Lee Lindquist, MD, associate professor of medicine at Northwestern University Feinberg School of Medicine and a physician at Northwestern Memorial Hospital. "There are good agencies out there, but there are plenty of bad ones and consumers need to be aware that they may not be getting the safe, qualified caregiver they expect. It's dangerous for the elderly patient who may be cognitively impaired."
Home Health vs. Home Care
One important distinction in any discussion of care in a home setting is the difference between agencies providing home care and home health. Home health is doctor-prescribed and agency employees are considered skilled with special training. Home health care nurses can administer medication.
According to the Bureau of Labor Statistics, employment of home health aides is expected to grow by 60 percent from 2010 to 2020.
By contrast, home care involves simple assistance with activities of daily living. These workers can remind a patient to take medication, but not administer the pills. Marie Fredette, executive director at the Arizona Association for Home Care said questionable home care and home health agencies are frequently confused and the consequences can be deadly.
"Home care agencies are not required to be licensed and don't even need to have to have business license," she noted. "There's no oversight and we hear of some giving medication when they're not permitted.
When working with medical home care companies, it's essential to check for the state's department of health website for the agency's Medicare certification status and any possible citations brought against the agency.
Linquist and other researchers surveyed 180 agencies nationwide. Of those, only one-third tested for caregiver competency and more than 58 percent relied on self-reporting to assess caregiver skills.
Several agencies surveyed in the study actually made up names of screening tests they claimed to give their job applicants.
"We had agencies say they used a 'National Scantron Test for Inappropriate Behavior' and an 'Assessment of Christian Morality Test'," Lindquist said. "To our knowledge, these tests don't exist. If you're not a smart consumer, you won't recognize which agencies are being deceitful."
Insufficient Background Checks
One of the study's most disturbing findings was the fact that only 55 percent of agencies performed a federal background check and only one-third tested for drugs.
"A number of agencies don't do a federal background check or look at other states besides their own," Lindquist said. "Someone could move from Wisconsin to Illinois and could have been convicted of abusing an elder adult or theft or rape and the agency would never know."
The drug test is another murky area as well. Fredette said that, in Arizona, TB testing in required by drug testing is at the agency's discretion.
In neighboring California, Mission Healthcare executes an 11-panel drug screen, while the industry standard is a 6-panel test. Marijuana, cocaine, opiates, methamphetamine, amphetamine, PCP, benzodiazepines (Valium, Xanex, Ativan), barbiturates, oxycotin and ecstasy are all included in the screening.
"We take it very seriously because these individuals are going into homes with a lot of medications," said Kerry Pawl, DPT, director. "If someone tests positive and is looking for the big name drugs, we'll know that ahead of time."
In addition to the lack of screening, many agencies don't require any kind of basic competencies for caregivers.
According to the study, only one-third test for caregiver skill competency. The study uncovered common method of assessing skill competencies was "client feedback," which was explained as expecting the senior or family member to alert the agency that their caregiver was doing a skill incorrectly.
That's not the case with AAHC's members.
"Per Arizona requirements, our home health aide members have 12 hours of education yearly in infection control, HIPPA, patient rights, reading and recording temperatures, pulse and respiration, nutrition, transfer techniques, and more," she said.
Supervisor support is another area that many agencies fall between the cracks, said Linquist. Ideally, agencies should send the supervisor on a home check frequently initially and then at least monthly. But this only happens half the time.
"Amazingly, some agencies considered supervision to be asking the caregiver how things were going over the phone or when the employee stopped in to get their paycheck," Lindquist said.
At Mission Healthcare, Pawl said he'd heard enough horror stories to establish a monthly unannounced supervisor visit and client call within a week of admission to check to the caregiver's prowess.
Those in the know offer a few tips to ensure the agency you're associating with-or entrusting to a care of a family member-is trustworthy.
In addition to checking the state health department's website, Fredette advised looking into professional association alliances for the agency.
Additionally, though it's not a requirement for Medicare home health agencies, she said it's noteworthy to learn if a social worker and physical therapist are on staff.
"In Arizona, it's not required to have these professionals but they do understand the psychosocial issues in home health," she added.
For Pawl, in addition to the drug testing and background checks, it's important to go in knowing the agency's level of customer service.
"I'd ask about minimums and use caution when there's a 4-hour care minimum," he advised. "If someone only needs 45 minutes of care and the agency goes to that level of customer service to accommodate, you're in good hands."
Robin Hocevar is senior regional editor at ADVANCE.