Helping Homecare: Evaluating Workplace Injury Outcomes in Homecare

Abstract

Abstract Background Minnesota is aging at a rapid pace. It is expected that 27% of the population will be 65 and older by 2030, and approximately 70% of that age group is expected to use long-term care services (Face Aging MN, 2019). Long-term care services may be provided in institutional settings such as hospitals or nursing homes, but an increasingly popular option has been to provide care inside the patient’s own home. Home-based care services have experienced substantial growth in Minnesota, going from 508 home health care services businesses employing 17,722 people in 2000 to 1,390 establishments employing 63,198 personnel in 2015 (Campbell, 2017). In this care setting, the provision of care largely falls to the direct-care workforce, an occupation comprised of home-health aides, personal care aides, and nursing assistants/nursing aides (PHI International, 2011). This workforce is essential for the growing demand of the aging population but has historically been characterized by poor industry retention (Morgan et al., 2014). One substantial contributor to the high turnover characteristic of the direct-care worker population is workplace injuries (Hewko et al., 2015). In 2017, direct-care workers in Minnesota (MN) reported injury rates ranging from 3.7/100 Full Time Equivalent Employees (FTE) to 7.8/100 FTE depending on care setting; both rates are greater than the statewide occupational injury average of 3.3/100 FTE as well as national injury averages (BLS, 2017). Not only is the elevated injury rate concerning for the safety and retention of the workforce, but studies of nurses have shown that employees’ injuries negatively contribute to the quality of care-related health outcomes for patients (Charney & Schirmer, 2007). To protect the worker, the patient, and the industry, a hierarchal investigation of the hazards originating from the immediate injury event, the work environment, and the employment quality must be established to provide effective and efficient workplace interventions. Objectives The overall objective of this thesis is to identify and describe the factors associated with injury in homecare workers in Minnesota and nationwide to inform the most impactful course of action to reduce occupational injuries and improve worker health. To determine the factors associated with injury holistically, injury outcomes will be examined on three levels: 1) the immediate injury event, 2) the workplace environment of the injury, and 3) the precariousness of employment. An examination of each level will be accomplished in three separate dissertation chapters (chapters 2, 3, and 4) and set up as three sequential papers. Manuscript 1: Aim: Determine the effect of the injury event defined by injury task-hazard exposure information on injury severity defined by total workers’ compensation claim cost in Minnesota homecare workers. Methods: A sample of 2526 Minnesota-based homecare workers were collected from a large regional workers’ compensation database over a 15-year period (2003-2017) and used in a generalized estimating equation analysis with a negative binomial family, log link, independent correlation, and robust estimate of variance. Results: Overall, injury event significantly differs in injury severity, (p<.001, CI: 0.019 - 0.046). Specifically, using the Household Chores – SHARPS (mean cost: $734) as the reference category, we found Handling – Infection Risk resulted in a significantly lower injury cost severity compared to the referent, while General Patient Care – Ground Inside; General Patient Care – Violence; Handling – Equipment; Handling – Ground Inside; Handling – Patient, Household Chores – Ergonomic; Household Chores – Ground Outside; Transitions – Ground Inside; Transitions – Ground Outside; Transitions – Vehicle; and Other resulted in a significantly higher claim cost severity. Manuscript 2: Aim: Assess the effect of the workplace environment on injury severity in Minnesota homecare workers and Minnesota direct-care workers in hospital settings. Methods: A sample of 2477 (55.79%) homecare workers and 1979 (44.41%) hospital direct-care workers was utilized in a multinomial logistic regression analysis with the standard error adjusted for non-independence of the employers. Additionally, we utilized a logistic regression analysis with the standard error adjusted for non-independence of the employers to explore an alternative definition of injury severity using injury claim type. Results: Compared to the reference group ($201 – $1,000), the odds of having injuries costing $0-$200 among homecare workers were 1.65 (p=0.01, CI: 1.14 – 2.39) times that of direct-care workers in hospital settings, the odds of having injuries costing $25,001 - $100,000 among homecare workers were 1.67 (p=0.05, CI: 1.01 – 2.79) times that of direct-care workers in hospital settings, and the odds of having injuries costing over $100,000 among homecare workers were 2.86 (p<0.01, CI: 1.77 – 4.63) times that of direct-care workers in hospital settings. The results of our logistic regression analysis of an alternative definition of injury severity as defined by injury claim type yielded null results. Manuscript 3: Aim: Assess the effect of employment precariousness on injury prevalence and severity in homecare workers. Methods: Using the probabilistic two-step sampling method of the National Home Health Aide Survey of 2007, a sample of 2093 homecare workers were utilized in a multivariate logistic regression and a multivariate multinomial logistic regression to explore the association of an adapted Employment Precariousness Score (adapted EPRES) measure and injury prevalence and severity, respectively. Results: Overall, for every one-unit increase in total EPRES, after controlling for demographic and agency characteristics, we noted an 81% decrease in injury prevalence odds (p=0.004, CI: 0.06-0.58). EPRES subscales of employment temporariness and workplace rights yielded 32% and 89% lower odds of injury in response to every unit increase of their scales, respectively. Conversely, there is a 2.29 increase in odds for every unit increase in the employment vulnerability subscale. Conclusion The hierarchal examination of workplace injuries suggests that both injury events and the workplace environment contribute to greater injury severity in Minnesota homecare workers. Employment precariousness, however, exhibited a protective effect against injury prevalence and severity in homecare workers overall and in the specific subcategories of employee contract temporariness, employee wages, and the presence of workplace rights. Conversely, the employment precariousness measure of employee vulnerability exhibits a significant association with greater injury prevalence and severity. Due to data limitations throughout, further study should be undertaken before any causal associations are drawn. In Minnesota, workplace occupational safety and health interventions should be focused on handling-related tasks, fall-related hazards, and the maintenance and organization of the patient’s home. All homecare employers should focus on occupational safety and health to ensure workers have agency against authoritarian treatment.