Academic journal article Health and Social Work

Abuse and Neglect of Clients in Agency-Based and Consumer-Directed Home Care

Academic journal article Health and Social Work

Abuse and Neglect of Clients in Agency-Based and Consumer-Directed Home Care

Article excerpt


Social workers in health care settings increasingly are concerned with the long-term management of chronic illness and with community-based care (Volland, 1996; Volland, Berkman, Stein, & Vaghy, 1999). As access to acute care settings becomes more constrained and hospital stays shorten, more sick and chronically impaired people require services at home (Proctor, Morrow-Howell, Li, & Dore, 2000). Home care ranges from home health services provided by highly trained professionals (including social workers) to supportive services delivered by nonprofessionals with little or no training (Benjamin, 1993; Egan & Kadushin, 1998). Amid the turmoil created by expansion in managed care and legislation designed to restrain growth in home care spending, new and perhaps less-costly models of supportive home care have emerged that rely on recipients for many of the service decisions previously made by professional case managers and providers (Batavia, DeJong, & McKnew, 1991; Simon-Rusinowitz & Hofland, 1993). These consumer-directed models of home care not only challenge traditional agency-based models, but also raise concerns that in the absence of monitoring by agency professionals, recipients are more vulnerable to abuse and neglect by home care workers. The research reported here addresses these concerns by comparing client reports of abuse and neglect by workers in agency-based and consumer-directed home care models.

Core social work values have always emphasized ideals of self-determination and empowerment of clients (NASW, 2000; Tower, 1994). As a result, interest in consumer-directed home care is growing among social workers in long-term care (Bradley, 2000; Feinberg & Ellano, 2000; Feinberg & Whitlatch, 1998; Freedman & Boyer, 2000; Geron, 1998). Controversy arises as professionals weigh the risk to clients from less traditional service delivery arrangements in the home setting. Many professionals think that consumer-directed home care poses risks of abuse to the client, unlike agency-based home care that provides better-trained and supervised home care workers (Micco, Hamilton, Martin, & McEwan, 1995). The scenario becomes further complicated when paid service providers are family members, who are hired because consumer direction permits recipients to choose anyone as their provider.

The study reported in this article examined variations in abuse and neglect of clients by workers associated with different home-based service models, taking into account relationships between clients and workers. Abuse and neglect is operationalized to include worker behaviors toward the client related to psychological risk (for example, yelling, threatening, or provider drug use), physical risk (both intentional and unintentional harm), material abuse, unwanted sexual advances, and neglect. This research has three purposes: (1) to determine whether worker abuse and neglect of the client is associated with type of service model (agency or consumer-directed), (2) to determine if the relationship between the recipient and provider (family or not) is related to worker abuse and neglect, and (3) to identify other characteristics of the client and service context associated with worker abuse and neglect.


Researchers who study abuse in vulnerable populations define mistreatment as physical abuse; psychological or verbal or emotional abuse; material or financial abuse; sexual abuse; and active and passive neglect (Kleinschmidt, 1997). Whereas there is a substantial body of literature on abuse of patients by nursing home staff (Harrington & Carrillo, 1999; National Center on Elder Abuse, 1997; Pillemer & Moore, 1989), relatively little research has been reported on abuse by paid providers in the home. Mistreated elderly people are more likely to have cognitive difficulties (Cooney & Howard, 1995; Decalmer & Glendenning, 1997; Kleinschmidt, 1997), be living with someone else, be in poor health, and have no one else to turn to for support (Nagatomo & Takigawa, 1998). …

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