Maggie (not her real name) is 36 years old, lives in the Midwest, and has been a home healthcare aide for the past 15 years. She started with a small agency at $9.00 per hour with minimal benefits. The only requirement for the job was no criminal record. Today, she makes $9.25 per hour, still with few benefits. She takes public transportation to the bus stop near the patient’s home, then walks the rest of the way. During the winter months, the trek can take up to two hours each way.

Like many HHAs, Maggie lives below the poverty line. She did not graduate from high school. She got into home healthcare because her mother had Parkinson’s disease. An HHA came to their home daily to help her mother perform basic tasks: getting in and out of bed, toileting, showering, and eating. Maggie learned to fill in for her mother’s needs between visits from the HHA.  
HHAs are among the most vulnerable workers in the broader classification of home healthcare workers, which includes registered nurses, occupational therapists, physical therapists, and other skilled medical professionals. Maggie and other HHAs often enter households where the work is dynamic and potentially dangerous. (See Table 1 for basic tasks performed by HHAs.) Patient handling presents ergonomic challenges. HHAs can be exposed to pathogens, drugs, household agents, heat, cold, and mold. Patients can be violent, mentally ill, or angry. Remembering to do everything right to avoid injuring the patient or themselves is a source of mental stress for HHAs. Sometimes they must deal with patients’ medical emergencies such as heart attacks. HHAs’ personal safety can be compromised by tense work environments brought on by the patient or the patient’s family, friends, or pets. In 2010, NIOSH published a hazard review on occupational hazards in home healthcare. The study found that 27,400 recorded injuries had occurred among more than 896,800 HHAs.
RESOURCES AARP Public Policy Institute: “Caregiving in the U.S.” (PDF, June 2015). Genworth: Cost of Care Survey 2018. Home Health Care Managing Practices: “The Future of Home Health Care” (October 2016). Home Healthcare Now: “Occupational Exposures of Home Healthcare Workers” (March 2017). Kaiser Family Foundation: “Medicaid Home and Community-Based Services Programs: 2012 Data Update” (November 2015). Medicare Payment Advisory Commission: “A Data Book: Health Care Spending and the Medicare Program” (PDF, June 2016).
Despite the hazards, Maggie loves her job. Growing up with a mother with a disability taught her the vital role of an HHA. Not showing up can be devastating to the patient’s health and safety. SCOPE OF THE PROBLEM  This year, there will be more people older than 65 years in America than those younger than five. This longevity comes at a price, with more Americans suffering from multiple chronic conditions including diabetes, dementia, and impaired mobility, according to an article in Home Health Care Managing Practice. Among older Americans, obesity and type II diabetes have increased compared to previous generations. A recent study by the Kaiser Family Foundation reported that 88 percent of people 65 years or older have at least one chronic condition, with 25 percent of these having four or more conditions. Chronic illness accounts for 75 percent of total national healthcare expenditures.  
Table 1. Activities Performed by Home Healthcare Aides/Personal Assistants
One alarming statistic from AARP is that Medicaid expenditures for home-based and community-based services have more than doubled, from $25.1 billion in 2002 to $55 billion in 2012. The graying of the U.S. population is the game changer in healthcare. According to the Medicare Payment Advisory Commission, Medicare enrollment is projected to increase by more than 50 percent over the next 15 years from 54 million beneficiaries today to more than 80 million in 2030. The Census projects that by 2030, the proportion of U.S. residents older than 65 will have nearly doubled from 2010 (20 percent vs. 13 percent). Further, the Census predicts that the population age 85 and above will double by 2036 and triple by 2049.  Therefore, providing care in the home is one of the most cost-effective and efficient mechanisms for maintaining patient health, now and in the future. (According to the insurance company Genworth, the monthly cost to patients of an HHA in 2018 was half the monthly cost of a private room in a nursing home.) It is estimated that more than 2 million home care workers in the U.S. provide personal assistance and healthcare support to older adults and people with disabilities in home and community-based settings. Most people prefer to be cared for in their own home rather than a nursing home or assisted living facility; according to the U.S. Bureau of Labor Statistics, the home care work force has more than doubled in size in the last 10 years. As much as 25 percent of these workers earn incomes below the poverty line.  

ERGONOMICS CASE STUDY IN MICHIGAN During 2018, the Michigan Occupational Safety and Health Administration conducted five compliance inspections in facilities that provide home healthcare services and delivered training and consulting to 68 home healthcare employers. MIOSHA trained a total of 94 employees who provide home healthcare services. Through these activities, MIOSHA has helped improve workplace safety and health in the home healthcare industry. From 2009 to 2017, the total recordable rate of nonfatal injuries and illnesses in the healthcare and social assistance sector, which encompasses home healthcare, fell from 6.7 cases per 100 workers per year to 4.7 cases per 100 workers per year, a 30 percent reduction, according to data from the U.S. Bureau of Labor Statistics. Occupational health and safety professionals need to focus on HHAs because of their exposure to many work hazards from which they don’t have the means to protect themselves. An injury report to MIOSHA illustrates how ergonomics interventions can protect HHAs. The report details the experience of an ergonomist who helped a small home healthcare company in the Midwest mitigate job hazards. The ergonomist developed an 18-month program to prevent injuries to both the HHA and the patient. The program included visits to several homes to document patient handling practices and mobility challenges, and identify the most common job risk factors associated with musculoskeletal disorders. The program also involved the development of training for all HHAs, documentation of injuries and illnesses caused by patient handling, and creation of a train-the-trainer program to teach senior HHAs the principles of ergonomics and safe patient handling.  During home visits, the ergonomist observed the following common job risk factors:
  1. getting the patient into and out of bed 
  2. dressing and undressing the patient
  3. toileting—safely positioning the patient on and off the toilet
  4. showering—removing clothes, safely moving and positioning the patient on a plastic seat in the shower, showering the patient, then drying and safely moving and positioning the patient back on a wheelchair or electric scooter
  5. using a portable patient lifting device, which requires additional education and training
  6. transportation: when provided, using a wheelchair to move the patient from the home to a vehicle, lifting and positioning the patient in a passenger seat, and performing the sequence in reverse order when the patient is removed from the car

Occupational health and safety professionals need to focus on HHAs because of their exposure to many work hazards from which they don’t have the means to protect themselves.
Common items in the home, usually supplied by the state government, that helped with patient handling and mobility included a wheelchair or electric scooter; a portable patient lifting device; a pneumatic bed that can be raised or lowered; and gate belts that are placed around a patient’s waist to help with maneuverability. Sometimes patients’ homes also have grab bars near the toilet and shower. Other items usually supplied by the HHAs themselves to make their jobs easier include a 16-inch plastic rotating disk for patients to stand on while the HHA pivots them into position. Typically, the plastic disk is used when the patient is lifted from a sitting to a standing position and pivoted to a chair, bed, toilet, shower, or automobile. Cloth straps with Velcro fasteners secure the patient’s legs together when pivoting the patient into or out of the bed. A cloth disk is used on chairs to help patients swivel in one direction or the other. A portable handle that inserts into a car door latch can temporarily support patients when they get into or out of an automobile seat. Portable support bars with suction cups can be attached inside shower stalls to help patients stabilize their position when standing in the shower. A portable sliding transfer bench with an aluminum, adjustable-height frame provides easy and safe access and a stable seating area for bathing and showering. The plastic seat has holes to drain water away from the patient. HHAs may also provide tools for picking up dropped items or removing them from high shelves.  After identifying the common job risk factors and evaluating the ergonomic tools for safety and effectiveness, the ergonomist developed a training program. He prepared a slide deck demonstrating the value of using these tools and performed a detailed job analysis on patient lifting devices. The step-by-step process of safely and efficiently using the patient lifting devices was documented and videotaped for the training session. The training sessions were typically two hours long and held at a local Red Cross. Approximately 200 HHAs were trained over a three-month period. A 10-question quiz was given at the end of each training session. To pass, the HHAs had to answer 80 percent of the questions correctly. All HHAs eventually passed.  In addition, five of the senior HHAs were selected to receive additional training for each of the six job risk factors. The training session was recorded, and the agency requires all new hires to view the recording and take a 10-question quiz at the end. The senior HHAs reinforced the video by personally training new hires on the job risk factors.  At the end of the 18-month program, the home healthcare company did not report any ergonomic-related musculoskeletal injuries. In fact, the company used the ergonomics training as a marketing tool to recruit more HHAs to their growing patient case load. ESTABLISHING POLICIES AND PROGRAMS  HHAs can help protect themselves on the job by performing risk assessments of patients’ homes prior to providing care. Well designed and applied risk assessment forms and processes allow HHAs to control known hazards, anticipate newly arising hazards, recognize existing hazards, and evaluate the extent of the hazards. Industrial hygienists and occupational and environmental health and safety professionals can help homecare services employers develop, implement, and sustain this “C.A.R.E.” process for protection of HHAs and others, including the use of risk assessment prior to the provision of service and client education. Educating families can help them recognize and control hazards in their homes, which include loose rugs, uneven surfaces, or materials stored on floors; poor lighting; aggressive pets; poor condition of walkways; and a number of other environmental conditions. In addition, families need to understand that the arrangement or storage of furniture or materials can make handling their loved ones difficult, and that equipment can reduce the physical demand of handling their loved ones. The design, maintenance, and cleanliness of households are typically under the control of the homeowner. Wheeled transfer devices have difficulties traveling over uneven floor surfaces such as rugs or thresholds. The healthcare provider needs to either rely on someone in the household to ensure surfaces are suitable for the use of transfer devices, prepare those surfaces prior to patient transfer, or see that those surfaces are prepared.  TECHNOLOGY’S POTENTIAL Home healthcare is a rapidly growing industry. There are many challenges for both the HHA and the patient, especially regarding movement, mobility, and medications in the home. While emerging technologies will not substitute for all that an HHA does (such as help the patient get into and out of bed, shower, eat, and so on), they may play an important role in mitigating these challenges.  It is only a matter of time before Google, Amazon, Microsoft, and Apple smartphone applications provide assistance to elderly homecare patients. Internet-based digital assistants (such as Amazon’s Alexa and Google Home) that respond to verbal commands can alert patients to take medications and remind them of upcoming appointments. These digital assistants have medical information that can help users take meds on time and in the right amounts, and avoid adverse drug interactions.  In addition, robots called personal assistants will become more common as their price goes down and their services expand. These personal assistants can bring medicines, food, and personal hygiene items to the patient.  Maggie isn’t sure if modern technology will help or hinder her job. She is dealing with the present. Her patient recently passed away from natural causes. This is part of the job: most of her patients pass away, all too often from a chronic disease complication, such as pneumonia. This is a new day for Maggie, and she is being assigned a new patient. Maggie is anxious because it means learning all she can about her new patient, not just the healthcare needs, but the nuances of the patient’s personality, what she likes, doesn’t like, her manner, and what brings her joy. Maggie says that despite the low pay and all the hazards associated with her job, if she can bring a quality of life to her patient and some joy in living, then that is all the reward she needs for now. And if technology can help her perform acts of kindness to her patient, then she is all for it.   JAMES D. MCGLOTHLIN, MPH, PhD, CPE, FAIHA, is professor emeritus of Industrial Hygiene and Ergonomics at Purdue University. COLIN J. BRIGHAM, CIH, CSP, CPE, CPEA, CSPHP, FAIHA, is past president and board member of the Association of Safe Patient Handling Professionals, a longtime member of the AIHA Ergonomics Committee, and contributor to standards for safe patient handling and mobility. Send feedback to The Synergist.
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Challenges and Opportunities for Safe Patient Handling and Mobility
Protecting Home Healthcare Aides
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Disadvantages of being unacclimatized:
  • Readily show signs of heat stress when exposed to hot environments.
  • Difficulty replacing all of the water lost in sweat.
  • Failure to replace the water lost will slow or prevent acclimatization.
Benefits of acclimatization:
  • Increased sweating efficiency (earlier onset of sweating, greater sweat production, and reduced electrolyte loss in sweat).
  • Stabilization of the circulation.
  • Work is performed with lower core temperature and heart rate.
  • Increased skin blood flow at a given core temperature.
Acclimatization plan:
  • Gradually increase exposure time in hot environmental conditions over a period of 7 to 14 days.
  • For new workers, the schedule should be no more than 20% of the usual duration of work in the hot environment on day 1 and a no more than 20% increase on each additional day.
  • For workers who have had previous experience with the job, the acclimatization regimen should be no more than 50% of the usual duration of work in the hot environment on day 1, 60% on day 2, 80% on day 3, and 100% on day 4.
  • The time required for non–physically fit individuals to develop acclimatization is about 50% greater than for the physically fit.
Level of acclimatization:
  • Relative to the initial level of physical fitness and the total heat stress experienced by the individual.
Maintaining acclimatization:
  • Can be maintained for a few days of non-heat exposure.
  • Absence from work in the heat for a week or more results in a significant loss in the beneficial adaptations leading to an increase likelihood of acute dehydration, illness, or fatigue.
  • Can be regained in 2 to 3 days upon return to a hot job.
  • Appears to be better maintained by those who are physically fit.
  • Seasonal shifts in temperatures may result in difficulties.
  • Working in hot, humid environments provides adaptive benefits that also apply in hot, desert environments, and vice versa.
  • Air conditioning will not affect acclimatization.
Acclimatization in Workers