For Whom the Service Tolls

Atul Gawande had a particularly good point in his book, Being Mortal, about how a nursing home is typically chosen by the family of a dementia patient (Gawande, 2014). I am paraphrasing here, but he wrote that a nursing home is typically selected from the point of what the family or seeker of the facility would like for themselves. The amenities, setting, staff, etc. all coalesce into the perceived wishes of the decision-maker, not the client or patient who must reside there.

I believe caregiving services are chosen the same way. The choice of a caregiver becomes dependent on what the primary caregiver feels is the reason or goal for the services, which is not necessarily in the best interests of the client. For example, one client needed bathing and dressing services in the morning and evening. The primary caregiver agreed this was part of the purpose of obtaining services, but felt having the bed linens changed, the trash thrown out, the bathroom cleaned and straightened, the dishes rinsed, laundry started and folded, and ironing completed were all very important as well. However, in-home caregivers usually work under guidelines that state 80% of their time is spent on direct caregiving and the remaining 20% on incidental light housework.

The perfect person is not going to appear at the door for each shift. Frequent changes are to be expected—most caregivers work for slightly above minimum wage and change jobs often. In 2018, the median caregiver turnover rate for home care agencies was 82% (Holly, 2019). Caregiver turnover is costly to client/company relationships as well as the agency’s bottom line. Why do caregivers leave for another agency? Specialized training programs, money, different hours, new clients, and better management. Burnout, overall job dissatisfaction, lack of a consistent schedule or short notice to assignments, having to learn and relearn the individualities of handing clients, etc., all contribute to home healthcare staff turnover. Family members can also create additional stress. Loved ones may feel no one else can provide their level of care and must weigh the escalating cost of additional services.

This scenario illustrates the first step in hiring in-home help. A quick assessment of the area(s) where assistance is needed includes the following categories:

• Personal care – toileting, bathing, feeding

• Emotional care – companionship, conversation, activities

• Household care – laundry, cooking, cleaning.

The caregivers that work best with dad are quiet, assertive, gentle personalities who wait for a response but only give instructions verbally if it is necessary. A lot of gesturing, pleasant tone of voice; greeting when they come in and saying goodbye when they leave—these are the best caregivers for dad and the ones he cooperates with. For my mother, those caregivers that get their tasks done correctly, help dad without eliciting too many complaints from him, and take initiative to do the related tasks are the ones that work best. No one wants to train new people and, if a change in staff is going to occur, family should be informed in advance as this can be disruptive to clients with cognitive impairment. It doesn’t take a Venn diagram to see that these diverse criteria would be difficult to find in any employee, not just an hourly caregiver coming for a short shift.

Why is there so much contrast in expectations? In the defense of those who are primary caregivers, these discrepancies illustrate the need to try to control a situation that is felt to be out of control. The contributing factors to these emotionally based demands include the patient’s deteriorating health, the need for care beyond capabilities, and a financially unsustainable expense for an extended period of time.

Sources:

Gawande A. (2014). Being Mortal: Medicine and What Matters in the End. New York, NY: Henry Holt and Company.

Holly R. Home care industry turnover reaches all-time high of 82%. Home Health Care News, May 8, 2019. Retrieved May 13, 2019 from https://homehealthcarenews.com.