06/15/2011 05:46 pm ET | Updated Aug 15, 2011

Home Health Care: Navigating Racial and Cultural Differences

'Like Associated with Like'

95-year-old Roz spent all her life in Westchester County in the company of Jewish people like herself. She was not strictly religious, but she grew up in a time and place when, as she said, "like associated with like." She still recalls one evening, some 70 years ago, when she went on her first and only date with a non-Jewish boy. "I felt like the whole town was watching and judging," she said.

So it was definitely a learning process when Marjorie, who is black and an evangelical Christian, came to care for Roz -- who was limited by severe arthritis and, later, the early stages of Alzheimer's. Roz's daughter, knowing her nonagenarian mother had had little experience with people of other races or cultures in her home, introduced Marjorie into her mother's apartment slowly. It was five hours a week at first, then 10, so when Roz needed full-time care, she was comfortable with Marjorie. Now, over the course of three years, the two consider one another deep and abiding friends. Says Roz of her friend and caretaker, "I like her way. She doesn't impose."

Marjorie's "way" is a purposefully cultivated professionalism and respect for her client, evident in one of Marjorie's first questions. "We always begin by asking how the client would like to be addressed," she notes.

That question went a long way for Roz -- Mrs. Goldberg, as she would prefer to be called -- who complains that even the youngest receptionist in a doctor's office blithely calls her by her first name.

With homebound elders in fragile health and often with a litany of limitations, transcending racial, ethnic and cultural differences does not come easy. But with training, time and generous doses of sensitivity and compassion, home health aides and the people they care for bridge those divides in admirable and sometimes surprising ways. The secret lies in commitment, trust, respect and constant communication.

Building Bridges through Commitment and Caring

Through training and in-service support at my agency, Partners in Care, we encourage aides to send a consistent message: I am here for you and I'm not going anywhere. Over time, this commitment and consistency translates into trust and can chip away a great deal of obstinacy and help bridge the divide with clients who see only differences, such as skin color or cultural background.

Home health care agencies consistently strive to provide patients with compatible aides, which can mean matching schedules, personalities, and experience and familiarity with certain customs, as well as personal needs and sensitivities. Sometimes, as in the case of a bedbound 250-pound client who needed frequent transferring and requested a male aide, we are able to accommodate in unexpected ways. In this case, the 98-pound female aide we sent over performed the transfers admirably (as we knew she would) and quickly won approval from the client.

"Cultural diversity is a big term," says Gale Storm, Manager of Education at Partners in Care. "In the classroom, we deal with all different client populations because we go into so many different types of homes. In the home and among our aides, we have every ethnicity you could think of -- and many that you've never even heard of."

Cultural sensitivity begins with the aide, who is trained to respect all cultures, customs, preferences and personal choices. Home aides are specifically trained to put a premium on sensitivity and respect, emphasizing that that this might not be a two-way street in every case, and that they shouldn't take things personally if a patient's behavior toward them seems unappreciative. "You can't teach sensitivity or a thick skin," Gale says, "but you can talk about it in training and foster it through experience."

This training went a long way for Delvina, a Jamaica native who has been a home health aide for nearly a decade. She was recently sent to care for a client of Hispanic origin, who refused her service because she, Delvina, was black. "I stayed calm, stayed professional and kept asking what I could do to help her," Delvina recalls. "I asked, Can I make you breakfast? Can I help you get dressed? I tried to make her comfortable." The supervisor was called, but in the end, the client was unrelenting.

"It happens," says Delvina. "I know I'm there to care, and a client's behavior doesn't change that fact. I try to remain positive every day, every time I go to the job."

The bottom line, Gale says, is that aides are going into someone's home and must always respect the client's wishes. This could mean taking off shoes at the door (we ask aides to carry slippers, for safety reasons) or removing an earring if it could be interpreted as culturally offensive, which we asked one young male aide to do recently.

As with many issues in home health care, communication is key. "The first day of class is all about communication," emphasizes Gale. "You can't go anywhere else with out that." Aides are encouraged to ask questions. It's one of the best ways they can learn about and therefore respect cultural traditions and personal wishes.

Ill Health, Underlying Complexities

Those of us in the home health care field as well as those whose loved ones in need of home care should bear in mind that when someone is suffering from a combination of diseases and discomforts, pain or confusion can undermine civility and courtesy -- as anyone who's suffered from even a bad flu will know. In addition, our clients are facing a precipitous loss of independence and privacy, even as our care strives to keep them as safe and independent as possible in their homes.

Sometimes intransigence or outright rudeness can mask health problems, as one of our care teams recently discovered. It began when Juliet W.'s client became verbally abusive, including hurling racial epithets at her. Juliet (whose name, along with others in this post, we've changed to protect privacy) followed protocol, reporting the situation to her supervisor, who sent a nurse to the home for an assessment. The nurse discovered that there was a problem with the client's medications and alerted the client's doctors. Once the medication management was straightened out, the first thing the client did was request Juliet's care.

"This is complicated stuff, and our parents grew up in a different world than we did," Jane Gross, founder of the New York Times' New Old Age blog and author of "A Bittersweet Season: Caring for Our Aging Parents--and Ourselves," writes in the comments section of a recent blog post. "In their advanced age, I think respecting their preferences, even if we find them bigoted, is a kindness, not a signal we agree with them. It is in my mind the wrong time to lecture them on civil rights. And only time will tell if we are color -- and culture -- blind when our time comes."

As Marjorie says of her relationship with Roz Goldberg, "It doesn't matter the color of your skin. It matters the care in your heart."

Have you had race or ethnicity issue enter into the home care debate in your home or the home of a loved one? Please share your story to continue the conversation.