04/03/2015 04:18 pm ET Updated Jun 03, 2015

Home Health Aides, Patients and Families: The Complex Challenge of Delivering Safety (Part One)

When Susan* returned home following hip replacement surgery, Barbara, a visiting home health aide, was an important part of the 72-year-old's support system. In addition to helping Susan bathe and dress herself each day, Barbara prepared lunch and dinner for her and helped with some light housecleaning. A week into Susan's recovery, however, her daughter showed up at her apartment unexpectedly one morning with Susan's two toddler-age grandchildren in tow. Apparently the daughter was accustomed to dropping the kids off with Susan while she did her shopping, and assumed that watching the kids was now part of Barbara's job.

Barbara politely explained that she was there to care for Susan, not her grandchildren, and that babysitting was not part of her work responsibilities. Once the daughter understood her mistake, she apologized and then lingered for a pleasant visit before heading off to the local supermarket -- taking her young children with her.

While this type of situation doesn't happen often, it's one that home care agencies must always be alert to. Although the majority of home care cases go smoothly, we need to ensure that our home health aides, nurses and therapists are also prepared for any difficulties that may arise in dealing with clients or their family members. These can range from simple disagreements over what a caregiver's duties are to troubling and even dangerous scenarios in which the client or a family member is struggling with mental, emotional or behavioral problems.

"Most of our interactions with clients and their families are very positive -- but at the same time, our home health aides go through an extensive training program that teaches them how to recognize and deal with problems in the home environment," explains Gale Storm, education manager for Partners in Care, a division of Visiting Nurse Service of New York. "One of the most important elements of this training involves developing good communication skills. Most problems can be prevented or defused through effective communication."

To hone this ability, our home health aides go through a 10-part curriculum that stresses such skills as listening carefully in a focused way, without judging what the other person is saying; rehearsing the caregiver's own message ahead of time; looking for body-language cues that may reveal underlying feelings; maintaining a pleasant tone and facial expression; and paraphrasing what the other person is saying out loud, to make sure all parties understand exactly what is being expressed.

Following their initial training, home health aides also receive ongoing refresher courses on these and other techniques for resolving problems. "Some of the most common areas of conflict arise when family members expect the home health aide to go beyond the scope of the client's plan of care," Gale says. "For example, the aide is responsible for keeping the client's personal spaces neat and clean, including the bathroom and kitchen area. But that doesn't include cooking or cleaning for the whole family, or caring for pets."

By outlining what the aide's responsibilities are, calmly and clearly, most misunderstandings of this kind can be quickly ironed out. In some cases, a volunteer organization or other community resource can fill a gap -- by walking the family dog, for example, or providing housecleaning services.

More deep-seated problems, on the other hand, may require the home health aide to disengage and confer with his or her supervisor. "We also train our home health aides to carefully observe the home environment," notes Gale. "Things they should be looking for include how the client and the client's family get along and whether there is good communication among them, and whether there are any signs of neglect or abuse -- not just physical, but financial or verbal as well. Sometimes, the client will confide in the caregiver that they're being mistreated by a relative or friend."

If a home health aide does notice something amiss, they are instructed to raise their concerns with their supervisor or the visiting nurse assigned to the case. Aides are also trained to leave the home and contact their supervisor immediately if they feel threatened, and to call 911 if the situation poses an imminent danger.

"While relatively rare, we do get cases in which family members are selling or using illegal drugs in the home, or are verbally or physically abusive, or seek sexual favors from the home caregiver," says Gale. In such instances, a group conference may be called in which the care team meets with the family in their home to discuss the matter. "If there's a safety issue involved, then these cases will usually have to be closed and the caregiver removed from the home until the situation is resolved," she adds.

Some of the most common home care problems arise in connection with patients or clients who are suffering from dementia, which can affect both their memory and personality. "We had one client who refused to take replacement aides when his aide needed time off, because he would only accept an aide who shared his same zodiac sign," recalls Gale. "With some Alzheimer's patients, an aide may need to introduce themselves each day as if they were meeting the client for the first time. These clients can also sometimes become combative."

In such cases, home health aides and other caregivers walk a fine line, since the difficulties they're encountering are related to the patient's medical condition itself. "Again, the training our aides receive is essential," says Gale. "The keys are for them to listen carefully and respond appropriately to the client's needs, bring concerns to the supervisor or supervising nurse when necessary, and know that our organization is there to support them if the situation becomes untenable. With this system in place, virtually any problem can ultimately be handled in a constructive way."

In the next two installments of this series, I'll offer advice on how family members can help "keep the peace" and ensure effective home health care for their loved one by identifying and addressing potential issues in the home environment before they become serious problems. I'll also explore some broader health care policy proposals aimed at enhancing the ability of home care workers to provide the best possible care for their clients in today's ever-changing health care landscape.

* Name changed to protect privacy